Child & Adolescent Psychiatry Flashcards
What are mental health outcomes associated with cannabis use in adolescents?
Depression
Psychosis
What are the most common scales used to assess Pediatric delirium?
The Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU)
Cornell Assessment for Pediatric Delirium (CAPD/CAPD-R)
What are evidence-based means of non pharmacologic pediatric delirium prevention?
reduction of pain
sleep disturbance
physical restraint use
addressing sensory and communication difficulties
ensuring early mobilization
providing frequent reorientation, including the use of familiar items from home
consistent presence of the child’s caregivers
What are evidence-based pharmacologic treatment of Pediatric delirium?
antipsychotics
alpha-2 agonists
melatonin
“Antipsychotics have been the mainstay of delirium treatment, with haloperidol, risperidone, olanzapine, and quetiapine showing equivalent safety profiles and improvement in agitation, sleep-wake disturbance, and symptom severity.,”
Name 5 social impacts of cannabis use in youth.
- Decreased performance in school, leading to lower educational attainment
- Higher unemployment levels
- Involvement in criminal activity
- Greater social assistance requirements
- withdrawal from their usual peer groups and conflict with family
- Lower Levels of Life Satisfaction
- Reduction in social, occupational or recreational activities
- Unable to fulfill major role obligations – school, work, family, friends
- Financial problems (leading to possible criminality)
- “gateway” to other drug use *
What is the relationship between cannabis and psychosis?
- Half of pts who develop induced psychotic symptoms with cannabis will go on to develop ongoing psychotic disorder
- Cannabis increases risk of psychosis from 40-400% (linked to how much use)
- The prevalence of schizophrenia is about 1% in the adult population, risk doubled in heavy cannabis users
- Use of cannabis and other illicit substances was associated with an earlier age at onset of psychotic disorders
What would you say to provide psychoeducation to a youth who vapes?
- Impact on respiratory system (Vaping Associated lung injury (VALI), chronic cough, bronchitis, asthma exacerbation, and decreased exercise tolerance)*
- Acute risk of injury (ie: burns, explosion)
- Highly addictive, quick tolerance/ dependence due to high nicotine content of pods (1 pod = 1 pack)
- Problematic use associated with the substances within the vapes (cannabis, nicotine, occasionally opioid, stimulants)
- Due to high concentration - acute nicotine intoxication/Nicotine toxicity – N/V, dizziness, H/A, confusion
- Vaping has been associated with high-risk behaviours and adverse mental health outcomes, notably depression and suicidality *
- Expensive
- Withdrawal
Dx of Catatonia. What are organic causes to be ruled out?
Neuro: Head trauma, cerebrovascular disease, encephalitis (e.g., anti-NMDAr or viral)
- Cancer: Brain tumor, paraneoplastic syndrome
- Metabolic: Hypercalcemia, diabetic ketoacidosis, hepatic encephalopathy, cerebral folate deficiency, homocystinuria
First psychotic episode. Parents asking for brain imaging. Explain why not and also what indications for brain imaging would be.
- Neurological exam is sufficient, and neuroimaging is not routinely recommended for first-episode psychosis (Canadian Schizophrenia Guidelines)
- Routine brain imaging often delays treatment and findings generally not contributory/ do not alter management in any meaningful way.
- Consider imaging if:
(a) History and neurological exam reveal: new/worsening headaches, n/v, seizures, focal neurological deficits
(b) Features of autoimmune encephalitis: rapid progression over <3 months, new focal findings, seizures
4M with imaginary friend. What is going on? Other DDx for visual hallucinations? What are 2 classes of medication that could cause VH?
Normal development
- DDx – adjustment d/o (severe stress), depression/ anxiety, PTSD, ASD, ID, sleep d/o
- Secondary to GMC – tumor, seizures, delirium, encephalitis
- Medications – steroids, opiate analgesics, anticholinergics
VH x 2 months, no other psychotic sx, no mood issues or bipolarity.
- PTSD, delirium, (temporal lobe) epilepsy, ASD
What is the therapeutic approach for pre-psychotic patients? Evidence-based approaches to treatment.
Approach to treatment for Clinical High Risk (Canadian Schizophrenia Guideline):
- Psychological interventions and medications can prevent or delay a first episode
- Offer Individual CBT +/- Family Intervention
- Offer Social Skills Training
- Treat comorbid conditions (e.g., depression)
- Monitor regularly for 3 years using validated tools
- Treatment should be provided by a psychiatrist or psychologist
- Use a staged and least-restrictive approach to treatment (e.g., CBT first then low dose SGA if needed)
What are the criteria for SIPS?
- SIPS – structured interview for psychosis-risk syndromes, which includes:
- Attenuated Positive Symptom Prodromal Syndrome (APS);
- Brief Intermittent Psychosis Prodromal Syndrome (BIPS);
- Genetic Risk & Deterioration Prodromal Syndrome (GRDS)
- SIPS assess:
- FHx
- GAF
- Scale of prodromal sx
- Schizotypal personality assessment
4F in hospital, seeing spiders. DDx? Recommendations?
- Delirium
- Work-up to determine cause
- Assessment – scales such as CAP-D (0-21yo), SOS-PD (0-16yo) or PAED (1-17yo) [pCAM-ICU is for >5yo]
CAPD: Cornell Assessment of Pediatric Delirium (age 0-21)
PAED: Pediatric Anesthesia Emergence Delirium Scale (age 1-17)
pCAM-ICU: Pediatric Confusion Assessment Method – ICU (age >5)
PsCAM-ICU: Preschool Confusion Assessment Method – ICU (age <5)
SOS-PD: Sophia Observation Withdrawal Symptoms – Pediatric Delirium (age 0-16)
- Non-pharmacological – early mobilization; remove unneeded unused lines; reorientation; parents at bedside; familiar items; maintain day-night cycle with multiple cues; reassurance
- Pharmacological – avoid polypharmacy + opiates + benzodiazepines + anticholinergic medications; Risperidone or Haldol/ Loxapine if hyperactive delirium. Titrate dose based on PRN use.
Metabolic syndrome criteria. What populations are most at risk? What are common secondary medical dx?
3 or more of the following
- Abdominal circumference >102cm for men, 88cm for women. For children 10-16 yo: the 90th percentile for waist circumference or adult cut point (whichever was lower) should define abdominal obesity.
- BP >130/85
- TG >1.7mmol/L
- HDL < 1.00mmol/L in men, <1.3mmol/L in women
- Fasting BG >5.6mmol/L
- Ethnicity – indigenous, blacks
T2DM, hypertension, cardiac disease, fatty liver, polycystic ovarian syndrome (PCOS), and pro-inflammatory states
Young child with cancer. Hospitalized x6 days. How do you explain why he is « not himself »?
- Ddx – delirium?
- Developmental regression in the context of critical illness (normal)
Which drugs cause VH?
- LSD, PCP, Amphetamines, Cannabis, Psylocibin
Which AP to avoid hyperPL?
1 Aripiprazole
Distant 3rd Clozapine
Secretion of prolactin by the pituitary gland is inhibited by dopamine in the hypothalamus. D2 blockade by antipsychotics in the hypothalamus releases this inhibition and causes hyperprolactinemia. D2 partial AGONISTS are not associated with hyperprolactinemia and can even treat it = Aripiprazole, Brexpiprazole, Cariprazine
Quetiapine is a D2 antagonist (not a partial agonist) but it (and Clozapine) have the lowest D2 blockade.
16 year old with schizophrenia. Attends a Section 23 school. Struggling with hallucinations.
a) Name 2 things that the teacher can do in order to support this student.
b) Name 2 things the teacher could do to decrease social isolation.
c) Name one intervention that a guidance counsellor can apply.
(a) Quiet room for evaluations and additional time for completion = (tests, exams); Headphones (+/- music) and ear plugs; Access to resource room/ supports; Body breaks; Technology adaptations (ie : Chromebook); Relaxation techniques. Adapt the schedule, workload and expectation according to capacities and absences with realistic expectations. Help with increased visual support.
(b) Integrate activities and projects of pre-selected groups; vocational projects; work in dyads or groups. Social skills training, tutoring from other student.
(c) IEP; specialized educator and decrease ratio; promote vocational projects; quiet and calm environment; cognitive remediation; cognitive remediation; build on strengths; consider school placement.
List two mental health disorders associated with hallucinations in youth (other than a psychotic disorder, SUD and bipolar disorder):
Anxiety disorders
Borderline Personality Disorder
PTSD
Depression
ASD/DD (less so)
Clinical vignette of an adolescent admitted and treated with an antipsychotic for acute psychosis. He is now febrile, delirious, and displays muscle stiffness. List two mandatory laboratory investigations. List three important components to evaluate on physical exam.
- Investigations – blood work, (CK, Creatinine, CBC, blood cultures, liver enzymes, LDH, Ca, PO4, Serum iron, urine myoglobin, ABG, coag, serum and urine toxicology)
- Most important is to rule out Ddx (ex. infection)
- Physical examination - Worry about NMS – (FARM)
- Temp
- HR/BP
- Rigidity
- Most important/dangerous: hyperthermia
List three features to differentiate schizophrenia from ASD in a child.
Temporal evolution/ onset of symptoms
Those with ASD do not spontaneously orient to emotional information
Origin of bizarre behaviours – delusions/ hallucinations/ disorganization vs. sensory hyper/hypo-sensitivities, adherence to routine/ rigidity
Period of normal or quasi-normal development before onset of symptoms (in scz)
Told of a family doctor who placed a youth on an antipsychotic and is now asking you what will be important to monitor over time. Asked to list five things.
Weight, BMI (Height), WC
Vitals – BP
Blood work – glucose/ HbA1c, lipid profile, PL (and effects of hyper-PL)
EPS + neurological exam
Psychotic Symptoms
Adolescent on clozapine. More lethargic past 2 weeks. Given most concerning side effect, name 3 signs or symptoms to do on history or physical exam. What lab investigation is most important to monitor? How often to check bloodwork in the first 6 months?
- Agranulocytosis – low NT count
- Fever, mouth ulcers, sore throat (maybe also HR/BP)
- Weekly for the first 6 months and biweekly for the next 6 months. CBC/ NT count weekly x 6 months. TnI and ERP weekly x first 4 weeks.
Prior to initiating treatment, obtain a baseline ANC; the ANC must be ≥2,000/mm3 in order to initiate treatment. Initiate treatment in an inpatient setting or an outpatient setting with medical supervision and monitor of vital signs for at least 6 to 8 hours after the first few doses. During the first 6 months (26 weeks) of treatment, ANC should be obtained at baseline and at least weekly. If count remains acceptable (ANC ≥2,000/mm3) during this time period, then may be monitored every other week for the next 6 months (26 weeks). If ANC continues to remain within these acceptable limits after the second 6 months (26 weeks) of therapy, monitoring can be decreased to every 4 weeks.
What is the indication for using clozapine? List three major side effects unique to clozapine.
Indication: treatment resistant schizophrenia (2 adequate trials of antipsychotics, 6-8 weeks duration)
Faster if self-injurious, suicidal behaviours, fast response needed
Side effects: agranulocytosis (low neutrophils), myocarditis/ cardiomyopathy, seizures, ileus/constipation, orthostatic changes in BP and HR/ bradycardia hypotension, QTc prolongation, NMS, anticholinergic toxicity, ileus/constipation
What do you check for bloodwork for clozapine and then monitor?
· CBC
· weekly x 6 months
· bi-weekly x 6 months
· q4weeks x thereafter
Name 4 parameters of metabolic syndrome? Which ethnic group in Canada at highest risk?
Waist circumference
BMI
BP
HBA1C/ fasting glucose
fasting lipid profile
Black and indigenous peoples ** not evidence-based, stupid
a) What are 3 signs/symptoms of hyperprolactinemia?
b) Which 2 antipsychotics least likely to increase prolactin?
a) Galactorrhea, gynecomastia, decreased libido, sexual dysfunction, decreased bone mass
In women specifically amenorrhea, oligomenorrhea, infertility *
b) aripiprazole, quetiapine, clozapine
9 year old with auditory hallucinations. Recently moved to Canada. Grandmother just died. Name 2 psychological triggers for AH and 2 symptoms need to ask to rule out psychosis.
- Severe emotional stress (grief/loss, recent immigration/ transition)
- Depression, in mood-congruent AH
- delusions
- disorganization
- functional change
- delusions
- mood incongruence
- Social withdrawal
- Language changes
AACAP “Hearing Voices and Seeing Things” 2017
Which medications are approved for the treatment of psychosis in pediatric patient?
HC – Aripiprazole (15+), JAMP Lurasidone is indicated for the management of the manifestations of schizophrenia in adolescents (15+)
FDA – Aripiprazole, Olanzapine, Paliperidone, Quetiapine, Risperidone , asenapine, brexpiprazole, lurasidone
Psychosis – treatment and good prognostic factors
- Antipsychotics are primary treatment
- Ongoing medication therapy should be provided to youth with schz
- Adjunctive meds to treat associated symptoms (agitation, depression, outbursts)
- Psychotherapeutic interventions should be provided in combination with medication therapies (cognitive-behavioral therapies, social skills training, cognitive remediation, and family interventions - FT, MI, CBT)
- Sudden onset + good pre-morbid function + good response to treatment + good insight + short duration of psychosis
- Poor long-term outcome is predicted by low premorbid functioning, insidious onset, higher rates of negative symptoms, childhood onset, and low intellectual functioning
Catatonia. Name two treatments.
ECT and benzodiazepines
Alternative - carbamazepine topiramate valproate zolpidem memantine and bromocriptine
Stem suggestive of psychosis prodrome
- Functional decline - 30% GAF in past year
- Sleep changes
- Social withdrawal
- Irritability/ anger
- Anhedonia, lack of motivation
- Negative symptoms – anhedonia, lack of motivation
- 3 different UHR groups: Genetic Risk & Deterioration (GRD), (Attenuated positive symptom syndrome) APSS, (brief Intermittent psychotic symptom syndrome) BIPS
Social withdrawal and isolation, idiosyncratic or bizarre preoccupations, unusual behaviors, academic failure, deteriorating self-care skills, and/or dysphoria. These changes may be associated with depression, anxiety, aggressive behaviors, or other conduct problems, including substance abuse, which often confuse the diagnostic picture. The prodromal phase may vary from an acute marked change in behavior to a chronic insidious deterioration.
NSSIB in ED. Parent are insisting on admission. Name 2 elements of psychoeducation to parents.
- NSSIB = not suicide attempt but maladaptive coping strategy
- Inpatient admission is not helpful and may actually result in further regression of distress tolerance/ emotional regulation skills.
- This learning is done in the community.
Youth with self-harm behavior. Asked to give 5 psychosocial strategies to address the behavior.
- Minimize alcohol/ substance use
- Skills
- Emotional regulation skills
- Improve communication
- Distraction
- Interpersonal effectiveness
- Problem-solving skills
- Conflict management Skills
- Affective Language Skills
- Psychotherapies
- DBT
- CBT (Individual, Family, Parent Training)
- FBT-Attachment for SI
- IPT – Individual for SI
- Psychodynamic therapy-Individual + Family
- Safety Planning
- Parent Skills Training
- Keep environment safe
Also Acceptable Answers:
- Interpersonal relationships/ supports
- Try to remove reinforcements/social contingencies
- Recognize warning signs
- Develop coping strategies (ex TIPP)
- Use friends, family and MH professionals for support
- Keep environment safe
- Motivational interventions/brief intervention
- Use mobile safety planning apps
- Mentalization-based treatment?
- Affective language skills
- Self-soothing skills
- Psycho-education for patient and family
- Cognitive problem-solving skills
Girl ingests 3 tabs x 325 mg acetaminophen. “3 safety questions?” What do you ask about?
- Where there any co-ingestions/ concurrent substance use?
- Was this a suicide attempt? (Clarify SI/ intent/ plan/ access to means (including guns))
- History of previous SA
- Precipitants - stressors, triggers
- Protective factors – supports, plans, evidence of future orientation
- Do you live alone?
- Are you still thinking of suicide?
(Screen for depression, mania, hypomania, severe anxiety)
Name 5 things to ask on safety/ risk assessment.
a) SI, plan, intent, access to means, future orientation
b) Triggers/ precipitants/protective factors
c) History of previous SA
d) Collateral history
e) Psychiatric diagnoses/comorbidities
f) Protective/ resiliency factors (ex: family, pets, religion)
g) Supports (ex : formal and informal)
h) Collateral information
i) Family history (of suicidality and mood d/o)
j) History of abuse, violence, bullying
k) Substance use
l) Exposure to suicide (ex. in media or friends/school)
m) Emotional/cognitive factors: hopelessness, helplessness, impaired problem-solving, agitation, despair, low SE, impulsivity
n) Familial conflict
o) If part of minority (first nation, lgbtq, …)
Young girl with self-harm behaviors. Name 4 strategies to reduce self-harm.
a) Distress tolerance skills
b) Emotional regulation skills
c) Distraction
d) Mindfulness, relaxation strategies
e) Anger management
f) Problem solving approach
g) Supports
h) Interpersonal effectiveness, friendships
i) Remove “means” – sharps, lighters, etc…
Girl ingested 100x100mg tabs of Quetiapine.What are 2 immediate steps for psychiatric care.
- Is this patient medically stable? ABC – vitals, LOC, QTc + involve other specialties as needed
- Assess Safety (+ Patient status in hospital – voluntary vs. involuntary)
- Assess for possible admission
Adolescent girl presents with self-injurious behavior. No mental health disorder present. List 5 techniques to decrease self-harming behavior.
- distraction (holding ice, cold shower)
- distress tolerance (TIPP= temperature, intense exercise, pace breathing, progressive muscle relaxation)
- emotion regulation techniques
- removing sharps and lethal means, and safety proofing home
- treat comorbidities
- meditation
- mindfulness
You write a prescription for AD in a child. The pharmacist does not want to dispense the medicine, stating it is not approved in patients <18yo. Give 2 reasons to explain the responses of the pharmacist and justify your prescription to the parent.
- AD not approved by Health Canada for those <18yo; although accepted in other countries (ie: USA). Treatment with AD is guided by Canadian and international treatment guidelines, such as CANMAT, Katzman, Canadian Pediatric Society and AACAP guidelines.
- There is a black box warning for increase in SI (not attempts). Note that untreated depression increases risk of SI and attempts.
- The FDA warning was based on an analysis published more than one decade ago about industry-sponsored randomized controlled trials (RCTs). However, since then, an increasing number of studies have questioned the methodological rigor of the FDA analysis
- Antidepressants very well studied in adolescents
3 important studies about SSRI (and their key findings) in children.
TADS – Treatment Of Adolescents With Depression (2007)
- TADS Key finding: Combination treatment (Fluoxetine + CBT) had the highest response rate
- Fluoxetine monotherapy better than CBT monotherapy
TORDIA – Treatment Of Resistant Depression In Adolescents 2010
- Adding CBT to either a new SSRI or an SNRI is superior to just switching meds alone
- No difference if SSRI vs. SNRI (but SNRI = less tolerability)
CAMS – child & adolescent anxiety multimodal study [separation/ social/ GAD]
- At 12 weeks, combo > (sertraline= CBT )> placebo
POTS – pediatric OCD treatment study
- At 12 weeks, combo > CBT > Sertraline > placebo
Name 5 differences in pharmacotherapy/ pharmacokinetics between methylphenidate and amphetamine.
In general, the primary pharmacologic effect of amphetamine and methylphenidate = increase central dopamine and norepinephrine activity, which impacts executive and attentional function.
Methylphenidate –
- Blocks reuptake of DA and NE (amp too)
- Metabolized by esterases in the liver (highly variable) – not CYP
Amphetamine –
- Inhibits VMAT-2 (which releases DA form vesicular storage)
- Inhibits MAO activity –> decreased breakdown of DA/NE
- Eliminated most via kidneys; excreted in urine mostly unchanged
Patient on fluoxetine and Strattera. What is the interaction? What is an example of another psychotropic that can interact with ?fluoxetine/ Strattera [unclear]?
- Fluoxetine inhibits 2D6 and therefore increases the serum concentration of Strattera. So beware of increasing the dose of Strattera.
- Other strong 2D6 inhibitors = bupropion, paroxetine; moderate = duloxetine
- Other 2D6 substrates = abilify, venlafaxine, risperidone, olanzapine
- Also: watch QTc as both SSRI and Strattera can increase QTc
Child on psychostimulant but difficulties with sleep and low weight. How do you switch from psychostimulant to Strattera?
CADDRA - Switching from a psychostimulant to atomoxetine or guanfacine XR:
- Since non-stimulants will take time to show clinical response, it is important to decide if the psychostimulant needs to be stopped before or if you combine both as you start atomoxetine or guanfacine XR.
- If the first medication shows no clinical effect despite optimal dosing, stop it and start the non-stimulant as monotherapy, following usual titration strategies.
- Only if it is not possible to stop the first medication (and if the first medication shows important clinical effect and needs to be continued until the non-stimulant shows its effects) then keep the first medication and add atomoxetine slowly, following usual titration strategies.
- If side effects occur, decide between reducing the psychostimulant versus atomoxetine or guanfacine XR dosage.
- Strattera – 0.5mg/kg/day x 7-14 days, then 0.8mg/kg/day x 7-14 days, then 1.2mg/kg/day x7-14 days. Max = 1.4mg/kg/day or 60mg (kids) or 100mg (youth)
- Guanfacine – Start at 1mg daily, maintain dose for 7 days, increase by no more than 1mg weekly Max = 4mg in age 6-12, 7mg in 13-17. As adjunct, max = 4mg.
Intoxication/ overdose on benzodiazepine. What is the antidote? What is the mechanism of action of benzodiazepine?
(a) Flumazenil.
But more generally, approach to management
- ABCs
- Naloxone if altered mental status and worried about opioid co-ingestion
- IV access, CCM
- If respiratory depression, definitive airway management
- Usually no decontamination
- Flumazenil indicated IF young children with isolated BZD ingestion with severe CNS depression – not in anyone who uses BZD chronically
(b) Bind to the GABA-A receptor of neurons; allosteric reaction –> increased activity of GABA at GABA receptor. Increase influx of Cl, which results in hyperpolarization of the inhibitory neuron –> less likely it will fire an action potential.
Aripiprazole – how does it differ from other AP. What are 2 advantages and 2 disadvantages of this medication?
- Partial D2 and 5HT1A agonist
- BENEFITS –
- Better metabolic profile
- Less hyperPL
- Slightly less weight gain then other AP
- There is an LAI (IM) formulation (Maintena)
- DRAWBACKS –
- Akathisia
- EPS/Parkinsonism
- Long half-life making reaching the steady state longer
Ethnic differences in metabolism. Name 4-5 approaches to how you would adjust your prescribing methods.
Practices:
- Start low, go slow
- Close monitoring of SE
- FHx of response
- Avoid polypharmacy
- Regularly reassess need for the medication and dc unnecessary agents
Summary:
- Caucasians, Blacks, Asians – slow metabolizer 2D6
- Blacks and Asians – slow metabolizer 2C19
- East Asians – slow metabolizer 3A4
- Differences in glycoproteins – drug transporter
- Polymorphisms of 5HT 2A and D3 receptors – more side effects, including EPS, respond to very low doses
- Indigenous and blacks: more risks Db2
Which AP to avoid hyperPL?
- Aripiprazole
- Quetiapine
- Clozapine
- Brexpiprazole
13 year old female of Haitian descent with ?oppositional behaviour. On Fluoxetine 30mg x 10days. Risperidone 0.5mg BID added 4 days ago. Agitated, tremulous. Provide two metabolic/ pharmacokinetic/ dynamic explanations for her symptoms. Describe 3 cultural themes to explore if parent/ parent are consider dc of treatment.
- Risperidone is a substrate for 2D6. Fluoxetine is an inhibitor of 2D6.
Therefore, there are increased serum levels of Risperidone = increased SE
She could also be a slow metabolizer. Younger patients + certain cultural groups (black) are more susceptible to EPS. Synergism of SSRI + AP that both cause akathisia.
- Consider a cultural formulation:
- Understanding/ meaning of symptoms/ dx/ treatment – pharmacotherapy
- Culturally appropriate supports/ care
- Psychosocial stressors and cultural factors impacting vulnerability/ resilience
- Expression of distress/ idioms of distress
- Religious and spiritual beliefs/ implications
- Patient-physician relationship and understanding/ trust
- Cultural identity
- Cultural community implications
Name 2 paradoxical reactions to benzodiazepines in children.
- Agitation/ irritability
- Excessive Movements/Excitability
- Impulsivity
- Talkativeness
- Insomnia
Describe most common side effects as a result of combining fluoxetine to risperidone. What is the mechanism of action?
- Medication interaction
- Inhibition of CYP450 2D6 metabolism by fluoxetine and its active metabolite.
- Fluoxetine increases the serum levels of Risperidone
- EPS, sedation, dizziness
List two medications associated with hallucinations in children
Medications – steroids, opiate analgesics, anticholinergics
Provide mechanism of action of methylphenidate and atomoxetine.
- methylphenidate= Methylphenidate (MPH) non-competitively blocks the reuptake of dopamine and noradrenaline into the terminal by blocking dopamine transporter (DAT) and noradrenaline transporter (NAT), increasing levels of dopamine and noradrenaline in the synaptic cleft.
- atomoxetine= SNRI; thought to be related to selective inhibition of the pre-synaptic norepinephrine transporter
Describe what makes aripiprazole unique relative to other antipsychotics, and give two concerning side effects
[a] From a pharmacological perspective, aripiprazole is different to other antipsychotic agents , as it is the only approved antipsychotic that reduces dopaminergic neurotransmission through D2 partial agonism, not D2 antagonism. (Partial d2 agonist + partial 5HT1 agonist)
[b] akathisia; EPS; NMS
Told of a family doctor who placed a youth on an antipsychotic and is now asking you what will be important to monitor over time. Asked to list five things.
- height, weight, BMI, WC
- vitals= BP
- bloodwork= glucose/HbA1C, lipid profile, liver profile, prolactin
- neuro exam for EPS
- response to treatment
- lifestyle behaviours
8 yo with GAD. Not treated with psychotherapy. Wants to start SSRI. Name 5 pharmacokinetic principles of SSRIs in this patient (question is not any more clear than this).
- Pre-pubertal children have a higher rate of activating side effects on SSRI
- Maturation of pathways impacts effectiveness of medications
- Children metabolize medications faster due to larger liver (liver to body ratio) and more efficient glomerular filtration (shorter ½ life)
- Higher proportion of water = larger volume of distribution of hydrophilic meds
- Less adipose tissues = accumulate lipophilic meds to a lesser extent and consequently eliminate them faster
- Increased BBB permeability
Name 5 lab investigation prior to initiating lithium
- Blood work – 1)CBC, 2)electrolytes, 3)extended electrolytes (Ca + albumin), 4)renal function (Cr. BUN), 5)thyroid function (TSH, T4)
- Urinalysis
- ECG (*Guidelines say >40 years, but we will do it!)
- Pregnancy test
- Weight, BMI
What is the general prevalence of ADHD in:
a) children and adolescents?
b) adults?
a) 5-9%
b) 3-5%
What is true about the heritability of ADHD?
a) low or high?
b) Risk of child having ADHD if parent had ADHD?
c) What percentage of kids with ADHD have a parent with ADHD?
a) high
b) 50%
c) 25%
What is known about the genetic pathophys of ADHD?
- ADHD is heterogeneous disorder, so likely complex genetic etiologies
- Many genes have been linked such as DAT and DRD4
What are etiologic risk factors associated with ADHD?
- smoking and alcohol use in pregnancy
- low birth weight
- psychosocial adversity
What is a possible underlying neural mechanism in ADHD?
- dysfunction of frontal-striatal pathways
- dorsolateral and anterior cingulate
What did the Multimodal Treatment of ADHD (MTA) study find with regards to the prevalence of comorbidities in children with ADHD?
- Up to 70% have comorbid psych disorders such as anxiety, depression, ODD, tic, OCD
How many criteria are needed to make a diagnosis of ADHD?
- Hyperative - 6/9 hyperactive symptoms
- Inattentive - 6-9 inattentive symptoms
- Combined - 6/9 of each
(note in adults, 5/9 needed)
Medication Selection: Medication-related factors in ADHD
Active ingredient /mode of action/drug interactions
Delivery system / onset of action / duration of action
Available doses
Canadian clinical indications
Affordability, accessibility and reimbursement
(public/private)
What are patient specific factors in ADHD med selection?
Age and individual variation
Duration of effect required by timing of symptoms
Concurrent psychiatric and medical issues
Physician, family and patient attitudes
Adolescent on clozapine. More lethargic past 2 weeks.
a) Given most concerning side effect, name 3 signs or symptoms to do on history or physical exam.
b) What lab investigation is most important to monitor?
a) agranulocytosis= fever, tachycardia, tachypnea, hypotension/blood pressure, examination of oral mucosa
b) CBC with differential (absolute neutrophil count)
What are some of the disntinguishing criteria of pyromania?
- Deliberate and purposeful fire setting on more than one occasion.
- Tension or affective arousal before the act.
- Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).
- Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
- The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication).
- The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.
How often do you check clozapine bloodwork in first year?
Baseline (must
First 6 months, weekly.
Second 6 months, every other week (as long as counts acceptable)
After that, every 4 weeks
What are the values assoicated with the hematology toxicity monitoring of clozapine?
Hematologic toxicity monitoring:
ANC 1,500 to 2,000/mm3: Continue treatment; monitor ANC twice weekly until counts stabilize or increase, then return to previous monitoring schedule.
ANC <1,500/mm3: Discontinue treatment and do not rechallenge patient; continue to monitor WBC/ANC daily until hematologic abnormality is resolved; monitor for signs of infection.
If WBC falls <1,000/mm3 or ANC falls <500/mm3, place patient in protective isolation with close observation.
Adolescent on clozapine. More lethargic past 2 weeks. If you are concerned about TOXICITY specifically,
a) Name 3 signs or symptoms to do on history or physical exam
b) What lab investigation is most important to monitor?
a) hypotension, myoclonus/seizures, mental status changes (sedation), sialorrhea
b) CBC with differential, clozapine level
a) Name 2 symptoms of paradoxical reaction to benzodiazepines.
b) State 2 things you would warn family about if there is a paradoxical reaction.
a) agitation/irritability
excessive movements/excitability
impulsivity
talkativeness
insomnia
b) seek medical support/present to ER
increased supervision
down-titrate
ultimately discontinue benzodiazepine
a) Name 3 differences in drug metabolism in ethnic minorities.
b) Describe 4 ways to dose medications in ethnic minorities.
a)
- Caucasians, Blacks, Asians – slow metabolizer 2D6
- Blacks and Asians – slow metabolizer 2C19
- East Asians – slow metabolizer 3A4
- Differences in glycoproteins – drug transporter
- Polymorphisms of 5HT 2A and D3 receptors – more side effects, including EPS, respond to very low doses
- Indigenous and blacks: more risks Db2
b)
- Start low, go slow
- Close monitoring of SE
- FHx of response
- Avoid polypharmacy
- Regularly reassess need for the medication and dc unnecessary agents
Kid with 2 year history of absence seizures and 4 month history of generalized tonic clonic seizures. On carbamazepine (no timeline listed).
a) What is the most likely diagnosis?
b) Want to start Prozac - what if any interaction with carbamazepine?
a) Seizure disorder = likley diagnosis in a child with seizures. Most common psych comorbidities in epilepsy: ADHD, ASD, depression, anxiety, psychosis, OCD, PD. (Note answer key = depression)
b) Carbamazepine is metabolized by CYP3A4. Fluoxetine inhibits CYP3A4. So the patient will have higher levels of serum Carbamazepine. Side effects could include confusion, ataxia, nystagmus, GI symptoms, SJS.
Carbamazepine also cause 1A2, 3A4, 2C19, 2C9 and 2B6 induction which could decrease concentration of fluoxetine
But most dangerous/relevant effect is one stated above possibly causing CBZ toxicity
What treatment is contraindicated for depression in seizures?
Wellbutrin/ Bupropion (and TCAs)
Name a second generation antidepressants that causes somnolence and 2 that cause insomnia.
a) Mirtazapine
b) Bupropion, Venlafaxine, SSRIs in some cases
a) What is the indication for using clozapine?
b) List three major side effects unique to clozapine.
a) Treatment resistant schizophrenia
(2 failed antipsychotic trials of at least 6 weeks at midpoint or higher of therapeutic dose range, documentation of adherence, and persistence of 2 positive symptoms with at least moderate severity or a single severe symptom)
b) Ileus, Agranulocytosis, Myocarditis, Seizure
What do you check for bloodwork for clozapine and then monitor?
- CBC
- weekly x 6 months
- bi-weekly x 6 months
- q4weeks x thereafter
*CAMESA: fasting glucose, insulin, lipid profile, AST/ALT, prolactin (baseline, 3 months, 6 months, 12 months)
Child with seizure disorder and depression.
a) Which med to choose?
b) What is contraindicated?
a) SSRI (sertraline and fluoxetine)
b) Bupropion and TCA
What are 3 signs/symptoms of hyperprolactinemia?
Galactorrhea
Gynecomastia
Osteopenia/Osteoporosis
Sexual dysfunction/Decreased Libido
In women - infertility and amenorrhea
bWhich 2 antipsychotics least likely to increase prolactin?
Aripiprazole
Quetiapine
(… and clozapine a distant 3rd, lol)
a) How is Aripiprazole different than other SGAs?
b) What are 2 benefits of Aripiprazole?
c) What are 2 side effects?
a) Partial D2 agonist
Partial 5HT1 agonist
5HT2A Antagonist
b) Less metabolic side effects
Less weight gain
Less hyperPL
c) Akathisia, EPS
NMS. In stem, provide 5 risk factors.
- Male (2:1)
- Age 20-25
- AP naive
- Dose and potency of DA agent
- Hx of NMS (15-20% recur)
- IM AP
- agitation
- Iron deficiency
- Rapid increase in dose
- GDD/ID
- FHx catatonia
- History of catatonia
- polypharmacy
- physical restraints
- hyperthermia/fever
- hyperT4
- sudden discontinuation of anticholinergic drug
- dehydration
- Acute medical illness
- Inconsistent use
List some school/ academic accommodations for ADHD.
- instructional interventions= give clear, precise instructions; get the student’s attention before providing instructions; use direct requests (“when-then”)
- behavioural interventions= provide immediate and frequent feedback; use visual cues in the classroom or on the desk for transitions; Chunk and break down steps to initiate tasks
- environmental intervention= preferential seating away from distractions; proximity to teacher
- academic interventions= Actively engage the student by providing work at the appropriate academic level; Permit student to write quizzes, tests and exams in a quiet room
- executive function interventions= find a tutor/academic coach; establish a routine
- post-secondary interventions= contact the student accessibility/disability centres; allow for extended time on tests/exams
Intense anger outbursts x several months with irritability in between outbursts.
a) What is the most likely diagnosis?
b) What else is on your Ddx?
a) DMDD
b) ASD
ADHD
IED
ODD/ CD
Depression/ anxiety/ BAD
Recall, DMDD
- Young as 6, up to 18
- Symptoms must be present by age 10
- Can’t be diagnosed with ODD, MDD, BD
- Non-episodic irritability
Name 2 elements that differentiate ADHD and mania.
- ADHD is an ongoing condition where BD is episodic
- decreased sleep, hypersexuality, grandiosity, hallucinations or delusions, and homicidal or suicidal thoughts and actions occur with childhood mania, but are rare or absent in uncomplicated ADHD.
What are comorbidities of Pyromania?
CD
ADHD
Adjustment Disorder
Adults – ASPD, SUD, Gambling
What are features of Pyromania?
Dx:
*impulse control disorder
(1) The person has set fires deliberately and on purpose on more than 1 occasion (multiple episodes involved)
(2) The person feels a tension or affective arousal before setting the fire
(3) Fascination, interest, attraction and/or curiosity for fire making paraphernalia, fire fighting equipment or any fire-related topic
(4) Pleasure, gratification, or relief may be felt when setting fires, while witnessing a fire or when participating in the aftermath
Exclusion criteria:
- The fire setting cannot be better explained by another disorder (mania, antisocial personality conduct disorder, other).
- The fire setting is not done (1) for monetary gain–insurance etc (2) to express a sociopolitical ideology, (3) to conceal a criminal act, (4) as a conscious expression of anger or vengeance, (5) to improve one’s living circumstances, (6) in response to a delusion or hallucination, and (7) as a result of impaired judgement due to delusion or intoxication.
a) What is advice for teens with ADHD who will be starting to drive?
Driver Training
- Pharmacotherapy + adherence
- Jerome Driving Questionnaire (CADDRA)
- Do not use mobile device and minimize distractions
- Do not drive at evenings/ night/ weekends
- Automatic transmission
- Report to MOT if any concerns/ repeated accidents
- Curfews
- Staying off major highways
- Absolutely no drugs or alcohol
- PRN use of short acting medication in evenings if necessary
What is the increased risk for MVC for teens with ADHD?
2-4X increased risk of MVC
What cognitive functions do you need for driving that are affected by ADHD?
- memory and learning
- executive functions
- complex attention
- perceptual and motor functions
- Language
- Social Cognition
(fyi) Neurodevelopmental immaturities in executive functioning (resulting in problems with attention, impulse control and emotional regulation) combined with a lack of driving experience can lead to problem driving styles in young people in general
Young boy with ADHD with motor (facial) tics. Ddx?
- persistent motor or vocal tic disorder (more than 1 year and either motor OR vocal tics but not both) vs provisional tic disorder (less than 1 year) vs Tourette’s disorder (both motor AND vocal tics)
- psychostimulant induced
- stereotypies/ASD
- OCD
- PANDAS
Which medication would you recommend for severe tics?
A-2 agonists
- Guanfacine
- Clonidine
- Tetrabenzine
- Atomoxetine in cases where stimulant is exacerbating tics
Are there any medications contraindicated for ADHD + Tourette’s syndrome?
- No specific contra-indication for tics+ADHD (Stimulants not containdicated)
- Canadian guidelines recommend against cannabinoids, levetiracetam, IVIG, fluoxetine, ondansetron
Pharmacotherapy for severe behavioural issues.
- Multimodal, non-pharmacological approaches across settings – parent skills training, emotional regulation, anger management, problem solving therapy)
- ADHD – stimulant, non-stimulant (a2-agonist and atomoxetine), Risperidone
- ASD – Risperidone, Aripiprazole
- Not ADHD or ASD – Risperidone
Which medications to treat ADHD in a child with Tourette’s Syndrome?
CADDRA:
- Stimulant medication is a safe and effective treatment for ADHD + Tic Disorder but requires careful monitoring of potential tic worsening
- the alpha-2-adrenergic agonists, clonidine and guanfacine XR, have shown promise in the treatment of tics, particularly in combination with ADHD
- In patients where stimulants may cause tic exacerbation, atomoxetine may be also considered as an option as it will rarely cause worsening of symptoms
- Methylphenidate long acting – Biphentin, Concerta
- Amphetamine long acting – Adderall, Vyvanse
- Alpha- agonist – Guanfacine, Clonidine
- SNRI – Atomoxetine
What do you have to monitor when a child is on medications for ADHD?
- Height
- Weight
- BP/ HR
- ECG is NOT routine
- Monitor for cardiac symptoms (by history)
- Be alert for signs of misuse, diversion
- Symptoms
- Side effects
Name 2 Health Canada warnings about psychostimulants.
Sudden (cardiac) death
Seizures
Psychosis
- On Vyvanse monograph:
- **Potential of abuse/misuse/diversion (only “serious warning”)
- Cardiovascular adverse events and sudden death (with structural cardiac abnormalities)
- Suppression of growth (and weight loss)
- New onset or aggravation of psychotic and manic symptoms
- Aggressive behavior or hostility
- Suicidal behavior and ideation
- Seizures
- Tics
- Peripheral vasculopathy (Raynaud’s)
- Ophtalmo: difficulties accommodation and blurred vision
What are some considerations before started psychostimulants?
- Cardiac symptoms including syncope, palpitations, chest pain, shortness of breath or seizures during exercise
- Cardiac disease including a clinically significant murmur (not functional, or other symptomatic heart disease
- Psychosis
- Mania
- Seizure
- Medical Contraindications
- Treatment with MAOI and for up to 14 days after discontinuation.
- Glaucoma (narrow angle)
- Untreated hyperthyroidism
- Moderate to severe hypertension
- Pheochromocytoma
- Patient Preference
Family history
- Premature (sudden/unexpected) death in family members <40 years old
- Cardiac history including hypertrophic cardiomyopathy, clinically important arrhythmias including long QT syndrome (LQTS), Marfan syndrome
List 5 behavioural strategies for ADHD in the classroom
- Sit in front of the class
- Noise cancelling headphones
- Break up instructions into small chunks/ step by step
- Similarly, break down tasks into small steps
- Quiet space for test and evaluations to decrease distractions
- More time for test/ assignments/ projects
- Body breaks
- Transitions – visual aids, warnings about upcoming transition
- Eye contact when speaking to the child
- Immediate/ frequent feedback (daily report cards)
- Access to scribe / minimize note taking
- Focus on quality and not quantity
- Write down homework
- Token economy / positive reinforcement
- Access to fidget/sensory objects
- Possibility to move without disturbing
- Testing on computer or orally if possible
- “When… then”
- Frequent feedback
- Immediate feedback
- Sit next to a “more attentive” buddy
Comorbidities of oppositional behaviour disorders?
DSM 5
- ADHD
- Conduct Disorder
- Major Depressive Disorder
- Anxiety
- Substance Use Disorders (in adults)
- Bipolar Disorder
- LD/ID
*Increased risk of suicide attempts once other psych disorders controlled for
Best medications for behavioural issues in ADHD?
- # 1 - Psychostimulants
- # 2 – Guanfacine
- # 3 – Atomoxetine
- # 4 – Clonidine
- # 5 – Risperidone
- # 6 – Valproate
Comorbidities of tics?
- Tics
- ADHD & OCD
- Also anxiety, depression, ODD/CD, LD, Bipolar Disorder, SUD
a) Ddx for school truancy.
b) Name three strategies to address school truancy.
(a) “Refusal”: Anxiety, separation anxiety, social anxiety, phobia, depression, somatization/ somatic symptoms/ IBS, factitious disorder, Panic disorder, PTSD
Truancy: Conduct disorder, ODD
(b)
- Treat underlying anxiety disorder
- Consider psycho-ed testing to assess learning needs/barriers
- Adapt school work (ie what was missed, where can re-start, etc) / accommodation
- Limit secondary gains (no TV or video games at home, etc)
- Psychoeducation
- Involve caregiver
- Gradual Exposure
- Multidisciplinary Supports
11 year old with ADHD. Stealing, lying. Severe aggression with peers and adults. Young parents, homeless.
a) What are 2 other diagnostic consideration.
b) Name 3 risk factors.
(a) SUD, CD, PTSD/ trauma, ODD, Adjustment disorder with conduct symptoms, ASD, ID, FASD
(b) Antenatal substance exposure (tobacco and alcohol); low birth weight, psychosocial adversity, Lack of stimulation and supervision, Low socio-economic status, depressed mother,
3 criteria of CD with limited prosocial emotions.
CD + 2 of the following
- Lack of remorse/guilt
- Callous/lack of empathy
- Unconcerned about performance
- Shallow/deficient affect
Name 3 (non-pharmacological) management approaches in ADHD.
- Parenting skills training (Incredible Years)
- School adaptations/ accommodations
- Functional assessment
- Positive reinforcement
- Psychoeducation
- Anger management skills; emotional regulation skills
- Treatment of comorbidities
- Social skills training
- Vocational support
Pharmacotherapy for severe behavioural issues.
- Multimodal, non-pharmacological approaches across settings – parent skills training, emotional regulation, anger management, problem solving therapy)
- ADHD – stimulant, non-stimulant, Risperidone
- ASD – Risperidone, Aripiprazole
- Not ADHD or ASD – Risperidone
Stutter. What is the work-up and what do you evaluate?
Childhood-Onset Fluency Disorder (Stuttering)
- sensory deficits (assess hearing), normal speech dysfluencies, secondary to meds, adult onset dysfluencies, Tourette
- SLP assessment – language (productive, receptive), verbal fluency, phonation, social pragmatic use of language
- Are there any concurrent difficulties? Coordination, ID, etc…
- Comorbidities
Name 3 diagnosis in which there are communication difficulties.
ASD, ID, language disorder, LDs, speech sound disorder, childhood-onset fluency disorder, social communication disorder, hearing impairment
What is the differential diagnosis of stuttering?
sensory deficits (assess hearing)
normal speech dysfluencies
secondary to meds
adult onset dysfluencies
Tourette
What are two interventions that can be used in stuttering?
- SLP Treatment with involvement of parents
- Cognitive behavioural therapy can also be used to identify thoughts processes that worsen stuttering, and to identify coping strategies related to stress from stuttering.
- Electronic delayed auditory feedback tools can also be used to help individuals to slow down their speech.
Oppositional behaviour reported by teacher. None at home. What would you ask hockey coach to confirm dx?
- Question - The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic.
- Mood at practice, relation to peers, respect of authority/adults, frustration tolerance, tantrums (frequency and duration)
- Other dx to consider - ADHD, LD
Scales to diagnose ADHD
- Conners
- SNAP-IV Teacher and Parent Rating Scale
- ASRS (Adult ADHD Self-Rating Scale)
- WFIRS-P (Weiss Functional Impairment Rating Scale-Parent)
- WFIRS-S (Weiss Functional Impairment Rating Scale-Self)
- WSR II (Weiss Symptom Record II)
- CADDRA Teacher Assessment Form
- CADDRA Clinician ADHD Baseline/Follow-Up Form
- CADDRA Patient ADHD Medication Form
Child with ADHD. Mother worried that the child will become “drugged”/ “addicted”. Which ADHD medication has the least risk of diversion and addiction?
- Non-stimulant medications
- Atomoxetine, Guanfacine
- Long Acting Stimulants
- Vyvanse – pro (inactive) drug that requires first pass metabolism, so it cannot be injected
- Other long-active stimulants (ie: Concerta/ OROS)
Asked to provide three features to delineate ADHD from bipolar disorder
CADDRA and CANMAT Bipolar Guidelines (Children & Adolescents)
- Hyperactivity/distractibility are chronic and not episodic
- Insomnia is present but need for sleep is unchanged
- Grandiosity is not present
- No psychosis
Given case of child with features consistent with ADHD
a) asked to provide a medication you would use to treat.
b) List four symptoms more common among preschoolers than older children treated with stimulants.
a) Stimulant medication – methylphenidate, amphetamine (Health Canada approved for age 6+); long acting stimulant with shorter duration of action (e.g., biphentin – methylphenidate controlled release)
b) Sleep problems (Pre-schoolers metabolize methylphenidate more slowly than school age children (AACAP PP)
Higher rate of emotional adverse events (crabbiness, irritability, proneness to crying) – AACAP PP
a) Provide 4 characteristics of a child with ADHD associated with better treatment adherence.
b) Provide two features important in the parent - physician relationship important to treatment adherence.
a) Child factors:
- Increased symptom severity
- Combined subtype
- Comorbidities
- Fewer side effects
- Long-acting formulation
b) Family factors:
- Belief that medication is safe
- Belief that ADHD is neurobiological disorder
- Good relationship with doctor
Parent-Physician Relationship Factors:
- Parental trust in healthcare provider
- Shared decision making
a) Which medications are indicated for treatment of ADHD if person has Tourette’s.
b) Name one relative contraindicated medication.
(a) Methylphenidate, Amphetamines, Alpha-2 agonist (Guanfacine, Clonidine), SNRI (Atomoxetine)
(b) Monitor for new or worsening tics with psychostimulants. Some resources indicated AMPH may be worse than MPH in increasing tics.
a) Name 2 sleep related side effects of stimulants.
b) Name 2 sleep disorders of (associated with?) ADHD.
a) Sleep-Related effects of stimulants
- Insomnia (delayed sleep onset latency >30 minutes)
- Reduction in Slow Wave and REM Sleep
- Increased wakefulness during the sleep period
b) Sleep Disorders
- Insomnia
- Circadian Rhythm Sleep-wake Disorder (Delayed sleep phase)
- Restless leg syndrome
- OSA
4 year old with aggressive symptoms. Name 3 differential diagnosis other than neurodevelopmental disorder.
DDx:
- ADHD – but this is a neurodevelopmental disorder
- Adjustment disorder with disturbance of conduct
- ODD
- Attachment disorder (Reactive Attachment Disorder or Disinhibited Social Engagement Disorder)
- PTSD
4 year old with aggressive symptoms. Name 1 psychosocial treatment.
Parent Child Interaction Therapy
Parent Management Training (Incredible Years, Triple P)
Child with ADHD/ODD.
What are 4 pieces of school collateral to further establish diagnosis or rule out other co-morbidities?
Psychoeducational testing (to rule out LD)
mood and anxiety
suspensions/expulsions/conduct disorder behaviours
quality of social relationships
Child with ADHD/ODD.
Two standardized measures to assess?
SNAP-IV
Conners
What are common side effects of stimulant treatment in ADHD?
Increased HR and BP
Appetite suppression and weight loss
GI upset
Dry mouth
Headache
Anxiety/Irritability
Initial insomnia
Rebound effect
What are ways to manage the side effects of stimulant medications?
Duration of action of stimulant
redistribute caloric intake once stimulant wears off
start low and go slow
dose reduction
monitor vitals
minimize other sympathomimetic agents (caffeine)
What are some long-term consequences of stimulant use?
Growth suppression
(MTA Study: 1cm/year for first two years and no difference in 3rd year; 1-2 cm adult growth less when treated for 10 years; benefits of treatment generally outweigh the risk)
Which medication(s) indicated for ADHD + seizure?
Any methylphenidate or amphetamine based stimulant medication provided seizures are well controlled by antiepileptic medication
FYI
- Higher incidence of ADHD in kids with epilepsy (than gen pop)
- Higher incidence of epilsepy in kids with ADHD (than gen pop)
- When kid has ADHD, epilepsy can more severe
- No evidence that stimulants psychostimulants increase the severity or frequency of seizures in patients with stable epilepsy.
- Consider drug ineractions
Carbamazepine– Methylphenidate: decrease Meth
Phenytoin, Phenobarbital – Methylphenidate: increase anticonvulsant
Carbamazepine, Phenytoin, Pheno – Guanfacine: decrease Guanfacine (3A4)
Symptoms of methylphenidate crash
Irritability
“Rebound” - Symptoms return or appear worse than when treated (CADDRA)
3 executive (dys)functions in ADHD
Initation
Ability to complete multi step tasks
Organization
Planning
Self-directed activity
4M diagnosed with ADHD, Combined Type.
2 things to tell mother about diagnosis of ADHD in preschoolers.
- Inattention and hyperactivity in preschoolers can be influenced by a number of factors. These can include intellectual impairment, expressive language issues, and their response to child abuse and neglect as well as conflictual environments
- American Academy of Pediatrics has suggested that ADHD can be diagnosed in children as early as age four
- Nonpharmacological approaches should be first-line treatment
.4M diagnosed with ADHD, Combined Type. 1 Psychotherapeutic treatment.
Parent management training – Incredible Years or Triple P Positive Parenting Program
Parent-Child Interaction Therapy
4M diagnosed with ADHD, Combined Type. 2 medication side effects that are different in preschoolers.
Higher rate of emotional adverse events (crabbiness, irritability, proneness to crying) – AACAP PP
Insomnia (slower metabolism of methylphenidate)
Decreased appetite and weight loss (most serious)
Paradoxical agitation/ irritability/ anxiety
Emotional outbursts
13F. Marks C’s. Teachers reporting not applying herself. Difficulty focusing. Particular difficulty in math. Now using cannabis.
3 differential diagnoses?
ADHD
LDs
SUD
13F. Marks C’s. Teachers reporting not applying herself. Difficulty focusing. Particular difficulty in math. Now using cannabis.
2 standardized measures to make a diagnosis?
- Conners, SNAP-IV,
- For LD maths:
o WIAT (Wechsler Individual Achievement Test)
o Keymath diagnostic arithmetic test
Describe the difference in presentation of depression in children vs. adolescent or adult.
Child:
- mood lability, irritability (instead of sadness as DSM criterion)
- low frustration tolerance, temper tantrums
- somatic complaints
- social withdrawal
- mood congruent auditory hallucinations
- Fewer melancholic symptoms
- Fewer delusions and suicide attempts
- Less likely to verbalize feelings of depression/anhedonia than adults
Adolescent –
- more melancholic symptoms and suicide attempts than children
- more hypersomnia and hyperphagia (DSM-5)
- more pervasive anhedonia (K&S)
- psychomotor retardation
- more mood reactivity and may seek out activities for temporary improvements in mood (AACAP)
Manic patient. Parents do not want Li.
What are 2 indicated treatment options of mania?
First Line
lithium (level 1)
risperidone (level 1)
aripiprazole (level 2)
asenapine (level 2)
quetiapine (level 2)
(Risperidone may be preferable to lithium for non‐obese youth, and youth with ADHD)
Manic patient. Parents do not want Li.
What are two symptoms of Li toxicity?
General symptoms of low-grade lithium toxicity:
weakness
tremor (new-onset or worsening)
mild ataxia
poor concentration
tinnitus
nausea
diarrhea
More significant toxicity
vomiting
gross/coarse tremor
slurred speech
confusion
nystagmus disorder
dysarthria
lethargy
If not treated, it may lead to seizure (tonic-clonic), coma, neurological damage, and death.
Name 2 elements that differentiate ADHD and mania.
ADHD
Mania
Neurodevelopmental
Not
None
Insomnia
None
Hyper verbose
Not
Episodic
Psychosis
Decreased need for sleep
Elation, grandiosity
Flight of ideas
Name some Depression scales that are used in children
Children’s depression rating scale
Children’s depression inventory
Mood and feelings questionnaire
Center for Epidemiological Studies Depression Scale for Children (CES-DC)
16F with depression. What would be 2 treatment approaches if she does not want pharmacotherapy?
CBT, IPT, internet-based psychotherapy
16F with depression.
What work-up before starting SSRI?
- No need for any work-up pre-SSRI unless there is special concern OR rule out a physical health cause re: ECG (already on other QTc prolonging agents) and Na (PHx)
- If indicated: b-hCG, tox screen, relectrolytes?
Boy who is depressed and sleep during the day. DDx?
major depressive disorder
substance use withdrawal (alcohol, amphetamines, cocaine)
obstructive sleep apnea
hypothyrodisim
circadian rhythm sleep-wake disorders
Reasons to admit to hospital with depression
safety concerns (suicidal, homicidal, mental health is impairing patient’s ability to care for themself/is at risk of causing serious physical impairment of patient)
psychotic symptoms
catatonic features
-oor nutritional intake, putting patient’s physical health at risk
failure of outpatient treatment
Which is the most used/ (?most evidence-based) medication for the treatment of depression in adolescents and why?
- Fluoxetine
- Many RCT, well tolerated, works, relatively stable serum levels due to long half-life
- long half life lessens the impact of nonadherence* PP
5 risk factors for transition of depression to BAD.
- Early onset, sudden onset
- Mood congruent psychosis
- FHx of BAD
- Psychomotor retardation
- Mania/ hypomania on AD
- Mixed symptoms, labile mood
- Atypical Depression (Hypersomnia, hyperphagia)
- Emotional/Behavioural Dysregulation
Adolescent with ASD. Name 3 risk factors for depression.
Social isolation
awareness of deficits (level 1)
FHx
sudden loss
stress at home or at school
alexithymia
low self-esteem
ACEs/ abuse
higher cognitive functioning,
capacity for introspection
stressful life events
quality of social relationships
Adolescent with ASD. Name 2 factors for risk of suicidal behaviours.
high functioning autism
Physical and sexual abuse
bullying
Factors inherent to their diagnosis (deficit in expression of feelings and thoughts)
Factors pertaining to the general population (abuse, depression, anxiety, etc.).
Contrast features of MDD vs grief
- In grief the predominant affect is feelings of emptiness and loss, while in an MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure.
- Dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, “pangs of grief” associated with thoghts/memories of deceased
- Depressed mood of an MDE is more persistent and not tied to specific thoughts or preoccupations.
- Pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of MDE.
- The thought content associated with grief - preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in an MDE.
- In grief, self-esteem preserved
- In MDE feelings of worthlessness and self-loathing are common.
- If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased
- In grief, thoughts about death and dying generally focused on the deceased and possibly about “joining” the deceased
- In MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.
8 yo with GAD. Not treated with psychotherapy. Wants to start SSRI. Name 5 pharmacokinetic principles of SSRIs in this patient
- Pre-pubertal children have a higher rate of activating side effects on SSRI
- Maturation of pathways impacts effectiveness of medications
- Children metabolize medications faster due to larger liver (liver to body ratio) and more efficient glomerular filtration (shorter ½ life)
- Higher proportion of water = larger volume of distribution of hydrophilic meds
- Less adipose tissues = accumulate lipophilic meds to a lesser extent and consequently eliminate them faster
- Increased BBB permeability
Name 5 lab investigation prior to initiating lithium
- thyroid function tests
- urinalysis
- creatinine/Urea
- serum calcium levels
- pregnancy test in female adolescents
- complete blood cell counts
Once a stable lithium dose is obtained, lithium levels, renal and thyroid function, and urinalyses should be monitored regularly (every 3-6 months)
What are the factors of adolescent depression that increase risk for bipolar disorder?
· Rapid symptom onset
· Mood-congruent psychotic features
· Psychomotor retardation
· AD (medication-induced) activation/ hypomania/ mania
Child with seizure disorder and depression.
a) Which med to choose?
b) What is contraindicated?
a) SSRI
b) Bupropion and TCA
10F. Father committed suicide 3 years ago. Doing CBT and family therapy. 2 years history of social decline. Now has rituals, rigid thinking. Suicidal thoughts x 1 week and tried to jump out of a window.
Name 4 DDx.
- Adjustment Disorder, MDE
- OCD
- PTSD
- GAD, SAD
- Clinical High Risk Psychosis
16M. Presents to office on his own with 4 weeks of depressed mood and vegetative symptoms. What 5 items do you want to evaluate for diagnosis management?
- Presence of Depressive and Other Comorbid Psychiatric and Medical Disorders
- Functional impairment, clarify baseline function
- Safety – SI, intent, plan, gestures, SH, HI
- Evaluate child and family’s strengths, supports and protective factors
- Presence of Ongoing or Past Exposure to Negative Events, the Environment In Which Depression Is Developing, Support, and Family Psychiatric History
Other (not in the PP)
- Psychosis
- Capacity for consent
List 2 medications used in maintenance of Bipolar Disorder.
Aripiprazole
Lithium
Divalproex
Lamotrigine adjunct (age 13+)
List 5 medication classes commonly prescribed in <18 year olds that can cause depression.
Accutane (Isotretinoin)
Steroids
Methotrexate
OCP
Anticonvulsants (Levetiracetam/Keppra)
Case about childhood trauma (mother murdered by a ex-boyfriend).
Who do you want to speak with when doing your assessment (2)?
Parents or other caregivers should be included in the evaluation
Child
biological father
school
CAS
Case about childhood trauma (mother murdered by a ex-boyfriend).
What are some interventions to consider?
TF-CBT (first line; most evidence. PRACTICE components)
Other trauma-focused psychotherapies:
(Child-parent psychotherapy
Psychodynamic trauma-focused therapy
EMDR (Katzman))
SSRIs can be considered for PTSD or for comorbidities with PTSD (Sertraline alone or as adjunct to CBT is not more effective than placebo and cannot be recommended – Katzman)
Medications other than SSRIs can be considered (sleep, nightmares)
School-based accommodations
Case about childhood trauma (mother murdered by a ex-boyfriend).
What are some psychological interventions to consider?
- TF-CBT (first line; most evidence. PRACTICE components)
- Other trauma-focused psychotherapies
- Child-parent psychotherapy
- Psychodynamic trauma-focused therapy
- EMDR (Katzman)
- Psychoeducation
- Relaxation training
- Affective modulation skills
- Cognitive coping and processing
- Trauma narrative
- In-vivo mastery of reminders
- Conjoint child-parent sessions – engage caregiver, regain sense of control, improve attunement/ communication,
Difference in presentation of PTSD in a child.
- May not have flashbacks but often have trauma expressed through play - repetitive play, trauma themes, trauma-specific re-enactment
- Nightmares – may be without trauma-specific content
- May have new aggression, oppositional behaviour
- May have new separation anxiety, new fears not obviously related to traumatic event (fear of the dark)
- Developmental regression (toileting and speech)
- In adults, avoidance may be of memories, thoughts and feelings; in children it is exclusively external reminders
- Specific subtype of PTSD for children <6 in DSM-5 without criteria for cognitive distortions, memory of event, or avoidance of memories/thoughts/feelings
Boy loses his arm in an accident. He has PTSD. What 2 medications are approved to prevent PTSD?
- Propranolol, Morphine, SSRI
- To prevent, none is approved (anxiety guidelines 2014)
- Propranolol: conflicting evidence (improved on parent reports but not child report)
- Morphine: cohort studies suggest it might be helpful
Boy loses his arm in an accident. He has PTSD. Medication for nightmares?
Prazosin
Boy loses his arm in an accident. He has PTSD.
What is the therapeutic approach?
- Trauma-focused CBT – stabilization, integration of trauma, reconnection
- PRACTICE – psychoeducation/ parenting skills; Relaxation skills; Affective modulation skills; Cognitive coping and processing; Trauma narrative; In vivo master of trauma reminders; Joint child-parent sessions; Enhancing future safety.
6 year old with a fear of fires since the neighbor’s home caught fire. New onset nightmares.
Name three other symptoms (trauma).
- markedly diminished interest or participation in significant activities
- persistent negative emotional state
- exaggerated startle response
- hypervigilance
- problems with concentration
Case of PTSD provided (mother murdered by her partner). Asked to provide the most empirically supported treatment and several components of that treatment
Trauma-focused CBT:
- Phase 1 – stabilization – affect regulation, coping
- Phase 2 – integrate traumatic memories – re-experience symptoms
- Phase 3 – reintegration/ maintenance – consolidation and resilience
PRACTICE
- Psycho-education
- Relaxation techniques
- Affective modulation skills
- Cognitive coping and processing
- Trauma narrative
- In vivo mastery of triggers/reminders
- Conjoint sessions with parents
- Enhance future safety
Case of PTSD provided (mother murdered by her partner).
Asked to provide a class of medication with some empirical support for treatment of PTSD in youth.
SSRIs
Case of PTSD provided (mother murdered by her partner).
Asked to provide a list of several sources of information other than the child in order to complete evaluation.
Family (bio family, foster family)/caregivers
School
CAS
Asked for two medications with some evidence to support their use in preventing development of PTSD.
Propranolol
Morphine
Provide one medication indicated for treatment of sleep disturbance and nightmares associated with PTSD.
Alpha -1 – blocker - Prazosin
a) What are 3-4 meds you may consider using in someone exhibiting a trauma reaction?
b) Which agents may be contraindicated?
a)
Clonidine, guanfacine (may reduce intrusive and hyperarousal symptoms in children with PTSD symptoms)
Prazosin (Dyssomnias, including nightmares and frequent nighttime awakenings)
SSRIs (not efficiacious in children, but could be used in adolescent with co-occurring MDD or anxiety)
b) Benzodiazepines
How to prevent PTSD and what medication could you use for nightmares?
Maintain – secure attachment, peer relationships, routines/ predictability
Child and Family Traumatic Stress Intervention (CFTSI)
Pyschological First Aid
Caring adults (parents, teachers, and health professionals) to reassure children
Encourage (but not press) them to express their feelings
Normalize disaster reaction
Address fears, worries and cocnerns as they arrive
Help them to resume normal roles and routines
Help parents and teachers identify acute stress responses.
*POTENTIALLY morphine (burns) + propranolol
Nightmares – Prazosin
What is the PRACTICE mnemonic in TF-CBT (lewis)?
- *PRACTICE** mnemonic (Lewis) TF-CBT
- *P**sychoeducation and Parenting Skills Training
- *R**elaxation
- *A**ffective modulation skills
- *C**ognitive coping and processing
- *T**rauma narrative
- *I**n Vivo mastery of trauma reminders
- *C**onjoint Child-Parent sessions
- *E**nhancing future safety and development
Patient with symptoms of ARFID.
Name 2 ways in which you can differentiate between ARFID AND AN.
No body image disturbance in ARFID and No fear of weight gain in ARFID
Patient with symptoms of ARFID.
Name 3 situations that can precipitate ARFID.
Sensory aversion
choking episode
repeated emesis
traumatic GI investigation
reflux
PCRP
What differentiates binge eating from BN?
In binge eating, there is no compensatory behaviour to avoid weight gain.
Name pharmacotherapy for BN.
Fluoxetine
Some evidence for TCA, topiramate, sertraline and citalopram
NOTE: contraindication for bupropion (Sz)
AN. Name 5 interventions the family can implement around mealtime to help the patient take nutrition.
Pre-planned meal plan (determined by parents)
Max 20min for mealtime.
Substitutions/ supplementation if unable to complete nutrition as presented.
Distractions – during and after meal.
Externalize the ED.
Providing validation and support
Name scale to evaluate eating disorder.
AACAP PP:
- Eating Disorder Examination Questionnaire (EDE-Q)
- Eating Disorder Inventory (EDI)
- Eating Attitudes Test (EAT)
Validated in younger children:
- Kids’ Eating Disorder Survey (KEDS)
- Child EDE-Q
- EDI-Child
- Child-Eating Attitudes Test (CHEAT)
BN is caused by what factors (2)?
Dieting to try to accomplish thin ideal physique leading to physiological starvation and hunger, promoting binge eating and followed by guilt and fear of weight gain leading to purging
Genetics
Abuse, PTSD
Social pressures to be thin
Body dissatisfaction
Negative affect
Name risk factors for BN (4).
Genetics and family history of mood, anxiety, SUD, cluster B
Idealization of thinness and dieting
Early menarche
Childhood obesity
Volatile family environment or history of abuse
Temperament novelty seeking, impulsivity, affective instability
Female Sex
What are the criteria for ARFID?
Criterion A
An eating or feeding disturbance (e.g. - apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with at least 1 of the following:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nutritional supplements
- Marked interference with psychosocial functioning
Criterion B
The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
Criterion C
The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced
What is the approach to management of ARFID?
Stabilize the patient from a physical health perspective
…Once this has occurred, next steps can be taken
- -Target precipitating event that triggered ARFID eg. anxiety related to choking, treated with CBT and/or pharmacotherapy such as an SSRI
- If ARFID is related to family conflict, this could be managed via family based therapy, CBT, psychoeducation, parent psychoeducation
- If ARFID related to sensory aversion, consider a food hierarchy or food chaining
Provide two stages of the Maudsley Approach to treatment of anorexia nervosa.
Phase I: weight restoration via psychoeducation, externalizing illness, raising anxiety, parents take control of eating
Phase II: Returning control over eating to the adolescent gradually
Phase III: review of progress, return to normal family life, identifying potential challenges
Three parameters on physical exam important when considering hospitalization of child with anorexia nervosa.
<75% IBW
heart rate <50 (during the day); <45 (at night)
systolic BP < 90
arrhythmia
orthostatic changes= >20 BPM HR; >10mmHg BP
refusal to eat
ongoing weight loss despite intensive management
hypothermia (<36)
Three parameters on physical exam important when considering hospitalization of child with bulimia nervosa.
syncope
hematemesis
hypokalemia (<3.2)
low Cl (<88)
arrhythmia
failure to respond to outpatient treatment
esophageal tear
Name 2 co-morbidities of BN
Depression (50%)
Panic Disorder
Alcohol, Substance Abuse
Cluster B Personality Disorder – BPD
Traits – perfectionism, harm avoidance, novelty seeking, impulsive, affective instability
Name 1 treatment of BN
CBT modified for BN
IPT
Fluoxetine
Also – tricyclics, topiramate, sertraline, citalopram
Name 2 co-morbidities of AN.
Depression (50%)
OCD (30%)
Cluster C Personality – OCPD
Traits – perfectionism, harm avoidance
13F with postural hypotension. You suspect ED. Now, gained 2.5kg in one week, bloated, hypokalemic.
a) What is the Dx
b) how to you treat this?
a) refeeding syndrome
b)
- Gradual refeeding, monitor K, P and Mg
- Treatment:
- reduce caloric intake
- evaluate cardiovascular function (ECG monitoring)
- monitor closely (Check P daily for 5 days, then q2 days for 3 weeks)
- If necessary, supplement with P (correct electrolyte anomalies and mineral deficiencies (IV, PO4 supp, K supp, thiamine, multivitamins))
- Pediatrician involved
- Treatment:
13F with postural hypotension. You suspect ED.
a) Decision about disposition
b) Provide 2 reasons for your decision.
a) Admit for medical stabilization
b) Unstable vitals
What genes are associated with OCD?
- Complex and polygenic for OCD
- Genetic loading has a significant impact on risk of developing condition
- 1st degree relative of OCD pt 4x as likely to develop OCD
- 5HT2A (serotonergic) and SLC1A1 (glutamate) are implicated OCD
What is the heritability of OCD?
- MZ concordance 80-87%
- DZ concordance 47-50%
- ½ of phenotypic variation due to genetics
- 1st degree relative of OCD pt 4x as likely to develop OCD
- Relatives of childhood-onset OCD are 30 x more likely than relatives of those without OCD to be diagnosed with the disorder
- Ordering and hoarding more genetic
- Genetic studies most often implicate genes for 5ht and glutamate regulation
ASD vs OCD. How do you differentiat?
ASD
OCD
Neurodevelopmental
Egosyntonic
Stereotypies
Socio-emotional difficulties
Communication/ language and non-verbal difficulties
Chronic, pervasive rigidity/concreteness
Not
Egodystonic
Compulsions to decrease anxiety
Not
Not
Rgidity re: obsessions/ compulsions
Alopecia in an adolescent. Provide 2 differential diagnoses.
- Trichotillomania
- Telogen Effluvium / Alopecia due to…
- GMC (autoimmune, low iron, hypothyroid) (Telogen effluvium)
- Meds like VPA, antithyroid agents, hormones, anticonvulsants, anticoagulants, beta blockers, angiotensin-converting enzyme inhibitors, and lithium.
- OCD
- ASD
- Dermatologic Alopecias
- Telogen effluvium
- Tinea capitis
- Traction alopecia
- Alopecia areata
- ID – stereotypies
- Body Dysmorphic Disorder
- NSSI
- Normal behaviour/ intentional hair removal
Trichotillomania. Explain Habit Reversal therapy.
HRT –
(a) awareness training – such as triggers
(b) competing response training – replacement behaviour
(c) motivation and compliance – cons list, positive reinforcement
(d) relaxation training – to help prevent the behaviour
(e) generalization training
OCD x 8 years, mild to moderate in severity. Name 2 effective/ evidence-based treatments.
CBT (ERP) is first line.
Second line is CBT in combination with SSRI (Sertraline, Citalopram, Fluoxetine, Fluvoxamine). You may consider augmentation with Risperidone or Aripiprazole.
Third line is CBT with Clomipramine.
(In moderate to severe OCD, inadequate response to CBT (ERP), patient preference (refusal of psychotherapy) or patient is >12yo – you may (should) consider combination treatment.)
OCD x 8 years, mild to moderate in severity. Name 2 comorbidities that worsen prognosis.
AN, Depression, LD, psychosis, BAD, depression, hoarding
ODD, Tics, ADHD associated with worse response to meds
Name 2 common obsessions in children
Obsessions - Contamination/ germs/ getting sick; something bad happening; thing being “just right”; sexual.
Name 2 common compulsions in children
Compulsions - Washing/ cleaning/ disinfection; arranging/ ordering/ repeating until “just right”; checking/ symmetry.
Trichotillomania. Name 3 cognitive behavioral techniques.
a) Habit reversal training - primary treatment for trichotillomania. How to recognize situations (urges/ preceding thoughts and emotions) where you are likely to pull your hair and how to substitute other behaviors instead (which may include relaxation and mindfulness techniques). For example, you might clench your fists to help stop the urge or redirect your hand from your hair to your ear.
b) Cognitive therapy - This therapy can help you identify and examine distorted beliefs you may have in relation to hair pulling. Cognitive restructuring.
c) Relaxation training (progressive muscle relaxation)
d) Acceptance and commitment therapy - can help you learn to accept your hair pulling urges without acting on them.
e) Exposure and response prevention (ERP)
FDA approved medications for treatment of OCD
Fluoxetine
Sertraline
Fluvoxamine
Clomipramine
C-YBOCs question – What are 4 features of establishing severity of OCD?
Time occupied by obsessive thoughts
Interference due to obsessive thoughts
Distress associated with obsessive thoughts
Resistance against obsessions
Degree of control over obsessive thoughts
Time spent performing compulsive behaviours
Interference due to compulsive behaviours
Distress associated with compulsive behaviours
Resistance against compulsions
Degree of control over compulsive thoughts
Trichotillomania. What are 3 steps in providing behavioral therapy?
HRT –
(a) awareness training – such as triggers
(b) competing response training – replacement behaviour
(c) motivation and compliance – cons list, positive reinforcement
(d) relaxation training – to help prevent the behaviour
(e) generalization training
Trichotillomania. Describe 2 principles behind operant conditioning.
Operant conditioning: process of learning through reinforcement and/or punishment
Positive reinforcement: response or behavior is strengthened by rewards, leading to the repetition of desired behavior. The reward is a reinforcing stimulus.
Negative reinforcement: the termination of an unpleasant state following a response.Negative reinforcement strengthens behavior because it stops or removes an unpleasant experience.
Punishment: an aversive event that decreases the behavior that it follows.
Which medications are approved for the treatment of OCD?
HC – Clomipramine (10+)
FDA – Sertraline (6+), Fluoxetine (7+) and Fluvoxamine (8+)
What are the criteria for Disinhibited Social Engagement Disorder?
A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
- Reduced or absent reticence in approaching and interacting with unfamiliar adults.
- Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
- Willingness to go off with an unfamiliar adult with minimal or no hesitation.
Behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior.
Child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
- Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios)
Child has developmental age of at least 9-months
What are some general features of Disinhibited Social Engagement Disorder?
In general:
- May approach unfamiliar adults without any fear;
- May seek comfort from unfamiliar adults;
- Wander away from caregiver without checking back
- Attaches indiscriminately
- Attention seeking, shallow, superficial interpersonally
- “impulsive-type behaviors”, attention-seeking and more shallow relationships
Case that is obviously DSED. What are some specific therapies to consider?
Management approach:
- Safety! (especially of current placement)
- Ensure they are provided with an emotionally available attachment figure.
- Dyadic therapist such as Circle of Security, Parent Child Interaction Therapy (PCIT), Dyadic developmental psychotherapy (DDP)), Attachment and Biobehavioural Catch-up (ABC), Video-based Intervention to Promote Positive parenting (VIPP), Child-Parent Psychotherapy
- Limit contact with noncaregiving adults (young children)
- Adjunctive interventions for children who display aggressive/oppositional behaviour
No therapeutic holding, “rebirthing” or other such nonsense.
4 year old child has been in foster homes for the last 2 year. Doesn’t settle with mom.
What is the most likely diagnosis?
Attachment disorder – Reactive Attachment Disorder and/or DSED
4 year old child has been in foster homes for the last 2 year. Doesn’t settle with mom.
Name 2 behaviors common in institutionalized kids but not in parent reared kids.
Do not seek comfort from or interaction with caregivers.
Do not feel reassured by caregivers/ difficult to calm/ reassure.
Agitation.
Mood lability.
Temper tantrums.
Reduced emotional responsiveness.
Restricted positive affect/ superficiality of affect.
Indiscrimination of attachment figures.
Unstable interpersonal relationships.
Lack of empathy.
Impulsivity.
4 year old child has been in foster homes for the last 2 year. Doesn’t settle with mom.
Name 2 symptoms that are unlikely to remit even with consistent care after institutionalized kids.
Symptoms of Reactive Attachment Disorder tend to disappear once placed in foster care or adopted.
Symptoms that are unlikely to remit despite adequate placement are linked to DSED
Children: indiscrimination, no safety base, familiarity
Teen: superficial, shallow or frequently changing interpersonal relations and interpersonal conflicts
Antisocial patient, hospitalized for repeated SA.
When do you formally re-evaluate suicide risk?
At daily/each assessments
if making threats or reporting ideation
with any mental status change
before passes/going off unit
before discharge
Antisocial patient, hospitalized for repeated SA. Other than suicide risk, what are two other risks to evaluate?
HI
physical impairment
elopement risk
risk of substance use
driving
boundaries around interactions with other patients
risk of harm to others
Why are some physicians weary of making a Dx of PD?
Stigmatization
developmental perspective
need a longitudinal assessment
sometimes subjective to make assessment
perception that they are “untreatable”
Are there any potential benefits to making the dx of a personality disorder?
appropriate treatment/ intervention
validation
psychoeducation
avoid unnecessary treatments/ pharmacotherapy/ side effects
stop contributing to auto-stigmatisation
Compare and contrast depressive symptoms [they listed the following: anhedonia, sleep
disturbance, poor concentration, appetite] in a pediatric patient vs. adolescent vs. adult [and
we had to indicate who each symptom difference in depression based on age).
