Pediatric Psychiatry

Question 1

Medication use in pediatric psychiatry

Answer 1

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

Question 2

DSM-5 tic disorders

Answer 2

Tourettes disorders: tics may wax and wane in frequency, but have been present for more than a year, onset before age 18

persistent motor or vocal tics : onset before age 18, patient present with one or the other symptom not both (must be present for more than a year)

Provisional tic disorder: must be present for more than a year and onset before age 18

Question 3

Overview of tic disorders

Answer 3

75% also have ADHD, 50% also have OCD

rule of thirds: 1/3 resolve, 1/3 improve, 1/3 stay the same - around 10% have persistent symptoms as adults

Question 4

First line treatment of tics

Answer 4

Clonidine, guanfacine, ER guanfacine

Question 5

Second line treatment of tics

Answer 5

Aripiprazole: approved for 6-17 years old, weight based dosing greater than 50kg 2mg daily x 2 days, 5mg daily x 5 days, target 10mg once daily, max 20mg
risperidone

Question 6

Third line treatment of tics

Answer 6

Haloperidol
pimozide

Question 7

DSM-5 oppositional defiant disorder

Answer 7

pattern of angry/irritable mood, argumentative behavior, or vindictiveness lasting at least 6 months
if older than 5 behavior should occur on most days for at least 6 months

Question 8

DSM-5 Conduct disorder

Answer 8

Repetitive persistent pattern of behavior in which the basic rights of others or societal norms or rules are violated with at least 3 of the following criterai present
- aggression to people and animals
- destruction of property
- deceitfulness or theft
- serious violation of rules

Specify whether:
childhood onset type: <10 years old
Adolescent onset type: > 10 years
Unspecified onset: unclear information to determine age at onset

Question 9

Treatment of ODD and CD

Answer 9

First choice : clonidine/ guanfacine
Second line: atypical antipsychotics to treat severe persistent aggression

EXAM Q treat underlying conditions (ADHD, depression/anxiety, mania) - ADHD common

Pharmacotherapy should only be considered adjunctive and only used after baseline symptoms have been determined or other interventions have failed

Often see combination stimulants/ alpha agonist treatment if ADHD with impulsivity or need for sedation for sleep

Question 10

Treatment of separation anxiety disorder

Answer 10

SSRIs are the first line drug therapy - EXAM Q
Fluoxetine - 8 years and older
Escitalopram - 12 years and older

first line treatment for mild anxiety is psychotherapy and combination for moderate to severe anxiety

Always treat co-morbidities

Question 11

DSM-5 autism spectrum disorder and symptoms

Answer 11

Persistant deficits in social communication and social interaction
restricted, repetitive patterns or behavior, interests, activities

symptoms include: aggression, hyperactivity, inattention, irritability, mood instability, self harm, sleep disturbance

no medications have shown efficacy in treating the core ASD symptoms

Question 12

Treatment of disruptive behaviors in ASD

Answer 12

First line is always applied behavioral analysis

Aripiprazole (6-17 years old) and risperidone (5-16 years old)

Question 13

Treatment of repetitive behaviors

Answer 13

haloperidol, risperidone, aripiprazole

Question 14

Treatment of ADHD

Answer 14

methylphenidate preferred
Clonidine/ guanfacine - modest effect

Question 15

Treatment of sleep problems

Answer 15

Melatonin 1-6mg nightly

Question 16

DSM-5 Disruptive modd dysregulation disorder (DMDD)

Answer 16

Severe recurrent temper outburts manifested verbally that are out of proportion with the intensity of the situation

Present in at least two of three settings (home, school, with peers)

diagnosis should not be made before age 6 or after age 18

Question 17

Treatment of DMDD

Answer 17

SSRIs and stimulants are considered to be first line treatment

need to differentiate from bipolar disorder

More similarity to depression, ADHD, or anxiety than bipolar disorder

Question 18

Pediatric depression

Answer 18

Children - physical complaints, irritability

Adolescents - express feelings of depression and suicidal behaviors more than younger ages

More chronic than episodic, instability in mood common

Question 19

Depression treatment

Answer 19

Nonpharm is first line: cognitive behavioral therapy

fluoxetine is the only antidepressant FDA approved to treat kids 8 years and older - EXAM Q
escitalopram 12 - 17 years old - EXAM Q

Black box warning for increased suicidal thought

Question 20

Pediatric bipolar disorder treatment

Answer 20

For all types of bipolar ( BP I with or without psychosis, and Bipolar, depressed)

Lithium is first line treatment - EXAM Q

Other treatment options for bipolar disorder
Aripiprazole - 10-17 yo
Asenapine 10-17 yo
Lurasidone 10-17 yo
olanzapine 13-17 yo
Olanzapine/fluoxetine (for bipolar I depression) 10-17 yo
Quetiapine 10-17yo
Risperidone 10-17 yo

Question 21

Pediatric post traumatic stress disorder

Answer 21

First line treatment is trauma focused therapy

First line treatment for pharmacotherapy is SSRIs
fluoxetine - 8 and older
escitalopram - 12 -17

Question 22

Childhood- onset schizophrenia

Answer 22

use adult diagnostic criteria

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

Treatment options
Aripirpazole 13-17 yo
Brexpiprazole 13-17 yo
Lurasidone 13-17 yo
Olanzapine 13-17 yo
Paliperidone 12-17 yo
Quetiapine 13-17 yo
Risperidone 13- 17 yo