Child and Adolescent Child and Adolescent PsychiatryPsychiatry

Howard Liu, M.D. Howard Liu, M.D. Psychiatry Clerkship DirectorPsychiatry Clerkship Director

Child & Adolescent Psychiatry Child & Adolescent Psychiatry UNMC UNMC

402-552-6006402-552-6006hyliu@unmc.eduRevised 3.15.12Revised 3.15.12

Normal Development

Goals / Objectives Goals / Objectives • Review common diagnoses in pediatric Review common diagnoses in pediatric

mental health mental health

• Recognize epidemiology of major Recognize epidemiology of major disorders disorders

• Recall first line treatment guidelines Recall first line treatment guidelines

What will we cover? What will we cover?

• ADHD ADHD

• Pediatric Bipolar Disorder Pediatric Bipolar Disorder

• Anxiety Disorders Anxiety Disorders

• Autism Autism

• Eating disorders Eating disorders

• Substance abuse Substance abuse

Fred Rogers Fred Rogers

• ““Play is often talked Play is often talked about as if it were a about as if it were a relief from serious relief from serious learning. But for learning. But for children play is children play is serious learning. serious learning. Play is really the Play is really the work of childhood.” work of childhood.”

Child Psychiatry Interview Child Psychiatry Interview Pearls Pearls

• Manage the room Manage the room

• Ask intimate questions privately Ask intimate questions privately

• Be able to “surf” from shallow to deep Be able to “surf” from shallow to deep

• Start with social history Start with social history

• Safety is #1 priority Safety is #1 priority

ADHDADHD

Pop Quiz: ADHD Pop Quiz: ADHD According to the largest study of ADHD According to the largest study of ADHD

to date (the MTA trial), which was the to date (the MTA trial), which was the most effective treatment for ADHD in most effective treatment for ADHD in kids after 1 year? kids after 1 year?

A.A.Stimulant medication Stimulant medication

B.B.Behavioral therapy Behavioral therapy

C.C.School intervention School intervention

D.D.Stimulant + Behavioral therapyStimulant + Behavioral therapy

E.E.Low sugar dietLow sugar diet

Elementary School child with ADHD

Epidemiology of ADHD in Epidemiology of ADHD in ChildrenChildren• Prevalence is ~ 9.5% of children, Prevalence is ~ 9.5% of children,

• 2/3 treated2/3 treated

• Males > Female by 4:1 Males > Female by 4:1

• Life course Life course – Hyperactivity Hyperactivity , Inattention persists , Inattention persists

• High comorbidity (2/3) High comorbidity (2/3) – ODD, learning disorder, smoking, etc. ODD, learning disorder, smoking, etc.

CDC National Survey Children’s Health 2007-2008 – 70,000 parents

Practice Parameter for the Assessment & Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. JAACAP 2007;46(7): 894-921

Diagnostic Criteria for ADHDDiagnostic Criteria for ADHD((DSM-IV)DSM-IV)

• Must occur before age 7 yearsMust occur before age 7 years

• Present for at least 6 monthsPresent for at least 6 months

• Causes impairment in at least 2 settingsCauses impairment in at least 2 settings

• Meets 6 of 9 symptoms of inattention Meets 6 of 9 symptoms of inattention AND/OR AND/OR

• 6 of 9 symptoms of 6 of 9 symptoms of hyperactivity/impulsivityhyperactivity/impulsivity

Diagnosis: Inattentive SubtypeDiagnosis: Inattentive Subtype• Careless mistakes in schoolwork Careless mistakes in schoolwork

• Poor attention in tasks or playPoor attention in tasks or play

• Doesn’t listen when spoken to directlyDoesn’t listen when spoken to directly

• Fails to finish things (not oppositional or unable)Fails to finish things (not oppositional or unable)

• Difficulty organizingDifficulty organizing

• Avoids/dislikes tasks requiring focusingAvoids/dislikes tasks requiring focusing

• Loses necessary itemsLoses necessary items

• Distracted by extraneous stimuliDistracted by extraneous stimuli

• Forgetful in daily activitiesForgetful in daily activities

Diagnosis: Hyperactive-Diagnosis: Hyperactive-ImpulsiveImpulsive

• Fidgets with hands/feet or squirms in seatFidgets with hands/feet or squirms in seat• Often leaves seat when inappropriateOften leaves seat when inappropriate• Runs about or climbs excessively when Runs about or climbs excessively when

inappropriateinappropriate• Difficulty playing quietlyDifficulty playing quietly• Often “on the go” or acts as if “driven by a Often “on the go” or acts as if “driven by a

motor”motor”• Often talks excessivelyOften talks excessively• Blurts answers before question completedBlurts answers before question completed• Difficulty awaiting turnDifficulty awaiting turn• Often interrupts or intrudes on othersOften interrupts or intrudes on others

TreatmentsTreatments

• Stimulant medications – 1Stimulant medications – 1stst line (MTA) line (MTA)

• Alternative non-stimulant medicationsAlternative non-stimulant medications

• PsychoeducationPsychoeducation

• Community supportCommunity support

• Behavioral interventionsBehavioral interventions

• School interventionsSchool interventions

Stimulant Medications: EfficacyStimulant Medications: Efficacy

• One of the most robust treatments in One of the most robust treatments in psychiatrypsychiatry

• 70% of children with ADHD will respond to any 70% of children with ADHD will respond to any one of the stimulants, all generally equal one of the stimulants, all generally equal efficacyefficacy

• An additional 20% will respond to the next one An additional 20% will respond to the next one attemptedattempted

• If the 1st and 2nd choices fail, check for wrong If the 1st and 2nd choices fail, check for wrong diagnosis and/or comorbiditydiagnosis and/or comorbidity

Medical Issues

• Growth: Faraone meta-analysis: – after 2-3 years on stimulants, kids were 1-2.5 cm

shorter – Growth rate increases when stimulants stopped

• Cardiac Risk – AHA: 1999 guidelines – no routine EKG – AHA: 2008 guidelines – ‘‘...it is reasonable for a

physician to consider obtaining an ECG as part of the evaluation of children being considered for stimulant drug therapy, but this should be at the physician’s judgment, and it is not mandatory to obtain one”

Bipolar disorderBipolar disorder

Pop Quiz: BipolarPop Quiz: BipolarA 14 year old girl is being treated for A 14 year old girl is being treated for

pediatric bipolar disorder, when she pediatric bipolar disorder, when she develops breast tenderness and develops breast tenderness and galactorrhea. Which medication is she galactorrhea. Which medication is she most likely taking? most likely taking?

A.A.Carbamazepine Carbamazepine B.B.Risperidone Risperidone C.C.LithiumLithiumD.D.Valproic Acid Valproic Acid E.E.Topiramate Topiramate

Diagnosis

• Mania: – Mood + 3 or 4 symptoms – D - Distractibility – I – Indiscretion (pleasurable activities) – G – Grandiosity– F – Flight of Ideas– A – Activity increases – S – Sleep deficit – T – Talkativeness (pressured)

• Developmental symptoms

Faust, DS et al. Diagnosis and Management of Childhood BPD in the Primary Care Setting. Clinical Pediatrics 2006;Vol. 45(9): 801-808.

FDA-Indicated Medications for PBD

• Approved down to age 12 years for acute mania and maintenance therapy– Lithium: grandfathered in based on adult literature

• Approved only for acute treatment of manic/mixed episodes in children aged 10-17 years – Risperidone: 2007 – Aripiprazole: 2008 – Quetiapine: 2008

• Approval in process– Olanzapine – Ziprasidone

Anxiety Disorders Anxiety Disorders

9 / 11 Attack 9 / 11 Attack

Common Anxiety Disorders

•Separation anxiety– Anxiety about separation from loved one – School refusal, somatic complaints – Risk factor panic disorder, agoraphobia

•PTSD – Preschool alternative criteria: less play

•OCD

•Panic disorder

•Generalized anxiety disorder

•Specific phobia / Social phobia

Treatment

•CBT – 1st line, often in combo with medication – Exposure & response prevention

•Medications – OCD: SSRI (POTS), clomipramine, augmentation – PTSD: SSRI, SGA (hyperarousal)– Panic / Separation anxiety / Social phobia / GAD :

•SSRI (RUPP study fluvoxamine)

•Pearl: for anxiety, always use CBT + SSRI

PERVASIVE DEVELOPMENTAL PERVASIVE DEVELOPMENTAL DISORDERSDISORDERS

Asperger’s Video Asperger’s Video

Pop Quiz: Autistic savants Pop Quiz: Autistic savants Kim Peek was the mega savant that Kim Peek was the mega savant that

inspired “Rain Man.” What is his inspired “Rain Man.” What is his prodigious skill? prodigious skill?

A.A. Near perfect recall of 12,000 books Near perfect recall of 12,000 books

B.B. Ability to hear any song and reproduce it Ability to hear any song and reproduce it on the piano on the piano

C.C. Ability to sculpt a perfect replica of any Ability to sculpt a perfect replica of any animal he sees animal he sees

D.D. Recitation of Pi from memory to 22,514 Recitation of Pi from memory to 22,514 digitsdigits

Pervasive Developmental Pervasive Developmental DisordersDisorders• Definition: Definition:

– Group of psychiatric conditions in which expected Group of psychiatric conditions in which expected social skillssocial skills, , language developmentlanguage development, and , and behavioral behavioral repertoire repertoire either don’t develop or are lost in early either don’t develop or are lost in early childhoodchildhood

• Early in life (by age 2) Early in life (by age 2)

• Cause persistent dysfunction Cause persistent dysfunction

• Often associated with mental retardation (50%) Often associated with mental retardation (50%)

• Spectrum of severity Spectrum of severity

DiagnosisDiagnosis

• History – early development, age of onset, family and medical history History – early development, age of onset, family and medical history – AAP 2007: screen AAP 2007: screen all kids all kids 18 months, age 2 18 months, age 2

• Developmental & psychological assessment Developmental & psychological assessment – Intelligence, learning Intelligence, learning – Communication – language, nonverbalCommunication – language, nonverbal– Adaptive behavior – generalize skills to real world Adaptive behavior – generalize skills to real world – OT / PT as needed OT / PT as needed

• Psychiatric exam Psychiatric exam – Social relatedness, behavior, language, play skills Social relatedness, behavior, language, play skills

• Medical – genetics, seizures, hearing, etc. Medical – genetics, seizures, hearing, etc.

EpidemiologyEpidemiology• Autistic Disorder Autistic Disorder

– Prevalence: 2.5 to 72 per 10,000 childrenPrevalence: 2.5 to 72 per 10,000 children– Distributed equally among all socioeconomic levelsDistributed equally among all socioeconomic levels– Male to female ratio 3:1Male to female ratio 3:1– Genetic cause Genetic cause – Debunked thimerosol, MMR vaccine theory Debunked thimerosol, MMR vaccine theory – Lifetime cost of care: $3 million Lifetime cost of care: $3 million

• Asperger’s disorder Asperger’s disorder – Prevalence: 4.3 per 10,000 Prevalence: 4.3 per 10,000 – Male to female ratio 10:1Male to female ratio 10:1

Autistic disorderAutistic disorder• 6 items from 3 categories 6 items from 3 categories

– Category 1: Social impairment Category 1: Social impairment •Nonverbal impairment (eye contact ,facial expression, posture, etc.) Nonverbal impairment (eye contact ,facial expression, posture, etc.)

•Peer relationships (not same age kids, often younger) Peer relationships (not same age kids, often younger)

•Lack of sharing interests with others Lack of sharing interests with others

•Lack of social or emotional reciprocityLack of social or emotional reciprocity

– Category 2: Communication – language, speechCategory 2: Communication – language, speech– Category 3: Restricted patterns of behavior, interest, Category 3: Restricted patterns of behavior, interest,

activities activities • intense interest 1 area, rigid, flapping hands, partsintense interest 1 area, rigid, flapping hands, parts

Asperger’s disorder – like Asperger’s disorder – like “WALL-E” “WALL-E” • Social impairment – but they want friends Social impairment – but they want friends

• Repetitive patterns of behavior Repetitive patterns of behavior – Star Wars, machines, World of Warcraft, etc. Star Wars, machines, World of Warcraft, etc.

• NO language delay NO language delay – often advanced speech – “Little Professor” often advanced speech – “Little Professor”

• ““High functioning autism” High functioning autism” – normal to high normal intelligence normal to high normal intelligence

Other PDD Disorders Other PDD Disorders • Rett’s Rett’s

– Girls > boys (boys often die in infancy) Girls > boys (boys often die in infancy) – Normal prenatal & perinatal Normal prenatal & perinatal – Head growth decelerates, 5-48 mos., usually Head growth decelerates, 5-48 mos., usually

before 1 year old before 1 year old – Loss of abilities, MR, languageLoss of abilities, MR, language– Motor deterioration, sudden death Motor deterioration, sudden death

• Childhood Disintegrative Childhood Disintegrative – Normal development x 2 years Normal development x 2 years – Loss of prior skills – language, social skills, bowel/bladder, play, motor skills Loss of prior skills – language, social skills, bowel/bladder, play, motor skills

Autistic DisorderAutistic DisorderTreatmentTreatment

• No cure for autistic disorderNo cure for autistic disorder• Primary goalsPrimary goals

– promote social and communication skillspromote social and communication skills– reduce maladaptive behaviorsreduce maladaptive behaviors– alleviate family stressalleviate family stress

• Best interventions are educational and behavioralBest interventions are educational and behavioral– Applied Behavior Analysis (ABA), Early Intervention Applied Behavior Analysis (ABA), Early Intervention – Evidence for efficacy in increasing IQ (Early Start Evidence for efficacy in increasing IQ (Early Start

Denver Model) Denver Model)

• Pharmacotherapy to target specific symptoms:Pharmacotherapy to target specific symptoms:– Antipsychotics, stimulants, SSRI’s Antipsychotics, stimulants, SSRI’s – ““Start low, go slow” Start low, go slow”

Eating Disorders Eating Disorders

Pop Quiz: Eating DisordersPop Quiz: Eating DisordersWhat is the % body weight below which What is the % body weight below which

one qualifies for anorexia nervosa? one qualifies for anorexia nervosa?

A.A.90% 90%

B.B.85%85%

C.C.80% 80%

D.D.75% 75%

E.E.70%70%

Anorexia Nervosa Anorexia Nervosa

• DSM DSM – Body weight < 85% expected or failure to gain Body weight < 85% expected or failure to gain

expected weight expected weight – Intense fear of gaining weight Intense fear of gaining weight – Denial, distorted body image Denial, distorted body image – Amenorrhea (3 consecutive cycles lost) Amenorrhea (3 consecutive cycles lost)

• ClinicalClinical– Often high achievers, athletesOften high achievers, athletes– Very rigid Very rigid

Bulimia nervosa Bulimia nervosa

• DSM DSM – Recurrent binges (lack of control, greater portion) Recurrent binges (lack of control, greater portion) – Recurrent purging (vomiting, laxatives, fasting, Recurrent purging (vomiting, laxatives, fasting,

excessive exercise) excessive exercise) – Binging and purging occur at least twice weekly for Binging and purging occur at least twice weekly for

3 months 3 months – Self image is unduly influenced by weight/shapeSelf image is unduly influenced by weight/shape– Does not occur during episodes of anorexia nervosa Does not occur during episodes of anorexia nervosa

Treatment

• Anorexia – Highest mortality rate of all mental illness – 5-10% die within 10 years, 18-20% within 20 years – Recovery: 1/4 get better, 1/4 worse, 1/2 partial recovery – Team approach:

• Therapy, pediatrician, residential treatment

•Lack of resources

• Bulimia – Best evidence for CBT – SSRI is helpful

Substance AbuseSubstance Abuse

Teen drinking Teen drinking

Pop Quiz: Substance abusePop Quiz: Substance abuseWhich teen movie stars a celebrity who Which teen movie stars a celebrity who

has has NOTNOT been convicted of a DUI? been convicted of a DUI?

A.A.Transformers Transformers

B.B.Mean Girls Mean Girls

C.C.Braveheart Braveheart

D.D.House of Wax House of Wax

E.E.Superbad Superbad

EpidemiologyEpidemiology

• Monitoring the Future 2008 Survey Monitoring the Future 2008 Survey

- 46,000 8- 46,000 8thth, 10, 10thth, 12, 12thth graders graders – NIDA, U of Michigan NIDA, U of Michigan – Any drug use: lifetime 20% 8Any drug use: lifetime 20% 8thth grade, 47% seniors grade, 47% seniors– Declining: Cigarettes, stimulants, alcohol Declining: Cigarettes, stimulants, alcohol – Steady: MarijuanaSteady: Marijuana– Increasing: prescription pillsIncreasing: prescription pills

•Almost Almost 10%10% of seniors had used vicodin in the past year! of seniors had used vicodin in the past year!

Teen Substance Abuse Teen Substance Abuse

• Abuse: 1 or more over 12 months Abuse: 1 or more over 12 months – Fail to meet expectations at work, school, or Fail to meet expectations at work, school, or

home home – Using when it’s dangerous (driving) Using when it’s dangerous (driving) – Legal problems that are substance related Legal problems that are substance related – Keep using despite repetitive problems Keep using despite repetitive problems – Occurs over 12 month period Occurs over 12 month period

Abuse vs. Dependence Abuse vs. Dependence

• Abuse: 1 or more over 12 months Abuse: 1 or more over 12 months – Fail to meet expectations at work, school, or Fail to meet expectations at work, school, or

home home – Using when it’s dangerous (driving) Using when it’s dangerous (driving) – Legal problems that are substance related Legal problems that are substance related – Keep using despite repetitive problems Keep using despite repetitive problems – Occurs over 12 month period Occurs over 12 month period

Abuse vs. Dependence Abuse vs. Dependence

• Dependence: 3 or more over 12 months Dependence: 3 or more over 12 months – Tolerance – need to use moreTolerance – need to use more– Withdrawal Withdrawal – Use larger amount than intended Use larger amount than intended – Desire to cut down Desire to cut down – Lots of time spent in obtaining substance Lots of time spent in obtaining substance – Important social, work, or play activities are given Important social, work, or play activities are given

up up – Used despite knowledge of having a problemUsed despite knowledge of having a problem

Treatment Treatment

• Programs Programs

• Individual therapy Individual therapy – Motivational interviewing Motivational interviewing

• Medications Medications – Smoking: Wellbutrin, Chantix Smoking: Wellbutrin, Chantix – Alcohol: Disulfiram, acamprosate Alcohol: Disulfiram, acamprosate – Opiates: suboxone, methadone Opiates: suboxone, methadone

It is never too late to have a happy It is never too late to have a happy childhood childhood Tom RobbinsTom Robbins