An Attention Deficit Hyperactivity Disorders PowerPoint Presentation

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Child and Adolescent Psychiatry Howard Liu, M.D. Psychiatry Clerkship Director Child & Adolescent Psychiatry UNMC 402-552-6006 hyliu@unmc.edu Revised 3.15.12

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Normal Development

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Goals / Objectives Review common diagnoses in pediatric mental health Recognize epidemiology of major disorders Recall first line treatment guidelines

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What will we cover? ADHD Pediatric Bipolar Disorder Anxiety Disorders Autism Eating disorders Substance abuse

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

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Child Psychiatry Interview Pearls Manage the room Ask intimate questions privately Be able to “surf” from shallow to deep Start with social history Safety is #1 priority

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ADHD

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Pop Quiz: ADHD According to the largest study of ADHD to date (the MTA trial), which was the most effective treatment for ADHD in kids after 1 year? Stimulant medication Behavioral therapy School intervention Stimulant + Behavioral therapy Low sugar diet

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Elementary School child with ADHD

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Epidemiology of ADHD in Children Prevalence is ~ 9.5% of children, 2/3 treated Males > Female by 4:1 Life course Hyperactivity , Inattention persists High comorbidity (2/3) 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

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Diagnostic Criteria for ADHD(DSM-IV) Must occur before age 7 years Present for at least 6 months Causes impairment in at least 2 settings Meets 6 of 9 symptoms of inattention AND/OR 6 of 9 symptoms of hyperactivity/impulsivity

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Diagnosis: Inattentive Subtype Careless mistakes in schoolwork Poor attention in tasks or play Doesn’t listen when spoken to directly Fails to finish things (not oppositional or unable) Difficulty organizing Avoids/dislikes tasks requiring focusing Loses necessary items Distracted by extraneous stimuli Forgetful in daily activities

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Diagnosis: Hyperactive-Impulsive Fidgets with hands/feet or squirms in seat Often leaves seat when inappropriate Runs about or climbs excessively when inappropriate Difficulty playing quietly Often “on the go” or acts as if “driven by a motor” Often talks excessively Blurts answers before question completed Difficulty awaiting turn Often interrupts or intrudes on others

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Treatments Stimulant medications – 1st line (MTA) Alternative non-stimulant medications Psychoeducation Community support Behavioral interventions School interventions

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Stimulant Medications: Efficacy One of the most robust treatments in psychiatry 70% of children with ADHD will respond to any one of the stimulants, all generally equal efficacy An additional 20% will respond to the next one attempted If the 1st and 2nd choices fail, check for wrong diagnosis and/or comorbidity

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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”

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Bipolar disorder

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Pop Quiz: Bipolar A 14 year old girl is being treated for pediatric bipolar disorder, when she develops breast tenderness and galactorrhea. Which medication is she most likely taking? Carbamazepine Risperidone Lithium Valproic Acid Topiramate

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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.

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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

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Anxiety Disorders

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9 / 11 Attack

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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

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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

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PERVASIVE DEVELOPMENTAL DISORDERS

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Asperger’s Video

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Pop Quiz: Autistic savants Kim Peek was the mega savant that inspired “Rain Man.” What is his prodigious skill? Near perfect recall of 12,000 books Ability to hear any song and reproduce it on the piano Ability to sculpt a perfect replica of any animal he sees Recitation of Pi from memory to 22,514 digits

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Pervasive Developmental Disorders Definition: Group of psychiatric conditions in which expected social skills, language development, and behavioral repertoire either don’t develop or are lost in early childhood Early in life (by age 2) Cause persistent dysfunction Often associated with mental retardation (50%) Spectrum of severity

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Diagnosis History – early development, age of onset, family and medical history AAP 2007: screen all kids 18 months, age 2 Developmental & psychological assessment Intelligence, learning Communication – language, nonverbal Adaptive behavior – generalize skills to real world OT / PT as needed Psychiatric exam Social relatedness, behavior, language, play skills Medical – genetics, seizures, hearing, etc.

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Epidemiology Autistic Disorder Prevalence: 2.5 to 72 per 10,000 children Distributed equally among all socioeconomic levels Male to female ratio 3:1 Genetic cause Debunked thimerosol, MMR vaccine theory Lifetime cost of care: $3 million Asperger’s disorder Prevalence: 4.3 per 10,000 Male to female ratio 10:1

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Autistic disorder 6 items from 3 categories Category 1: Social impairment Nonverbal impairment (eye contact ,facial expression, posture, etc.) Peer relationships (not same age kids, often younger) Lack of sharing interests with others Lack of social or emotional reciprocity Category 2: Communication – language, speech Category 3: Restricted patterns of behavior, interest, activities intense interest 1 area, rigid, flapping hands, parts

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Asperger’s disorder – like “WALL-E” Social impairment – but they want friends Repetitive patterns of behavior Star Wars, machines, World of Warcraft, etc. NO language delay often advanced speech – “Little Professor” “High functioning autism” normal to high normal intelligence

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Other PDD Disorders Rett’s Girls > boys (boys often die in infancy) Normal prenatal & perinatal Head growth decelerates, 5-48 mos., usually before 1 year old Loss of abilities, MR, language Motor deterioration, sudden death Childhood Disintegrative Normal development x 2 years Loss of prior skills – language, social skills, bowel/bladder, play, motor skills

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Autistic DisorderTreatment No cure for autistic disorder Primary goals promote social and communication skills reduce maladaptive behaviors alleviate family stress Best interventions are educational and behavioral Applied Behavior Analysis (ABA), Early Intervention Evidence for efficacy in increasing IQ (Early Start Denver Model) Pharmacotherapy to target specific symptoms: Antipsychotics, stimulants, SSRI’s “Start low, go slow”

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Eating Disorders

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Pop Quiz: Eating Disorders What is the % body weight below which one qualifies for anorexia nervosa? 90% 85% 80% 75% 70%

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Anorexia Nervosa DSM Body weight < 85% expected or failure to gain expected weight Intense fear of gaining weight Denial, distorted body image Amenorrhea (3 consecutive cycles lost) Clinical Often high achievers, athletes Very rigid

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Bulimia nervosa DSM Recurrent binges (lack of control, greater portion) Recurrent purging (vomiting, laxatives, fasting, excessive exercise) Binging and purging occur at least twice weekly for 3 months Self image is unduly influenced by weight/shape Does not occur during episodes of anorexia nervosa

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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

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Substance Abuse

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Teen drinking

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Pop Quiz: Substance abuse Which teen movie stars a celebrity who has NOT been convicted of a DUI? Transformers Mean Girls Braveheart House of Wax Superbad

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Epidemiology Monitoring the Future 2008 Survey - 46,000 8th, 10th, 12th graders NIDA, U of Michigan Any drug use: lifetime 20% 8th grade, 47% seniors Declining: Cigarettes, stimulants, alcohol Steady: Marijuana Increasing: prescription pills Almost 10% of seniors had used vicodin in the past year!

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Teen Substance Abuse Abuse: 1 or more over 12 months Fail to meet expectations at work, school, or home Using when it’s dangerous (driving) Legal problems that are substance related Keep using despite repetitive problems Occurs over 12 month period

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Abuse vs. Dependence Abuse: 1 or more over 12 months Fail to meet expectations at work, school, or home Using when it’s dangerous (driving) Legal problems that are substance related Keep using despite repetitive problems Occurs over 12 month period

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Abuse vs. Dependence Dependence: 3 or more over 12 months Tolerance – need to use more Withdrawal Use larger amount than intended Desire to cut down Lots of time spent in obtaining substance Important social, work, or play activities are given up Used despite knowledge of having a problem

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Treatment Programs Individual therapy Motivational interviewing Medications Smoking: Wellbutrin, Chantix Alcohol: Disulfiram, acamprosate Opiates: suboxone, methadone

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