Ott Pharmacotherapy of Ped Psych Flashcards
Why must medications be used with caution in pediatric patients?
Kids have a higher risk for significant adverse effects compared to adults
Definition of Tourette’s disorder
-Tics may wax and wane in frequency, but have been present for over a year
-Onset before age 18
Common comorbidities associated with tic disorders
-~75% have ADHD
-~50% have OCD
Tic disorder rule of thirds
-1/3 resolve
-1/3 improve
-1/3 stay the same
-~10% have persistent symptoms as adults
First-line treatment for tics
Alpha 2 agonists:
-Tics of mild to moderate severity
-~30% reduction
Second-line treatment for tics
Atypical antipsychotics (30-60% reduction_
Third-line treatment for tics
Typical antipsychotics (~80% reduction)
What are the alpha 2 agonists used to treat tics?
-Clonidine
-Guanfacine
-Guanfacine ER
What are the atypical antipsychotics used to treat tics?
-Aripiprazole
-Risperidone
What are the typical antipsychotics used to treat tics?
-Haloperidol
-Pimozide
What is the age range that aripiprazole is approved for treating?
6-17 years old
How do you treat ADHD and Tourette’s at the same time?
-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
What must be specified when diagnosing conduct disorder?
-Childhood-onset type: less than 10 years old
-Adolescent-onset type: older than 10 years old (no symptoms under 10)
-Unspecified onset: unclear information to determine age at onset
When should pharmacotherapy be considered in patient with ODD or 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
How do you treat ODD and CD?
Treat underlying conditions (ADHD, depression/anxiety, mania) - ADHD common
Which drugs are considered first choice to treat ODD and CD?
Stimulants and clonidine/guanfacine before atypical antipsychotics
When are atypical antipsychotics used for ODD and CD?
May be used to treat severe aggression, serious oppositional behaviors, defiance
What medications are often given to ODD and CD patients?
Combination stimulant/alpha agonist treatment of ADHD with impulsivity or need for sedation for sleep
What is first-line treatment for separation anxiety disorder?
First-line treatment for mild anxiety is psychotherapy with combination therapy for moderate to severe anxiety
What is the first-line drug choice for separation anxiety disorder?
SSRIs are the first-line drug therapy choice
What are common co-morbidities associated with separation anxiety disorder
-Depression
-ADHD
-Bipolar disorder
Co-morbidities must be treated
What is autism spectrum disorder?
-Persistent deficits in social communication and social interaction across multiple contexts
-Restricted, repetitive patterns of behavior, interests, activities
Behavioral symptoms associated with autism spectrum disorder
-Aggression
-Hyperactivity
-Inattention
-Irritability
-Mood instability
-Poor frustration tolerance
-Self-harm
-Severe temper tantrum
-Sleep disturbances
-OCD symptoms
-Hypersensitivity of senses
Medical problems associated with autism spectrum disorder
-Seizure disorder
-GI disorders
What medications are used to treat the core ASD symptoms?
No medications have shown efficacy in treating the core ASD symptoms
First line treatment for disruptive behaviors in ASD
Behavioral interventions
What are considered first-line drug agents in the treatment of ASD?
Atypical antipsychotics:
-Aripiprazole
-Risperidone
Age range to use risperidone
5-16 years old
Lamotrigine/levetiracetam use in ASD
No significant effect on irritability
How to treat sleep problems in ASD
Melatonin reduced sleep latency and increased time asleep - give 1-6 mg nightly
How to treat ADHD in ASD
-Stimulants - methylphenidate is preferred
-Clonidine/guanfacine - modest effect on irritability and explosive behavior
How to treat repetitive behaviors in ASD
Antipsychotics - haloperidol, risperidone, aripiprazole
Definition of disruptive mood dysregulation disorder
-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
First-line treatment for DMDD
SSRIs and stimulants
How to treat DMDD
-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
Symptoms of depression in children
-Physical complaints
-Irritability
-Conduct problems
-May have suicidal ideation
Symptoms of depression in adolescents
-Express feelings of depression
-More suicidal behaviors than younger children
Differences in depression for peds patients compared to adult patients
-More chronic than episodic
-Instability in mood is common
-May be a marker for bipolar disorder
First-line treatment for depression in peds patients
-Non-pharmacologic treatment - need motivation of family/caregivers for success
-Cognitive behavioral therapy - remission rates of 70%
What antidepressants are used in peds patients?
-Fluoxetine
-Escitalopram
Which antidepressant must be avoided in peds patients?
Paroxetine for suicidal thinking
Age range for use of fluoxetine
Can be used in anyone as young as 8 years old
Age range for use of escitalopram
12-17 years old
Antidepressant black box warning
-Suicidality
-Highest risk in first 3 months of treatment
-Med guide with each prescription
-Antidepressants may lower completed suicide rate
Preferred drug options to treat bipolar 1, mixed or manic, without psychosis
-Lithium
-Valproate
-Carbamazepine
-Olanzapine
-Risperidone
-Quetiapine
-May augment with second agent if needed after 4 weeks
Preferred drug options to treat bipolar 1, mixed or manic, with psychosis
-Lithium
-Valproate
-Carbamazepine WITH any atypical antipsychotic
-Consider d/c of atypical if remission for 12-24 months
Preferred drug options to treat bipolar, depressed
-First line: lithium
-SSRI/bupropion for depression that continues with lithium treatment (adjunct to lithium)
First-line treatment for peds PTSD
-Trauma-focused psychotherapy
-SSRIs
How to diagnose childhood-onset schizophrenia
Use adult diagnostic criteria
What is childhood-onset schizoprhenia?
-Not explained by substance use of PDD/autism
-Visual hallucinations are more common in peds than adults
-Onset of symptoms before age 13
-Rare in children, adolescent prevalence reaches adult prevalence of 0.5-1.0%
