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PMHS Review Class

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Sina Linman

on 22 March 2013

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Transcript of PMHS Review Class

Napnap April 2013 PMHS Review Why Primary Care? Introduction Objectives Common disorders starting in Childhood A.Collaborative problem solving
B.Motivational interviewing
C.Behavioral interventions
D.Relaxation
E.Solution focused therapy
F.CBT
G.Parent Management
H.Social skills training
I.Music
J.Educational support services
K.Family therapy Nonpharmacological Treatment ADHD Coding and ICD-10 DSM-V The past is never dead, It’s not even past. William Faulkner Know what you know
Know what you don't know
Make a plan For each of the following diagnosis describe diagnostic criteria and/or screening tools as well as management strategies and pscyho-education
ADHD
Anxiety
Mood disorders and suicidal ideation
Autistic Spectrum disorder
Substance use, abuse and addiction
Trauma (PTSD)
Chronic Pain syndromes
Eating Disorders
Non-accidental trauma (abuse)
Enuresis/encopresis
Oppositional defiant disorder Objectives 7: Identify psychotropic drug classes and describe their indication for use, common side effects, precautions.
Stimulants
Antidepressants
Anxiolytics
Mood stabilizers
Atypical Antipsychotics Objectives 1:Describe the components of a comprehensive mental health assessment including a mental status exam, assessment for risk factors.
2:Describe how mental health disorders are diagnosed and use of the Multiaxial Classification System.
3:Describe age appropriate health promotion education.
4:Identify appropriate psychopharmacological or non-pharmacological treatment options for specific mental health diagnosis
5:Discuss CPT codes for mental health in primary care Objectives 6:Discuss the basics of the following non-pharmacologic management
Collaborative problem solving
Motivational interviewing
Behavioral interventions
Cognitive behavioral therapy
Relaxation therapy
Solution focused therapy
Social skills training
Parent management training
Family therapy
Social skills training Objectives Announcements

Review Class Define the Gap Sina Linman No conflict of interest to report Philosophy : Review is no substitute for learning Integration Mental Health Into PRIMARY CARE practice Standard of Care ...but how can you do it in the 10 minute visit? Integration of mental health screening into Primary Care is the Cost effective
Effective
Feasible
Better Outcomes
Standard of Care Mental Health Promotion
Primary Prevention Because we are already engaged! and to pass the PMHS certification exam only 6,000 Pediatric Psychiatirs with a need for 30,000 Know what you know: know what you don’t know and make a plan. A Child’s Emotional Bill of Rights
A child has a right to be listened to.
A child has a right to the truth.
A child has the right to develop individually.
A child has a right to boundaries.
A child has a right to play.
A child has a right to be protected from bullying.
A child has a right to approval and acceptance.
A child has a right to show their feelings.
A child has a right to guidance. Eileen Johnson, 2011 INTRODUCTION PMHS:
WHAT, SO WHAT and WHY TOOLS Treatment Diagnostic Criteria and
Management Strategies What (The Problem): Mental health and psychosocial probglems ar beginning to surpass physical health problem in children and youth. 1 out of 4 children in the US is affected by mental illness yet only 20-25% recieve treatment and 1 in 11 suffers from a serious mental illness that causes significant imparement Home-Peers-School So What (The Consequence of Missed Opportunities): 45% of suicide victims visit their primary care physician the month prior to their death Suicide is the 3rd leading cause of death for 10-24 y/o Now what (the answer): Primary Prevention (Universal Strategies) to
Prevent Problems
Increase Competencies http://www.health.state.mn.us/divs/fh/mch/devscrn/glance2012.pdf What to Teach Anticipatory Guidance Family Focused Based on "normal" for developmental age Problem solving Who is in charge? It is OK to say “no” Choices: give at least two, but limit Develop Positive Thinking Anger Control Reward vs punishment Engagement Listening Behavior change No Drugs, Drinking, Smoking Stranger danger MEDIA!!!!!!! "I" statements Informal Formal Parenting Classes Self awareness Safety Parent Effectivness Training Parent Communication Training Behavior Modification Skills
Time out
Time in When to Teach
Teachable moments Groups Friendship is born at that moment when one person says to another: "What! You too? Thought I was the only one."
C.S. Lewis Normalize normal behavior Top 5 worries of teens and their parents: How to cope with stress
Depression
Anxiety
Self-esteem
Parent-child relationship Advocacy Healthy Lifestyle 7-6-5-4-3-2-1-0 COPE 7: more than 7 hours of sleep
6: glasses of water
5: fruits and veggies
4: "nice" things a day
3: servings of dairy
2: hours of screen time
1: hour of busy activity
0: sugary drinks and candy Nature deficit disorder Screening and Assessment Half of all life-time mental health disorders start by age 14 First symptoms appear 2-4 years before onset of the full blown disorder Opportunities for prevention ED and Juvenal Justice Untreated mental illness can lead to drug and ETOH abuse, violence and school failure You only find what you look for
You only look for what you know Mental Retardation
Autism
Learning Disability
Conduct Disorder
Tourette
Separation Anxiety
ADHD
ODD (Oppositional Defiant Disorder)
CD (Conduct Disorder) MDD (Major Depressive Disorder)
Bipolar
ADHD
Anxiety
OCD (Obcessive Compulsive Disorder)
Schizophrenia Common Adult disorders that start in Childhood At least a 60% rate of inaccuracy in primary care mental health assessment….. Age Specific Screening at Every Visit http://www.health.state.mn.us/divs/fh/mch/devscrn/glance2012.pdf Teens 1. Confidentiality (unless there is a safety concern.)

2. “I ask these questions of everyone.”

3. Engagement is the key to success (where they feel safe and secure) HEADESS http://www.bcchildrens.ca/NR/rdonlyres/6E51B8A4-8B88-4D4F-A7D9-13CB9F46E1D6/11051/headss20assessment20guide1.pdf Ask them what confidentaility means to them! Set the stage:
Introduce yourself to the patient and have them introduce you to others in the room.... With EMR how do your assure this? Psychopharmacology for Primary Care Professional Issues 7 petals of the Prezi Flower of PMHS
Define the problem
Mental Health Promotion/Prevention
Assessment/Tools
Treatment
Nonpharmacological
Psychopharmacology
Treatment Plan
Professional Issues
Summary Validate: example You can't always tell by looking ASQ birth to 60 months
parent administered, reliability KySS Assessment Questions
Older Infants and Toddlers
Preschool
School age and Teens PEDS Pediatric Symptom Checklist (PSC)
4-18
New!!! NOT 36, but 17 eliciting and attending to the parents’ concerns
documenting and maintaining a developmental history
making accurate observations of the child,
identifying the risk and protective factors
maintaining an accurate record and documentation Surveillance Follow up Clinical Interview: Age Specific Tools do NOT make a diagnosis, so... Early childhood:
perinatal, planned pregnancy, maternal health, substances, labor
Quality of parent-child interaction
toileting, feeding, sleeping,
emerging personality (shy, restless, friendly)
abuse Middle Childhood:
school problems: behavior, LD
gender concerns
punishment
friendships
bullying Late childhood:
peers/family
concerns about independence
substance use/abuse
sexual orientation/concerns/activity
body image/ self-esteem: (weight) (purge/binge)
approach/avoidance, aggression
school problems
legal concerns
who is in the “family”
assessment questionnaires
future plans GOALS:
Understand the concern: listen, engage
Rule out an emergency
Make a working diagnosis
Develop a plan Exposure to:
violence
abuse
neglect
substance abuse even in utero (ex: cocaine: agitated baseline and don’t respond well to usual)
Likes, dislikes
School issues (Grade level, classroom, special ed).
Strengths Always consider: Check your assumptions at the door "Strike" Mental Status Exam Not static: what you see at the visit http://www.livesinthebalance.org/what-is-collaborative-problem-solving-cps •1: Why is this kid acting this way??
•"How come what works for other kids isn't working for this one??
•"What can I do instead??
•2: Plan A: continue with unilateral action
B: collaborate, kids do well if they can
C: drop the whole problem http://www.motivationalinterview.org/ Client centered collaborative conversation about change that allows for self- determination.
Goal oriented to create ambivalence by open ended questions, elaborating, affirming, reflecting and summarizing OARS
Nonconfrontational engaging, guiding and evoking
4 Principles
Express empathy (Engage)
Develop discrepancy (Guide)
Roll with Resistance.
Support self-efficacy Behavior Modification: Behavior modification is the use of empirically demonstrated behavior change techniques to increase or decrease the frequency of behaviors,
Rewards: Stickers on the calendar
Punishments: Natural consequence http://www.innerhealthstudio.com/relaxation-therapy.html Used to quiet the mind to help focus, not emptying the mind
Mindfulness Deep breathing
Shake it out
Shut it out
Conscious muscle relaxation
Yawn and stretch http://www.sfbta.org/ There’s nothing wrong with you that what’s right with you can’t fix
It is about being brief and focusing on solutions, rather than on problems. http://www.socialskillstrainingproject.com/ CBT based program to teach social skills to those with social deficits (autism, ODD, ADHD) Refer to School or Educational Psychologist
IEP or 504
Collaborate Family therapy is based on the belief that the family is a unique social system with its own structure and patterns of communication.
REFER " Music therapy also provides avenues for communication that can be helpful to those who find it difficult to express themselves in words." http://www.musictherapy.org/about/quotes/ http://sss.usf.edu/504tutorial/Module6/Comparison.html IEP school is funded to develop indiviaual plan
adequate and apporpriate education plan 504 is a cival rights law that protects individual rights General Principals: Think like a psychiatrist No magic bullets – only treat if you NEED to
Treat symptoms not the disease: “what is causing this?”
Benefits vs side effects
Measure effects with checklists
Start low and go slow
One at a time
Taper on, taper off
Time for effect may differ
Medication categories are simplistic
FDA “labels” meds but does not regulate prescribing practice
Meds do not just go to the brain (side effects)
Pharmacokinetics and Pharmacodynamics in 2 minutes
When changing meds
oCorrect diagnosis
oCompliant
oTherapeutic dosage and adequate trial 7 Sins of Psycopharmacology Not doing a comprehensive evaluation
Not correctly handling dosing (too little, too much, too fast, wrong time, not monitoring)
No allowing suitable duration before changing medications or adding (polypharmacy)
Not understanding a patients psychological background
Thinking medications are the answer to all problems
Lack of communication
Not keeping up with the field Teenage 10 No drinking, no smoking, no drugs
Don't talk to strangers even on the internet
No sexting: the "media" is not your friend
Your parents need to know where you are
You are not in charge and sometimes life is not fair
Don't fight too much with your siblings
If you smell bad no one wants to be with you
You are responsible for who you are and who you become, Moderation
All feelings are legitimate and are OK.
We all make mistakes, but do not lie to your parents or it just makes it worse All I Really Need To Know I Learned In Kindergarten
by Robert Fulghum

Most of what I really need
To know about how to live
And what to do and how to be
I learned in kindergarten.
Wisdom was not at the top
Of the graduate school mountain,
But there in the sandpile at Sunday school.

These are the things I learned:

Share everything.
Play fair.
Don't hit people.
Put things back where you found them.
Clean up your own mess.
Don't take things that aren't yours.
Say you're sorry when you hurt somebody.
Wash your hands before you eat.
Flush.
Warm cookies and cold milk are good for you.
Live a balanced life -
Learn some and think some
And draw and paint and sing and dance
And play and work everyday some.
Take a nap every afternoon.
When you go out into the world,
Watch out for traffic,
Hold hands and stick together.
Be aware of wonder. Don't ask if you can't handle
the answer The greatest healing therapy is love and friendship.
Herbert Humphrey Autistic Spectrum Disorder Enuresis/Encopresis Mood Disorders Obcessive Compulisve Disorder Post Tramatic Stress Disorder Behavior Disorders Relationship Disoders Reactive Attachment Disorder Substance Abuse Sleep Eating Tics Personality Disorders Psychotic Normative anxiety and fears in childhood and adolescence

Age Development Conditioned Periods of Fear and Anxiety Psychopathological Relevant Symptoms Corresponding DSM-IV Anxiety Disorder
Early infancy Within first weeks Fear of loss, eg, physical contact to caregivers – –
0–6 months Salient sensoric stimuli – –

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Late infancy 6–8 months Shyness/anxiety with stranger Separation anxiety disorder

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Toddlerhood 12–18 months Separation anxiety Sleep disturbances, nocturnal panic attacks, oppositional deviant behavior Separation anxiety disorder, panic attacks
2–3 years Fears of thunder and lightening, fire, water, darkness, nightmares Crying, clinging, withdrawal, freezing, eloping seek for security and physical contact, avoidance of salient stimuli (eg, turning the light on), pavor nocturnus, enuresis Specific phobias (environmental subtype), panic disorder
Fears of animals – Specific phobias (animal subtype)

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Early childhood 4–5 years Fear of death or dead people – Generalized anxiety disorder, panic attacks

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Primary/elementary school age 5–7 years Fear of specific objects (animals, monsters, ghosts) – Specific phobias
Fear of germs or getting a serious illness – Obsessive compulsive disorder
Fear of natural disasters, fear of traumatic events (eg, getting burned, being hit by a car or truck) – Specific phobias (environmental subtype), acute stress disorder, posttraumatic stress disorder, generalized anxiety disorder
School anxiety, performance anxiety Withdrawal, timidity, extreme shyness to unfamiliar people and peers, feelings of shame Social anxiety disorder

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Adolescence 12–18 years Rejection from peers Fear of negative evaluation Social anxiety disorder Guns Sex Media Nature deficit disorder Temperament, Age and
Self Regulation Psychological resilience is an individual's tendency to cope with stress and adversity Good self esteem and social support
The ability to cope with stress effectively and in a healthy manner
Having good problem-solving skills
Seeking help
Holding the belief that there is something one can do to manage your feelings and cope
Having social support
Being connected with others, such as family or friends
Self-disclosure of the trauma to loved ones
Spirituality
Having an identity as a survivor as opposed to a victim
Helping others
Finding positive meaning in the trauma Autism Paranoia Antisocial Death New Job Moving Mental Health Diagnosis Home School Social LGBTQIA Knowing is not enough; we must apply. Willing is not enough; we must do.
Goethe Active Listening
“I” statements
Conflict resolution Appearance: Posture, poise, grooming, tattoos, piercings, hair color, makeup, clothing, dirty, malnourished, dental erosion, Attitude toward clinician or rapport: friendly, guarded, suspicious Affect/mood: mood is basic emotion or world view while (pts words) affect is current emotion (is it congruent with their own perception) euthymic, dysphoric, angry, anxious, apathetic, exaggerated, blunted, Activity Level/Behavior: Eye contact, gait, tremor, no movement, hyperactive, impulsivity Speech: intonation, quality and rate, slurred, rapid, mumbling Thought process : quality, tempo, form- flight of ideas, loose associations, tangential.
Content : delusions: false unshakable ideas (grandiosity, paranoia), overvalued ideas (hypochondriasis, anorexia) obsessions (uncontrolled thoughts), phobias (unfounded dread of something), preoccupations (see suicide) Perceptions: hallucinations-sensory perception in absence of external stimulus and illusions-false perception from external stimulus, fantasy, depersonalization (consider temporal lobe epilepsy) voices in your head Suicidal or Homicidal behavior/ideation: If they are preoccupied with this, this is a big risk factor Cognitive function: alert, oriented, attention, memory Insight/Judgment: Insight is understanding of illness while judgment has to do with understanding outcome of behavior (consequence of action). Is it age appropriate? Any observation about parent-child interaction Objective Physical Exam EMR : use a check list 1: General Mental Health Screening Tools In Primary Care
HEADSS
The Pediatric Symptoms Checklist (PSC)
The Child Behavior Checklist (CBCL)
Parents Evaluations of Developmental Status (PEDS)
The Guidelines for Adolescent Preventive Services (GAPS)
KySS Questionnaires Depression
CES-DC
Children’s Depression Inventory
PHQ-9
SMFQ
KADS
Two question survey Anxiety
State-Trait Anxiety Inventory for Children
SCARED Substance use
CAGE
CRAFFT Suicide
Columbia Suicide Severity Rating Scale Now what? (DECSION POINT) Consider severity, persistence and resistance to change
Consider needs of child/family: do they need treatment?
1: Triage
2: Intervene
3: Consult
4: Refer: ALWAYS refer a child who is a danger to himself or others So what? Treatment of symptoms
Stigma
Ethics
Culture  Antipsychotics (neuroleptics)
 Mood Stabilizers
 Antidepressants
 Anxiolytics (antianxiety
 Sedatives
 Hypnotics
 Psychostimulants
 Antihistamines, antimuscarinics, dopamine agonists Know Lithium 100-91 Superior functioning in all areas (at home, at school and with peers);
90-81 Good functioning in all areas; secure in family, school, and with peers; there may be transient difficulties
80-71 No more than slight impairments in functioning at home, at school, or with peers
70-61 Some difficulty in a single area but generally functioning well
60-51 Variable functioning with sporadic difficulties or symptoms in several but not all
social areas
50-41 Moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area
40-31 Major impairment of functioning in several areas and unable to function in one of these areas
30-21 Unable to function in almost all areas
20-11 Needs considerable supervision to prevent hurting others or self
10-1 Needs constant supervision Engagement is the key! Parent Interview/Children’s Interview
Parent Questions:
“Do you have any concerns or worry about your child’s mental/emotional health or his/his behaviors or has there been a change in how he/she usually is a home or at school?” Yes?
What
Where
When
Who
How
Why Assessment of Concern
Impairment (0-10)
Distress (to whom)
Severity of symptoms
Frequency
Intensity
Duration 1: Subjective:
CC, HPI
Past psychiatric history
Substance Abuse
Past History: social/developmental: (The younger the child, the less verbal skills they have. The less insight they have, and the more atypical their symptoms may appear.)
Family history Working diagnosis:

o Remember children do not present like adults
o The younger the child, the more behavioral responses to stressors and the harder to sort out
o Symptom based treatment
o We can’t cure most of these, but we can manage the symptoms *Though the FDA has not officially approved fluoxetine and sertraline for treating anxiety disorders such as social phobia, separation anxiety, or generalized anxiety disorders, there is convincing evidence for using these medications for these disorders.
** Sertraline has some evidence supporting its use in MDD, but not enough evidence to support an FDA indication Antidepressants Confidentiality EMR Secondary Certification AKATHISIA – Intense feeling of physical restlessness; inability to sit still or lie quietly.
It may or may not be visible to others.
Can be extremely uncomfortable.
Treatment is usually to decrease or DC medication.

DYSTONIA – 1) Sustained muscular contraction or spasm that may produce abnormal posture,
rigidity of head, neck or trunk.
2) Tends to occur during the first few days of treatment or increase of
antipsychotic drug.
3) Treatment with Cogentin or Benadryl IM is usually given providing relief in
minutes.

EPS – Abnormal involuntary movements of the body;
Usually occurs early in the course of treatment;
Symptoms go away when drug is discontinued;

TARDIVE DYSKINESIA – Involuntary, purposeless movements of the mouth, tongue, face, trunk or extremities that appear 3 or more months following the use of an antipsychotic drug. (The longer you are on antipsychotics the greater the chances of developing TD.)
-May not be reversible even if drug is discontinued.
-Prevention and early diagnosis is essential.
-MD/Nurse should do assessment for abnormal movements at least
every 6 months. HALF-LIFE OF A DRUG – A calculated and measured time that it takes for half, or 50%, of the concentration of a drug to clear from your body after it has been absorbed. E.g. A medicine has a half-life of 12 hours, so the times to give the medicine should beat least every 12 hours so that there is an overlap of the amount of medicine in the body. Anti-depressants Sexual Development Not just the physical changes, but developing the self. With small children the focus is on the parent SOAP SPECIFIC SCREENING TOOLS Vanderbilt
ADHD
ODD
CD Still subjective data Culture Bias Judgement Know your own limits Assessment Plan Integration of psychiatric assessment in with physical exam with focus on
prevention
early detection
early treatment It's not a choice.
It's not a "lifestyle"-- it's who they are.
It is not a "sexual preference"--it is a sexual identity.
Family of Choice--Respect who they consider to be their family.
Don't out someone-- you may endanger their safety, shelter of employement. Teach coping skills. The Transgender Child by My Princess Son Straight or gay Abstinence Who am I? Social, Emotional, Cognitive Cuts, Bruises, Tanner Staging Thryoid Growth Body Modification Ethnic differences sexual interst out of proportion with other interests
interest in sex that is compulsive to the exclusion of other age appropriate activities
sexual knowledge greater than their peers
approaching strangers rather than peers to engage in sexual activity
attempting to bribe or force other children to engage in sex acts
other children complain about their sexual behavior
sexual discussion leads to anxiety, fear or anger Teach parents normal sexual behavior
and red flag behavior In the US the average age of first masterbation for boys is 12.26 years. Masterbation in toddlers is usually not sexual but rather self exploration. Occasional masterbation is nomal behavior in toddlers and preschoolers. ADHD
Conners
SNAP
Vanderbilt Eating Disorder
SKOFF
EAT-26 Aggression
MOAS
YMRS OCD
CY-BOCS Muscle Movement
AIMS Bipolar
FIND Bullying can take many forms but it usually includes the following types of behavior:

• Physical – hitting, kicking, pinching, punching, scratching, spitting or any other form of physical attack. Damage to or taking someone else’s belongings may also constitute as physical bullying.

• Verbal – name calling, insulting, making racist, sexist or homophobic jokes, remarks or teasing, using sexually suggestive or abusive language, offensive remarks

• Indirect – spreading nasty stories about someone, exclusion from social groups, being made the subject of malicious rumours, sending abusive mail, and email and text messages (cyber bullying).

• Cyber Bullying - any type of bullying that is carried out by electronic medium. There are 7 types including: Text message bullying
Picture/video clip bullying via mobile phone cameras
Phone call bullying via mobile phones
E-mail bullying
Chat-room bullying
Bullying through instant messaging (IM)
Bullying via websites In a 2007 study, 86% of LGBT students said that they had experienced harassment at school during the previous year. ( A new review of studies from 13 countries found signs of an apparent connection between bullying, being bullied, and suicide. (Yale School of Medicine) It is estimated that 160,000 children miss school every day due to fear of attack or intimidation by other students. Source: National Education Association. 1 in 7 Students in Grades K-12 is either a bully or a victim of bullying 56% of students have personally witnessed some type of bullying at school The bully, the bullied and the by-stander. Prevention: http://brightfutures.aap.org/pdfs/preventive%20services%20pdfs/anticipatory%20guidance.pdf Abstinence Sibling Rivalry Toilet Training Do you have concerns about how your child....
1: Child's learning, development and behavior?
2: Talks and makes speech sounds?
3: Understands what you say?
4: Uses his hands and fingers to do things?
5: Uses his or her arms and legs?
6: Behavior?
7: Gets along with others?
8: Is leaning to do things for himself?
9: Is learning preschool or school skills?
10: List any other concerns. power point Consent
and
Assent Putting it all together Due Out May 2013 ? The Blank Page Common Sense Parenting (Boys Town)
Effective Praise
Show approval
Describe the positive behavior
Give a reason
Give a reward (optional)
Preventive Teaching
Describe the positive behavior
Give a reason
Example: When you
Practice
Corrective Teaching
Stop the (describe the negative behavior)
Give the negative consequence
Describe the positive behavior
Practice
Example: You did (x) so you lost (y). I want you to (z). Show Me how you do this.
Teaching Self Control
1: Calm Down:
2: Follow up teaching: Thoughts-Feeling –Behavior
Short term: targets certain behavior
ABC: antecedent, behavior, consequence “Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy.”
-Paracelsus Power Point Habits D.A. R. E Internalizing and Externalizing
symptoms Risk Factors 5 half-lifes to clear Peak Continuing Education Lab studies at baseline, periodically during titration, and every 6 months
CBC (complete blood count)
LFT (liver function tests)
TSH (thyroid)
Fasting blood glucose, Hb A1c
Fasting lipids: cholesterol, triglycerides
Trough med level
Urinalysis, urine tox screen
Prolactin The Opposite of Depression is…. Mood Stabilizers Antipsychotic Medications Other Medications to Treat Attention Deficit Hyperactivity Disorder Stimulant Medications There are times when anti-histamines such as hydroxyzine or diphenhydramine are prescribed to relief anxiety. While these medications may be effective in the short run sedating a patient and calming the “crisis” they are generally not good medications for long-term use in the treatment of ongoing anxiety symptoms….or sleep!! Antihistamines
FDA approval for children
Xanax : No
Ativan: Yes Benzo Benzodiazepines as a class are excellent anti anxiety medications. They can be very effective in the treatment of anxiety related problems in the developmentally disabled. These medications include but are not necessarily limited to diazepam, alprazolam, lorazepam, chlordiazepoxide, clonazepam, chlorazepate, oxazepam, flurazepam, and temazepam. Problems arise in these medications most often relate to somulence, difficulty with short term memory, development of tolerance requiring increasingly higher doses, and also with the half life and active metabolites of some of the medications in this class leading to unwanted prolonged effects. Benzodiazepines

Relief of physical symptoms

Do NOT use with a history of liver disease Duloxetine (Cymbalta)
Venlafaxine (Effexor)

Desvenlafaxine (Pristiq)

Duloxetine (Cymbalta) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Option for Depression + ADHD

Should not be used with a history of eating disorder or seizures

Bupropion is a treatment for smoking Buproprion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, *Aplenzin)
SSRIs preferred in child/teen depression

Lexapro Depression
Prozac Depression and OCD
Zoloft OCD
Fluvoxamine OCD SSRI Summary
FDA approved MDD 12 to 17 yo
Tends to increase the anxiety in young children
Tends to be stimulating

Don’t need much
10 mg. is about the same as 40 mg. Celexa Escitalopram (Lexapro) Half-life 35 hrs
5-10 mg
Well tolerated Citalopram (Celexa)
FDA approved OCD 8 to 17yo


Generic fluvoxamine is available Fluvoxamine (Luvox) FDA approved OCD 6 to 17 yo
Half-life 21 hr
(Not a true 24 hr drug -18 hrs in rapid metabolizer)
Give at night due to sedation
Weight gain
Best efficacy especially for social phobia
Scored tabs: 12.5-25mg and titrate up
May have rebound increase in anxiety: either double it or stop it Sertraline (Zoloft) 1st line for depression No studies in childhood anxiety
FDA approved MDD 8 to 18 yo
FDA approved OCD 7 to 17 yo
Long-acting so useful in noncompliance
Stimulating
5-10 mg q am
Titrate at 4 weeks: double if no effect, let it ride if some effect Fluoxetine (Prozac) SSRI withdrawal
Paroxetine probably the worst
Does not happen with fluoxetine
Characterized by flu-like syndrome
Fever, shaking, fatigue, sweating, nausea, diarrhea
Usually starts within 24-36 hours and resolves within 2-3 days, although may last longer
Treat by restarting medication and slowing down the taper SSRI’s There is no efficacy difference between any of the SSRI’s
All are potentially equally beneficial for depression and anxiety
Individuals have different responses but there are not group efficacy differences
The anxiety disorders that can be treated with an SSRI include GAD, Separation Anxiety, Social Anxiety Disorder, OCD, Panic Disorder, PTSD. Elective Mutism SSRI’s

Preferred medications for treating child and adolescent depression (First line)

First line treatment for GAD, OCD, PTSD, and panic disorder Selective Serotonin Reuptake Inhibitors (SSRIs)
Amitriptyline (Elavil)

Imipramine (Tofranil)

Clomipramine (Anafranil) Tricyclic Antidepressants
Tricyclic Antidepressants

Selective Serotonin Reuptake Inhibitors

Novel Antidepressant Classes of Antidepressant Divalproex Sodium (Depakote)
Carbamazepine (Tegretol)

Oxcarbazepine (Trileptal)
Gabapentin (Neurontin)
Topiramate (Topamax) Anticonvulsants/AED Effective in treating manic symptoms

Used in combination with other medications to treat resistant depression

Protects against suicidal behavior

“Lost” medication Lithium (Eskalith, Lithobid) A wide variety of uses
Bipolar Disorder
Augmentation in depression
Explosive behavior
Mood irritability
Conduct disorder Mood Stabilizers New (Antiepilepsy Meds)
Oxcarbamazepine
Gabapentin
Lamotrogine
Topiramate
Others Old
Lithium
Depakote
Carbamazepine Mood Stabilizers All antipsychotics may cause an increase in cholesterol, triglycerides, and risk for diabetes
Draw baseline labs and record weight
HgbA1c, fasting lipid panel
Check labs at least yearly, perhaps sooner if significant weight gain Metabolic Syndrome

FDA approved for the treatment of:

Schizophrenia 12 to 17 years old *Paliperidone (Invega)
FDA approved for the treatment of:

Bipolar Disorder 13 to 17 years old

Schizophrenia 13 to 17 years old Olanzapine (Zyprexa) FDA approved for the treatment of:

Bipolar Disorder 10 to 17 years old

Schizophrenia 13 to 17 years old

Seroquel XR not approved < 18 years old Quetiapine (Seroquel, Seroquel XR) FDA approved for the treatment of:

Autism (Irritability) 6 to 17 years old

Bipolar Disorder 10 to 17 years old

Schizophrenia 13 to 17 years old Aripiprazole (Abilify)
Clozapine (Clozaril)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
*Paliperidone (Invega)
*Iloperidone (Fanapt)
*Asenapine (Saphris)
*Lurasidone (Latuda) Atypical/Novel/2nd Generation Haloperidol (Haldol)

Pimozide (Orap)

Chlorpromazine (Thorazine)

Thioridazine (Mellaril) Typical/Conventional/1st Generation Psychotic disorders

Bipolar disorder

Irritability associated with autism

Severely agitated/violent behaviors Antipsychotics Clonidine or Tenex
Need to be given everyday, multiple doses each day
Take weeks to work
Main side effect is sedation
Wellbutrin
Given every day
Risk of seizures
Needs to be given 24/7
Takes weeks to work Other Medications for Attention, Hyperactivity Atomoxetine (Strattera)
Non-stimulant, dose by weight
Needs to be given everyday and takes weeks to work
Can be refilled over the phone
May be better for persons with anxiety
Primary side effects
Sedation, nausea and vomiting, weight loss, Other Medications for Attention, Hyperactivity Atomoxetine (Strattera)
Guanfacine (Tenex, *Intuniv)

Bupropion (Wellbutrin)
Clonidine (Catapres, *Kapvay)
Imipramine (Tofranil) Nonstimulant Medications Responders Most children adolescents are under dosed
OK to increase dose rapidly
Short half-lives
There is no efficacy difference between various stimulants Common Issues With Stimulants Appetite loss (expected)
Insomnia
Tics
Headache
Nausea
Rebound irritability
Growth suppression Common Stimulant Side Effects

Dexedrine and Dextrostat

Adderall and Adderall XR

Lisdexamfetamine dimesylate (Vyvanse) Dextroamphetamine Adderall XR Metadate CD Medication Comparisons: Dexedrine Products Medication Comparison: Methylphenidate Products Stimulants
Other medications to treat ADHD
Antipsychotic medications
Mood Stabilizers
Antidepressants
Benzodiazepines Psychotropic Medications Pharmacokinetics: What the body does to a drug
Pharmacodynamics: The biochemical and physiologic effects of drugs and their mechanism of action The full range of psychiatric medications are prescribed for children and teenagers.

Several medications are used off-label.

Medication is itself a therapeutic issue

The categories of medications are not exclusive Medication Priniciples Weekly or biweekly checkups when starting or increasing meds
Monthly checkups once stable
Height and weight checks
PMD: Annual checkups, blood pressure, EKG or EEG if needed
Dental and eye checkups General Principles of Follow Up

Not recommended due to side effects (increased diastolic blood pressure, increased pulse, dermatological) Venlafaxine (Effexor, Effexor XR) Complex mechanism of action involving multiple neurotransmitter systems

Rapid onset of action in adults

Sedating so prescribed at bedtime

Good choice for “anxious” depression Mirtazapine (Remeron)
Bupropion (Wellbutrin, *Aplenzin)
Mirtazapine (Remeron)
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Trazodone (*Oleptro) Novel Antidepressants Restlessness
A common side effect and may show itself as aggression or irritability
Take weeks to work
Emergence of suicidal thinking
Fact or fiction
Assessing suicidality
Sexual dysfunction SSRI Issues in School Can be equally efficacious, so select by side effect profile
Side effect differences
Weight gain, sedation, activation
Knowledge of the parent about a particular drug
Past history
Cost Choosing an SSRI All SSRI’s have the same general potential side effects
Restlessness, akathesia
Insomnia or fatigue
Appetite changes, increased or decreased
GI upset
Headaches
Sexual dysfunction SSRI’s Pooled data 4400 patients (2003):
The average risk of suicidality was 4% on drugs
placebo risk of 2%.
NO SUICDES occurred in the trials.
2004-2006 decrease in drugs but increase in suicidality Black Box Fluoxetine (Prozac)
Parosetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram (Lexapro)
*Vilazodone (Vibryd) Selective Serotonin Reuptake Inhibitors Depression Not recommended
OCD Clomipramine
ADHD Imipramine
School Phobia Mixed Results
Bedwetting Amitriptyline/Imipramine
Night Terrors Imipramine Tricyclics Antidepressant
Medications The literature suggests that the relative risks for diabetes, weight gain, and elevated lipids is as follows:
Clozapine = Olanzapine > Risperidone = Quetiapine > Aripiprazole = Ziprasidone
The additional use of Depakote or lithium may increase the risks Weight Gain for Each Drug Gold standard for treating schizophrenia

Two previous therapeutic trials

Clozaril National Registry

Labs each week X 6 months Clozapine (Clozaril) FDA approved for the treatment of:

Autism (Irritability) 5 to 16 years old

Bipolar Disorder 10 to 17 years old

Schizophrenia 13 to 17 years old Risperidone (Risperdal) New (Atypical)
More expensive
Some may have less weight gain
Some may have less prolactin change
May cause less tardive
More research in kids and adolescents Old (Typical)
Less expensive
Weight gain
Elevated prolactin
Tardive dyskinesia
Few trials with kids and adolescents Differences Between Old and New Antipsychotics The New
Clozapine
Risperidone
Paliperidone
Olanzapine
Ziprasidone
Aripiprazole
Quetiapine The Old
Haldoperidol
Thioridazine
Thiothixene
Proclorpromazine
Perphenazine
Fluphenazine Antipsychotics: Old or New?
Typical vs Atypical Decreases b/p in adults
Disruptive aggressive (comorbid odd)
Sedating: resolves over time
4 weeks to reach effect
1 mg in pm x 1 week: increase by 1mg /week Intunive Kapvay Alpha Students will not eat lunch
Appetite suppression is expected
What time do the meds wear off?
They don’t work if you don’t take them
Bothersome tics
Are there other reasons for attention problems?
Learning issues, anxiety Stimulant Issues in School Extended release suspension
6-12 yo

Efficacy 45 min-12 hours Quillivant XR Daytrana SODAS™ is a trademark of Elan Corporation, Plc Ritalin® LA: Extended-release Delivery via SODAS™ Technology
Mehtylphenidate
Immediate release or extended release
Amphetamine
Immediate release or extended release

Only work 70-80% of the time Stimulants Target Symptoms (Behaviors) Psychotropic Medications Effective12/1/2011 Prescribing psychoactive medication for children is controversial. However, at times it is necessary to assist children in controlling problems with mood, behavior, anxiety, aggression and other difficulties. As a clinician I have to be convinced that to not medicate would be more harmful than to proceed with medication treatment. Basic Psychopharmacology
for Children and Adolescents Children
Imaginary friends
Events controlled by thoughts/feelings
Teens
Moody and irritable
Oppositional and antisocial
Unique insights into the nature of reality Normal Behavior Principles of medication treatment
Add to your understanding of why medications are prescribed for children and teenagers.
Distinguish between antidepressants, stimulants, antipsychotics and anticonvulsants.
Recognize brand and generic names in each class of psychiatric medications. Goals/Objectives Lamotrogine
Rash Topiramate
“Dopamax”
Sedation Mood Stabilizer Depakote
Weight gain
Polycystic ovaries
Osteoporosis Lithium
Weight gain
Acne
Increased thirst and urination
May effect thyroid and kidneys
Cognitive impact Side Effects MULTIPLE….Can’t cover them all
Commonly used in children and adolescents
St John’s Wart
Melatonin
Secretin
Kava
Valarian CAM It is the delivery system

Onset, peak, duration Selecting Meythelphenidate Lab studies at baseline, periodically during titration, and every 6 months
CBC (complete blood count)
LFT (liver function tests)
TSH (thyroid)
Fasting blood glucose, Hb A1c
Fasting lipids: cholesterol, triglycerides
Trough med level
Urinalysis, urine tox screen
Prolactin
Amitriptyline (Elavil)

Imipramine (Tofranil)

Clomipramine (Anafranil) Tricyclic Antidepressants The Opposite of Depression is…. Mood Stabilizers Most children adolescents are under dosed

OK to increase dose rapidly

Short half-lives

There is no efficacy difference between various stimulants Common Issues With Stimulants Stimulant Medications Pharmacokinetics: What the body does to a drug
Pharmacodynamics: The biochemical and physiologic effects of drugs and their mechanism of action Sina Linman, ARNP, CPNP, PMHS
UNMC An Overview of Psychiatric Medications for Children and Adolescents Children/teens can and do have serious mental illness including Major Depression, Bipolar Disorder, and Schizophrenia
The full range of psychiatric medications are prescribed to those < 18 years of age
Medication is only one part of treatment
Many new medications are actually “old wine in new bottles” Conclusions There are times when anti-histamines such as hydroxyzine or diphenhydramine are prescribed to relief anxiety. While these medications may be effective in the short run sedating a patient and calming the “crisis” they are generally not good medications for long-term use in the treatment of ongoing anxiety symptoms….or sleep!! Antihistamines Benzodiazepines as a class are excellent anti anxiety medications. They can be very effective in the treatment of anxiety related problems in the developmentally disabled. These medications include but are not necessarily limited to diazepam, alprazolam, lorazepam, chlordiazepoxide, clonazepam, chlorazepate, oxazepam, flurazepam, and temazepam. Problems arise in these medications most often relate to somulence, difficulty with short term memory, development of tolerance requiring increasingly higher doses, and also with the half life and active metabolites of some of the medications in this class leading to unwanted prolonged effects. Benzodiazepines

Relief of physical symptoms

Do NOT use with a history of liver disease Duloxetine (Cymbalta)
Venlafaxine (Effexor)

Desvenlafaxine (Pristiq)

Duloxetine (Cymbalta) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Complex mechanism of action involving multiple neurotransmitter systems

Rapid onset of action in adults

Sedating so prescribed at bedtime

Good choice for “anxious” depression Mirtazapine (Remeron)
Option for Depression + ADHD

Should not be used with a history of eating disorder or seizures

Bupropion is a treatment for smoking Buproprion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, *Aplenzin)
SSRIs preferred in child/teen depression

Lexapro Depression
Prozac Depression and OCD
Zoloft OCD
Fluvoxamine OCD SSRI Summary Half-life 35 hrs
5-10 mg
Well tolerated Citalopram (Celexa) FDA approved OCD 6 to 17 yo
Half-life 21 hr
(Not a true 24 hr drug -18 hrs in rapid metabolizer)
Give at night due to sedation
Weight gain
Best efficacy especially for social phobia
Scored tabs: 12.5-25mg and titrate up
May have rebound increase in anxiety: either double it or stop it Sertraline (Zoloft) 1st line for depression No studies in childhood anxiety
FDA approved MDD 8 to 18 yo
FDA approved OCD 7 to 17 yo
Long-acting so useful in noncompliance
Stimulating
5-10 mg q am

Titrate at 4 weeks: double if no effect, let it ride if some effect Fluoxetine (Prozac) Can be equally efficacious, so select by side effect profile
Side effect differences
Weight gain, sedation, activation
Knowledge of the parent about a particular drug
Past history
Cost Choosing an SSRI SSRI withdrawal
Paroxetine probably the worst
Does not happen with fluoxetine

Characterized by flu-like syndrome
Fever, shaking, fatigue, sweating, nausea, diarrhea
Usually starts within 24-36 hours and resolves within 2-3 days, although may last longer

Treat by restarting medication and slowing down the taper SSRI’s All SSRI’s have the same general potential side effects
Restlessness, akathesia
Insomnia or fatigue
Appetite changes, increased or decreased
GI upset
Headaches
Sexual dysfunction SSRI’s There is no efficacy difference between any of the SSRI’s
All are potentially equally beneficial for depression and anxiety
Individuals have different responses but there are not group efficacy differences

The anxiety disorders that can be treated with an SSRI include:
GAD, Separation Anxiety, Social Anxiety Disorder, OCD, Panic Disorder, PTSD. Elective Mutism SSRI’s Fluoxetine (Prozac)
Parosetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram (Lexapro)
*Vilazodone (Vibryd) Selective Serotonin Reuptake Inhibitors

Preferred medications for treating child and adolescent depression (First line)

First line treatment for GAD, OCD, PTSD, and panic disorder Selective Serotonin Reuptake Inhibitors (SSRIs)
Tricyclic Antidepressants

Selective Serotonin Reuptake Inhibitors

Novel Antidepressant Classes of Antidepressant Divalproex Sodium (Depakote)
Carbamazepine (Tegretol)

Oxcarbazepine (Trileptal)
Gabapentin (Neurontin)
Topiramate (Topamax) Anticonvulsants/AED Effective in treating manic symptoms

Used in combination with other medications to treat resistant depression

Protects against suicidal behavior

“Lost” medication Lithium (Eskalith, Lithobid) The literature suggests that the relative risks for diabetes, weight gain, and elevated lipids is as follows:

Clozapine = Olanzapine > Risperidone = Quetiapine > Aripiprazole = Ziprasidone

The additional use of Depakote or lithium may increase the risks Weight Gain for
Each Drug Gold standard for treating schizophrenia

Two previous therapeutic trials

Clozaril National Registry

Labs each week X 6 months Clozapine (Clozaril)
FDA approved for the treatment of:

Bipolar Disorder 13 to 17 years old

Schizophrenia 13 to 17 years old Olanzapine (Zyprexa) FDA approved for the treatment of:

Autism (Irritability) 5 to 16 years old

Bipolar Disorder 10 to 17 years old

Schizophrenia 13 to 17 years old Risperidone (Risperdal) FDA approved for the treatment of:

Bipolar Disorder 10 to 17 years old

Schizophrenia 13 to 17 years old

Seroquel XR not approved < 18 years old Quetiapine (Seroquel, Seroquel XR) FDA approved for the treatment of:

Autism (Irritability) 6 to 17 years old

Bipolar Disorder 10 to 17 years old

Schizophrenia 13 to 17 years old Aripiprazole (Abilify) Haloperidol (Haldol)

Pimozide (Orap)

Chlorpromazine (Thorazine)

Thioridazine (Mellaril) Typical/Conventional/1st Generation Antipsychotic Medications Clonidine or Tenex
Need to be given everyday, multiple doses each day
Take weeks to work
Main side effect is sedation
Wellbutrin
Given every day
Risk of seizures
Needs to be given 24/7
Takes weeks to work Other Medications for Attention, Hyperactivity Atomoxetine (Strattera)
Guanfacine (Tenex, *Intuniv)

Bupropion (Wellbutrin)
Clonidine (Catapres, *Kapvay)
Imipramine (Tofranil) Nonstimulant Medications Other Medications to Treat Attention Deficit Hyperactivity Disorder Responders Appetite loss (expected)
Insomnia
Tics
Headache
Nausea
Rebound irritability
Growth suppression Common Stimulant Side Effects

Dexedrine and Dextrostat

Adderall and Adderall XR

Lisdexamfetamine dimesylate (Vyvanse) Dextroamphetamine Adderall XR Metadate CD Medication Comparisons: Dexedrine Products Medication Comparison: Methylphenidate Products The full range of psychiatric medications are prescribed for children and teenagers.

Several medications are used off-label.

Medication is itself a therapeutic issue

The categories of medications are not exclusive Medication Priniciples Weekly or biweekly checkups when starting or increasing meds
Monthly checkups once stable
Height and weight checks
PMD: Annual checkups, blood pressure, EKG or EEG if needed
Dental and eye checkups General Principles of Follow Up
FDA approval for children
Xanax : No
Ativan: Yes Benzo

Not recommended due to side effects (increased diastolic blood pressure, increased pulse, dermatological) Venlafaxine (Effexor, Effexor XR)
Bupropion (Wellbutrin, *Aplenzin)
Mirtazapine (Remeron)
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Trazodone (*Oleptro) Novel Antidepressants Restlessness
A common side effect and may show itself as aggression or irritability
Take weeks to work
Emergence of suicidal thinking
Fact or fiction
Assessing suicidality
Sexual dysfunction SSRI Issues in School
FDA approved MDD 12 to 17 yo
Tends to increase the anxiety in young children
Tends to be stimulating

Don’t need much
10 mg. is about the same as 40 mg. Celexa Escitalopram (Lexapro)
FDA approved OCD 8 to 17yo


Generic fluvoxamine is available Fluvoxamine (Luvox) Depression Not recommended
OCD Clomipramine
ADHD Imipramine
School Phobia Mixed Results
Bedwetting Amitriptyline/Imipramine
Night Terrors Imipramine Tricyclics Antidepressant
Medications A wide variety of uses
Bipolar Disorder
Augmentation in depression
Explosive behavior
Mood irritability
Conduct disorder Mood Stabilizers New (Antiepilepsy Meds)
Oxcarbamazepine
Gabapentin
Lamotrogine
Topiramate
Others Old
Lithium
Depakote
Carbamazepine Mood Stabilizers All antipsychotics may cause an increase in cholesterol, triglycerides, and risk for diabetes

Draw baseline labs and record weight
HgbA1c, fasting lipid panel

Check labs at least yearly, perhaps sooner if significant weight gain Metabolic Syndrome

FDA approved for the treatment of:

Schizophrenia 12 to 17 years old *Paliperidone (Invega)
Clozapine (Clozaril)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
*Paliperidone (Invega)
*Iloperidone (Fanapt)
*Asenapine (Saphris)
*Lurasidone (Latuda) Atypical/Novel/2nd Generation The New
Clozapine
Risperidone
Paliperidone
Olanzapine
Ziprasidone
Aripiprazole
Quetiapine The Old
Haldoperidol
Thioridazine
Thiothixene
Proclorpromazine
Perphenazine
Fluphenazine Antipsychotics: Old or New?
Typical vs Atypical Psychotic disorders

Bipolar disorder

Irritability associated with autism

Severely agitated/violent behaviors Antipsychotics Atomoxetine (Strattera)
Non-stimulant, dose by weight
Needs to be given everyday and takes weeks to work
Can be refilled over the phone
May be better for persons with anxiety
Primary side effects
Sedation, nausea and vomiting, weight loss, Other Medications for Attention, Hyperactivity Students will not eat lunch
Appetite suppression is expected

What time do the meds wear off?

They don’t work if you don’t take them

Bothersome tics

Are there other reasons for attention problems?
Learning issues, anxiety Stimulant Issues in School Daytrana SODAS™ is a trademark of Elan Corporation, Plc Ritalin® LA: Extended-release Delivery via SODAS™ Technology It is the delivery system

Onset, peak, duration Selecting Meythelphenidate
Mehtylphenidate
Immediate release or extended release
Amphetamine
Immediate release or extended release

Only work 70-80% of the time Stimulants Stimulants
Other medications to treat ADHD
Antipsychotic medications
Mood Stabilizers
Antidepressants
Benzodiazepines Psychotropic Medications Basic Psychopharmacology
for Children and Adolescents Prescribing psychoactive medication for children is controversial. However, at times it is necessary to assist children in controlling problems with mood, behavior, anxiety, aggression and other difficulties. As a clinician I have to be convinced that to not medicate would be more harmful than to proceed with medication treatment. Children
Imaginary friends
Events controlled by thoughts/feelings
Teens
Moody and irritable
Oppositional and antisocial
Unique insights into the nature of reality Normal Behavior Pooled data 4400 patients (2003):
The average risk of suicidality was 4% on drugs
placebo risk of 2%.
NO SUICDES occurred in the trials.
2004-2006 decrease in drugs but increase in suicidality Black Box Lamotrogine
Rash Topiramate
“Dopamax”
Sedation Depakote
Weight gain
Polycystic ovaries
Osteoporosis Lithium
Weight gain
Acne
Increased thirst and urination
May effect thyroid and kidneys
Cognitive impact Side Effects New (Atypical)
More expensive
Some may have less weight gain
Some may have less prolactin change
May cause less tardive
More research in kids and adolescents Old (Typical)
Less expensive
Weight gain
Elevated prolactin
Tardive dyskinesia
Few trials with kids and adolescents MULTIPLE….Can’t cover them all
Commonly used in children and adolescents
St John’s Wart
Melatonin
Secretin
Kava
Valarian CAM Decreases b/p in adults
Disruptive aggressive (comorbid odd)
Sedating: resolves over time
4 weeks to reach effect
1 mg in pm x 1 week: increase by 1mg /week Intunive Kapvay Alpha Extended release suspension
6-12 yo

Efficacy 45 min-12 hours Quillivant XR Target Symptoms (Behaviors) Psychotropic Medications Effective12/1/2011 Principles of medication treatment:

Add to your understanding of why medications are prescribed for children and teenagers.

Distinguish between antidepressants, stimulants, antipsychotics and anticonvulsants.

Recognize brand and generic names in each class of psychiatric medications. Principles of medication treatment:

Add to your understanding of why medications are prescribed for children and teenagers.

Distinguish between antidepressants, stimulants, antipsychotics and anticonvulsants.

Recognize brand and generic names in each class of psychiatric medications. Parent Management Training Programs: help parents and others manage the child’s behavior. 

Individual Psychotherapy: develop more effective anger management. 

Family Psychotherapy: improve communication and mutual understanding.
 
Cognitive Problem-Solving Skills Training

Therapies to assist with problem solving and decrease negativity. 

Social Skills Training to increase flexibility and improve social skills and frustration tolerance with peers. 

Medication for ADHD, anxiety, mood disorders Treatment Frequent sadness, tearfulness, crying
Decreased interest in activities; or inability to enjoy previously favorite activities
Hopelessness
Persistent boredom; low energy
Social isolation, poor communication
Low self esteem and guilt
Extreme sensitivity to rejection or failure
Increased irritability, anger, or hostility
Difficulty with relationships
Frequent complaints of physical illnesses such as headaches and stomachaches
Frequent absences from school or poor performance in school
Poor concentration
A major change in eating and/or sleeping patterns
Talk of or efforts to run away from home
Thoughts or expressions of suicide or self destructive behavior PHQ 9
SMFQ
KADS Affects up to 30% of children and adolescents

Accounts for 30% of healthcare visits in children and teens 4 to 16 years of age

One third to one half continue symptoms into adulthood

Pain with no organic cause. Must rule out specific causes Chronic Pain Syndrome ADHD, Combined Type: (314.01)if both criteria 1A and 1B are met for the past 6 months

ADHD, Predominantly Inattentive Type: (314) if criterion 1A is met but criterion 1B is not met for the past six months

ADHD, Predominantly Hyperactive-Impulsive Type: (314.01 if Criterion 1B is met but Criterion 1A is not met for the past six months.
NOS 314.9 Diagnostic Types Comorbidity Aggression to people and animals
often bullies, threatens, or intimidates others
often initiates physical fights
has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
has been physically cruel to people
has been physically cruel to animals
has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
has forced someone into sexual activity Conduct Disorder Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others

Moderate: number of conduct problems and effect on others intermediate between “mild” and "severe"

Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others Conduct Disorder Depression is a RISK factor for suicide

1O% of HS students have thoughts

Preventable if we know how to screen
Columbia Suicide Severity Rating

http://www.cssrs.columbia.edu/docs/C-SSRS_Screening_2012_with_Triage_Points.pd
Everyone can be trained to administer this Suicide Pre-teen: Concrete thinker, personalizes, early understanding of their own mortality
TX: Talk about it, they want details, how, why
Teen (12 and above): Cognitively understand but exploring the spiritual side, very intense emotions (depression, anger, acting out)
TX: They need to talk, others need to listen, if symptoms persist may need help
http://griefspeaks.com/id28.html Grief Infants-2: sense when something is disrupted in their world (can be divorce)—react to caretakers grief with: sleep disturbances, not eating well, irritability, excessive crying, increased need to be held and comforted, increased separation anxiety 
TX: extra comfort, by holding more, rocking, playing calming music, feed him in a quiet place limit distractions, needs to feel secure and safe, talk softly(take care of the caretaker and help the caretaker to feel supported) Grief and Loss Postpartum Blues
70-80%
Labile mood lasting hours to days

Postpartum Depression
10-15% within 4 weeks of delivery
Parent or patient
Difficulty caring for the child
Edenburgh Special Cases #1 Hopelessness
Method available
Family hx of suicide
Giving away possessions
Prior history of self harm or impulsivity
ALWAYS SCREEN DEPRESSED PATIENT FOR SUICIDE
Plan and Means Risk Factors for Suicide Suicidal
No response to 2 interventions or in 2 months
Increasing symptoms
Recurrent episodes
Family preference Depression Referral SSRI: benefits likely outweigh the risks
TADS (Treatment for Adolescents with Depression Study)
12 weeks
SSRI only 61%
CBT only 43%
Combination of SSRI and CBT 71% Depression Treatment D = Depressed mood
E = Energy loss/fatigue
P = Pleasure lost
R = Retardation or excitation
E = Eating changed—appetite/weight
S = Sleep changed
S = Suicidal thoughts
I = I'm a failure (loss of confidence)
O = Only me to blame (guilt)
N = No concentration Another Mnemonic Education of the patient and the family about the illness
Psychotherapy helps the child understand himself or herself, adapt to stresses, rebuild self-esteem and improve relationships.
Medications: Mood stabilizing medications such as lithium, valproic acid, or “atypical antipsychotic”, and psychotherapy.
Mood stabilizing medications often reduce the number and severity of manic episodes, and also help to prevent depression. Bipolar Disorder: Treatment Manic +/- depressive symptoms.
mostly depression
combination of manic and depressive (highs alternate with lows)

Bipolar disorder can begin in childhood/teens but usually diagnosed in adult life)

Risk Factors:
if one or both parents have Bipolar Disorder,
Family history of drug or alcohol abuse Bipolar Disorder Psychological Management (60%)
First line of treatment mild-severe
CBT
Exposure
Medication (54%)
SSRI
Benzo
Combination SSRI and CBT (80%)
Placebo (23%) Anxiety Treatment Acute Stress disorder may resolve or may develop into a more severe disorder such as PTSD.
Acute: At least 2 days and less than 3 months
Chronic : 3 months or more
Delayed onset: 6 months after the stressor
Distress with increased arousal, avoidance Post traumatic stress disorder Symptoms include dissociative symptoms such as numbing, detachment, a reduction in awareness of the surroundings, de-realization, or depersonalization; re-experiencing of the trauma, avoidance of associated stimuli, and significant anxiety, including irritability, poor concentration, difficulty sleeping, and restlessness. The symptoms must be present for a minimum of two days and a maximum of four weeks and must occur within four weeks of the traumatic event for a diagnosis to be made. 308.3 Acute Stress Disorder Symptoms and Treatment PTSD:
Persistent symptoms that occur after a traumatic event . Nightmares, flashbacks, emotional numbness, depression, anger, irritability, distracted, easily startled
Refer
Obsessive-Compulsive Disorder:
obsession causes distress and the compulsion is a way to try to handle it.
Refer Anxiety Disorders Constant thoughts and intense fears about the safety of parents and caretakers
Refusing to go to school
Frequent stomachaches and other physical complaints
Extreme worries about sleeping away from home
Being overly clingy
Panic or tantrums at times of separation from parents
Trouble sleeping or nightmares Separation anxiety
Wound up
Worn-out
Absentminded
Restless
Touchy
Sleepless GAD Worry WARTS KySS Worries, Parent and 10-21 y
State and Trait
Scared Anxiety Tools NO CURE
Refer
Behavioral and Educational Interventions
Language
Treat comorbidities
Screen for them
Risperidone (Side effect is weight gain)
CAM ASD Treatment Without treatment children fall behind in school, have social problems, higher rates of: substance abuse, conduct disorder, accidents, divorce, job loss

Combination of behavioral and medication therapy
Behavior therapy: point systems or charts to reward good behavior, “time out,” family time and positive attention.
Individual therapy: examine upsetting thoughts or feelings, learn alternative ways of handling emotions, change or better cope with ADHD symptoms-- organizing schoolwork or dealing with emotional experiences.
Social skills training: model social skills--waiting for a turn, sharing toys, or asking for help, reading others’ facial expression or tone; Structured play dates
Medications: Stimulant and non-stimulant meds ADHD Treatment Some symptoms that cause impairment were present before age 7 years.

Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

There must be clear evidence of significant impairment in social, school, or work functioning.

The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). ADHD Tools
Vanderbilt
6-12 years old
Conners
3-17 years old ADHD Causes of Fatigue Concentration Killers Overlapping Presentation The Pediatric Symptoms Checklist (PSC) 4-18

The Child Behavior Checklist (CBCL) 1-18

Parents Evaluations of Developmental Status (PEDS)

ASQ, Birth-60 months

The Guidelines for Adolescent Preventive Services (GAPS), younger, middle, older adol.

KySS Questionnaires, infant - teens General Screening Tools A repetitive and persistent pattern of behavior in which the basic rights of others or a more major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria the past 12 months, with the least one criterion present in the past six months:
312.8 (No remorse) Conduct Disorder All children display, but this must be persistent over months to years and cause impairment of function( 3-4%), directed at authority
Tantrum lasts for up to 3-4 hrs
More willing to lose a privilege than a battle, so hard to discipline by withholding
ODD and CD often comorbid with ADHD ODD Mayo Clinic, 2007 Multiple settings—home, school, after-school activities

1-16 % of all school-age children and adolescents have ODD

No clear causes, but some factors are:
Child’s inherent temperament
Family's response to the child's temperament
A genetic component coupled with certain environmental conditions —
lack of supervision,
poor quality child care
family instability
A biochemical or neurological factor
The child's perception that he or she isn't getting enough of the parent's time and attention ODD: frequency & causes Questionnaire 313.81 Oppositional Defiant Disorder
and Conduct Disorder AACAP, 1999 Self-injury is act of deliberate injury at times to change a way of feeling or relieve painful feelings.
Carving, scratching, branding, marking, picking and pulling skin and hair, burning/abrasions, cutting, biting, head banging, bruising, hitting
To take risks, rebel, reject their parents' values, state their individuality or merely be accepted. 
Desperation or anger to seek attention, to show their hopelessness and worthlessness, or because they have suicidal thoughts. 
Associated with
depression, psychosis, PTSD and bipolar disorder. 
Some may develop Borderline Personality Disorder as adults.  Self-injurious behavior Preschool (3-5): Cognitively not able to understand death as permanent ask lots of questions.
TX: short, honest answers, comfort, reassurance, nurturing and consistent routine
School age (5-9): May accept permanence, asks why fantasize
TX: need to learn terms to describe feelings such as numb, grief, sadness.  Death play is normal and allows for integration Grief GLAD-PC
5% of children
10-20% adolescents Mean age 14 y/o
M:F is 1:1 in children, young adults 1:2
40-7-% have comorbidity
Anxiety
ODD
Substance Abuse Depression Consider
CBC
TSH, FT4
Urine toxicology
Pregnancy test Differential
Anemia
Hypothyroid
Infection (Mono)
Medications
Hormones
Steroids
Accutane
Substance use Depression Preschool - increased tantrums and oppositional, regression,
separation anxiety, but don’t look sad

Elementary - tantrums, oppositional, dropping grades, avoid
friends/activities, may not look sad, irritable/aggressive

Middle school - dropping grades, avoid friends and activities,
bored, look sad, sleep/wt changes, SIB, MJ use, shoplifting

High school - dropping grade, irritable, quit clubs/teams, drop
out of school, bored, heavy drug use, sex, running away, ICP Depression Symptoms in Children Five or more In the past two weeks:
Depressed mood, can be irritable mood in children/teens
Decreased interest or pleasure in daily activities
Significant weight gain or loss without dieting (FTT)
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive guilt
Decreased ability to think/concentrate, indecisiveness
Recurrent thoughts of death or suicide, suicide attempt DSM Criteria for Depression SIGECAPS

S leep disturbance (increased or decreased)
I nterest reduced (not enjoying anything)
G uilt sensation and worthlessness
E nergy loss and fatigue
C oncentration problems
A ppetite problem (increased or decreased)
P sychomotor agitation or retardation
S uicidality Mnemonics Depression
CES-DC
Children’s Depression Inventory, 7-17
Two question survey for adults (parents)
Do you feel down, depressed or hopeless?
Do you have little interest or pleasure?

Do they have the means and/or a plan? Tools Severe changes in mood-either unusually happy or silly, or very irritable, angry, agitated, or aggressive

Unrealistic highs in self-esteem – e.g., a teenager who feels all powerful or like a superhero with special powers
Great increase in energy and the ability to go with little or no sleep for days without feeling tired
Increase in talking - the adolescent talks too much, too fast, changes topics too quickly, and cannot be interrupted
Distractibility - the teen's attention moves constantly from one thing to the next
Repeated high risk-taking behavior; such as, abusing alcohol and drugs, reckless driving, or sexual promiscuity
Overlaps with symptoms of: drug abuse, delinquency, ADHD, or even schizophrenia. Bipolar disorder: symptoms Mania: DeTeR the HIGH*
Distractibility
Talkativeness
Reckless behavior
Hyposomnia
Ideas that race
Grandiosity
Hypersexuality
* Created by Carey Gross Hypomania: TAD HIGH
Talkative
Attention deficit
Decreased need for sleep
High self-esteem/grandiosity
Ideas that race
Goal-directed activity increased
High-risk activity Mania: Mnemonics D istractibility
I ndiscretion (DSM-IV's "excessive involvement in pleasurable activities")
G randiosity
F light of ideas
A ctivity increase
S leep deficit (decreased need for sleep)
T alkativeness (pressured speech) DIGFAST for Bipolar REFER Bipolar Psychological
Temperament
Conditioning

Biological
Genetic predisposition
Abnormal activity of norepinephrine Anxiety Causes Anxiety Disorders GAD: at least 6 months of worry. Physical symptoms (fatigue, trembling, muscle tension, HA, nausea, abd pain), low self esteem, low self confidence
Phobias: Specific (Fear when there is no actual danger. Avoidance of the situation)Social (fear of humiliation of embarrassment witch leads to avoidance), no friends
Panic: Episodes of intense fear with no warning with chest pain, heart palpitations, SOB, dizziness, abd distress, feeling of unreality, fear of dying Comorbid or anxiety may be the result of another primary diagnosis Anxiety Depression
Anxiety
Bipolar
PTSD
OCD Mood Disorders Sleep 44-83%
Fragile X 5%
Tuberous Sclerosis 1-4
Epilepsy 11-39 %
Tic 9% MR 40-68%
ADHD 30-75%
Mood 25-40%
Depression 25%
Anxiety 17-84%
OCD 1.5-81%
Phobias 44-64%
Challenging behaviors
Ex: rumination, aggression, irritable ASD and Comorbidity M-Chat @ 18months

Identify problem EARLY and refer

May co-manage ASD ASD . Trial with stimulant
Methylphenidate
Dexamphetamine salts


Start low and increase
Goal is normalization
Monitor effects and side effects
Compliance ADHD Treatment AACAP, 2009 Most common mental disorder in children

Estimates of 3-5% of preschool and school-age children have ADHD (2 mil. in USA)(NIMH)
1 in a class of 25-30

Often lasts into adulthood: 30-70% of children with ADHD will continue to have symptoms as adults
May self medicate ADHD Eating Disorders
Adjustment Disorders
Cognitive Function
Relationship Problems
Enuresis/Encopresis
Sleep Hygiene ADHD
ASD
Mood Disorders
Anxiety
PTSD
Bipolar
Depression
Suicide and Non-suicidal self injury
OCD
Movement Disorders
Oppositional/conduct disorder
Substance Abuse Diagnosis and Treatment Depression is almost always due to psychosocial losses/stressors in children and teens unlike adults which have both psychosocial and biochemical depression

Risk factors in youth - poor attachment, chaotic home, loss of parent, ADHD, trauma, bullying, caretaking

Symptoms unpleasant that is sustained, persistent and interferes with function in home, school or with peers

Major Depressive Disorder
Dysthymia Depression is………
waking up afraid you are going to live. Depression Rule out a physical problem

Headache

Belly Ache

Somatization

Health habits Chronic Pain Syndrome Primary Care Role is to Rule Out a Physical Cause Prevalence for PTSD is variable 3-58%
Any age: after experiencing a traumatic event
Thoughts, dreams, flashbacks, Post traumatic stress and Acute Stress disorders General anxiety disorder (GAD)
Obsessives-compulsive disorder (OCD)
Social phobia/Separation anxiety/School refusal
Selective mutism
Panic disorder
Specific phobia
Acute vs PTSD Anxiety 6 mo
No gaze/fixation face
No joyful smile
9 mo
No reciprocal vocals
No smiles
12 mo
No babbling, mama, dada
No bye-bye, pointing, showing, 18 mo
No single words
No simple pretend play
24 mo
No spontaneous two word phrases
Lack of interest in other children
Any unexplained regression of social of language skills at any age ASD Red Flags developmental disabilities that can cause significant impairments in social, communication, and behavioral skills
1:88 …….they are in your primary care practice Autistic Spectrum Disorder 6-9% of children ages 5-12 yrs
Boys diagnosed 3x girls—
probably because boys more hyperactive and disruptive
Girls more inattentive

Cause: multimodal
Genetic and environmental

Consequence of non-treatment
School problems
Increased risk taking: MVA, substance use, pregnancy
Risk factor for other psychiatric diagnosis ADHD ADHD Sina Linman, ARNP, CPNP, PMHS
NAPNAP
Orlando 2013 Diagnosis and Treatment Plan
PMHS Review Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years

Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years
Refer/co-manage Conduct Disorder Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level A pattern of negativistic. hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
often loses temper
often argues with adults
often actively defies or refuses to comply with adults' requests or rules
often deliberately annoys people
often blames others for his or her mistakes or misbehavior
is often touchy or easily annoyed by others
is often angry and resentful
is often spiteful or vindictive Oppositional Defiant Disorder Cutting, Eraser Game, Suicide and Non-suicidE
Self-Injury Up to 30% of children
Headache
Recurrent abdominal pain Chronic Pain syndromes http://www.psychtreatment.com/dsmIV_miscellaneous_criteria.htm

Persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection

Persistent disregard of the child's basic physical needs

Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)

REFER FOR INTENSE THERAPY 309.9 Adjustment Disorder Unspecified

309.24 Adjustment Disorder with Anxiety

309.0 Adjustment Disorder with Depressed Mood

309.3 Adjustment Disorder with Disturbance of Conduct

309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood

309.4 Adjustment Disorder with Mixed Disturbance of Emotions and Conduct Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least I month.
The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).
The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food.
The onset is before age 6 years. REFER
http://www.drugabuse.gov/
http://www.hbo.com/addiction/adolescent_addiction/27_addiction_among_adolescents.html
http://www.niaaa.nih.gov/ Changes in school performance (falling grades, skipping school, tardiness)
Changes in peer group (hanging out with drug-using, antisocial, older friends)
Breaking rules at home, school, in the community
Extreme mood swings, depression, irritability, anger, negative attitude
Sudden increases or decreases in activity level
Withdrawal from the family; keeping secrets
Changes in physical appearance (weight loss, lack of cleanliness, strange smells)
Red, watery, glassy eyes or runny nose not due to allergies or cold
Changes in eating or sleeping habits
Lack of motivation or interest in things other teenagers enjoy (hobbies, sports)
Lying, stealing, hiding things
Using street or drug language or possession of drug paraphernalia/items
Cigarette smoking A. Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations)
B. The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive months.
C. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
D. The onset is before age 18 years.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).
F. Criteria have never been met for Tourette's Disorder or Chronic Motor or Vocal Tic Disorder.
307.21 A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization)
B. The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
C. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g.. Huntington's disease or postviral encephalitis).
307.23 American schools harbor approximately 2.1 million bullies and 2.7 million of their victims. Dan Olweus, National School Safety Center Conduct Disorder: Bullying Serious violations of rules
often stays out at night despite parental prohibitions, beginning before age 13 years
has run away from home overnight at least twice while living in a parental or parental surrogate home (or once without returning for a lengthy period)
is often truant from school, beginning before age of 13 years Conduct Disorder Destruction of Property
has deliberately engaged in fire setting with the intention of causing serious damage
has deliberately destroyed others' property (other than by fire setting) Conduct Disorder Aggression to people and animals
often bullies, threatens, or intimidates others
often initiates physical fights
has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
has been physically cruel to people
has been physically cruel to animals
has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
has forced someone into sexual activity Conduct Disorder A repetitive and persistent pattern of behavior in which the basic rights of others or a more major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria the past 12 months, with the least one criterion present in the past six months:
312.8 (No remorse) Conduct Disorder All children display, but this must be persistent over months to years and cause impairment of function( 3-4%), directed at authority
Tantrum lasts for up to 3-4 hrs
More willing to lose a privilege than a battle, so hard to discipline by withholding
ODD and CD often comorbid with ADHD ODD Postpartum Blues
70-80%
Labile mood lasting hours to days
Postpartum Depression
10-15% within 4 weeks of delivery
Parent or patient
Difficulty caring for the child
Edenburgh Special Case REFER
Mental Retardation
317 Mild Mental Retardation: IQ level 50-55 to approximately
318.0 Moderate Mental Retardation: IQ level 35-40 to 50-55
318.1 Severe Mental Retardation: IQ level 20-25 to 35-40
318.2 Profound Mental Retardation: IQ level below 20- 25
319 Mental Retardation
Severity Unspecified: when there is a strong presumption of Mental Retardation but the person's intelligence is untestable by standard tests Need more research
Genetic vulnerability
Disruptive behaviors, antisocial, mood disorders, substance abuse, permissive, neglectful harsh or inconsistent parenting and poverty
Frontal lobe and low serotonin levels may contribute Cause of ODD and CD Disruptive Behavior Disorder, NOS

Do not meet the full criteria for conduct or oppositional disorder but have clinically significant impairment Deceitfulness or theft
has broken into someone else's house, building, or car
often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) Conduct Disorder Mayo Clinic, 2007 Multiple settings—home, school, after-school activities

1-16 % of all school-age children and adolescents have ODD

No clear causes, but some factors are:
Child’s inherent temperament
Family's response to the child's temperament
A genetic component coupled with certain environmental conditions —
lack of supervision,
poor quality child care
family instability
A biochemical or neurological factor
The child's perception that he or she isn't getting enough of the parent's time and attention ODD: frequency & causes Infants-2: sense when something is disrupted in their world (can be divorce)—react to caretakers grief with: sleep disturbances, not eating well, irritability, excessive crying, increased need to be held and comforted, increased separation anxiety 
TX: extra comfort, by holding more, rocking, playing calming music, feed him in a quiet place limit distractions, needs to feel secure and safe, talk softly(take care of the caretaker and help the caretaker to feel supported) Grief and Loss Persistent eating of nonnutritive substances for a period of at least 1 month.
The eating of nonnutritive substances is inappropriate to the develop­mental level.
The eating behavior is not part of a culturally sanctioned practice.
If the eating behavior occurs exclusively during the course of another mental disorder (e.g., Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention. Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between “mild” and "severe"
Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others Conduct Disorder http://www.psychtreatment.com/dsmIV_miscellaneous_criteria.htm May have traits, but current definition has an age limitation 301.9 Personality Disorder

Persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection

Persistent disregard of the child's basic physical needs

Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)

REFER FOR INTENSE THERAPY RAD risk factors
Mental Retardation
317 Mild Mental Retardation: IQ level 50-55 to approximately
318.0 Moderate Mental Retardation: IQ level 35-40 to 50-55
318.1 Severe Mental Retardation: IQ level 20-25 to 35-40
318.2 Profound Mental Retardation: IQ level below 20- 25
319 Mental Retardation
Severity Unspecified: when there is a strong presumption of Mental Retardation but the person's intelligence is untestable by standard tests Mental Retardation 309.9 Adjustment Disorder Unspecified

309.24 Adjustment Disorder with Anxiety

309.0 Adjustment Disorder with Depressed Mood

309.3 Adjustment Disorder with Disturbance of Conduct

309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood

309.4 Adjustment Disorder with Mixed Disturbance of Emotions and Conduct
Adjustment Disorder Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning.
B. The behavior is not due to an associated gastrointestinal or other general medical condition (e.g.. esophageal reflux).
C. The behavior does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. If the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Disorder, they are sufficiently severe to warrant independent clinical attention. 307.53 Rumination Disorder Feeding Disorder of Infancy of Early Childhood 307.59 Gen: thin, flat affect, grey
Vital signs: hypothermia, bradycardia, hypotension, orthostatic,
Skin/hair: dry skin, lanugo, bruising, thin hair. Callous on finger, brittle nails, acrocyanosis
HEENT: dry lips, inflamed gums, loss of tooth enamel, parotidites, sunken eyes
Breasts: atrophic
Cardiac: arrhythmias, murmurs, mitral valve prolapse Physical Exam Thyroid
Bowel: Inflammatory bowel disease, celiac, abd mass leading to vomiting
Cancer
Diabetes
Adrenal insufficiency
Psych: depression, OCD, substance abuse, psychotic
CNS causing vomiting
Chronic Infections Eating Disorder Differential SCOFF

Make yourself SICK when you feel uncomfortably full?
Worry you have lost CONTROL over how much you eat?
Recently lost more than 14 pounds within three months?
Believe you are FAT when others say you are too thin?
Would you say that FOOD dominates your life? Eating Disorder Screen Correlates with
low self esteem
Depression
Anxiety
OCD
self injury
substance abuse REFER
http://www.drugabuse.gov/
http://www.hbo.com/addiction/adolescent_addiction/27_addiction_among_adolescents.html
http://www.niaaa.nih.gov/ Drug Abuse Quick tool: "WITHDraw IT" (3 of 7 within 12 month period):

W ithdrawal
I nterest or Important activities given up or reduced
T olerance
H arm to physical and psychosocial known but continue to use
D esire to cut down, control
I ntended time, amount exceeded
T ime spent, too much Drug Dependence Substance use
CAGE
CRAFFT
Urine toxicology screen Substance Screening Tools Changes in school performance (falling grades, skipping school, tardiness)
Changes in peer group (hanging out with drug-using, antisocial, older friends)
Breaking rules at home, school, in the community
Extreme mood swings, depression, irritability, anger, negative attitude
Sudden increases or decreases in activity level
Withdrawal from the family; keeping secrets
Changes in physical appearance (weight loss, lack of cleanliness, strange smells)
Red, watery, glassy eyes or runny nose not due to allergies or cold
Changes in eating or sleeping habits
Lack of motivation or interest in things other teenagers enjoy (hobbies, sports)
Lying, stealing, hiding things
Using street or drug language or possession of drug paraphernalia/items
Cigarette smoking Concerning Behaviors to Look for in an Adolescent Who Might be Using Drugs PREVENTION is the key
Reportable with goal of safety and help
Mandatory reporter
Does not require a signed release to talk to DHS
KNOW YOUR STATES LAWS about this!!!!!
It can happen to anyone A. Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations)
B. The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive months.
C. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
D. The onset is before age 18 years.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).
F. Criteria have never been met for Tourette's Disorder or Chronic Motor or Vocal Tic Disorder.
307.21 Transient Tic Disorder A. Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations), but not both, have been present at some time during the illness.
B. The tics occur many times a day nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
C. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
D. The onset is before age 18 years.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).
F. Criteria have never been met for Tourette’s Disorder.
307.22 Chronic Motor
or
Vocal Tic Disorder AIMS

Screen for it especially if on psych meds
Is it medication related?
If not refer
Differential: consider seizure disorder Movement Need more research
Genetic vulnerability
Disruptive behaviors, antisocial, mood disorders, substance abuse, permissive, neglectful harsh or inconsistent parenting and poverty
Frontal lobe and low serotonin levels may contribute Cause of ODD and CD American schools harbor approximately 2.1 million bullies and 2.7 million of their victims. Dan Olweus, National School Safety Center Conduct Disorder: Bullying Deceitfulness or theft
has broken into someone else's house, building, or car
often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) Conduct Disorder Serious violations of rules
often stays out at night despite parental prohibitions, beginning before age 13 years
has run away from home overnight at least twice while living in a parental or parental surrogate home (or once without returning for a lengthy period)
is often truant from school, beginning before age of 13 years Conduct Disorder Aggression to people and animals
often bullies, threatens, or intimidates others
often initiates physical fights
has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
has been physically cruel to people
has been physically cruel to animals
has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
has forced someone into sexual activity Conduct Disorder Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between “mild” and "severe"
Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others Conduct Disorder All children display, but this must be persistent over months to years and cause impairment of function( 3-4%), directed at authority
Tantrum lasts for up to 3-4 hrs
More willing to lose a privilege than a battle, so hard to discipline by withholding
ODD and CD often comorbid with ADHD ODD Infants-2: sense when something is disrupted in their world (can be divorce)—react to caretakers grief with: sleep disturbances, not eating well, irritability, excessive crying, increased need to be held and comforted, increased separation anxiety 
TX: extra comfort, by holding more, rocking, playing calming music, feed him in a quiet place limit distractions, needs to feel secure and safe, talk softly(take care of the caretaker and help the caretaker to feel supported) Grief and Loss Postpartum Blues
70-80%
Labile mood lasting hours to days
Postpartum Depression
10-15% within 4 weeks of delivery
Parent or patient
Difficulty caring for the child
Edenburgh Special Case Nocturnal Only
Diurnal Only
Nocturnal and Diurnal Repeated voiding of urine into bed or clothes (whether involuntary or intentional).

The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupa­tional), or other important areas of functioning.

Chronological age is at least 5 years (or equivalent developmental level).

The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition ( e.g., diabetes, spina bifida, a seizure disorder). Enuresis 307.6 787.6 With Constipation and Overflow Incontinence
307.7 Without Constipation and Overflow Incontinence Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.

At least one such event a month for at least 3 months.

Chronological age is at least 4 years (or equivalent developmental level).

The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation. Encopresis Inhibited Type: if Criterion A1 predominates in the clinical presentation
Disinhibited Type: if Criterion A2 predominates in the clinical presentation Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either 1 or 2

persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper-vigilant, or highly ambivalent contradictory responses (e.g., the child may respond to care with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)

(2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)
313.89 Reactive Attachment Disorder of
Infancy or Early Childhood REFER Reactive attachment
disorder Over protective Parents create “Peter Pan Kids” who don’t assume responsibility
Peter Pan Parents: never want to grow up Relational Problems V62.81 Relationship Disorder NOS 1.Reading Disorder: (315) Reading achievement is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.
2. Mathematics: Math achievement is substantially below….
3: Written expression Learning Disorders 315.9 GU: delayed puberty, inability to concentrate urine
Abd: scaphoid, epigastric tenderness, palpable stool, abd masses
Extremities: cool, peripheral edema
Neurological : decreased DTRs Comprehensive Chem
CBC with ESR: anemia
CK: muscle breakdown with over exercising
Lipid: elevated LDH with binge
THS, FT4
Prolactin and FSH: ovarian failure, prolactinoma
UA: spec gravity, pregnancy
Drug Screen
Stool and urine emetide (by product of ipecac) Screen, evaluate and REFER

Little evidence

Family based therapy
Psychotherapy
Prozac has FDA approval for bulimia
Anorexia improved response with use of SSRI AFTER regaining weight Evidence Based Treatment Etiology: genetic and neurobiological factors
Primary care role is to identify, refer and help to monitor
Prevention Feeding Disorder of Infancy or Early Childhood
Bulimia
Anorexia
Rumination Disorder
PICA
NOS: this is the biggest category
Over eating? Obesity? Is this an addiction? Eating Disorders 87% are under the age of
20 y/o
Up to 10% Mortality Rate Eating Disorders Physical: Fatigue, repeated health complaints, red and glazed eyes, and a lasting cough.
Emotional: Personality change, sudden mood changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and a general lack of interest.
Family: Starting arguments, breaking rules, or withdrawing from the family.
School: Decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems.
Social problems: New friends who are less interested in standard home and school activities, problems with the law, and changes to less conventional styles in dress and music. Substance abuse: warning signs 6: Motion sickness pills
7: Sexual performance meds (internet)
8: Pseudoephedrine
9: Herbal ecstasy
10: Other Herbals K2
Huffing
Bath salts
Tobacco
Fat, salt, sugar ????? Substances
Types of Substances Include: alcohol, amphetamines, cocaine, caffeine, hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), cannabis, and sedatives-hypnotics-anxiolytics


Polysubstance Dependence: the criteria for abuse or dependence for any one substance is not met, the client abuses more than one substance and groups them together Substances Substance Related Disorders Substance Use: Possibly even one time : 50-80% have used some drug recreationally , May begin before 12 years old

Substance Abuse: viewed as less severe, continued use, knowing it is causing harm, does not apply to caffeine and nicotine

Substance Dependence: taking larger amounts with unsuccessful attempts to quit

Substance Intoxication: the development of a substance specific (reversible) syndrome, condition related to recent ingestion of psychoactive substance

Substance Withdrawal: follows termination of a psychoactive substance (Abstinence Syndrome) Teens
Afraid of anyone in your home?
Whom could you tell if someone touched you ?
Has this happened to you?
What happens when parents are angry with you? Each other?
Have the police come ? Parents
Afraid of anyone in the home?
Feel so frustrated you could hit or hurt?
Feeling overwhelmed?
Have police come to your house? Screening for Maltreatment “Accidental” Injury or Death Risk taking: Part of adolescence…… A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization)
B. The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
C. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g.. Huntington's disease or postviral encephalitis).
307.23 Tourette’s Destruction of Property
has deliberately engaged in fire setting with the intention of causing serious damage
has deliberately destroyed others' property (other than by fire setting) Conduct Disorder A repetitive and persistent pattern of behavior in which the basic rights of others or a more major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria the past 12 months, with the least one criterion present in the past six months:
312.8 (No remorse) Conduct Disorder Behavior Modification

Imipramine of DDAVP for enuresis

Encopresis may need long term stool softener as well as bowel retraining (behavior) Treatment Enuresis/Encopresis Refer Cognitive Function Problems Know the support systems in the community.
Trans kids seem to be the “lost kids” in the group. Risk Factor Persistent eating of nonnutritive substances for a period of at least 1 month.
The eating of nonnutritive substances is inappropriate to the develop­mental level.
The eating behavior is not part of a culturally sanctioned practice.
If the eating behavior occurs exclusively during the course of another mental disorder (e.g., Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention. 307.52 Pica Assess risk of Dependence Substance
Abuse 1: Dextromethorphan (1/10) ‘Skittling”
2: Pain relievers
3: Caffeine and energy drinks
4: Diet Pills
5: Laxatives and diuretics OTC Drugs of Abuse Substance Use and Abuse
Gambling
Sex
? Internet
http://www.hbo.com/addiction/adolescent_addiction/index.html?current=1 Addiction disorders Tics
Tourettes
Akathesia
EPS
Tardive Movement disorders Disruptive Behavior Disorder, NOS

Do not meet the full criteria for conduct or oppositional disorder but have clinically significant impairment Mayo Clinic, 2007 Multiple settings—home, school, after-school activities

1-16 % of all school-age children and adolescents have ODD

No clear causes, but some factors are:
Child’s inherent temperament
Family's response to the child's temperament
A genetic component coupled with certain environmental conditions —
lack of supervision,
poor quality child care
family instability
A biochemical or neurological factor
The child's perception that he or she isn't getting enough of the parent's time and attention ODD: frequency & causes Physical Abuse
Sexual Abuse
Mental Abuse
Neglect--------Not all abuse leaves bruises Abuse:
Nonaccidental
Trauma unable to adjust to or cope with a particular stressor, like a major life event of this section, sorry! STUDY????? based on education and screening SLEEP HYGIENE!!!!!!!!!!!! 1-2-3 Magic
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