PHM 456HPHM 456HIntroduction to Pediatric Pharmacy Practice 2004Introduction to Pediatric Pharmacy Practice 2004

Drug Related Issues in Drug Related Issues in Pediatric PsychiatryPediatric Psychiatry

Claire De Souza BSc MD FRCP(C)Claire De Souza BSc MD FRCP(C)November 4November 4thth 2004 2004

Audience Survey: Audience Survey:

Experience with pediatric psychiatry: Experience with pediatric psychiatry: medications?medications?patients?patients?

Learning ObjectivesLearning ObjectivesAt the end of this presentation, the student will:At the end of this presentation, the student will:

be familiar with the spectrum of psychiatric illness in be familiar with the spectrum of psychiatric illness in the pediatric population and the assessment involvedthe pediatric population and the assessment involved

have a greater understanding of have a greater understanding of pediatric depression pediatric depression ADHDADHD

any others?any others?

OutlineOutline Starting PrinciplesStarting Principles Spectrum of Psychiatric Disorders in the Spectrum of Psychiatric Disorders in the

Pediatric PopulationPediatric Population Review of Pediatric DepressionReview of Pediatric Depression Review of ADHDReview of ADHD

PrinciplesPrinciples accurate diagnosisaccurate diagnosis

biological, psychological, social contributorsbiological, psychological, social contributors informs a comprehensive management planinforms a comprehensive management plan

biological, psychological, social interventionsbiological, psychological, social interventions medications used depending on diagnosis, symptoms, medications used depending on diagnosis, symptoms,

and severityand severity antidepressants - SSRIsantidepressants - SSRIs anti-anxiety - benzodiazepinesanti-anxiety - benzodiazepines anti-psychotics – atypicalanti-psychotics – atypical start start lowlow, go slow, go slow

Spectrum of Psychiatric DisordersSpectrum of Psychiatric Disorders Mood Disorders Mood Disorders Anxiety Disorders Anxiety Disorders Psychotic Disorders Psychotic Disorders Substance Use DisordersSubstance Use Disorders Personality DisordersPersonality Disorders Disruptive Behavioural DisordersDisruptive Behavioural Disorders Elimination DisordersElimination Disorders Eating DisordersEating Disorders Tic DisordersTic Disorders Somatoform DisordersSomatoform Disorders etc. etc.

Reference: DSM-IVReference: DSM-IV

DepressionDepression

DepressionDepression 2% children, 4-8% teens (2% children, 4-8% teens (: : ♂ ♂ = 2:1)= 2:1)

suicide attempt - 9% of teenssuicide attempt - 9% of teens symptoms for 2 weeks:symptoms for 2 weeks:

mood – “bored”, irritablemood – “bored”, irritable cognitive – SI, guilt, worthlessness, concentrationcognitive – SI, guilt, worthlessness, concentration physical - change in sleepphysical - change in sleep↑↑, appetite, appetite↑↑, energy, psychomotor , energy, psychomotor interpersonal – change in interest levelinterpersonal – change in interest level change in functioning (social, academic) / xs distresschange in functioning (social, academic) / xs distress

other features: other features: anxiety - phobias, separation anxietyanxiety - phobias, separation anxiety behaviour - tantrums, oppositional, aggressionbehaviour - tantrums, oppositional, aggression somatic complaintssomatic complaints psychosis – auditory hallucinationspsychosis – auditory hallucinations

range in severityrange in severity

Depression continued …Depression continued … contributing factors (B/P/S)contributing factors (B/P/S)

biological – ie genetics, history of depressionbiological – ie genetics, history of depression psychological – ie loss, trauma, separationpsychological – ie loss, trauma, separation social – ie interpersonal, SES, academicsocial – ie interpersonal, SES, academic

comorbidity: anxiety, substance use, behaviour, etccomorbidity: anxiety, substance use, behaviour, etc

prognosis: recurrenceprognosis: recurrence 20-60 % recurrence in 2 yrs; 70% within 5 yrs20-60 % recurrence in 2 yrs; 70% within 5 yrs episodes become more frequent, more severe, last longerepisodes become more frequent, more severe, last longer 20-40% 20-40% bipolar disorder within 5 years bipolar disorder within 5 years

Depression continued …Depression continued …

Assessment Assessment interview with family interview with family interview with child/teen interview with child/teen interview with parents interview with parents collaterol information from school etc as requiredcollaterol information from school etc as required

Depression continued Depression continued ……

Differential DiagnosisDifferential Diagnosis – extensive – extensive Adjustment Disorder, Dysthymic Disorder, Adjustment Disorder, Dysthymic Disorder,

Bipolar Disorder, Anxiety Disorder, Eating Bipolar Disorder, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Disruptive Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Behavioural Disorder, Personality Disorder, Substance use Disorder, General Medical Substance use Disorder, General Medical Condition (thyroid, anemia, mono etc), Condition (thyroid, anemia, mono etc), Bereavement etc.Bereavement etc.

Depression continued Depression continued ……

Management (B / P / S):Management (B / P / S): PsychoeducationPsychoeducation MedicationsMedications Therapy – individual (CBT, IPT), familyTherapy – individual (CBT, IPT), family School InterventionSchool Intervention Resources / ReferencesResources / References

websites: websites: http://www.mooddisorders.on.ca/mdao.asphttp://www.mooddisorders.on.ca/mdao.asp

http://www.aacap.org/http://www.aacap.org/ (Facts for Families) (Facts for Families)

Depression continued Depression continued ……MedicationsMedications duration: 9 months or moreduration: 9 months or more 11stst line: SSRIs line: SSRIs (ie Prozac, Zoloft, Celexa) – off-label(ie Prozac, Zoloft, Celexa) – off-label

start low, go slow; increase as tolerated & as requiredstart low, go slow; increase as tolerated & as required ControversyControversy

Efficacy – limited evidence - ProzacEfficacy – limited evidence - Prozac Safety – Health Canada warningSafety – Health Canada warning

MD to monitor: SI, disinhibition, agitation, akathisia MD to monitor: SI, disinhibition, agitation, akathisia off-label use based on limited studies, experience, adult studiesoff-label use based on limited studies, experience, adult studies

drug interactions – cytP450drug interactions – cytP450 Medications added as required (Sx, Rx resistance): Medications added as required (Sx, Rx resistance):

ie BZDs, atypical antipsychoticsie BZDs, atypical antipsychotics

Depression continued Depression continued ……

Red FlagsRed Flags requesting script renewalsrequesting script renewals appearing dysphoric, suicidal, appearing dysphoric, suicidal,

hypomanic, psychotichypomanic, psychotic non-compliance: withdrawal, non-compliance: withdrawal,

worsening symptomsworsening symptoms stockpiling medications, buying stockpiling medications, buying

++OTCs++OTCs medical problems – cytP450 medical problems – cytP450

drug interactionsdrug interactions

Depression continued Depression continued ……ApproachApproach

review Health Canada warning review Health Canada warning discuss need for monitoring by MDdiscuss need for monitoring by MD advise them not to stop medication suddenly advise them not to stop medication suddenly questions / concerns questions / concerns MD MD advise them about what to look for:advise them about what to look for:

ie. restlessness, disinhibition, aggression, ie. restlessness, disinhibition, aggression, anxiety, worsened depressionanxiety, worsened depression

direct them to resourcesdirect them to resources if concerned about patient’s safety – refer to ERif concerned about patient’s safety – refer to ER

Reference: FDA website, Health Canada, NIMH websitesReference: FDA website, Health Canada, NIMH websites

Attention Deficit Attention Deficit Hyperactivity DisorderHyperactivity Disorder

ADHDADHD 5-9 % of children; 5-9 % of children; ♂: ♂: = 4:1 (= 4:1 (NB:NB: under-Dxunder-Dx))

symptoms – 2+ settings, onset < age 7symptoms – 2+ settings, onset < age 7 inattention – careless mistakes, can’t sustain attn, distractible, forgetful, inattention – careless mistakes, can’t sustain attn, distractible, forgetful,

disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids time/effort-consuming taskstime/effort-consuming tasks

hyperactivity – fidgets, leaves seat, hyperactivity – fidgets, leaves seat, ↑ ↑ runs/climbs, on the “go”, xs runs/climbs, on the “go”, xs talking, can’t play quietlytalking, can’t play quietly

impulsivity- blurts out, interrupts, problems waiting turnimpulsivity- blurts out, interrupts, problems waiting turn interferes with functioning: academic, family, socialinterferes with functioning: academic, family, social

diagnosis diagnosis subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined

reference: DSM-IVreference: DSM-IV

ADHD continuedADHD continued etiology - DA mediated; problems with inhibitory & etiology - DA mediated; problems with inhibitory &

executive controlexecutive control factors:factors:

biological – FHx, difficult temperamentbiological – FHx, difficult temperament psychological - self-esteempsychological - self-esteem social - interpersonal, academic, poor social skillssocial - interpersonal, academic, poor social skills

comorbidity comorbidity learning disorders (in 40% with ADHD), behavioural learning disorders (in 40% with ADHD), behavioural

problems (ODD, CD), substance abuse, depression, anxietyproblems (ODD, CD), substance abuse, depression, anxiety prognosisprognosis

65% 65% adulthood adulthood

ADHD continuedADHD continued

Assessment: Assessment: Interview with Interview with

familyfamily child / teen child / teen parents parents

QuestionnairesQuestionnaires ie Connors Rating Scale – parent / teacher formie Connors Rating Scale – parent / teacher form

Information from schoolInformation from school Psychoeducational testingPsychoeducational testing

ADHD continuedADHD continued

Differential DiagnosisDifferential Diagnosis – extensive – extensive Learning disorderLearning disorder General Medical Condition (hearing, vision, General Medical Condition (hearing, vision,

thyroid, congenital, genetic, lead poisoning, head thyroid, congenital, genetic, lead poisoning, head injury etc)injury etc)

Adjustment Disorder, Dysthymic Disorder, Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Psychotic Bipolar Disorder, Anxiety Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, etc.Personality Disorder, Substance use Disorder, etc.

ADHD continuedADHD continuedManagement (B / P / S):Management (B / P / S): PsychoeducationPsychoeducation MedicationsMedications Social skills trainingSocial skills training Parent management Parent management

(+) reinforcement, structure(+) reinforcement, structure School Intervention School Intervention

classroom modifications, individual education plan (IEP)classroom modifications, individual education plan (IEP) Resources / ReferencesResources / References

websites: websites: www.adrn.orgwww.adrn.org http://http://www.aacap.orgwww.aacap.org// (Facts for Families) (Facts for Families)

ADHD continuedADHD continuedMedicationsMedications stimulants - 1stimulants - 1stst line line

short acting – Ritalin, Dexedrineshort acting – Ritalin, Dexedrine long acting – ie Concerta, Dexedrine SRlong acting – ie Concerta, Dexedrine SR Blinded placebo / stimulant trials Blinded placebo / stimulant trials

to determine dose, acceptabilityto determine dose, acceptability coordinated with objective scale – ie Connors Rating Scalecoordinated with objective scale – ie Connors Rating Scale

restricted use – limited scriptsrestricted use – limited scripts abuse potentialabuse potential

other medications for co-morbidity – ie depression, anxiety, other medications for co-morbidity – ie depression, anxiety, ticstics

Use – for school day primarily; also, during weekend & Use – for school day primarily; also, during weekend & summer if problems (social, academic) off meds summer if problems (social, academic) off meds

ADHD continuedADHD continued

Red FlagsRed Flags requesting script renewalsrequesting script renewals non-compliancenon-compliance substance abusesubstance abuse stockpiling medicationsstockpiling medications medical problems - epilepsymedical problems - epilepsy

ADHD continuedADHD continued

ApproachApproach controversy controversy

““over-diagnosed” over-diagnosed” concerns about long-term side effectsconcerns about long-term side effects problems if no treatment problems if no treatment

academic, social, family academic, social, family comorbidity comorbidity

advise them to direct their questions / concerns advise them to direct their questions / concerns MDMD

Questions / CasesQuestions / Cases