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4.22 > Lecture 3: Management of CNS disorders in children & adolescents > Flashcards

Lecture 3: Management of CNS disorders in children & adolescents Flashcards

1
Q

What are neurodevelopmental disorders

A

multifaceted conditions characterized by impairments in cognition, communication, behaviour and or/ motor skills resulting from abnormal brain development eg intellectual disability, communication disorders, autism spectrum disorder, attention deficit/ hyperactivity disorder

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2
Q

What are emotional and behaviour disorders

A

characterized as either internalizing or externalizing problems – as a consequence of stressful environment at home or school, neglect/ abuse e.g. depression, anxiety, eating disorders, conduct disorders, challenging behaviours

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3
Q

What are the common pschotropic drugs used in CAMHS?

A
  • Antidepressants
  • Antipsuchotics
  • AEDs
  • Phycostimulants
  • Miscellaneous (hypnotics, anxiolytics, adrenergic agents)
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4
Q

What is an off label drug?

A

A licesnsed drug that is being used for an unlicensed indication (inckudes doses, population, form)

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5
Q

What is an unlicensed drug?

A

A drug that does not have marketing authority in the UK

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6
Q

what are prescribing issues in CAMHS?

A
  • Children unable to swallow large capsules or tablets
  • Cant tolerate bitter/ unpleasant taste
  • In austism, there may be sensory/ musular factors or have unusual eating habits
  • Pharmacokinetics and drug disposition differrs been different afes of kids
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7
Q

What are antipshychotics used for?

A

Psychosis, bipolar disorder, ASD assosicaited stereotypes, compulsions, aggression and self injerous behaviour

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8
Q

What symptoms do antipsychotics address?

A

Delusions, paranoea, disordered thinking, aggression, irritability

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9
Q

What is the impact of antipsychotics on patients?

A
  • Weight gain
  • Metabolic/ endocrine disorders
  • Lowered seizure threshold
  • Potential for neuroleptic malignant syndrome
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10
Q

What is the difference between 1st and 2nd generation antipyschotics?

A

Both as effective as each other, only difference is in the side effects. Second generation are less likely to cause Extrapyramidal side effects (i.e inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements) and other symptoms (hyper prolactinaemia, sexual dysfunction) as a consequence of blocked dopamine receptors . 2nd gen show efficacy against positive and negative symptoms. They are more cardiac toxic, cause weight gain/ hypoglycaemia

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11
Q

What monitoring is required for antipyschotics?

A

Identify, manage, treat the metabolic effects of the second generation antipshcyotis

  • Weight/ BMI: initially and every 3 months
  • Us & Es: baseline and yearly blood glucose and lipids: initially and evry 3 months
  • Prolactin: If symptoms of hyperprolactinaemia present
  • ECG: initially if patient cardiac risk
  • LFTs: baseline and yearly
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12
Q

What causes ADHD?

A

Exact cause is unknown
- Genetics: issues with dopamine receptor or transporter gene
- Parental factors: smoking, illicit drugs, POMs - can affect brain development
- Premature birth: eg trauma from contracted labour/ hypoxia
- Encironemnetal toxins: mercury/ lead ingested during pregnancy, contaminated water

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13
Q

What is hyperkinetic disorder?

A

Another class of ADHD, ICD 10 classification. It is a narrower restrictive term requiring more pervasive and impairing symptoms

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14
Q

what is the diagnosis of ADHD?

A

Clinical interview using reports and standerdised scales

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15
Q

What is the prefrontal cortex?

A

Regulates attention - inhibits distracting stimuli/ thoughts

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16
Q

What is the parietal cortex?

A

Allocating attention to left and right

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17
Q

What is the temporal cortex?

A

Selective attention to features

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18
Q

What comorbidity is related to ADHD

A

High comorbidity of tics, anxiety, ODD, mood

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19
Q

How do you manage pre school overactivity ADHD?

A

General behaviour management training for parents eg triple P, incredible years

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20
Q

How do you manage mild ADHD?

A

General behavious management training for parents, Triple P. If required, ADHD specific behaviour management training

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21
Q

How do you treat moderate/ severe ADHD?

A

When symptoms start to impact on learning, relationships, self esteem ,risk taking then start medication

22
Q

What is the developmental impact of ADHD?

A
  • Preschool: behavioural disturbance
  • School age: behavioural problems, acedemic problems, poor social interaction, co morbidity
  • Adolescent: acedemic imoairment, poor social interaction, lower self esteem, smoking, alcholl, drugs, antisocial behaviour, forensic problems
  • college age: Acedemic failure, not coping with daily tasts, occupational difficulties, low self esteem, alcohol and substance abuse, co morbidity, forensic problems
  • Adult: not coping with daily tasks, unemployment, low self esteem, relationship problems, martail discord, alchol and substance abuse, mood instability
23
Q

What are the ADHD medication limitations?

A

Medication doesnt change the underlying condition or cure ADHD, 60-70% of indivuduals still have symptoms in adult lufe. Medication is used to manage the symptoms/ behaviours to help ahcieve goals/ outcomes, to enjoy usuao interests and activities, to be more focused and less distracted. It is not to change personality - if this happens then the dose/ medication is wrong

24
Q

What is the manangement and treatment for ADHD?

A

A multimodal approach consisiting of psychosoial interventions, education supports and pharmacotherapy but pressures on services often mean that medication is tries 1st line

1st - stimulants (methylphenidatae first, if not tolerated then dexamphetamine)
2nd -atomoxetine or guanfacie
3rd - clonidine

25
Q

What is th eeffect of drugs used in ADHD?

A

Drug treatment enhances noradrenaline and dopamine transmission, so assume both are implicitly involved. Dexamphetamine facilitaes release of dopamine from presynaptic cytoplasmic storage vesicle, so increase in synapse and blocks dopamine transporter proetin so inhibits reuptake.

Methylphenidate acts primarily on the dopamine transporter and has little effect on synaptic release

25
Q

What is the pathophysiology of ADHD?

A

DEfective inhibitory response in a compromised pre fronal cortex ie brain filter and braking system.

25
Q

What different tablets does methylphenidate come in and how long do they act for?

A
  • MPH IR: effective for 3-4 hours
  • MPH SR: Equasym XL (30:70) - 8-10 hours
  • Medikinet XL (50:50) - 8 hours
  • Concerta XL 22:78 - 12 hours
26
Q

What is methylphenidate?

A

A racemic micture - therapeutic effect is mainly due t the d enantiomer

27
Q

What tablet does dexamphetamine come in?

A

IR tablets only. ELvanse is lisdexamphetamine dimesylate - it is a sustained release formulation which is a pro drug of dexamphetamine. It is less susceptible to abuse

28
Q

What are the formulaytion types of methylphenidate?

A
  • Inner/outer coats
  • Mixed types of drug beads in a capsule: slow and fast release
29
Q

Describe the release of methylphenidate from a concerta 18mg tablet

A

In the morning, a methylphenidate overcoat provides an immediate release of 22% of the dose within 1 hour, the push mechanism absorbs fluid and expands, acting as an osmotic pump to provide smooth delivery of MPH for the rest of the morning. In the afternoon, as the push mechanism continues to expand, a higher concentration of MPH is released during the afternoon. Delivering an ascending profile results in a smooth effect through 12 hours, with or without food.

30
Q

What is atomoxetine?

A

Second line for ADHD. Its not as good in chidlren. Makes you drowsy. Primarily an inhibitor of norepinephrine. Reduced chance of misuse compared to stimulants but perhaps reduced efficacy. For children/ adolescents of up to 70kg body weight, treatment should be initiated at a dose of 500micrograms/ kg daily, and increased if necessary up to a maximum of 1.8mg/ kg daily, either as a single dose or in two divided doses. It is metabilised by cyp2d6

31
Q

What are the non stimulant drugs for ADHD?

A

Guanfacine:
- sustained release preparation
- Long ter, to get therapeuatic effect (2-3 weeks)
- Has calming effect: may be useful in aggressive/ challanging behaviour and in reducing tics

Clonidine:
- Unlicensed for ADHD
- 2-3 times a day dosing
- Longest time to reach therapeautic dose (150-300 mcg a day)
- Drop in blood pressure is a major issue

32
Q

What are the prescribing issues in stimulant use?

A
  1. CD POM SCH2: prescription requirements/ storage/ supply regulations
  2. Children unable to swallow certain formulations
  3. Dosing frequency is inconvenient/ awkward due to school times
  4. Physical health monitoring
33
Q

What monitoring is required for stimulants?

A
  • Monitoring of physical health parameters
  • Baseline heart rate and blood pressure. Repeat every dose adjustment and every 6 months
  • Pre treatment height and weight on growth chart and every 6 months
  • Complete history documenting cocomitant medicines, past, present medical and pychiatric disorders, family history of sudden cardiac death and unexplained death
  • Increase in contra indications, including history of depression, anorexia, suicidal tendencies, pychosis, pre existing cardio vascular disorders
34
Q

What are the main symptoms of tics and tourettes?

A

Involuntary sounds or movements known as tics
- vocal sounds such as grunting, coughing or shouting out words which are offensive, impolite or abuse
- Physical movements such as jerking of the head or jumping up and down

35
Q

What are the comorbidies of tics?

A

Often associated with ADHD and OCD and runs in familes due to the genetic component

36
Q

What medication is used to treat tourettes?

A
  • Antipshotics/ neuropletics: aripiprazole, sulpiride, risperidone, haloperidol
  • Clonidine - stimulates the alpha 2 adrenergic systme which inhibits the release of noradrenalin. It causes drowsiciness/ depression/ hypotension

Co-morbid ADHD: stimulant medication thought to exacerbate tics so atomoxetine often used instead

37
Q

What is the presentation of OCD?

A

There is a fear of deliberately harming yourself or others eg fear you may attack someone else. Fear if harming yourself or others by mistake or accident eg fear you may set the house on fire accidently. Fear of contamination by disease, infection or an unpleasant substance which leads to constant hand washing. Need for symmetry or orderliness eg you need to have labels all facing the same way.

38
Q

What are the treatments for OCD?

A

SSRI - block seratonin receptors.

Sertraline usually 1st line for children aged 6-17 for OCD. Higher than depression doses - 150mg daily

Clomipramide - most potent SSRI, 300mg daily

Antipsychots are used to address the delusional aspect - aripiprazole, risperidonje

39
Q

how do you treat depression in children and adolescents?

A

Mainly SSRI’s - fluoxetine 10mg/day. Second line sertraline or citalopram. Dont use paroxetine, venlafaxine, TCA. Must be written information to parents.
SSRI are subject to p450 metabolism - they are absorbed and metabolised faster so may need higher doses.
Behavioural adverse effects are more liekly - agitation, restlesness

40
Q

What is the treatment of eating disorders?

A

Primarily psychological
- Address physical health issues first ie. nutritional status in anorexia (thiamine to prevent wenickes encephalopathy)
- For delusional aspect in anorexia - olanzapine used or SSRI - cautioned due weakened heart caused by emaciation
- In bulimia, SSRI fluoxetine is prescribed at higher doses than for depression

41
Q

Why can’t we just treat children as if they were small adults?

A

greater metabolic capacity meaning a more rapid elimination of drugs that use hepatic pathways
more efficient renal elimination
greater body water and less adipose tissue (affects accumulation and distribution of lipophilic drugs)
generally require higher weight adjusted doses to achieve comparable adult blood levels

42
Q

When would fluoxetine be prescribed for depression?

A

in children over 8 years with moderate to severe depressive episode (only under specialist supervision)

43
Q

When would sertraline be prescribed for depression?

A

patients aged 6-17 but not for major depressive disorder (it is not as commonly used)

44
Q

How are SSRIs metabolised>

A

P450 metabolism; absorbed and metabolised faster so may need higher doses

45
Q

What are the side effects to watch out for with SSRIs?

A

behavioural adverse effects like agitation and restlessness
can cause discontinuation syndrome so they should never be stopped abruptly

46
Q

When are anti-epileptic drugs used?

A

in affective disorders for ‘mood stabilisation’

47
Q

What type of drugs are methylphenidate and dexamphetamine?

A

POM schedule 2 controlled drugs

48
Q

What form are dexamphetamine tablets available as?

A

IR tablets only

49
Q

What is Elvanse?

A

(lisdexamphetamine dimesylate) an SR formulation which is a pro-drug of dexamphetamine which is less susceptible to abuse

50
Q

What are reasons for reluctance in diagnosing children with mental health conditions?

A

diagnostic uncertainty: when does temperament reach a diagnostic threshold (deviance, distress, dysfunction and danger)
uncertainty in how to treat the child: psychological vs pharmaceutical)
severity of the illness and side effects (does the need justify the use)
evidence base: ethics of conducting research in children

4.22 (36 decks)

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