Lecture 65 + 66 - Pharmacotherapy of Pediatric Psychiatry Flashcards
Medication use in pediatric psychiatry
Kids have higher risk of significant adverse effects from medications than adults
DSM-5 Tic Disorders
tourette’s disorder
persistent (chronic) motor or vocal tic disorder
provisional tic disorder
Tourette’s Disorder
- Both multiple motor and one or more vocal tics present at some time, not necessarily concurrently
- Tics may wax and wane in frequency, but have been present for > 1 year
- Onset before age 18
Persistent (chronic) motor or vocal tie disorder
- Single or multiple motor or vocal tics present, but not both
- Tics may wax and wane in frequency, but have been present for > 1 year
- Onset before age 18
Provisional Tic Disorder
sx as above, but present for < 1 year
Overview of Tic Disorders
~75% also have ADHD, ~ 50% also have OCD
Rule of Thirds: 1/3 resolve, 1/3 improve, 1/3 stay the same - ~ 10% have persistent symptoms as adults
Pharmacologic Treatment of Tics - first line
- Alpha-2 agonists
- Tics of mild-moderate severity
- ~ 30% reduction
- Clonidine
- Guanfacine
- ER guanfacine
Pharmacologic Treatment of Tics - second line
- Atypical antipsychotics
- 30 – 60% reduction
- Aripiprazole
- Risperidone
Pharmacologic Treatment of Tics - third line
- Typical antipsychotics
- ~ 80% reduction
- Haloperidol
- Pimozide
Antipsychotics
pimozide, haloperidol, aripiprazole, risperidone/paliperidone, quetiapine, olanzapine, ziprasidone
Aripiprazole
FDA approved for ages 6-17 years old
weight based dosing for those less than 50 kg
Stimulant use in Tourette’s
ADHD is a common co-morbidity in Tourette’s syndrome.
Use of amphetamine-based stimulants can exacerbate motor and vocal tic symptoms.
Must treat both ADHD and Tourette’s
* Can discontinue amphetamine-based stimulant and give a trial of atomoxetine or a tricyclic antidepressant.
* If ADHD symptoms are not well-controlled, can resume amphetamine-based stimulant and adjust dose of antipsychotic to better control Tourette’s symptoms.
DSM-5 Oppositional Defiant Disorder
◦ Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months
DSM-5 Conduct Disorder
◦ Repetitive and persistent pattern of behavior in which the basic rights of others or societal norms or rules are violated with at least three (3) of the following criteria present in the past year: aggression to people/animals, destruction of property, deceitfulness or theft, serious violations of rules
specify whether:
* Childhood-onset type: < 10 years old
* Adolescent-onset type: > 10 years (no symptoms under 10 years old)
* Unspecified onset: unclear information to determine age at onset
Treatment of ODD and CD
Pharmacotherapy is considered adjunctive, palliative, non-curative and should only be used after baseline symptoms/behaviors have been determined, other interventions have failed and/or aggression has escalated to dangerous levels
Treat underlying condition (ADHD, depression/anxiety, mania) – ADHD common
First choice for treating ODD and CD
Stimulants and clonidine/guanfacine are considered drugs of first choice before using atypical antipsychotics
Atypical antipsychotics may be used to treat severe persistent aggression, serious oppositional behaviors, defiance
Often see combination stimulant/alpha agonist treatment if ADHD with impulsivity or need for sedation for sleep
Treatment of Separation Anxiety Disorder
First-line treatment for mild anxiety is psychotherapy with combination therapy for moderate to severe anxiety
SSRIs are the first-line drug therapy choice
Treat co-morbidities (depression, ADHD, screen for bipolar disorder)
DSM-5 Autism Spectrum Disorder
Persistent deficits in social communication and social interaction across multiple contexts
Restricted, repetitive patterns of behavior, interests, activities
Hallmark Signs and Symptoms of ASD
Associated behavioral symptoms: aggression, hyperactivity, inattention, irritability, mood instability, poor frustration tolerance, self-harm, severe temper tantrum, sleep disturbances, OCD symptoms, hypersensitivity of senses
Associated medical problems include seizure disorder (up to 30% have at least on seizure by age 20) and GI disorders
No medications have shown efficacy in treating the core ASD symptoms
Treatment of Disruptive Behaviors in ASD
Behavioral interventions are first-line treatment (Applied Behavioral Analysis)
Atypical antipsychotics: aripiprazole (6 – 17 years old) and risperidone (5 – 16 years old) are FDA-approved for the management of irritability/aggression and are considered first-line agents; may have efficacy for stereotypy and hyperactivity
Lamotrigine/levetiracetam have no significant effect on irritability
Treatment of Repetitive Behaviors
Antipsychotics – haloperidol, risperidone, aripiprazole
Treatment of ADHD
Stimulants – methylphenidate preferred
Clonidine/guanfacine – modest effect on irritability and explosive behavior
Treatment of Sleep Problems
Melatonin reduced sleep latency and increased time asleep – give 1 – 6 mg nightly
DSM-5 Disruptive Mood Dysregulation Disorder (DMDD)
Severe recurrent temper outbursts manifested verbally that are out of proportion with the intensity/duration of the situation
Present in at least two of three settings (home, school, with peers) and are severe in at least one of these
Diagnosis should not be made before age 6 or after age 18
DMDD - Treatment
More similarity to depression, ADHD, or anxiety than bipolar disorder
Need to differentiate from bipolar disorder - both for using antidepressants as well as evaluating need for mood stabilizers
SSRIs and stimulants are considered to be first-line treatment
Pediatric Depression
Children – physical complaints, irritability, conduct problems, can have suicidal ideation
Adolescents – express feelings of depression and suicidal behaviors than more than younger children
More chronic than episodic, instability in mood common; may be marker for bipolar disorder
Depression Treatment - Nonpharmacologic
Nonpharmacologic treatment is first-line, need motivation of family/caregivers for success
Depression Treatment
Cognitive Behavioral Therapy – remission rates of 70%
Antidepressants – Black box warning for suicidality
* Highest risk in 1st 3 months of treatment
* Med guide with each prescription
* Antidepressants may lower completed suicide rate
Fluoxetine is the only antidepressant FDA-
approved to treat kids down to 8 years old
Escitalopram – 12 – 17 years old
Paroxetine – 1st antidepressant with suicidal thinking warning – avoid in kids
Drug Treatment for Bipolar I, mixed or manic, without psychosis
Lithium, valproate, carbamazepine, olanzapine, risperidone, quetiapine; may augment with 2nd agent if needed after 4 weeks
Drug Treatment for Bipolar I, mixed or manic, with psychosis
Lithium, valproate, carbamazepine WITH any atypical antipsychotic, consider d/c of atypical if remission for 12- 24 months
Drug Treatment for Bipolar, depressed
1st line – lithium; SSRI/bupropion for depression that continues with lithium treatment (adjunct to lithium)
Pediatric PTSD
Trauma-focused psychotherapy is the first-line treatment:
* TF-CBT – psychoeducation, relaxation, coping & processing, parenting skills
* TF- psychodynamic – personality coherence
SSRIs are first-line treatment
Childhood Onset Schizophrenia
Use adult diagnostic criteria
Prominent hallucinations/delusions present for at least one month and not explained by substance use or PDD/autism
Visual hallucinations more common than in adults
Onset of symptoms before age 13
Rare in children, adolescent prevalence reaches adult prevalence of 0.5 – 1.0%
FDA Approved Indications - Aripiprazole
Bipolar Disorder - 10 yr
Irritability with Autism - 6 yr
Schizophrenia - 13 yr
Tourette’s Disorder - 6 yr
FDA Approved Indications - Asenapine
Bipolar Disorder - 10 yr
FDA Approved Indications - Brexpiprazole
Schizophrenia - 13 yr
FDA Approved Indications - Lurasidone
Schizophrenia - 13 yr
Bipolar Depression - 10 yr
FDA Approved Indications - Olanzapine
Schizophrenia - 13 yr
Bipolar Disorder - 13 yr
FDA Approved Indications - Olanzapine/Fluoxetine
Bipolar I Depression - 10 yr
FDA Approved Indications - Paliperidone
Schizophrenia - 12 yr
FDA Approved Indications - Quetiapine
Bipolar Disorder - 10 yr
Schizophrenia - 13 yr
FDA Approved Indications - Risperidone
Bipolar Disorder - 10 yr
Irritability with Autism - 5 yr
Schizophrenia - 13 yr
