Otts Sections Flashcards
What is the clinical course for ADHD?
- 1/3 of children with ADHD will have it as a adult
- There is an INCREASED risk of substance use and antisocial personalty if untreated
What is the potential impact of ADHD?
- Poor Grades, Low self-esteem, Bad relationships, cant work
What is the diagnostic criteria for ADHD?
- 6 symptoms in each domain [work, school, home…]
- Older patients - 5 symptoms for either two specifiers
- Inattentive or hyperactive symptoms at 12 yo [present in two or more settings]
What are the ADHD types?
- Combined, Predominatly inattentice presentation, Predominantly hyperactive Presention
What are the Inattentive symptoms [persisting for at least 6 months]?
- Fail to give attention to detail
- Difficulty sustaining attention
- Doesnt listen
- Doesnt follow directinos
- Difficulty doing tasks
- Avoids tasks that need work
- Easily distracted
- Forgetful
What are the Hyperactive symptoms [persisting for at least 6 months]?
- Fidgets
- Leaves seat
- Runs or climbs
- Unable to play quietly
- Talks Excessively
- Can’t wait turns
- Interrupts
What are some of the Non-Pharmacologic treatment for ADHD?
- Behavioral Therapy, Psychosocial Treatment
What are some of the Pharmacologic Treatments for ADHD?
- Stimulants
- Non-Stimulants
What is the specific dosing for Stimulants in ADHD?
- Effects in short periods
- DO NOT NEED to calculate for Kids
- IR good in kids
- DO NOT USE 2 DIFFERENT STIMULANTS
- DO NOT give too late in the day
What are some of the speaical consideration drugs used in ADHD?
- Mydayis [NOT for 12 and under]
- Daytrana [Patch - ONLY if they respond to methylphendate]
- Vyvanse [Prodrug - Misuse deterrent]
- Jornay PM [PM dose so it work in AM]
What are some of the stimulant adverse effects in ADHD?
- Appetite loss, Stomach pain, Headache, Sleep issues, Decreased growth, Increased BP, Increased HR, Sudden Cardiac Death
What are some of the stimulant monitoring in ADHD?
- Appetite, Behavior, Blood Pressure, Growth Rate, Heart Rate, Sleep, ECG
What are the Alpha 2 Agonist in ADHD?
- Intuniv & Kapvay
What is important to know about Guanfacine [Intuniv] in ADHD?
- 3A4 Substrate
- Once Daily
What is important to know about Clonidine [Kapvay] in ADHD?
- Twice Daily
What are the Norepineephrine Reuptake Inhibitors in ADHD?
- Atomoxetine & Viloxazine
What is important to know about Atomoxetine in ADHD?
- 6 and older
- 2D6 Substrate
- Weight Based dosing [<70 kg = 0.5 mg/kg & > 70 kg = 40 mg[]
What are the adverse effects of the non-stimulants in ADHD?
- A2A: Decreased HR and BP, Orthostasis, Sleepy, Dizziness
- NRI: Increased HR and BP, Increased suicidal thinking [BOXED WARNING]
What are some of the monitoring for the non-stimulants in ADHD?
- Appetite, Behavior, Blood Pressure, Growth Rate, Heart Rate, LFT, Sleep
What is important to know about Burpropion in ADHD?
- NOT FDA approved for ADHD
- 2D6
- CONTRAINDICATED: Seizure and eating disorder
What is important to know about Monafinil in ADHD?
- FDA for narcolepsy, OSA, Shift work sleep
- Headache, Decreased Appetite, SJS/TEN
What is important to know about the TCAs in ADHD?
- Less effective than methylphenidate
- Cardiac sudden death in childern
What is important to know about the mood stabilizers in ADHD?
- May be useful if there is comordbid bipolar disorderm conduct disorder, intermittent explosive disorder
- SHOULD NOT use atypical antipsychotics as monotherapy
How does the American Academy of Pediatrics [AAP] use there guidelines for ADHD?
- Pre-school: Parent Training then FDA med
- Elementary and Middle-school: FDA med + Parent Training
- Adolescents: FDA Med
What are the AAP remcommendated drugs to use in ADHD?
- Preschool: Methylphenidate [NO non-stim]
- Elementary/Middle school: Stimulants; Atomoxtine, Guanfacine, Clonidine
- Addon: Guanfacine and Clonidine are the ONLY ones
What are the NICE: ADHD Guidelines for Adults?
- Methylphenidate OR Lisdexamfetamine
- Dextroamphetamine [cant use Lisdex]
- Atomoxtine [last line]
What is important to know about medication use in pediatric psychiatry?
- Kids have higher risks of significant adverse effects from medicaiton than adults
How does the DSM-5 describe tic disorders in pediatric psychiatry?
- Tourettes: Both motor and vocal tics for > 1y
- Persistent motor OR vocal tic disorder: >1y
- Provisional Tic Disorder: <1y
What is important to know about Tic Disorders in pediatric psychiatry?
- ~75% have ADHD, ~50% have OCD
- 1/3 resolve, 1/3 improve, 1/3 stay the same
What is the pharmacologic treatment for Tics in pediatric psychiatry?
- 1st: Alpha 2 Agonist [helps with ADHD too]
- 2nd: Atypical Antipsychotics [Aripiprazole & Ripseridone; weight gain]
- 3rd: Typical Antipsychotics [Haloperidol; Pimozide = LAST LINE]
What antipsychotics medications are used in Tics in pediatric psychiatry?
- Pimozide [QTc Prolongation, 3A4, EPS]
- Haloperidol [EPS]
- Aripiprazole [FDA approved]
- Risperidone [D2 blockade]
What stimulants are used in Tourette’s in pediatric psychiatry?
- ADHD is common with Tourettes
- Amphetamine = EXACERBATION
- MUST treat both - Atomoxetine or TCA?
How does the DSM-5 describe Oppositional Defiant Disorder in pediatric psychiatry?
- Patterns of angry/irritable mood, argumentative/definat behavior lasting 6 months
How does the DSM-5 describe Conduct Disorder in pediatric psychiatry?
- When ODD is properly diagnosed with 3 of the following criteria in the past year:
- Agression to people, Destruction of property, Theft, Serious violation of Rules [<10y]
What is the treatment of ODD & CD in pediatric psychiatry?
- Stimulants and Clonidine/Guanfacine [could help with sleep]
- Atypical Antipsychotics
How does the DSM-5 describe Separation Anxiety Disorder in Pediatric Psychiatry?
- Excessive fear or anxiety concerning separation
- Lasting 4 weeks in kids and 6 months in adults
What is the treatment for separation anxiety in pediatric psychiatry?
- SSRIs = 1st line
- Psychotherapy with combo = mild anxiety
How does the DSM-5 describe autism spectrum disorder in pediatric psychiatry ?
- Deficits in social communications and interactions
- Restricted, repetitive patterns of behavior, interests activities
What are some of the hallmark signs & symptoms of ASD in pediatric psychiatry ?
- Aggression, Hyperactivity, inattention, irritability, mood instability, self-harm, OCD…
- Seizures? GI issues?
What is the treatment of disruptive behaviors in ASD in pediatric psychiatry ?
- Typical Antipsychotics: Haloperidol
- Atypical Antipsychotics: Aripiprazole [6-17] & Reisperidone [5-16]
- Mood Stabilizers
- NO Lamotrigine or Levetiracetam = NO effect on irritablity
How dose the DSM-5 describe disruptive mood dysregulation disorder in pediatric psychiatry ?
- Temper outbursts verbally that are out of proportion compared to the situation [before 6 or after 18]
- happens in 2 -3 settings [Home, School, with peers]
what is the treatment for DMDD in pediatric psychiatry ?
- Antidepressants - similar to depression, ADHD, or Anxiety
- SSRIs & Stimulants = 1st line
How is pediatric depression described in pediatric psychiatry ?
- Kids: physical complaints, irritability, conduct problems, suicidal ideation
- Teens: express feelings of depressions and suicidal behaviors
What is the Depression treatment for pediatric psychiatry ?
- Non-pharmacologic = 1st line [70% remission]
- Antidepressants BOXED WARNING for suicidality [Paroxetine AVOID in kids]
- Fluoxetine 8 yo
- Escitalopram 12 - 17 yo
What is the treatment by diagnosis and specifier for pediatric bipolar disorder?
- Bipolar I w/o psychosis: Lithium
- Bipolar I w/ psychosis: Lithium
- Bipolar: Lithium
How is pediatric PTSD described in pediatric psychiatry?
- Very similar to adults [Reexperiencing, avoidance, hypervigilance]
- Trauma-focused psychotherapy = 1st line
- Pharmacotherapy: SSRIs = 1st line
How is Child-hood onset schizophrenia described in pediatric psychiatry?
- Visual hallucinations are more common than in adults
- before 13 yo
- Rare in kids
Based on the DSM-5, what substances are abused?
- Alcohol, Caffeine, Cannabis, Hallucinogens, Inhalants, Opioids, Stimulants, Tobacco, Others
How does the DSM-5 describe substance use disorder?
- 2 of the following for 12 months
- Large amounts than normal, Persistant desire, increased time spent to get substance, craving, getting in trouble, give up activities, use even tho you know its bad, tolerance, withdrawal
What is the clinical course for substance use disorders?
- late teens, early 20s
- plan for setbacks - greatest during the 1st year
What are the stages of alcohol withdrawal?
- Stage 1: 6-8h; hyperactivity & craving alcohol
- Stage 2: 24h; hallucinations
- Stage 3: 1-2d; grand mal seizures
- Stage 4: 3-5d; Delirium Tremens
What are some of the risk factors for Delirium tremens in substance
- Prior DTs - increase severity each time
- # of detox
- 1 pint of whiskey per day for 10 of 14 days
- Withdrawal
- Hepatic dysfunction
What is the way that we treat alcohol withdrawal?
- BENZO = drug of choice
- CIWA < 8-10: Non-pharm
- CIWA 8-15: Medicate
- CIWA > 15: Complicated if untreated
What is important to know about Lorazepam in alcohol withdrawal?
- Can be used in liver dysfunction
What are some of the other treatment considerations within alcohol withdrawal?
- THIAMINE!
- Carbamazepine & Valproate maybe
- Phenytoin NOT effective
What is the Wernicke-Korsakoff syndrome within Alcohol withdrawal?
- Wernike’s Encephalopathy: Thaimine deficiency
- Give 1000 mg Thaimine before dextrose fluids
- Thaimine is a co-factor in glucose metabolism
What is important to know about Disulfiram within Alcohol Withdrawal?
- Blocks ADH - what metabolize alcohol
- Causes unpleasant effects up to 14 days after D/C
What is important to know about Acamprosate within Alcohol Withdrawal?
- Abstinence Drug
- Renal Elimination
- BOXED WARNING: suicidality
- Safe to use with alochol
What is important to know about Naltrexone within alcohol withdrawal?
- Decrease binge drinking
- NEED to evaluate pain as it is a partial antagonist [Decrease pain relief from opioids]
- Injection site reactions
What are some ways that we treat the symptoms from Opioid withdrawal?
- Muscle Aches: Tylenol or NSAIDS
- Anxiety: Hydroxyzine or Benzo
- N/V: Ondansetron
- Diarrhea: Loperamide
- Sweating: Clonidine or Lofexidine
What Alpha-2 Agonist are used for opioid withdrawal symptoms?
- Clonidine or Lofexidine
What are some of the maintenance treatments of opioids use disorders?
- Methadone: licensed treatment
- Buprenorphine: combo with narcan
What are the clinical pearls for Methadone in substance use disorder?
- 3A4; 2B6, 2C19, 2D6
- QTc Prolongation
What are the clinical pearls for Buprenorphine in substance use disorder?
- Give with Narcan
- Sublingually
- 3A4
- Serotonin Syndrome
- Respiratory Depression - partial agonist
What is important to know about Buprenorphine ER injection?
- Need to be on buprenorphine for 7 days before
- Serotonin Syndrome
