Lecture 65 + 66 - Pharmacotherapy of Pediatric Psychiatry Flashcards
(42 cards)
Medication use in pediatric psychiatry
Kids have higher risk of significant adverse effects from medications than adults
DSM-5 Tic Disorders
tourette’s disorder
persistent (chronic) motor or vocal tic disorder
provisional tic disorder
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
Persistent (chronic) motor or vocal tie 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
Provisional Tic Disorder
sx as above, but present for < 1 year
Overview of Tic Disorders
~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
Pharmacologic Treatment of Tics - first line
- Alpha-2 agonists
- Tics of mild-moderate severity
- ~ 30% reduction
- Clonidine
- Guanfacine
- ER guanfacine
Pharmacologic Treatment of Tics - second line
- Atypical antipsychotics
- 30 – 60% reduction
- Aripiprazole
- Risperidone
Pharmacologic Treatment of Tics - third line
- Typical antipsychotics
- ~ 80% reduction
- Haloperidol
- Pimozide
Antipsychotics
pimozide, haloperidol, aripiprazole, risperidone/paliperidone, quetiapine, olanzapine, ziprasidone
Aripiprazole
FDA approved for ages 6-17 years old
weight based dosing for those less than 50 kg
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.
DSM-5 Oppositional Defiant Disorder
◦ Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months
DSM-5 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: 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
Treatment of ODD and CD
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
First choice for treating ODD and CD
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
Treatment of Separation Anxiety Disorder
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)
DSM-5 Autism Spectrum Disorder
Persistent deficits in social communication and social interaction across multiple contexts
Restricted, repetitive patterns of behavior, interests, activities
Hallmark Signs and Symptoms of ASD
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
Treatment of Disruptive Behaviors in ASD
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
Treatment of Repetitive Behaviors
Antipsychotics – haloperidol, risperidone, aripiprazole
Treatment of ADHD
Stimulants – methylphenidate preferred
Clonidine/guanfacine – modest effect on irritability and explosive behavior
Treatment of Sleep Problems
Melatonin reduced sleep latency and increased time asleep – give 1 – 6 mg nightly
DSM-5 Disruptive Mood Dysregulation Disorder (DMDD)
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
