Pediatric psych

Question 1

How many children with ADHD outgrow their ADHD

Answer 1

50%

Question 2

What is ADHD most commonly comorbid with

Answer 2

classic triad of ADHD, tic disorder and OCD

oppositional defiant disorder (ODD) in 50% ADHD cases

conduct disorder (CD) in 20% ADHD cases

substance use disorder

learning disability (reading disability in 25% ADHD cases; other learning disability in 50% ADHD cases)

Question 3

Progression of ADHD

Answer 3

common progression pattern of ADHD -> ODD -> CD -> antisocial personality disorder

Question 4

ADHD DSM 5 criteria

Answer 4

A) persistent inattention and / or hyperactivity-impulsivity that interfere with functioning or development inattention if 6+ of the following symptoms for 6+ months (5+ symptoms for adolescents and adults age >17)

• hyperactivity and impulsivity if 6+ of following symptoms for 6+ months (5+ symptoms for adolescents and adults age 17+)
• impulsivity

B) symptoms present prior to age 12 years

C) symptoms present in 2+ settings (home, school, work, activities, family, friends)

D) interference with psychosocial function

E) other psychiatric disorder ruled out

Question 5

ADHD treatment

Answer 5

1st line medications - long acting psychostimulant:
mixed amphetamine salt (Adderall)
methylphenidate controlled release (Biphentin)
methylphenidate OROS (Concerta)
lisdexafetamine (Vyvanse)
1st line psychostimulants are long acting and have less peaks and trough
Vyvanse is a pro-drug and thus cannot be abused

2nd line - selective norepinephrine reuptake inhibitor (NRI) Atomoxetine (Strattera)
non stimulant
once titrated to effective dose, Atomoxetine last the entire day

3rd line medication - intermediate and short acting psychostimulants:
methylphenidate (Ritalin)
dextroamphetamine (dexedrine, Dex, Spansules)
Guanfacine XR (Intuniv XR)

4th line - off label antidepressants including TCA (imipramine), NDRI (bupropion), Modafinil

Question 6

Psychotherapy for ADHD

Answer 6

CBT

IPT

Family therapy

Question 7

DSM 5 criteria ODD

Answer 7

A) angry / irritable mood, argumentative / defiant behaviour or vindictiveness for 6+ months with 4+ symptoms during interactions with 1+ person who is not a sibling
angry / irritable mood
often loses temper
often touchy or easily annoyed
often angry and resentful
argumentative / defiant behaviour
argue with authority figure or adult
actively defies or refuses to comply with rules or request from authority figure
often deliberately annoys others often blames others for his or her mistakes or behaviours
vindictiveness
spiteful or vindictive for 2+ times in last 6 months

the symptoms need to be persistent and frequent in order to distinguish from normal behaviour

if <5 years old, then need to have symptoms most days for 6+ months
if >5 years old, then need to have symptoms at least weekly for >6 months

B) disturbance in behaviour leads to distress in people around the individual or impair psychosocial function

C) substance use, psychiatric disorder ruled out (does not meet criteria for disruption mood dysregulation disorder (DMDD))

Question 8

ODD management

Answer 8

no medication recommended for ODD by itself

Psychosocial Intervention
outpatient psychological interventions include individual therapy including anger management, self expression and cognitive behavioural therapy

family counselling to improve family communication, relationship and help family work together

parent training multi system community based therapy where teams go into homes for interventions

Prevention for children at risk of ODD

Question 9

Conduct disorder DSM 5 diagnostic criteria

Answer 9

A) repetitive and persistent behaviour that violate basic rights of others or major age-appropriate societal norms or rules with 3+ of the following symptoms in past 12 months and 1+ in past 6 months
aggression to people and animals:
bullies, threatens or intimidates others
initiates physical fights
used weapon that can cause serious physical harm to others such as gun, bat, knife
physically cruel to people or animals
stolen while confronting victim such as mugging, extortion
forced someone into sexual activity

destruction of property:
fire setting with intention of causing serious damage
destroyed other’s property

deceitfulness or theft:
broken into house, building or car
lies to obtain goods or favours or avoid obligation
stolen without confronting victim such as shoplifting

serious violation of rules
stays out at night despite parental prohibition
ran away from home
truancy from school

B) disturbance in behaviour impair psychosocial function

C) if 18+ years, antisocial personality disorder criteria was not met

Question 10

Usual onset of CD

Answer 10

Onset rarely after age 16

Question 11

CD management

Answer 11

Medication

always treat comorbidities first

if CD symptoms alone:
if impulsivity or aggression: mood stabilizer, neuroleptic (i.e. antipsychotic) or clonidine
if hyperactivity: psychostimulants or clonidine

Psychosocial Interventions

effective psychosocial interventions include cognitive problem solving, skills training, parent management training, family therapy, multi systemic therapy: intensive family and community based treatment addressing external anti-social behaviour of youth

therapists on call and visit / counsel child in their natural environment

facilitate good relationship with 1 adult as positive role model

other psychosocial interventions include academic support or special education find suitable placement if being abused

Question 12

Most common comorbidities associated with ASD

Answer 12

language disorder

learning disability

ADHD

intellectual disability

Question 13

DSM 5 criteria for ASD

Answer 13

A) Persistent deficit in social communication and interaction in multiple contexts, as manifested in all of the following

deficit in social-emotional reciprocity (ability to engage with others and share thoughts & feelings)

deficit in nonverbal communication behaviour used in social interaction including coordination of non-verbal behaviours

deficit in developing, maintaining and understanding relationships

B) Restricted and repetitive behaviour, interests or activities, as shown by 2+ of the following

stereotyped or repetitive motor movement, use of object or speech motor stereotypes

insistence on sameness

highly restricted, fixated interests that are abnormal in intensity or focus

hyper or hypo-activity to sensory input or unusual interest in sensory aspect of environment

C) symptoms present in early developmental period (by age 4)

D) symptoms impair psychosocial functioning

E) intellectual disability and global developmental delay are ruled out

Question 14

Management for ASD

Answer 14

Gold standard is applied behavioural analysis (ABA) operant conditioning

atypical antipsychotics (risperidone and aripiprazole) to treat irritability, tantrum, aggression and self-injurious behaviour if present

Risperidone can improve repetitive behaviours

Question 15

Components of presentation of depression in children that is different than adults

Answer 15

Irritable/behavioural problems

School refusal

Somatic complaints

Auditory hallucinations

Question 16

Components of presentation of depression in adolescents that is different than adults

Answer 16

Substance use and impulsive behaviours

hypersomnia and hyperphagia

delusions

Hypersomnia, psychomotor retardation and abrupt onset suggest bipolar affective disorder

Question 17

Management of pediatric depression

Answer 17

mild to moderate depression:
1st line = cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT)
2nd line = antidepressant

for severe depression:
1st line = antidepressant with CBT
if no response after adequate trial of SSRI, switch to another SSRI

for 1st depression episode, treat for at least 6 months
for 2nd depression episode, treat for at least 1 year
for >2 depression episodes, treat 1-3 years or indefinitely

Question 18

What type of antidepressants are contraindicated in children

Answer 18

tricyclic antidepressants are ineffective, associated with serious adverse effects and are contraindicated in children

Question 19

What is the only antidepressant approved for use in children

Answer 19

SSRI Fluoxetine (Prozac) is the only antidepressant approved by FDA for depression in children under 12 years of age

other SSRI used off label for depression in children and adolescents include Sertraline, Citalopram and Escitalopram

Fluoxetine has advantage of being available in a liquid format and easy titration

Question 20

What is a risk of starting SSRI in children

Answer 20

antidepressants increase risk of suicide in the short term in children

when starting antidepressants, develop safety plan with patient and parents including keeping safe and contact physician if strong suicidal urges

when starting antidepressants, close monitoring (weekly for 1st month, every 2 weeks during 2nd month) recommended for treatment emergent suicidality

Question 21

Management of depression with psychotic features in pediatric population

Answer 21

pediatric patients suffering from depression with psychotic feature have high risk of suicide, so require inpatient psychiatric admission

in pediatric patients, depression with psychotic features usually treated with antidepressant and antipsychotic

Question 22

DSM 5 criteria for disruptive mood dysregulation disorder

Answer 22

A) severe recurrent temper outburst verbally and / or behaviourally, which are out of proportion to situation or provocation

B) temper outburst inconsistent with developmental level

C) temper outbursts occur 3+ times per week

D) mood between temper outbursts is persistently irritable or angry most of the day nearly everyday

E) A-D present for 1+ year, where patient was never symptom free for 3+ months

F) A-D present in 2+ settings (home, school, peer)

G) diagnosis should not be made for the first time between age of 6 years and 18 years

H) onset of symptoms <10 years

I) no distinct period lasting 1+ day of manic or hypomanic episode

J) behaviour do not occur exclusively during major depressive disorder or another mental disorder (ASD, PTSD, separation anxiety disorder, persistent depressive disorder)

K) substance, medication, medical condition ruled out

Question 23

What is a classic anxiety disorder triad in the pediatric population

Answer 23

generalized anxiety disorder

social anxiety disorder

separation anxiety disorder with panic features

Question 24

Management of anxiety disorder in pediatric population

Answer 24

1st line = psychosocial interventions including talk therapy (psychoeducation, CBT, IPT), school interventions

2nd line = antidepressants (SSRI preferred over tricyclic antidepressant)

atypical antipsychotic or benzodiazepine may be added as last line

benzodiazepine less commonly used due to risk of dependency and disinhibition, so usually only used short term for acute anxiety or to bridge effect of SSRI

for specific phobia, consider benzodiazepine PRN instead of antidepressants as 2nd line

for selective mutism, consider cognitive approaches (positive reinforcer, modelling, systematic desensitization, in-vivo exposure, in-vivo graded exposure) or adding antidepressants

Question 25

DSM 5 criteria separation anxiety disorder

Answer 25

A) developmentally inappropriate and excessive fear or anxiety concerning separation from those the individual is attached to (e.g. parents), as evidenced by 3+ of the following
distress when anticipating or experiencing separation
persistent and excessive worry about losing major attachment figures
persistent and excessive worry about experiencing an untoward event that cause separation
reluctance or refusal to go out elsewhere due to fear of separation
reluctance of being alone or without major attachment figure
reluctance to sleep away not near major attachment figure
repeated nightmares with theme of separation
complaints of physical symptoms (headache, stomachache, nausea, vomiting) when separated from major attachment figure

B) fear, anxiety or avoidance is persistent 4+ weeks in children <18 years of age or 6+ months in adults

C) disturbance cause distress and impair psychosocial function

D) other psychiatric disorder ruled out

note that children diagnosed with separation anxiety disorder should be >5 years old, because presentation of separation anxiety is appropriate for children <5 years old

Question 26

Truancy vs school refusal

Answer 26

truancy is associated with antisocial behaviour, absence of emotional distress, unwillingness to do school work, concealment from parents and not staying at home during school hours

school refusal is not associated with antisocial behaviour, presence of emotional distress, willingness to do school work, no concealment from parents and staying at home during school hours

Question 27

School refusal management

Answer 27

CBT and behavioural interventions (mostly exposure therapy)

pharmacotherapy if needed, mainly for psychiatric symptoms
pharmacotherapy never used as sole intervention
SSRI (fluvoxamine, sertraline) 1st line treatment for anxiety symptoms causing school refusal
Benzo PRN short term can also be used to address anxiety symptoms