AST 7 - Pediatric Psychiatry

Average age of ADHD diagnosis

7 years

Anatomical changes

Dec brain volume

Dec DA activity in midbrain

Dec bloodflow in frontal lobe

Smaller brain structures

NT Deficits in ADHD

DA (unable to maintain attention, resist distractions)

NE (failure to maintain control/mood)

Diagnostic Criteria

at least 6 inattention or hyperactivity or impulsivity symptoms AND last >6 months AND are inappropriate for the developmental level

Symptoms must be present in which settings

2+ (home, school, work)

First line for 4-5 year olds

Behavior therapy

Second line for 4-5 year olds

Methylphenidate

First line for >6 year olds

Amphetamine or Methylphenidate

Second line for >6 year olds

Atomoxetine

Guanfacine XR

Clonidine XR

Non pharm interventions

CBT

School related intervention (BCM - behavioral classroom management)

Child related intervention (BPI)

Stimulant drug classes

MPH

AMP

Methylphenidate MOA

Inhibit presynaptic reuptake of DA and NE

Amphetamine MOA

Stimulate release of DA and NE into presynaptic nerve terminal

BBW for ALL Stimulants

High potential for abuse and dependence (SUD and Addiction)

therefore all stimulants are CII**

CIs for Stimulants (not necessarily hard-stops)

MAOi use in last 14 d

Symptomatic CVD

Glaucoma

Hyperthyroidism

Hx SUD

Mod-Severe HTN

Stimulant warnings

Elevated NE and DA levels can inc HTN

Exacerbation of psychosis

Loss of appetite

Risk of Serotonin syndrome

Lower seizure threshold

Ritalin duration of action

3-5h

Ritalin SR or Methylin ER duration of action

6-8h

Ritalin LA or Aptensio XR duration of action

8-12h

Pros of Methylphenidate (3)

Less likely to suppress appetite

Less likely to induce insomnia

Many capsules can be opened and sprinkled in food

Cons of Methylphenidate

Short duration with IR/SR formulations

Avoid Concerta if patient has

GI obstruction

Conditions that decrease motility

Daytrana route, administration instructions, max wear

PATCH

rotate sites, apply to hip area 2h BEFORE desired effect w/ maximum wear of 9h

How long will Daytrana last after removal

2-3h after

Daytrana counseling

Do NOT cut patch

Do not flush in toilet (fold over on itself)

Concerta OROS route

Osmotic release oral system

tablet acts as an osmotic pump, releasing drug over course of a day (not all at once)

Concerta counseling

Do NOT crush tablets

May see ghost tablet in stool

Dexmethylphenidate (Focalin) Counseling

Can be sprinkled on applesauce

Pros of Amphetamine

More predictable PK w/ long acting formulations

Can be opened and sprinkled on applesauce

Cons of Amphetamine

Greater growth suppression

Greater abuse potential

Lisdexamfetamine (Vyvanse) Pro

Lower potential for abuse (given as prodrug)

Lisdexamphetamine (Vyvanse) Administration counseling

You can open and dissolve in water or yogurt

Xelstrym Dextroamphetamine patch Counseling

SAME as Daytrana

EXCEPT can apply to hip, upper arm, chest, upper back, flank area

If falls off, can replace as long as time was <9h

Main Stimulant ADEs

GI

Insomnia '

HTN

Tics

Psychiatric exacerbations

T or F: Most stimulants require a taper off

FALSE - most don't need taper unless abuse involved

Non-stimulant class options for ADHD

NRIs

Central Alpha 2 agonists

Central Alpha 2 agonists

Clonidine

Guanfacine

NRIs

Atomoxetine

Viloxazine

BBW for ADHD NRIs

Risk of suicidal ideation

Med guide required upon dispensing

Atomoxetine extra CIs

Glaucoma

Pheochromocytoma (adrenal tumor)

Severe CVD

Atomoxetine warnings

Liver toxicity

Aggression

Atomoxetine metabolism

2D6 substrate

MOA of Alpha 2 agonists

inhibit pre-synaptic NE release --> inc blood flow to PFC

Alpha 2 agonists Warnings

Dose-dependet CV effects

Sedation, Drowsiness

REQUIRE A TAPER

Why do Alpha 2 agonists require a taper

Risk for rebound HTN

Alpha 2 agonists (Clonidine, Guanfacine) counseling

May take weeks to notice benefit

Kapvay (Clonidine) and Guanfacine counseling

Cannot be crushed

T or F: If a patient requires IR and ER regimen, utilize the SAME drug ingredient

TRUE

First line med class for ADHD

Stimulants

When to consider non-stimulants

Hx SUD

CIs

Non-tolerance of ADEs

NRI ADEs

Dec appetite

Tachycardia

Viloxazine Metabolism

1A2 Inhibitor

CBT duration recommendation

8-16 weekly sessions

SSRI Options

Fluoxetine

Escitalopram

First Line for Childhood depression >8 years

Fluoxetine

Escitalopram is approved for which age range for Childhood depression

>12 years

Symptoms of Bipolar Disorder less likely in peds

Grandiosity

Reckless behaviors

Bipolar disorder Meds approved

Antipsychotics - Quetiapine and Olanzepine

Olanzepine approved for what ages

>4 years

T or F: Mood stabilizers like Lithium can be used in children for Bipolar Disorder

FALSE - not effective in this population

First Line for Anxiety disorders in Peds

CBT

If anxiety symptoms are moderate-severe, which meds are considered

SSRIs: Fluoxetine, Escitalopram

SNRIs: Duloxetine

BB for social anxiety

Which med is helpful in pediatric social anxiety

BB (ex. propanolol)

Schizophrenia Sx more common in peds

Hyperactivity

Cognitive problems

Hallucinations

Schizophrenia First Line Tx Options

Olanzepine (>13)

Risperidone

Quetiapine

Aripiprazole

Lurasidone

Clozapine role in therapy for Pediatric Schizophrenia

Reserved for treatment resistant schizophrenia

For ages >6

Environmental factors that inc risk of Autism

Advanced paternal age

Maternal DM during pregnancy

Low birth weight

Prematurity

Level 1 defined as

requiring support

Level 2 defined as

requiring substantial support

Level 3 defined as

requiring very substantial support

Screening Red Flag Sx at 12, 14, 18 months

12 mon - does not respond to name

14 mon - does not point at objects to show interest

18 mon - does not play pretend

First line for Hyperactivity/Inattention symptoms of ASD

Psychostimulants

Alternatives for treating Hyperactivity/Inattention symptoms when First line not effective

NRIs (Atomoxetine)

Alpha 2 agonists (Clonidine, Guanfacine)

Atypical Antipsychotics have less data but can be used primarily to address which symptom

Aggression

Medication classes to treat Irritability and severe disruptive behavior

Atypical Antipsychotics - Aripiprazole, Risperidone, (FDA Approved) Consider Olanzepine, Quetiapine

Anticonvulsants

SNRI (Venlafaxine)

Atypical antipsychotic ADEs

Weight gain

Dyslipidemia

EPS Sx

Hyperprolactinemia

Medication classes to treat Repetitive behavior and Compulsions

Atypical Antipsychotics

Anticonvulsants

SSRI (Fluoxetine, Fluvoxamine)

Medication classes to treat Anxiety and Depression

SSRI

Alpha-2 Agonists

Atypical Antipsychotics

First line treatment for Anxiety and Depression symptoms

CBT

Adverse effect of SSRIs in children

Hyperactivation