CPS Mental Health Committee Flashcards
What are challenges facing children with untreated ADHD? (6)
- School difficulties
- Low self-esteem
- Family stress
- Psychiatric comorbidities
- Poor social skills –> social isolation
- Poor peer/sibling relationships
What behavioural condition are children with repaired congenital heart disease at risk of?
ADHD
Among persons with known structural CHD, sudden death is associated with which two specific conditions?
- Tetralogy of fallot
- Transposition of the great arteries
What is the risk of sudden death of children on ADHD medications compared to children in the general population?
SAME risk!
What screening questions should be asked to identify potential cardiac risk factors for sudden death among children starting stimulant medication?
-if yes to any of these questions, what is your next management step?
1. Symptoms of:
Shortness of breath with exercise?
Decreased exercise tolerance?
Fainting or seizures with exercise, startle or fright
Palpitations brought on by exercise
2. Personal MHx of:
Wolf Parkinson White syndrome
Cardiomyopathy
Heart transplant
Pulmonary hypertension
Implantable defibrillator
3. Personal or family history of:
sudden or unexplained death: -SIDS -unexplained drowning -unexplained motor vehicle accidents
nonischemic heart disease
Long QT syndrome or other familial arrhythmias
-next management step if yes: consult cardiology
What is the recommendation on whether you should obtain an ECG prior to or during ADHD medication therapy?
If the history, family history and physical exam are all normal, there is no indication to perform an ECG
For patients with known congenital heart disease or arrhythmias, are they are increased risk of sudden death with ADHD medications?
Keep in mind that in certain patients with known congenital heart disease (ie. TOF or transposition), there is already an increased risk of sudden cardiac death.
-however, ADHD medications do NOT raise the risk of sudden death further (no evidence that shows this)
What is the Feingold diet in ADHD management?
An “alternative” therapy in ADHD management where a salicylate and additive-free diet is pursued -multiple controlled studies showed that this was not effective
How effective is elimination of food allergens in the managment of ADHD?
-what foods are commonly implicated?
Double-blind, placebo controlled food allergen challenge studies showed some improvement in behaviour:
- Appropriate elimination diets are more likely to improve behaviour in younger children with:
1. Atopic histories
2. Family history of migraine
3. Family history of food reactivity - common foods: milk, nuts, fish, wheat, soy, additives
How effective is the elimination of sugar and aspartame from the diet in treating ADHD?
-what about The Yeast Connexion?
No effect!
Many studies have shown no causality between dietary sucrose or aspartame on children’s behaviour
-yeast connexion: postulates that chronic candidasis and candida toxin production = antifungal agents and a diet free of any sugar source that could promote yeast growth and any foods made with or contaminated by molds and yeast (eg. bread, cheese, processed foods, dried fruits) = NOT scientifically validated
Is there scientific evidence to support the following in ADHD treatment?
-megavitamin therapy -iron -magnesium -vitamin B6 -zinc -essential fatty acids
- megavitamin therapy: NO! double-blind, placebo controlled, study showed NO improvement
- iron: NO!
- magnesium: NO! One small study showed behavioural improvement but only one study
- vitamin B6: NO! Again only one study showed an improvement
- Zinc: NO!
- essential fatty acids: NO! three blinded placebo controlled studies on essential fatty acid supplementation with evening primrose oil and fish oil showed NO behavioural improvement!
What are nootropics used in alternatives therapies for ADHD? (2)
Substances reported to enhance mental competence
- Piracetam = thought to enhance dopamine and noreadenaline transmission -no controlled studies to date
- Deanol: acetylcholine precursor -double blind placebo controlled study showed improved ADHD comparable to methylphenidate BUT the study quality was poor!!
What is the evidence behind use of valerian in improving ADHD?
-most worrisome possible side effect?
In adults, valerian has been shown to be more effective than placebo in clinical randomized trials for improving sleep disorders and insomnia -no studies in children
-most common side effects: GI upset and headache but most worrisome possible side effect is in people with Grave’s disease due to inhibiton of thyroid hormones
What is auditory stimulation in ADHD alternative therapy?
Tomatis method of sound training = based on hypothesis that focus and attention can be improved with a combination of auditory stimulation and listening training, using human voice and classical music…no controlled studies to date.
What is the role of biofeedback in treatment of ADHD?
-what about hypnotherapy?
May be offered in cases where medication is not suitable:
- Poor response
- Significant side effects
- Parental and/or child refusal -involves substantial commitment from the child and the family
hypnotherapy may be helpful in decreasing anxiety/stress related to ADHD; most helpful when integrated into multimodal treatment context. No studies have shown that it improves ADHD symptoms but does improve sleep disturbance or tics
Why has kava been banned?
Too many side effects!
-Causes muscle weakness, rash, weight loss, increased HDL, hematuria, necrotizing hepatitis when combined with other herbs
What are side effects associated with use of blue-green algae in alternative therapy for ADHD?
Gastrointestinal symptoms, weakness, numbness, tingling -
blue green algae can produce toxins AND be contaminated with animal feces, heavy metals, sewage
What are possible side effects of melatonin?
- Possible suppression of puberty
- Proconvulsant effects in children with neurological disabilities
- Headache/fatigue/irritability/sleepiness
What are the clinical features of postpartum blues?
- timing?
- how long does it last?
Emotional disturbance with crying, confusion, mood lability, anxiety and depressed mood
- appear during the first week postpartum
- lasts few hours to few days
What are the clinical features of postpartum psychosis? -timing?
Severe disorder with delusions, hallucinations, gross impairment in functioning
-begins within 4 weeks postpartum
What are the clinical features of postpartum depression?
-how does the severity of symptoms compare with episodes of depression at other times?
Clinical features
Symptoms of depression (YOU KNOW THIS) that are present for at least one month and result in impairment of woman’s functioning
how does the severity of symptoms compare with episodes of depression at other times?
- can last several months
- compared with depression at other times, usually have more mild symptoms
What are risk factors for postpartum depression? (3)
- Family history of psychiatric disorders
- Depression symptoms during the pregnancy
- History of mood disorders
What are the prenatal consequences of maternal depression? (6)
1. Effects on mother:
a. Inadequate prenatal care
b. Poor nutrition
c. Preeclampsia
2. Effects on fetus/newborn:
a. Higher preterm birth
b. Low birth weight
c. Spontaneous abortion
What are the consequences of maternal depression on infants? (5)
Depends if mom has hostile vs. withdrawn affect
- Cognition: Lower cognitive performance, passivity
2. Behavior:
a. Withdrawal
b. Self-regulatory behaviour (ie. sucking on thumb)
c. Dysregulated attention and arousal
d. Internalize an angry and protective style of coping
What are the consequences of maternal depression on toddlers? (5)
- Passive noncompliance
- Less mature expression of autonomy
- Internalizing and externalizing problems
- Lower interaction
- Less creative play
True or false: boys are more sensitive than girls to the effects of postpartum depression in their mother.
True! May develop poorer cognitive functioning as a result
True or false: there is no association between ADHD in children and maternal mental health
FALSE!
What are factors that may exacerbate parental depression? (6)
- Marital conflict & Stressful life events
- Limited social support & Poverty/Lower socioeconomic status
- Lower maternal education
True or false: infants of depressed mothers interacted better with their nondepressed fathers who could “buffer” the effects of the mother’s depression on infant interaction behaviour
True!
What are sources of resiliency in children with depressed parents?
- Easy-going, robust temperament making them less vulnerable to their depressed parents’ negative behaviour
- -Good social and cognitive skills that help them receive positive attention from adults other than their depressed parents. Also helps reduce their depressed parent’s feeling of noncompetence and rejection
- Ability to understand that they are not to blame for the parent’s illness-related behaviour
What should the selection of an antidepressant for prenatal or postpartum depression be based on?
- Previous response and adverse effects to antidepressants
- Risk of interactions with concurrent meds
- Published adverse effects associated with breastfeeding
How can you reduce infant’s exposure to SSRIs in a mother who is taking SSRIs while breastfeeding?
Pump and dump approximately 8-9 hrs after the mother has taken the medication
A school-age child in your practice has a depressed mother. To decrease the negative effects on the child, what can you recommend?
- Family therapy to improve resiliency in the child and help the family focus on communication about the illness
- Psychotherapy for the depressed parent
Can St. John’s wort be used during pregnancy?
No data on reproductive safety so DO NOT recommend as safe therapy during pregnancy
What are useful questions to elicit information about postpartum depression?
1. Mother baby relationship:
- How are you feeling about being a new mother?
- Are you enjoying your baby?
- Do you find that your baby is easy or difficult to care for
- Social support:
How are things going in your family?
3. Personal health:
- Are you getting enough rest?
- How is your appetite?
- During the past month, have you often been bothered by feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
When is the peak prevalence of postpartum depression?
3 months post partum
Does the use of antidepressant medication have risk of teratogenicity? What about long term effects on neurodevelopment of the child? What about bad effects of antidepressant medication during lactation?
No to all questions?
What is the Lovaas method of autism treatment?
-how effective is this?
Behavioural intervention intended to build positive behaviours (ie. language) and suppress unwanted behaviuors (ie. self stim or aggression)
- positively reinforce desired behaviour and ignore or punish unwanted behaviour -discrete trial training = present a stimulus, watch the child’s response, and provide a consequence
- key is to start this intervention as early as possible (2-3 years of 40 hr per week of treatment applied by therapists and families)
What is the difference between normalized teaching and discrete trial training for children with autism?
-which is more effective?
Discrete trial training: highly structured sessions in which the child and teacher are seated and the pace is set by the teacher, the stimuli is presented by the teacher repeatedly until the desired response is given
-normalized teaching: loosely structured sessions that occur during the child’s play and are paced by the child. The child chooses which stimuli will precede a response opportunity and thus this changes from session to session
-multiple case studies show that normalized training was more effective than discrete trial training
Which of the SSRIs has the shortest half life?
-longest half life?
- shortest half life- Fluvoxemine
- longest half life: Fluoxetine PROZAC
Which SSRI can cause prolonged QT?
Citalopram (dose dependent)
What are features of serotonin syndrome?
- Agitation
- Tremors
- Tachycardia
- Diaphoresis
- Fever
- Autonomic symptoms
- Ataxia
- Myoclonus
What medications can have interactions with St. John Wort’s? (4)
- OCP
- Warfarin
- Theophylline
- Cyclosporine
What are the 6 SSRIs available in Canada?
- Fluoxetine - Prozac (long t 1/2)
- Sertraline - Zoloft
- Citalopram - Celexa (Can cause QT prolongation)
- Escitalopram - Cipralex
- Fluvoxamine - Luvox (short t 1/2)
- Paroxetine - Paxil (highest incidence of withdrawal symptoms & has shown negative efficacy in treatment of child and adolescent depression?
What is the mechanism of action of SSRIs?
- Block reuptake and increase concentration of serotonin within the synapse
- Some may also influence other neurotransmitters (dopamine and norepinephrine) leading to differences in effectiveness and adverse effects
Which SSRI has the highest incidence of withdrawal symptoms on abrupt discontinuation?
Which SSRI has the lowest incidence?
Highest incidence: -Paroxetine
Lowest incidence:-Fluoxetine ( long t 1/2)
Are laboratory investigations routinely required before initiating or maintaining SSRI medication use?
No!-Would only consider lab investigations to rule out other causes of depression (hypothyroidism), to assess comorbid medical conditions (hepatic impairment) or to monitor therapeutic drug levels of meds used in combo with SSRI (ie. valproic acid)
SSRIs are metabolized through which route?
Hepatic
Which SSRI has the most evidence supporting its efficacy in children?
-In adolescents?
Which SSRI has shown negative efficacy in treatment of child and adolescent depression?
Children: Fluoxetine - only fluoxetine has demonstrated benefit over placebo in children < 12 yo
-Adolescents: Fluoxetine has most evidence but also escitalopram, citalopram and sertraline (in RCTs)-SSRI with
negative efficacy: paroxetine (3 RCTs)
What are common side effects of SSRIs (5)?
- G: GIT- GI symptoms, appetite changes
- CNS: S: Sleep disturbance (too much or too little), Sexual dysfunction, Headaches
Which SSRI has been associated with dose-dependent QT prolongation?
Citalopram if dosages > 40 mg/kg/day-congenital long QT syndrome is a contraindication for citalopram usage
What is the current thinking surrounding SSRI use and suicidality?
Multiple systematic reviews have found that:-the potential benefits of SSRI use outweight the potential harms (more risk of committing suicide with untreated depression, few suicide attempts and no completed suicides across any RCTs)
When starting a patient on SSRI, how often should clinical monitoring and follow-up occur?
Frequency:
- Weekly for the first four weeks following initiation
- q2wks for the next month
- at 3 months-then as clinically indicated beyond the 3 month mark
Counseling:
- Should include evaluation of suicidal thoughts and medication side effects
- Should counsel patients not to abruptly stop SSRI (except fluoxetine)
How long should SSRI therapy be continued?
Once complete response is achieved with the medication at a steady dose, should continue for minimum 6-12 months to decrease risk of depressive relapse
How should an SSRI be discontinued?
-Slow taper
Points:
- Should occur during a relatively stress free time (ie. during the summer)
- In complex patients, should `consider psychiatry consult before stopping medication
What is the medication of choice for treatment of childhood anxiety disorders?
SSRIs - studied in randomized placebo-controlled trials
When should you consider SSRI in treatment of anxiety symptoms (2)?
- If anxiety is severe or significantly impairing
- If child is unable to benefit from psychotherapy
In a patient with anxiety, what condition should you screen for before starting an SSRI?
Bipolar disorder - personal or family history-those with history should be referred to psych
In RCTs for youth, which SSRI has been shown to be the most superior for treatment of:-depression-anxiety
Depression - fluoxetine
Anxiety - none!
All show same effectiveness**Thus, in anxiety, selection of SSRI (fluoxetine, fluvoxamine, sertraline) is based less on evidence of efficacy and more on tolerability and family history of SSRI responsiveness among first-degree relatives
What are the three most significant factors that impact children’s well-being during the process of parental separation or divorce?
- Quality of parenting
- Quality of parent-child interaction
3 Degree, frequency, intensity and duration and hostile conflict
Which two vaccines should especially be promoted for street-involved youth?
- Hepatitis B
- HPV
What does HEEADSSS consist of?
Home
Education
Eating
Activities
Drugs
Sexuality
Suicide
Safety
