Lecture 65 + 66 - Pharmacotherapy of Pediatric Psychiatry

Question 1

Medication use in pediatric psychiatry

Answer 1

Kids have higher risk of significant adverse effects from medications than adults

Question 2

DSM-5 Tic Disorders

Answer 2

tourette’s disorder
persistent (chronic) motor or vocal tic disorder
provisional tic disorder

Question 3

Tourette’s Disorder

Answer 3

• Both multiple motor and one or more vocal tics present at some time, not necessarily concurrently
• Tics may wax and wane in frequency, but have been present for > 1 year
• Onset before age 18

Question 4

Persistent (chronic) motor or vocal tie disorder

Answer 4

• Single or multiple motor or vocal tics present, but not both
• Tics may wax and wane in frequency, but have been present for > 1 year
• Onset before age 18

Question 5

Provisional Tic Disorder

Answer 5

sx as above, but present for < 1 year

Question 6

Overview of Tic Disorders

Answer 6

~75% also have ADHD, ~ 50% also have OCD
Rule of Thirds: 1/3 resolve, 1/3 improve, 1/3 stay the same - ~ 10% have persistent symptoms as adults

Question 7

Pharmacologic Treatment of Tics - first line

Answer 7

• Alpha-2 agonists
• Tics of mild-moderate severity
• ~ 30% reduction
• Clonidine
• Guanfacine
• ER guanfacine

Question 8

Pharmacologic Treatment of Tics - second line

Answer 8

• Atypical antipsychotics
• 30 – 60% reduction
• Aripiprazole
• Risperidone

Question 9

Pharmacologic Treatment of Tics - third line

Answer 9

• Typical antipsychotics
• ~ 80% reduction
• Haloperidol
• Pimozide

Question 10

Antipsychotics

Answer 10

pimozide, haloperidol, aripiprazole, risperidone/paliperidone, quetiapine, olanzapine, ziprasidone

Question 11

Aripiprazole

Answer 11

FDA approved for ages 6-17 years old
weight based dosing for those less than 50 kg

Question 12

Stimulant use in Tourette’s

Answer 12

ADHD is a common co-morbidity in Tourette’s syndrome.
Use of amphetamine-based stimulants can exacerbate motor and vocal tic symptoms.
Must treat both ADHD and Tourette’s
* Can discontinue amphetamine-based stimulant and give a trial of atomoxetine or a tricyclic antidepressant.
* If ADHD symptoms are not well-controlled, can resume amphetamine-based stimulant and adjust dose of antipsychotic to better control Tourette’s symptoms.

Question 13

DSM-5 Oppositional Defiant Disorder

Answer 13

◦ Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months

Question 14

DSM-5 Conduct Disorder

Answer 14

◦ Repetitive and persistent pattern of behavior in which the basic rights of others or societal norms or rules are violated with at least three (3) of the following criteria present in the past year: aggression to people/animals, destruction of property, deceitfulness or theft, serious violations of rules
specify whether:
* Childhood-onset type: < 10 years old
* Adolescent-onset type: > 10 years (no symptoms under 10 years old)
* Unspecified onset: unclear information to determine age at onset

Question 15

Treatment of ODD and CD

Answer 15

Pharmacotherapy is considered adjunctive, palliative, non-curative and should only be used after baseline symptoms/behaviors have been determined, other interventions have failed and/or aggression has escalated to dangerous levels
Treat underlying condition (ADHD, depression/anxiety, mania) – ADHD common

Question 16

First choice for treating ODD and CD

Answer 16

Stimulants and clonidine/guanfacine are considered drugs of first choice before using atypical antipsychotics
Atypical antipsychotics may be used to treat severe persistent aggression, serious oppositional behaviors, defiance
Often see combination stimulant/alpha agonist treatment if ADHD with impulsivity or need for sedation for sleep

Question 17

Treatment of Separation Anxiety Disorder

Answer 17

First-line treatment for mild anxiety is psychotherapy with combination therapy for moderate to severe anxiety
SSRIs are the first-line drug therapy choice
Treat co-morbidities (depression, ADHD, screen for bipolar disorder)

Question 18

DSM-5 Autism Spectrum Disorder

Answer 18

Persistent deficits in social communication and social interaction across multiple contexts
Restricted, repetitive patterns of behavior, interests, activities

Question 19

Hallmark Signs and Symptoms of ASD

Answer 19

Associated behavioral symptoms: aggression, hyperactivity, inattention, irritability, mood instability, poor frustration tolerance, self-harm, severe temper tantrum, sleep disturbances, OCD symptoms, hypersensitivity of senses
Associated medical problems include seizure disorder (up to 30% have at least on seizure by age 20) and GI disorders
No medications have shown efficacy in treating the core ASD symptoms

Question 20

Treatment of Disruptive Behaviors in ASD

Answer 20

Behavioral interventions are first-line treatment (Applied Behavioral Analysis)
Atypical antipsychotics: aripiprazole (6 – 17 years old) and risperidone (5 – 16 years old) are FDA-approved for the management of irritability/aggression and are considered first-line agents; may have efficacy for stereotypy and hyperactivity
Lamotrigine/levetiracetam have no significant effect on irritability

Question 21

Treatment of Repetitive Behaviors

Answer 21

Antipsychotics – haloperidol, risperidone, aripiprazole

Question 22

Treatment of ADHD

Answer 22

Stimulants – methylphenidate preferred
Clonidine/guanfacine – modest effect on irritability and explosive behavior

Question 23

Treatment of Sleep Problems

Answer 23

Melatonin reduced sleep latency and increased time asleep – give 1 – 6 mg nightly

Question 24

DSM-5 Disruptive Mood Dysregulation Disorder (DMDD)

Answer 24

Severe recurrent temper outbursts manifested verbally that are out of proportion with the intensity/duration of the situation
Present in at least two of three settings (home, school, with peers) and are severe in at least one of these
Diagnosis should not be made before age 6 or after age 18

Question 25

DMDD - Treatment

Answer 25

More similarity to depression, ADHD, or anxiety than bipolar disorder
Need to differentiate from bipolar disorder - both for using antidepressants as well as evaluating need for mood stabilizers
SSRIs and stimulants are considered to be first-line treatment

Question 26

Pediatric Depression

Answer 26

Children – physical complaints, irritability, conduct problems, can have suicidal ideation
Adolescents – express feelings of depression and suicidal behaviors than more than younger children
More chronic than episodic, instability in mood common; may be marker for bipolar disorder

Question 27

Depression Treatment - Nonpharmacologic

Answer 27

Nonpharmacologic treatment is first-line, need motivation of family/caregivers for success

Question 28

Depression Treatment

Answer 28

Cognitive Behavioral Therapy – remission rates of 70%
Antidepressants – Black box warning for suicidality
* Highest risk in 1st 3 months of treatment
* Med guide with each prescription
* Antidepressants may lower completed suicide rate
Fluoxetine is the only antidepressant FDA-
approved to treat kids down to 8 years old
Escitalopram – 12 – 17 years old
Paroxetine – 1st antidepressant with suicidal thinking warning – avoid in kids

Question 29

Drug Treatment for Bipolar I, mixed or manic, without psychosis

Answer 29

Lithium, valproate, carbamazepine, olanzapine, risperidone, quetiapine; may augment with 2nd agent if needed after 4 weeks

Question 30

Drug Treatment for Bipolar I, mixed or manic, with psychosis

Answer 30

Lithium, valproate, carbamazepine WITH any atypical antipsychotic, consider d/c of atypical if remission for 12- 24 months

Question 31

Drug Treatment for Bipolar, depressed

Answer 31

1st line – lithium; SSRI/bupropion for depression that continues with lithium treatment (adjunct to lithium)

Question 32

Pediatric PTSD

Answer 32

Trauma-focused psychotherapy is the first-line treatment:
* TF-CBT – psychoeducation, relaxation, coping & processing, parenting skills
* TF- psychodynamic – personality coherence
SSRIs are first-line treatment

Question 33

Childhood Onset Schizophrenia

Answer 33

Use adult diagnostic criteria
Prominent hallucinations/delusions present for at least one month and not explained by substance use or PDD/autism
Visual hallucinations more common than in adults
Onset of symptoms before age 13
Rare in children, adolescent prevalence reaches adult prevalence of 0.5 – 1.0%

Question 34

FDA Approved Indications - Aripiprazole

Answer 34

Bipolar Disorder - 10 yr
Irritability with Autism - 6 yr
Schizophrenia - 13 yr
Tourette’s Disorder - 6 yr

Question 35

FDA Approved Indications - Asenapine

Answer 35

Bipolar Disorder - 10 yr

Question 36

FDA Approved Indications - Brexpiprazole

Answer 36

Schizophrenia - 13 yr

Question 37

FDA Approved Indications - Lurasidone

Answer 37

Schizophrenia - 13 yr
Bipolar Depression - 10 yr

Question 38

FDA Approved Indications - Olanzapine

Answer 38

Schizophrenia - 13 yr
Bipolar Disorder - 13 yr

Question 39

FDA Approved Indications - Olanzapine/Fluoxetine

Answer 39

Bipolar I Depression - 10 yr

Question 40

FDA Approved Indications - Paliperidone

Answer 40

Schizophrenia - 12 yr

Question 41

FDA Approved Indications - Quetiapine

Answer 41

Bipolar Disorder - 10 yr
Schizophrenia - 13 yr

Question 42

FDA Approved Indications - Risperidone

Answer 42

Bipolar Disorder - 10 yr
Irritability with Autism - 5 yr
Schizophrenia - 13 yr