Mental illness in Children and adolescents Flashcards
Depressive Disorders in children/adolescents
Anxiety disorders in children/adolescents
ADHD
Substance use disorders in children/adolescents
Autism Spectrum Disorder
Psychotic Disorders in Children and Adolescents
Prescribing recommendations for children:
-Accurate assessment
-Evaluate various child/adolescent’s contexts
-Obtain information from various sources( e.g. home and school)
-Be aware of pediatric pharmacokinetic principles
-Use psychotropics only for serious disruptive behaviors or symptoms
-Establish alliance with patient and parents
-Be aware that evidence of adults may not be the same for children and adolescents
-Maintain informed consent from responsible party and assent from patient
-Address the patient’s fears and resistance to psychotropics
-Consultations with other experienced clinicians are recommended
Pharmacokinetics in children: Lipophilic medications
Lipophilic Medications:
Most psychotropic medications are highly lipophilic
The percentage of total body fat increases during the first year of life, then decreases gradually until puberty
Children have different volumes of fat for drug storage at different ages.
Pharmacokinetics in Children: CYP/Metabolizing enzymes:
Both CYP450 and phase II drug metabolizing enzymes generally are absent in infancy, though rapidly develop over the first few years of life.
Toddlers and older children may have levels of these drug-metabolizing enzymes which exceed adult levels!
These decline until puberty, where they generally remain the same until adulthood.
Pharmacokinetics in children: Liver mass effects
Relative to body weight, the liver mass of a toddler is 40-50% greater than an adult. A 6 year old’s liver mass is 30% greater than an adult.
Children tend to clear drugs more rapidly than adults
Children may require higher mg/kg concentrations to achieve the same plasma levels
Pharmacokinetics in children: Renal Filtration
-By age 1, GFR and renal tubular mechanisms for secretion have reached adult levels
-fluid intake may be greater in children relative to adults
-medications have a more rapid renal clearance in children compared to adults
Issues with Diagnosing Depression in Children and Adolescents:
Limited research conducted on children and adolescents
-Mood disorders may mimic other conditions (e.g. ADHD)
-Treatment of bipolar disorder
What medications are used to treat depression in children?
SSRI’s and TCA’s.
-See table in PPT for specifics.
-Taper gradually to prevent withdrawal side effects.
FDA approved medications for treatment of OCD
Clomipramine > 10 y/o
Fluvoxamine > 8 y/o
Sertraline > 6 y/o
Fluoxetine > 7 y/o
Medication Augmentation:
Clomipramine, Clonazepam, Neuroleptics, Add second SSRI, Lithium
Non-OCD anxiety disorders:
Sertraline does not have FDA approval for treatment of anxiety disorders in childrenbut there is good evidence for its efficacy.
Medications should be dosed at rates done in clinical trials.
Typical dosages for sertraline based on CAMS study are 100-150 mg by week .
Typical dosage for fluoxetine are based on TADS and TORDIA studies. May titrate up to 40 mg by week 12.
Oppositional Defiant Disorder:
No official medications approved by FDA for treatment
Best evidence is for psychotherapy and psychosocial interventions
Off-label use of stimulants (high comorbidity with ADHD), as well as mood stabilizers (Divalproex and Lithium)
Atypical Antipsychotics used as well (Risperidone has some evidence)
Bottom line: Treat with psychotherapy and use medications for any comorbid psychiatric disorders.
Pediatric Bipolar I, Manic or Mixed.
Controversial diagnosis
Psychosocial interventions are necessary in addition to medications
Approved Medications by FDA for manic and mixed states in ages 10-17: Lithium, Quetiapine, Risperidone, Aripiprazole. Olanzapine has been approved to age 13 and up.
Off label use: Carbamazepine, Divalproex in monotherapy and as augmentation to approved meds, Ziprasidone, and Clozapine
Topiramate and Oxcarbazepine only have negative studies in children, DON”T USE THEM!!
Diagnostic criterial for ADHD in children:
Onset usually by seven years old
Many theories exist to etiology
Potentially linked to pre-frontal cortex neurodevelopmental abnormalities
Dopamine and other neurotransmitters linked to development of ADHD
Environmental factors may play role
Diagnosed by various healthcare professionals
Characterized by inattentiveness, impulsivity, and hyperactivity
Atomoxetine for ADHD in children.
Selective NE reuptake inhibitor
Advantages:
low abuse potential
less insomnia
Less growth problems
Disadvantages:
delayed onset of effect (2-4 weeks)
lower efficacy than stimulants
Starting dose: Starting dose 0.25 mg per pound for children and adolescents weighting less than 154 pounds
Dose based on weight: 0.5mg/kg/day, up to 1.2mg/kg/day as tolerated
Adverse effects: nausea, stomach pain, moodiness, increased heart rate, Black Box – suicidality
Bupropion for ADHD
NE reuptake and DA reuptake inhibitor
Dosing is somewhat unclear in children
What are the Alpha-adrenergic agonists for ADHD
May strengthen working memory by improving functional connectivity in prefrontal cortex
Guanfacine
Guanfacine (Intuniv) more selective for A2a receptor (long acting)
less sedation and dizziness than clonidine
2-4 mg with effect between 2-4 weeks
Clonidine
Clonidine (Kapvay – Catapress)less effective than stimulants, used as adjunct to manage tics, sleep problems and aggression
Methylphenidate vs. amphetamine:
Methylphenidate vs. Amphetamine:
Methylphenidate blocks the reuptake of DA and NE but has little effect on presynaptic release of dopamine
Amphetamine blocks reuptake of DA and NE and increases release of DA and NE
Long Acting Forms - 3 delivery options:
SODAS (Spheroidal Oral Drug Absorption Systems) and Diffucaps= combination of immediate and extended release beads
OROS (Osmotic Release Oral System): capsule with H2O permeable holes which release medication depending on osmotic pressure
3rd option: Lisdexamfetamine, a prodrug bound to L-lysine which uses GI tract to metabolize dextroamphetamine
