Pediatric Psychiatry

what are the goals of pediatric primary care when it comes to psychiatric disorders?

-screening & surveillance

-early identification

-triage & initiate Tx for uncomplicated issues

-refer for complex behavioral issues

what is ADHD?

-neurodevelopmental condition characterized by diminished sustained attention, increased impulsivity, increased hyperactivity, &/or a combination

ADHD can be associated with what other conditions?

-learning disorders

-mood disorders

-anxiety disorders

-disruptive behavior disorder

is ADHD more common in males or females?

-males

what is the most impt contributing factor to the development of ADHD?

-genetics

is ADHD associated with structural changes of the CNS?

-no

what foods are hypothesized to contribute to the hyperactivity of ADHD?

-colorings

-preservatives

-sugar

what neurochemical factors are linked to ADHD?

-aberrant catecholamine metabolism & low serotonin → dopamine & norepinephrine dysregulation

what are developmental factors that contribute to ADHD?

-prematurity

-maternal infections during pregnancy

-perinatal insult to brain due to infection during infancy

-September birth month

what are psychosocial factors that contribute to ADHD?

-chronic abuse

-maltreatment

-neglect

when should you begin suspected ADHD in children?

-4yo

what should be red flags that warrant suspicion for ADHD in children?

-academic problems

-behavioral problems

-Sx of inattention

-Sx of hyperactivity

-Sx of impulsivity

the DSM-5 criteria requires what for consideration of an ADHD Dx?

-functional impairment in 2+ settings for 6+ months

what are the DSM-5 specifiers of ADHD?

-combined presentation

-predominantly inattentive

-predominantly hyperactive/impulsive

what is the DSM-5 criteria for ADHD?

-persistent pattern of inattention &/or hyperactivity-impulsivity that interferes with functioning or development

• 1: inattention = 6+ Sx for 6+ months to a degree that is inconsistent with developmental level & negatively impacts social/academic activities

  • poor close attention to details

  • difficulty sustaining attention to tasks/play activities

  • doesn’t listen when spoken to directly

  • doesn’t follow thru on instructions & fails to finish schoolwork or chores

  • difficulty organizing tasks & activities

  • avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

  • easily distracted by extraneous stimuli

  • forgetful

• 2: hyperactivity & impulsivity = 6+ Sx for 6+ months

  • fidgets with/taps hands or feet or squirms in seat

  • leaves seat in situation when remaining seated is expected

  • runs about or climbs in inappropriate situations

  • unable to play or engage in leisure activities quietly

  • often on the go (“driven by a motor”)

  • talks excessively

  • blurts out answers before questions are completed

  • difficulty waiting for their turn

  • interrupts or intrudes on others

what are the clinical features of ADHD in infancy?

-rarely diagnosed

-more active in crib

-sleeps little

-cries a lot

what are clinical features of ADHD in school-aged children?

-finishing tests rapidly but only answering 2 questions

-can’t wait to be called on in school → responds before appropriate

-can’t be put off at home → needs immediate attention

-impulsivity & inability to delay gratification

-susceptible to accidents

-possible aggression & defiance

during an H&P, what components are essential for identifying ADHD?

-prenatal Hx

-perinatal Hx → pregnancy complications, gestational diabetes, preeclampsia

-toddler Hx

-FHx

-psychosocial Hx → environmental exposures, family stress, problematic relationships

-hearing assessment

-vision assessment

-CV exam

-thyroid exam

what is the DDx for ADHD?

-anxiety

-normal activity for age

-depression

-mania

-oppositional defiant disorder

-conduct disorder

even though PE is often normal with ADHD, what component should be assessed for possible abnormalities at each visit?

-child’s behavior in office setting

what is the 1st Sx of ADHD to remit?

-overactivity

remission of ADHD typically occurs when?

-12-20yo

what is the last Sx of ADHD to remit?

-distractibility

the long-term prognosis of patients with ADHD depends on what?

-degree of persistent comorbidities

-social disability

-chaotic family factors

what is the Tx for ADHD in patients < 5yo?

-behavioral therapy

-lifestyle modifications (for parents)

• establish structure & stick to it

• avoid problems by keeping patient busy

• set clear expectations & rules

• encourage movement & sleep

what is the Tx for ADHD in patients > 6yo?

-1st line = stimulants

• dopamine agonists = methylphenidate (Ritilin), amphetamine & dextroamphetamine (Adderall)

-2nd line = non-stimulants

• selective norepinephrine reuptake inhibitors = atomoxetine (Strattera), viloxazine (Quelbree)

  • initial response in 4 weeks

  • full therapeutic effects in 12 weeks

• alpha adrenergic agonist = clonidine

  • preferred for patients with tics

-lifestyle modifications (for parents)

• establish structure & stick to it

• avoid problems by keeping patient busy

• set clear expectations & rules

• encourage movement & sleep

what is the 1st line pharmacotherapy for ADHD?

-stimulants

• methylphenidate (Ritilin)

• amphetamine & dextroamphetamine (Adderall)

what are possible adverse effects of the stimulants used to treat ADHD?

-elevated BP & pulse

-weight changes

-stunted growth

what are the non-stimulant pharmacotherapy options for ADHD?

-selective norepinephrine reuptake inhibitors = atomoxetine (Strattera), viloxazine (Qelbree)

-clonidine

atomoxetine (Strattera) & viloxazine (Qelbree) are (stimulant/non-stimulant) medications for ADHD that primarily help with what Sx?

-non-stimulant

-inattention & impulsivity

when prescribing a selective norepinephrine reuptake inhibitor for ADHD, what patient education must be provided?

-take 4 weeks for effects → 12 weeks for maximal effects

-may increase suicidal ideations

what pharmacotherapy for ADHD is preferred for patients who also have tics?

-clonidine

what are risk factors for developing aggressive behavior during youth?

-childhood maltreatment

• abuse

• neglect

• harsh punitive parents

• chronic exposure to violence in media & life

what is disruptive mood dysregulation disorder?

-behavior disorder characterized by severe developmentally inappropriate & recurrent temper outbursts > 3x/week & a persistent irritable or angry mood between the outbursts

children with disruptive mood dysregulation disorder most likely will develop what conditions later in life?

-MDD

-anxiety

is disruptive mood dysregulation disorder more common in males or females?

-males

what is the DSM-5 criteria for disruptive mood dysregulation disorder?

-outbursts out of proportion in intensity or duration to a situation

-temper outbursts inconsistent with developmental level

-outbursts occur > 3x/week

-mood between outbursts is persistently irritable or angry for most of the day & observable by others

-1st 4 criteria have been present for 12+ months

-criteria present in 2 of 3 settings (home, school, with peers) & are severe in 1+

-Dx not made for 1st time before 6yo or after 18yo

-age of onset before 10yo

-no distinct period that lasts for 1+ days during which full Sx criteria for manic or hypomanic episode has been met

what is the Tx for disruptive mood dysregulation disorder?

-psychotherapy

-pharmacotherapy

• stimulants = methylphenidate

• SSRIs = citalopram

• antipsychotics = risperidone, aripiprazole (avoid if possible)

what are risk factors for ODD?

-caregiver dysfunction

-family dysfunction

-environmental dysfunction

what are the 3 types of ODD?

-angry/irritable mood

-argumentative/defiant behavior

-vindictiveness

what is the difference between the 3 types of ODD?

-angry/irritable mood = patients lose their temper, are easily annoyed, & feel irritable most of the time

-argumentative/defiant behavior = patients have a pattern of arguing with authority, actively refuse to comply with requests, deliberately break rules, purposefully annoy others, & don’t take responsibility for their actions

-vindictiveness = patients show vindictive or spiteful actions > 2x/6mo

what are the hallmark features of ODD characterized by an angry/irritable mood?

-lose temper

-easily annoyed

-irritable most of the time

what are the hallmark features of ODD characterized by argumentative/defiant behavior?

-pattern of arguing with authority

-actively refuse to comply with requests

-deliberately break rules

-purposefully annoy others

-don’t take responsibility for actions (blame others)

what are the hallmark features of ODD characterized by vindictiveness?

-vindictive/spiteful actions > 2x/6mo

what are typical characteristics of ODD?

-mistrust disorder (feel everyone is against them)

-enduring patterns of negativistic, disobedient, & hostile behavior toward authority figures

-inability to take responsibility for mistakes

-place blame on others for mistakes

-easily annoyed → state of anger & resentment

-difficulty in classroom & with peer relationships

-generally don’t resort to physical aggression or significant destructive behavior

what are the clinical features of ODD?

-behavior most typically displayed with adults/peers the patient knows well

-interferes with interpersonal relationships & school performance

-children rejected by peers → become isolated & lonely

-perform poorly in school despite adequate intelligence

-low self-esteem

-poor frustration tolerance

-depressed mood

-temper outbursts

-adolescents = substance abuse

what are the diagnostic red flags that point to ODD?

-arguing with adults

-loss of temper

-chronic anger

-resentful

-easily annoyed by others

-active defiance of requests/rules

*all outside range for age & development

what is the Tx for ODD?

-deal with trust issues

-family intervention by directly training parents in child management skills & careful assessment of family interactions

-cognitive therapy &/or individual psychotherapy

what is conduct disorder?

-repetitive & persistent pattern of aggressive behavior where the rights of others or major age-appropriate societal norms/rules are violated

patients with conduct disorder typically demonstrate behaviors in what 4 categories?

-physical aggression or threats of harm to others

-destruction of their own property

-theft or acts of deceit

-frequent violation of age-appropriate rules

what are common comorbidities of conduct disorder?

-ADHD

-depression

-learning disorders

what are risk factors for conduct disorder?

-parental factors

-sociocultural factors

-psych factors

-neurobiological factors

-child abuse

-maltreatment

what are clinical features of conduct disorder?

-slow development until a consistent pattern that involves violating rights of others emerges

-aggressive behavior toward people, animals, or property

-impaired social attachments → hostile, uncooperative, provocative

-superficially charming

-bully smaller & weaker peers

-lack trust in adults

-aggressive behavior isn’t directed towards a definable goal

what is the Tx for conduct disorder?

-behavioral health referral

-multisystemic therapy (MST)

-pharmacotherapy

• atypical antipsychotics = risperidone

• mood stabilizers = lithium

• ADHD meds

-identify & help learning disabilities if present

-teach problem-solving skills & empathy

-conflict management skills

what is disordered anxiety?

-disorder of anxiety that is overwhelming, disruptive to life, persistent, & interfering with functioning

how do children with anxiety disorders typically present?

-physical complaint → h/a or abdo pain

what is disordered panic?

-presence of recurrent unexpected panic attacks followed by 1+ months of persistent concern about having another attack or a significant behavioral change related to attacks

are panic disorders more common in males or females?

-females

what are recommended Tx strategies for anxiety & panic disorders?

-CBT

-pharmacotherapy

• SSRIs = sertraline (Zoloft), escitalopram (Lexapro)

-reassurance

-referrals

what is depression?

-unpleasant moods that are sustained, persistent, & accompanied by distressing neurovegetative Sx that negatively impact functioning

what is the most impt risk factor for youth suicide?

-mood disorders

what are typical presenting complaints of depression?

-irritability or anger

-decline in school performance

-oppositional or defiant behavior

-withdrawal

-somatic complaints

what are the clinical features of depression?

-depressed or irritable mood with significant distress or impairment in function that is a change from previous functioning

-diminished interest or pleasure

-insomnia or hypersomnia

-fatigue

-decreased ability to concentrate

-feelings of guilt or worthlessness

-psychomotor retardation or agitation

-recurrent thoughts of death & suicide

what are the 5 primary depressive Sx?

-anhedonia

-dysphoric mood

-fatigability

-morbid ideation

-somatic Sx

how should you screen for depression?

-annual PHQ-A in patients > 12yo

what is the Tx for depression?

-CBT

-pharmacotherapy (adjunctive)

• SSRIs = citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), sertraline (Zoloft)

-lifestyle modifications = improved sleep hygiene, exercise, improve nutrition, increased school support

-for parents = positive parenting, address stressors, support positive peer relationships