Peds - Mental Health

Tantrums Description

Brief episodes of extreme or unpleasant behavior that appear disproportionate to the situation, typically in response to frustration or anger

Presentation of Typical Tantrums

Occur b/w 1-4 y/o

Children with intellectual disabilities exhibit tantrums when their intellectual age is at 3-4 y/o

Autism Description

pervasive development disorder characterized by persistent difficulties with social communications and restricted, repetitive patterns of behavior

Autism Clinical Presentation

Infants may have delayed or absent social smiling

Young children may spend extended time in solitary play and be socially withdrawn with limited responsiveness in communication

Speech may include echolalia, perseveration

Disruption of routines may cause behavioral dysregulation

Autism Testing

GOLD STANDARD - Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnosis Interview (ADI)

Autism Mgmt

Most effective interventions are focused on behavioral training, especially: ABA, discrete trial training, FBA, structured teaching

Meds: antipsychs, SSRIs, stimulants, alpha-agonists, melatonin for sleep

ADHD Clinical Presentation

Preschoolers show more aggression and restlessness

Older children and adolescents show more inattention and disorganization

Girls with ADHD more likely to have anxiety/depression

Boys with ADHD more likely to have oppositional defiance disorder

ADHD Eval

History should explore behaviors and their impact on academic performance, family/peer relationships, safety, self-esteem, and daily activities

Rating sclaes such as the Vanderbilt, Conners

ADHD Mgmt

Behavior and academic interventions and meds when appropriate.

Behavioral therapy is the core of overall treatment

Meds work best in combo with therapy

Medications for ADHD

Stimulants - 1st line: methylphenidate or amphetamine compounds (Concerta, Vyvanse, Adderall)

Non-stimulants - 2nd line: atomoxetine, alpha-agonists

Oppositional Defiant DO (ODD)

persistent angry or irritable mood, argumentative or defiant behavior, and vindictiveness for at least 6 months

Mgmt: focus on diminishing persistent and sometimes severe irritable mood

Conduct DO

aggressive and rule-breaking behaviors that ignore or violate the basic rights of others. Often leads to conflicts with adults or peers. May require legal system action

Mgmt: focus on diminishing maladaptive behaviors and developing empathy

Intermittent Explosive DO

problems controlling emotions and behaviors that results in behaviors that violate social norms and the rights of others; aggressive behaviors are UNPLANNED, out of proportion to the provocation

Mgmt: pharmacotherapy and psychotherapies work best together - fluoxetine

Anxiety Characteristics

Uneasiness, excessive rumination, and apprehension about the future; chronic, recurring, and variable in intensity and duration

• Does not include OCD or PTSD in current DSM

Anxiety Mgmt

For mild to moderate anxiety → psychotherapies and psychoeducation are first-line

• pharmacotherapy and psychotherapy work best together

• coordination with family and school

• stress mgmt, supportive therapies, and biofeedback

SSRI For Anxiety

Medication of choice but can initially exacerbate symptoms

• Fluoxetine/prozac, sertraline/zoloft, and fluvoxamine are FDA-approved

TCA, Benzos, anticonvulsants, beta-blockers

Start low and go slow

Depression Description

Major depressive disorder requires a minimum of 2 weeks of symptoms (SIGECAPS) including either: depressed mood OR loss of interest or pleasure in nearly all activities

Depression Mgmt

Pharmacologic and psychotherapy should be considered

Improvement may be slow, f/u immediately if there are significant SE

Depression - suicide

Fatal complication of MDD; prior history of suicidal thoughts and prominent feelings of hopelessness are risk factors

Substance use, conduct problems, and impulsivity incr risk fo suicide

Medications for Depression

Antidepressants should be given min. 6 week trial at therapeutic dose prior to switching unless significant SE

Tx for 6-9 mo after remission

If failure of 2+ meds → psychiatrist consult

Augment with lithium, thyroid hormone, lamotrigine, bupropion

Notable SE: thoughts of suicide, incr agitation, restlessness

1st line Tx for Depression

SSRI

• response rate of 50-70%

• Fluoxetine/prozac is only one FDA approved in ages 8 and younger

• Escitalopram/Lexapro is FDA approved for ages 12 and older

Psychotherapy and Depression

Good efficacy as monotherapy in mild-moderate depression

Greatest benefit when combined with medication in mod-sev depression

Bipolar DO Definition

Characterized by periods of abnormally and persistently elevated, expansive, or irritable mood + heightened levels of energy and activity

Associated symptoms: grandiosity, diminished need for sleep, pressured speech, racing thoughts, impaired judgement

Manic Sx for at least 1 wk

Medications for Bipolar

Lithium (acute episodes and maintenance; blood level monitor), divalproex sodium, CBZ, olanzapine, risperidone, quetiapine, ziprasidone, lurasidone, aripiprazole

Anticonvulsants (CBZ) not FDA approved

Disruptive Mood Dysregulation DO (DMDD) Presentation

severe tantrums, inconsistent with age: persistent irritability and severe behavioral outbursts at least 3 times per week for 1+ year

Chronic irritability

Mgmt of DMDD

methylphenidate may reduce symptoms, adding citalopram may further reduce tantrum severity

identify and treat comorbids (MDD, ADHD, conduct DO, SUD)

Substance Use: Screening

should occur at all teenage well visits; may consider beginning in adolescence, as the age of first use can be < 12 y/o

CRAFFT Substance Use

C → CAR: driving under influence of drugs

R → RELAX; using drugs to relax, fit in, feel better

A → ALONE; consuming drugs/alcohol while alone

F → FORGETTING; forgetting things as a result of drugs/alcohol

F → FAMILY/FRIENDS; telling the teen to stop/cut back

T → TROUBLE; getting into trouble bc of drugs/alochol

Common SE and Tx options for SUD

Paranoia → Haloperidol

Seizures → Diazepam

Hyperthermia → Slow cooling

HTN → Beta blockers

Opiate OD → Naloxone

Substance Use OD

Toxicologic emergencies are common

Mgmt should be directed at supportive medical tx and f/u care should include counseling after toxicologic effects have diminished

Substance Use Treatment

Depends on individual pt factors

Drug treatment facilities