Child and Adolescent psychiatric Disorders

Behavior modifications for ADHD?

parent training family therapy classroom interventions. for more behavioral interventions, read slide 44.

ADR of stimulants?

psychosis or mania aggression severe anxiety development of tics Reduce dose or stop stimulant therapy.

Criteria of DSM-IV for ADHD?

- Impairment in more than 1 setting - Information from parents, guardians, teachers, etc. - Rule out alternative cause

difference between sympotms in adults vs children < 17 yo.

6 or more must be present for children and 5 or more must be present for patients > 17 yo and adults.

Enuresis diagnosis?

> 5 years old. Must rule out GMC. Must occur at least twice a week for more than 3 months or significant distress/impairment in social, academic/occupational or other area of functioning.

Desmopressin acetate is preferred treatment in children when?

> 9 years old. Available in a nasal spray and oral tablet. NASAL SPRAY SHOULD NOT BE USED. ADR: seizure secondary to hyponatremia. Avoid complication by restricting evening fluids 1 hour before and 8 hours after medication administration. DO NOT USE ORAL TAB IN CHILDREN WITH INCREASED RISK OF HYPONATREMIA. Dose: 200 to 600 mcg every night. Takes 2 weeks to evaluate therapy.

What is the newest ADHD treatment?

Amphetamine sulfate (EVEKEO).

Pathophysiology of ADHD?

Decreased effectiveness of dopamine and/or NE in the PFC area of brain due to defective dopamine receptor 4. DRD4 receptors are primarily located in prefrontal area. Over expression of dopamine active transporter may be another cause.

How do central alpha-2a receptor agonist treat ADHD?

Decreases excessive arousal by blocking NE outflow. Increases blood flow to pre-frontal cortex. Does not cause/worsen tics. Use to treat tic disorders. May worsen depressive sympotms. Especially effective for ADHD with aggressiveness, disruptive behavior and insomnia.

Which of the following drugs is more potent in stunting growth among children? a. Dextroamphetamine b. MPH

Dextroamphetamine > MPH in first year. ensure to give a drug free trial every year to assess necessity of medication.

Antidepressant therapy indicated for individuals >12 yo?

Escitalopram

Effect of conventional antipsychotics on ADHD?

Improve symptoms of hyperactivity and impulsivity. Can have negative effects on learning and cognitive functioning. Can cause extra pyramidal Side effects. Can cause endocrine disorders.

Role of TCA in ADHD treatment?

Inhibits NE and 5-HT reuptake. 3rd line agents due to side effects.

According to the Amecian Academy of Pediatrics, ADHD is a chronic condition. True or False.

True.

The only antidepressant pharmacotherapy that is indicated for children with depression?

Fluoxetine

antidepressant for the treatment of OCD?

Fluoxetine, sertraline and fluvoxamine (strong fufu).

Areas of the brain affected by decreased brain volume?

- Right Prefrontal Cortex - Caudate Nucleus - Anterior Cingulate Gyrus - Cerebellum

Which sex is mostly diagnosed with ADHD?

Male over females.

The most common childhood psychiatric condition?

ADHD xterized by developmentally inappropriate inattention, impulsivity and or hyperactivity.

Mental disorders that can coexist with bipolar disorder in childhood and adolescence?

ADHD, Anxiety Disorders, Conduct disorders, Oppositional Defiant Disorder, Substance abuse and Learning disabilities.

Which therapy is given to combat headache?

APAP (preferred) or Ibuprofen.

Major depressive disorder treatment should include the following?

Acute, continuation and possibly a maintenance phase. Supportive management Psychotherapy (cognitive behavioral therapy or interpersonal therapy) IF RESPONSE IS NOT SUFFICIENT, PHARMACOTHERAPY IS INDICATED.

What kind of diet are ADHD patients recommended to follow?

Allergy Elimination Diet. Feingold Diet.

If irritability/jitteriness occurs?

Assess for comorbid condition like bipolar disorder and reduce dosage or consider mood stabilizer or atypical antipsychotic.

Non stimulant therapy to ADHD?

Atomexetine (STRATTERA), Bupropion (WELLBUTRIN), TCA (imipramine, desipramine, nortiptyline), Alpha 2a agonists (clonidine, guanfacine), Atypical antipsychotics.

Before recommending TCA to a child, what step must be considered?

Baseline electrocardiogram recommended before initiation.

Treatment for Oppositional Defiant Disorder Treatment?

Behavioral modification first. Then pharmacotherapy adjunctive. Mood stabilizers like (lithium carbonate and divalproex), Antipsychotics or stimulants.

MOA of stimulants?

Blocks reuptake of dopamine and norepinephrine. Increase catecholamine release. Inhibit MAO (Methylphenidate > amphetamine).

Most common type of ADHD subtypes are?

Combined type.

If rebound symptoms occur?

Consider longer-acting stimulant trial like atomoxetine or antidepressant.

What therapy is given to combat reduced appetite and weight loss?

Cyproheptadine. Also effective for insomnia issues.

Suicidal attempts, melancholic symptoms and delusions are common in both depressed adults and children: True/False.

False. Only adults experience such symptoms. Children experience boredom, anxiety, failing adjustment and sleep disturbance.

Environmental insults to ADHD?

Lead, pesticides, ETOH, tobacco smoke.

The most frequently prescribed therapy for ADHD?

Methylphenidate products. Next is amphetamine then atomoxetine.

Therapy to treat ADHD aggression and explosive behavior?

Mood Stabilizers. E.g; Lithium, Anticonvulsants (valporate, oxcarbazepine, Carbamazepine). Remember Mood stabilizers are not effective for inattentive sub-type of ADHD.

Tools for diagnosing ADHD?

NICHQ vanderbilt Assessment Scale (parents and teachers) 2. Conners adult ADHD rating scales 3. Neuropsychiatric EEG-Based Assessment Aid (NEBA) 4. Computerized Neurocognitive batteries.

Preferred/1st line treatment for enuresis?

Non Pharmacological: fluid restriction after 6 pm. Reward dry nights, lifting and waking often, bed wetting alarm. Pharmacological treatment: Desmopressin Acetate.

Onset of ADHD?

Onset typically by age 3 and must occurs by age 12 or younger. 6 or more of the symptoms must be present for 6 months. Significant impairment must be seen in 2 or more settings. maladaptive and inconsistent with developmental level.

Treatment for Tourette's disorder?

Pharmacotherapy: -alpha 2 receptor agonist (clonidine and guanfacine) 2. Antipsychotics/ Neuroleptics like; Dopamine (most effective), Atypical antipsychotics (risperideone-most studied and Pimozide), Typical (Haloperidol - most studied and less cardiac toxicity than pimozide).

What are the common side effects of stimulants?

Reduced appetite, weight loss, stomach ache, insomia, Headache, rebound symptoms, irritability/jitteriness.

What is the pharmacotherapy of choice for Anxiety disorder?

SSRIs. others are SSNRI, TCA, Buspirone, BZD, Hydroxyzine pamoate.

Pharmacotherapay for ADHD?

Stimulants Atomoxetine Non stimulants

Pharmacotherapy to Conduct disorder?

Stimulants, Mood stabilizers, central alpha 2a receptor agonist, antipsychotics, antidepressants.

What is the first line treatment for ADHD?

Stimulants. All subclass equally effective.

Anxiety Disorder?

Symptoms: fear and worry. Complaints: headache or stomach ache. Treatment: Initial therapy - Psychotherapy.

Which therapy is mostly preferred to reduce abuse of ADHD medication?

VYVANSE (lisdexamfetamine). It is a prodrug. It can not be injected. FOCALIN XR is recommended due to its low adverse effects.

What are atypical antipsychotics used for in ADHD?

to control severe aggression in refractory cases of ADHD especially when bipolar disorder is a comorbid condition. causes metabolic side effects and endocrine disorders.