4.9 Pharmacotherapy of pediatric psychiatry Flashcards
How does the DSM5 define tourette’s disorder?
Tics may wax and wane in frequency, but have been present for >1 year
According to the DSM5, when does tourette’s disorder start?
Onset before age 18
How does the DSM5 define persistent (chronic) motor or vocal tic disorder?
- Single or multiple motor or vocal tics present, but not both
- Tics may wax and wane in frequency, but have been present for >1 year
Can persistent (chronic) motor or vocal tic disorder be attributable to substance use or another medical condition?
No
How does the DSM5 define provisional tic disorder?
Sxs as persistent (chronic) motor or vocal tic disorder, but present for <1 year
Pts w tic disorders also have what other conditions?
75% also have ADHD, 50% also have OCD
What is the rule of thirds for progression of tic disorders?
- 1/3 resolve, 1/3 improve, 1/3 stay the -same
- 10% have persistent sxs as adults
What is the 1st line pharmacologic tx of tics?
- Alpha 2 agonists: clonidine, guanfacine, ER guanfacine
- For tics of mild-moderate severity
- 30% reduction
What is the 2nd line pharmacologic tx of tics?
- Atypical antipsychotics: aripriprazole, risperidone
- 30-60% reduction
What is the 3rd line pharmacologic tx of tics?
- Typical antipsychotics: haloperidol, pimozide
- 80% reduction
Aripiprazole is approved for what age range?
FDA approved for 6-17 yo
What is the dosing if a pt taking aripiprazole is <50 kg?
- 2 mg daily x 2 days, increase to 5 mg daily
- Max: 10 mg
What is the dosing if a pt taking aripirazole is >50 kg?
- 2 mg daily x 2 days, 5 mg daily x days
- Target 10 mg once daily
- Max: 20 mg
What can use of amphetamine-based stimulants exacerbate?
Exacerbate motor and vocal tic sxs
What must be treated along w Tourette’s?
ADHD
If a pt doesn’t tolerate or want to take amphetamine based stimulants, what are the other options?
Can d/c amphetamine based stimulants and give a trial of atomoxetine or a tricyclic antidepressant
After trying atomoxetine or a tricyclic antidepressant and it doesn’t work, what are next steps?
If ADHD sxs are not well controlled, can resume amphetamine based stimulant and adjust dose of antipsychotic to better control Tourette’s sxs
What are common behaviors in conduct disorder?
- Destruction of property
- Deceitfulness or theft
- Serious violations of rules
What must be specified for conduct disorder?
Specify whether:
- Childhood-onset type: <10 yo
- Adolescent-onset type: >10 yo (no sxs under 10 yo)
- Unspecified onset: unclear info to determine age onset
For tx of ODD and CD, what is pharmacotherapy is considered as?
- Pharmacotherapy is considered adjunctive, palliative, non-curative
- Should only be used after baseline sxs/behaviors have been determined
- Other interventions have failed and/or aggression has escalated to dangerous levels
What can atypical antipsychotics be used for regarding ODD and CD?
May be used to tx severe persistent aggression, serious oppositional behaviors, defiance
For treatment of ODD and CD, when do we often see combination stimulant/alpha agonist tx?
If ADHD w impulsivity or need for sedation for sleep
What is 1st line for tx of mild separation anxiety disorder?
Psychotherapy
What is 1st line for tx moderate to severe mild separation anxiety disorder?
Combination therapy of psychotherapy + SSRIs
What is the 1st line medication choice for separation anxiety disorder?
SSRIs
How does the DSM5 define autism spectrum disorder?
- Persistent deficits in social comm and social interaction across multiple contexts
- Restricted, repetitive patterns of behavior, interests, activities
What are the associated behavior sxs of ASD?
Aggression, hyperactivity, inattention, irritability, mood instability, poor frustration tolerance, self-harm, severe temper tantrum, sleep disturbances, OCD sxs, hypersensitivity of senses
What are the associated medical problems of ASD?
Seizure disorder (up to 30% have at least one seizure by age 20) and GI disorders
Are there any meds that tx the core ASD sxs?
No
What is the 1st line tx for disruptive behaviors in ASD?
Behavioral interventions (applied behavioral analysis)
What meds are used for tx of disruptive behaviors in ASD?
Atypical antipsychotics:
- Aripiprazole (6-17 yo) and risperidone (5-16 yo) are FDA approved for mgmt of irritability/aggression and are considered 1st line agents
- May have efficacy for stereotypy and hyperactivity
What meds have no effect on disruptive behaviors of ASD?
Lamotrigine/levetiracetam have no significant effect on irritability
What is the tx for repetitive behaviors?
Antipsychotics: haloperidol, risperidone, aripiprazole
What is the tx for ADHD?
- Stimulants: methylphenidate preferred
- Clonidine/guanfacine: modest effect on irritability and explosive behavior
What is the tx for sleep?
Melatonin reduced sleep latency and increased time asleep: 1-6 mg nightly
How does the DSM5 define disruptive mood dysregulation disorder?
Severe recurrent temper outbursts manifested verbally that are out of proportion w intensity/duration of situation
According to the DSM5, where must disruptive mood dysregulation disorder be present?
Present in at least 2 out of 3 settings (home, school, w peers) and are severe in at least 1
When should diagnosis of disruptive mood dysregulation disorder not be made?
Diagnosis should not be made before age 6 or after age 18
What must disruptive mood dysregulation disorder be differentiated from?
Need to differentiate from bipolar disorder - both for using antidepressants as well as evaluating need for mood stabilizers
What is considered 1st line tx for disruptive mood dysregulation disorder?
SSRIs and stimulants
What are sxs of pediatric depression in children?
Physical complaints, irritability, conduct problems, can have suicidal ideation
What are sxs of pediatric depression in adolescents?
Express feelings of depression and suicidal behaviors than more younger children
Is pediatric depression more short or long term?
- More chronic than episodic, instability in mood common
- May be a marker for bipolar disorder
What is 1st line tx for depression?
- Nonpharm is 1st line; need motivation of family/caregivers for success
- Cognitive behavioral therapy: remission rates of 70%
What is the black box warning for antidepressants?
Black box warning for suicidality:
- Highest risk in first 3 months of tx
- Med guide w each prescription
- Antidepressants may lower completed suicide rate
What is the use of fluoxetine for depression?
Only antidepressant FDA approved t tx kids down to 8 yo
What is the use of escitalopram for depression?
For 12-17 year olds
What is the paroxetine for depression?
1st antidepressant w suicidal thinking warning - avoid in kids
What are the preferred drug options for bipolar 1, mixed or maniac, w/o psychosis?
Lithium, valproate, carbamazepine, olanzapine, risperidone, quetiapine; may augment w 2nd agent if needed after 4 weeks
What are the preferred drug options for bipolar 1, mixed or maniac, w psychosis?
Lithium, valproate, carbamazepine, W any atypical antipsychotic, consider d/c of atypical if remission for 12-24 months
What are the preferred drug options for bipolar, depressed?
1st line - lithium, SSRI/bupropion for depression that continues w lithium tx (adjunct to lithium)
What is 1st line nonpharm tx for PTSD?
Trauma focused psychotherapy
What is 1st line pharm tx for PTSD?
SSRIs
What is childhood onset schizophrenia not explained by?
Not explained by substance use or PDD/autism
What is more common in childhood onset schizophrenia?
Visual hallucinations more common than in adults
When does sxs onset in childhood onset schizophrenia?
Onset of sxs before age 13
What is the prevalence of childhood onset schizophrenia?
Rare in children, adolescent prevalence reaches adult prevalence of 0.05-1%
