Child Psychiatry Workshop

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• Child Psychiatry Workshop
• Dr Brendan Belsham
• Child and adolescent psychiatrist

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Outline

• Some specific challenges in child psychiatry
• Clinical picture of key conditions
• Tea
• General management considerations
• Psychopharmacology
• Lunch
• Cases

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Specific challenges in child psychiatry

• Dealing with different agendas
• Conditions in evolution
• Importance of multiple informants
• Medicolegal issues
• Importance of working holistically

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Dealing with different agendas

• Parents
• Often attend under duress
• Child often used as a pawn
• School
• Insist the child be on medication
• Insist the child is off medication
• Child
• The actual patient!
• Often attends under duress
• Consent issues
• Advocacy groups/scientology/citizens commission
  for HR
• Difficult to balance the needs/demands of all

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Conditions in evolution

• Influence of childhood development on symptoms,
  eg terrible twos and ODD
• Influence of cognitive level, learning disability
• Inappropriateness of DSMIV in childhood
• Labeling issues
• Dimensional versus categorical conditions
• Provides a window of opportunity for promotive
  and preventive intervention

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Importance of multiple informants

• Diagnosis requires understanding of childs
  behaviour in various settings and through
  different eyes.
• ADHD self-report, parent report and teacher
  report often yield very disparate findings
• Must interview the child separately

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Medicolegal issues

• Informed consent required from both parents
• Often divorced and/or at loggerheads
• Dearth of research in psychopharmacology
• Off-label usage of medications

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ADHD

• A biological, brain condition causing
  developmentally inappropriate impairments in
  concentration, hyperactivity and impulsivity
• Affects 7 of school-age children, across all
  cultures
• 31 males to females
• A chronic disorder with significant impairment
  and cost to society across the life span

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Three clusters of symptoms

• Inattentiveness
• Hyperactivity
• Impulsivity

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Inattentiveness

• Short concentration span
• Resistance to sustained mental effort
• Distractibility
• Forgetfulness
• Frequently loses things
• Difficulty organising tasks poor planning
• Not listening to instructions
• Rushes work, frequent careless mistakes
• Not completing tasks

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• Hyperactivity
• Constantly on the go, as if driven by a motor
• Runs about or climbs excessively
• Restless, unable to stay seated
• Fidgets excessively
• Excessively talkative
• Plays loudly
• Impulsivity
• Often interrupts or intrudes on others
• Cannot wait turn
• Blurts out reply before the question completed

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Domains of executive functioning

• 1. Activation
• getting started, setting and maintaining
  priorities
• 2. Focus
• maintaining focus, shifting focus when
  appropriate (hyperfocusing)
• 3. Effort
• regulating alertness (daytime drowsiness),
  sustaining effort through boring tasks
• 4. Memory
• Working memory
• 5. Action
• Monitoring and self-regulation of action
• 6. Emotions
• -ability to self-regulate
• -ability to delay gratification
• -ability to tolerate frustration

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However
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• Comorbidity
• 2 or more conditions co-ocurring
• Differential diagnosis
• Does the child have ADHD at all?
• All inattentiveness does not equal ADHD

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Comorbidity the rule rather than the exception
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ODD
Mood/Anxiety
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Tic
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Conduct
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Jensen, P et al, 1999
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ADHD comorbidity

• Very frequent (gt50)
• Oppositional Defiant Disorder (ODD)
• Conduct Disorder
• Frequent (up to 50)
• Specific learning disorder
• Anxiety Disorder
• Developmental Co-ordination Disorder
• Infrequent (lt20)
• Depression
• Tic disorders
• Rare
• Paediatric Bipolar Disorder
• Mental retardation
• Pervasive Developmental Disorders

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Oppositional Defiant Disorder

• In 40 of children with ADHD
• Pervasive pattern of negativistic, hostile,
  defiant behaviour, including
• Losing temper
• Arguing with adults
• Defying adults
• Deliberately annoys others
• Blames others for his mistakes
• Easily annoyed
• Angry and resentful
• Spiteful and vindictive
• Symptoms suggest mood impairment

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Conduct Disorder

• In 11 of those with ADHD
• Pervasive pattern of violating the rights of
  others or basic societal norms, including
• Aggression to people and animals
• Destruction of property
• Deceitfulness or theft
• Serious violations of rules
• External locus of control
• Lack of remorse
• Often includes substance abuse

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Anxiety Disorders

• Generalised Anxiety Disorder (GAD)
• Separation Anxiety Disorder
• Social anxiety Disorder
• Obsessive Compulsive Disorder (OCD)
• Tend to overlap and occur together
• Commonly affect concentration, motor activity

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Anxiety and ADHD

• Anxiety can be secondary to ADHD
• Anxiety can mimic ADHD
• True comorbidity

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Generalised anxiety disorder (GAD)

• Previously overanxious disorder of childhood
• In GAD, the child worries about various issues,
  across broad spectrum
• Causes impairment in daily functioning

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Separation Anxiety Disorder

• Developmentally inappropriate and excessive
  anxiety concerning separation from home or from
  attachment figures
• Commonest cause of school refusal
• Unable to sleep independently
• Nightmares involving theme of separation
• Commonly have somatic complaints
• Persistent worry about something untoward
  happening to attachment figure

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Social Anxiety Disorder

• Also social phobia
• Intense fear of scrutiny or embarrassment in
  front of others, causing significant impairment
  in daily functioning
• Must distinguish from normal shyness
• Speaking in front of the class
• Answering the phone
• Selective mutism may be a variant

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Obsessive Compulsive Disorder

• Commonly begins in childhood, often unrecognised
• Obsessions
• Recurrent, intrusive thoughts or images
• Cause marked distress
• Compulsions
• Excessive need for reassurance
• Night-time rituals
• may be mental
• Triad of ADHD, OCD, Tourettes
• Can severely affect schoolwork, completion of
  tasks

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Childhood depression

• Two week period of
• Depressed, sad, empty, tearful, or irritable
• Diminished enjoyment, interest or pleasure in
  daily activities
• Decreased /increased sleep
• Decreased/increased appetite or weight change
• Low energy levels, fatigue
• Psychomotor agitation /retardation
• Impaired concentration, indecisiveness
• Thoughts of worthlessness, guilt
• Suicidal thinking, thoughts of death

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• Other symptoms
• Commonly associated with anxiety
• Regression of skills
• Somatic complaints
• Psychotic symptoms, auditory hallucinations
• depressive equivalents behavioural
  disturbance
• Differences from depression seen in adults
• Children often dont sustain a mood state for
  very long 2 week criterion may be inappropriate
• Neurovegetative features relatively rare
• Must distinguish from
• demoralisation or irritability due to ADHD
• normal sadness or irritability

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Paediatric bipolar disorder (BPD)

• DSM IV definition requires a clear-cut manic
  episode
• 1 week period of sustained abnormally elevated or
  irritable mood (rage attacks), accompanied by
• Decreased need for sleep
• Increased energy
• Decreased concentration distractibility
• More talkative than usual pressure to keep
  talking
• Flight of ideas, or subjective experience of
  racing thoughts
• Increase in goal-directed activity or psychomotor
  agitation
• Poor judgment participation in pleasurable
  activities that are risky hypersexual buying
  sprees
• Inflated self-esteem, grandiosity

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Diagnostic controversies

• Recent data (2007) suggest a 40x increase in
  diagnosis of BPD in youth
• Looser criteria being used, which allow for a
  non-episodic, chronic irritability without
  hallmark features of
• Euphoria
• Grandiosity
• Hypersexuality
• Best to rather use other terms, eg severe mood
  dysregulation or emotional dysregulation, unless
  strict criteria are met

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Differential diagnosis ADHD v BPD

• BPD
• Discrete episodes
• Average onset around 10
• Hallmark symptoms more specific for BPD
• (reactive attachment dis)
• Rage attacks
• FH of BPD
• May well respond to stimulants, but adverse mood
  effects commoner

• ADHD
• Chronic, non-episodic
• Evident in toddler yrs
• Euphoria, grandiosity, hypersexuality rare
• (manic defence)
• Low frustration tolerance
• FH of ADHD
• Response to stimulants in 80

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TEA!
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General management considerations in child
psychiatry

• Addressing the home environment
• Addressing the school environment
• Psychotherapy
• Other allied therapies
• Psychopharmacology
• Admission to hospital
• Alternative treatments
• Ongoing monitoring

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Addressing the home environment

• Importance of healthy attachment
• Identify and treat parental psychopathology
• Address high expressed emotion
• Eg homework tutor
• Parent counseling and education
• Parent management training/behaviour modification
• Hiding behind the diagnosis
• The child in two homes
• Reporting abuse the child care act

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(No Transcript)
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Addressing the school environment

• Is the child correctly placed?
• Classroom interventions
• Address high expressed emotion
• Seating arrangement
• Behaviour modification
• token economy
• Facilitator
• Bullying

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Psychopharmacology

• Only once non-pharmacological strategies have
  been attempted and failed
• Consent
• Off-label usage
• Introduce one agent at a time
• Monitor clinical response (not EEG)
• Side-effects

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Medication in ADHD

• Stimulants (methylphenidate) act on dopamine
  primarily
• Ritalin, Concerta
• Non-stimulant acts on noradrenaline primarily
• Strattera (Atomoxetine)
• Medication found to improve
• Core symptoms of inattention, hyperactivity,
  impulsivity (70 RR)
• Related symptoms
• Non-compliance, defiance
• Aggression
• Social interactions
• Academic performance
• Family functioning
• Self-esteem
• Reduces later substance abuse in adolescents and
  adults

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Substance abuse in unmedicated and medicated ADHD
and control adolescents (gt15 years)
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Ritalin
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Possible stimulant side-effects

• Loss of appetite
• Weight loss
• Insomnia
• Stomach aches
• Headaches
• Jitteriness/anxiety
• Subduing effect
• Rebound tearfulness/irritability
• Tics

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Concerta

• Also methylphenidate
• Unique mechanism allows gradual release over
  10-12 hours
• Advantages
• Once daily dosing
• More optimal cover over the day
• More constant blood levels usually result in less
  rebound
• Disadvantages
• Swallowing
• Insomnia more likely
• Weight loss more likely

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Strattera

• Has 24-hour action
• Advantages
• Once daily dosing
• Does not aggravate tic disorders
• Does not aggravate anxiety may improve it
• Provides 24-hour cover, improving quality of life
  at home, in the early mornings and around bedtime
• Disadvantages
• Takes 4-6 weeks before improvement is evident
• Possible sedation
• Cost, medical aid funding

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Oppositional Defiant Disorder

• Parent management training
• Behaviour modification
• If ADHD comorbid, treat this first
• Stimulants
• Reduce aggression, improve negative social
  interactions
• Higher doses
• As a last resort, Risperdal
• Antipsychotic medication, with mood-stabilising
  properties
• Risks
• Uncertain long-term outcome
• Increases prolactin
• Tardive dyskinesia
• Weight gain

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Medication for childhood anxiety disorders

• Only once less invasive strategies have been
  attempted and failed
• Selective serotonin uptake inhibitors (SSRI)
• Prozac, Cipramil, Luvox,
• Zoloft in OCD
• Common side-effects
• GIT, eg nausea, diarrhoea, cramps
• Headaches
• Tiredness
• Sleep disturbance
• Appetite disturbance, weight gain
• Behavioural activation, mania

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Medication for childhood anxiety disorders

• Tricyclic antidepressants
• Anafranil, Tofranil
• Risks
• Cardiotoxic in overdose
• Sedation
• Dry mouth
• Constipation

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Medication in childhood depression

• High placebo response rate
• Tricyclic antidepressants have not been shown to
  beat placebo
• SSRIs the gold-standard
• Prozac FDA approved
• Recent controversy around induction of
  suicidality
• Treat associated ADHD

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Paediatric bipolar disorder

• Mood stabilisers are the mainstay
• Epilim, Convulex
• Lamictin
• Tegretol
• Risperdal
• Lithium
• Multiple medications often required
• Often need to treat associated anxiety, ADHD

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Monitoring medication

• Requires good communication between
• Home (both homes where relevant)
• School
• Doctor
• Other professionals
• Monitor clinical response
• Duration of treatment