PHRM845 Exam 4 (Ott) Flashcards
Pharmacotherapy of pediatric psychiatry
Medication use in pediatric psychiatry
-Psychiatric medications used in adults are often used in children without FDA approval and clinical evidence is often sparse
-Clinical trials are underway for many medications, efficacy sometimes questionable, but this population is a focus of significant clinical research
-Psychiatric diagnoses difficult in kids, with the exception of depression and ADHD–very specific diagnosis for children
-Addition of Disruptive Mood Dysregulation Disorder
-Kids have higher risk of significant adverse effects from medications than adults
-The same side effects occur, but at a greater rate (e.g., we think of aripiprazole as being a weight-neutral antipsychotic in adults, but averages 20 pounds weight gain in kids)
*strongly think about risk vs. benefit
Impact of living situation
-Recent studies and information provided by the GAO and Health and Human Services
that evaluated 2008 data in 5 states revealed that kids in foster care were 2.7 to 4.5 times
more likely to receive psychotropic medications
Reasons?
* Traumatic living situations leading to behavioral dysregulation?
* Removed from home into ward/foster care
* Loss of parents and siblings, no matter how dysfunctional
* Physical, emotional, sexual abuse
* Already have underlying psychiatric disorders?
* Treating a situation, not an illness?
*mental health conditions run in families
*Co-reactive attachment disorder: difficult to make connections in foster care
DSM-5 Tic disorders
Tourette’s Disorder
* 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
* Not attributable to substance use or another medical condition
Persistent (Chronic) Motor or Vocal Tic Disorder
* 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
* Not attributable to substance use or another medical condition
Provisional Tic Disorder: symptoms as above (single or multiple motor and/or vocal tics), but present for < 1 year
*can control tics for short period of time–stress builds up and we have to let people go to a safe/private place if they want.
Overview of tic disorders
Simple:
* Motor:eye blinking, shoulder shrugging, grimacing
* Vocal: coughing, throat clearing, grunting, barking, snorting
Complex:
* Motor:facial gestures, biting self, jumping
* Vocal: repeating words or phrases out of context, coprolalia (involuntary swearing or use of obscene language), echolalia (repetition of words spoken by another person), palilalia
(repeating complete words or phrases with decreasing volume and increasing speed)
Male predominance
10-25% of boys have transient tic symptoms
~75% also have ADHD, ~ 50% also have OCD–can treat tics and ADHD with stimulant, but may exacerbate tics
Genetics – 2/3 of patients will have relative with a tic disorder
-Rule of Thirds: 1/3 resolve, 1/3 improve, 1/3 stay the same - ~ 10% have persistent symptoms as adults (COUNSELING POINT! Meds do not work for 1/3 of pts)
Pharmacological tx of tics
First line
* Alpha-2 agonists
* Tics of mild-moderate severity (mildest in terms of SE)
* ~ 30% reduction
* Clonidine
* Guanfacine
* ER guanfacine
-Takes a little bit of time to see impact
Second line
* Atypical antipsychotics
* 30 – 60% reduction
* Aripiprazole
* Risperidone
Third line
* Typical antipsychotics (for the 1/3 that do not get better)
* ~ 80% reduction
* Haloperidol (most typical antipsychotic prescribed)
* Pimozide
Antipsychotics
Aripiprazole
-FDA-approved
-6-17 y/o (have a lot of safety data)
-Weight based dosing under 50 mg
Haloperidol
Risperidone/paliperidone
Stimulant Use in Tourette’s
-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.
*tell pt expectation (DO NOT expect a full recovery)
Oppositional Defiant Disorder
Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months
◦ If < 5 years old – behavior should occur on most days for at least 6 months
◦ If > 5 years – behavior at least once weekly for 6 months
◦ Associated with distress in the individual or others in his/her immediate social context–disruptive in family home/wherever they are staying
**usually first
Conduct Disorder
◦ 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
-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
**usually second
**they like people, but don’t care what happens to them
Tx of ODD and CD
-Conduct disorder can progress to
antisocial personality disorder in ~40% of patients
-Multimodal treatment including individual and family psychotherapy, pharmacotherapy, and social interventions
-Psychosocial interventions are first-line options
-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
-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
-If atypical antipsychotic treatment failure at 2 weeks, consider alternate atypical or typical antipsychotic or mood stabilizer
-Often see combination stimulant/alpha agonist treatment if ADHD with
impulsivity or need for sedation
for sleep
*if sx isn’t there, it is time to get rid of medicine
*Stimulant MUST be there
Separation anxiety disorder
Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached:
Persistent or excessive fear or worry:
* Distress when anticipating or experiencing separation
* Losing major attachment figure or about possible harm to them
* Experiencing an untoward event that causes separation
* Reluctance or refusal to go out, away from home, school
* Reluctance to be alone or without out major attachment figure
* Reluctance or refusal to sleep away from home
* Repeated nightmares with the theme of separation
* Complaints of physical symptoms (HA or stomachache) when separated
Lasting at least 4 weeks in children/adolescents and 6 months in adults
*Difficulty forming relationships due to fear of something happening to person leaving
Treatment of Separation Anxiety Disorder
-Treatment similar to other anxiety disorders
-Multimodal treatment including psychotherapy and medications
-Combination treatment > medication monotherapy > CBT monotherapy
-First-line treatment for mild anxiety is
psychotherapy with combination therapy for
moderate to severe anxiety
-SSRIs are the first-line drug therapy choice–only 2 with FDA approval (Fluoxetine and Escitalopram)
-Venlafaxine, TCAs, buspirone, benzodiazepines have been considered as
alternatives
-Treat co-morbidities (depression, ADHD,
screen for bipolar disorder)
Intellectual disability
Onset during developmental period that
includes intellectual and adaptive functioning
deficits
* Deficits in intellectual functions – reasoning, problem solving, planning, abstract thinking, judgment, academic learning, learning from experience
* Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. -Limited functioning in one or more activities of daily life.
* Onset of intellectual and adaptive deficits during the developmental period.
* Specify as mild, moderate, severe, profound
*Present from birth (may not be noticed that early)
*IQ score tells what level of cognitive function they are
Autism spectrum disorder
-Persistent deficits in social communication and social interaction across multiple contexts
~Social-emotional reciprocity; abnormal social approach; failure of normal conversation; reduced sharing of interests, emotions, affect; failure to initiate or respond to social
interactions
~Nonverbal communicative behaviors for social interaction; poorly integrated communication, abnormal eye contact or
body language, deficits in gestures, lack of facial expression
~Developing, maintaining and understanding relationships; difficulties adjusting behavior to suit social context
-Restricted, repetitive patterns of behavior, interests, activities
~Stereotyped or repetitive motor movements, use of objects, speech
~Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
~Highly restricted, fixated interests that are abnormal in intensity of focus (strong attachment to or preoccupation
with unusual objects)
~Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (apparent indifference
to pain/temperature, excessive smelling/touching of objects
*Ex: only talk about trains
Hallmark Signs & Symptoms of ASD
-Profound impairment in socialization, delayed or unusual communication, and repetitive
stereotyped behaviors and/or restricted interests
-Associated behavioral symptoms: aggression,
hyperactivity, inattention, irritability, mood instability, poor frustration tolerance, self-harm, severe temper tantrum, sleep
disturbances, OCD symptoms, hypersensitivity of senses
-Behavioral symptoms tend to increase with decreased verbal ability and must be present in the early developmental years
-Associated medical problems include seizure disorder (up to 30% have at least on seizure by
age 20) and GI disorders
-Intellectual disability has a high rate
of co-morbidity
-No medications have shown efficacy in treating the core ASD symptoms
*this is how kids get stuck on a bunch of meds
*Don’t know what the cause is
*Low dose risperidone or aripiprazole to help with hypersensitivity
