9/12/20151 Child Psychiatry for Medical Students Part I Khalid Bazaid, MB BS, FRCPC Assistant Professor Child & Adolescent Psychiatrist Department of Psychiatry.

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Child Psychiatry for Child Psychiatry for Medical Students Part IMedical Students Part I

Khalid Bazaid, MB BS, FRCPCKhalid Bazaid, MB BS, FRCPCAssistant ProfessorAssistant Professor

Child & Adolescent PsychiatristChild & Adolescent PsychiatristDepartment of PsychiatryDepartment of Psychiatry

College of MedicineCollege of MedicineKing Saud UniversityKing Saud University

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OutlinesOutlines Introduction to Child & Adolescent psychiatryIntroduction to Child & Adolescent psychiatry

Review disorders first usually diagnosed in Infancy, Childhood and Review disorders first usually diagnosed in Infancy, Childhood and AdolescenceAdolescence– MRMR– PDDPDD– ADHDADHD– Disruptive DisordersDisruptive Disorders

Review childhood presentation of general psychiatric disordersReview childhood presentation of general psychiatric disorders– Elimination disordersElimination disorders– MoodMood– AnxietyAnxiety– PsychosisPsychosis

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Remember: Children are not miniature adultsRemember: Children are not miniature adults

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5 Days5 Days 2 Months2 Months

1 Year1 Year 28 Years28 Years

Child PsychiatryChild Psychiatry

Relatively small specialty numerically BUT has a large reach.Relatively small specialty numerically BUT has a large reach. Between general psychiatry and pediatricsBetween general psychiatry and pediatrics 7-20% children have mental health problems7-20% children have mental health problems 10% of these see specialist child mental health services10% of these see specialist child mental health services 40% of consultations in GP are family ones40% of consultations in GP are family ones > 25% of these relate to mental health> 25% of these relate to mental health Therefore 10% of total GP consultations may be children’s mental Therefore 10% of total GP consultations may be children’s mental

health relatedhealth related Pediatric OPD 30% mental health relatedPediatric OPD 30% mental health related Pediatric inpatients nearer 60%.Pediatric inpatients nearer 60%. An appreciation of child mental health is important whatever specialty An appreciation of child mental health is important whatever specialty

you go into.you go into.

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Child Psychiatry: Child Psychiatry: Epidemiology Epidemiology

5 to 15 percent with clinically significant disorders

Below age 12 years: Boys outnumber girls, Higher rates of behavioral/learning/developmental disorders

12 to 18 years: Girls outnumber boys, Higher rates of anxiety/affective disorders

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Distribution of DisordersDistribution of DisordersDiagnostic groupings:Diagnostic groupings:

Disruptive behaviour disorders – Conduct disorder (prevalence 5.3%), Disruptive behaviour disorders – Conduct disorder (prevalence 5.3%), Oppositional defiant disorderOppositional defiant disorder

Hyperkinetic disorders (ADHD) (up to 5%).Hyperkinetic disorders (ADHD) (up to 5%). Tic Disorders e.g. Tourettes’ (up to 2%)Tic Disorders e.g. Tourettes’ (up to 2%) Affective disorders – Depression (2%), BPAD.Affective disorders – Depression (2%), BPAD. Anxiety disorders (3.8%), GAD, phobias, separation anxiety, panic, PTSD.Anxiety disorders (3.8%), GAD, phobias, separation anxiety, panic, PTSD. Obsessive Compulsive disorder (3%)Obsessive Compulsive disorder (3%) Dissociative and somatoform disorders (rare)Dissociative and somatoform disorders (rare) Psychosis e.g. drug induced, schizophrenia (v. rare in childhood, peak Psychosis e.g. drug induced, schizophrenia (v. rare in childhood, peak

incidence late teens to early twenties).incidence late teens to early twenties). Developmental disorders – general (2.4%) or specific learning disability, autistic Developmental disorders – general (2.4%) or specific learning disability, autistic

spectrum disorders (0.06 to 1.5%) and other PDDspectrum disorders (0.06 to 1.5%) and other PDD Social functioning disorders e.g. elective mutism, attachment disordersSocial functioning disorders e.g. elective mutism, attachment disorders Eating disorders (3%) e.g. Anorexia, Bulimia, Binge eatingEating disorders (3%) e.g. Anorexia, Bulimia, Binge eating

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EVALUATION STRATEGIESEVALUATION STRATEGIESEVALUATION STRATEGIESEVALUATION STRATEGIES

Patient InterviewPatient Interview

Testing Testing (IQ, Education, Projective,(IQ, Education, Projective, Personality, Neuropsychiatry,Personality, Neuropsychiatry, labs, EEG, MRI)labs, EEG, MRI)

ObservationObservation

Collateral InformationCollateral Information (Parents, School)(Parents, School)

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Mental RetardationMental Retardation• Epidemiology: 1-3% in USEpidemiology: 1-3% in US• IQ 70 or less on an individually IQ 70 or less on an individually

administered IQ testadministered IQ test• Onset before age 18Onset before age 18• Delays in two or more adaptive areas, Delays in two or more adaptive areas,

e.g., self care; communication; work; e.g., self care; communication; work; leisure; health; or safetyleisure; health; or safety

• Testing:Testing:• Intelligence testing - compares Intelligence testing - compares

individual test performance to individual test performance to normative of age group normative of age group • E.g., WISC-IV (6 to17y) or E.g., WISC-IV (6 to17y) or

Stanford-Binet V5 (2 to 85+y)Stanford-Binet V5 (2 to 85+y)• Vineland Adaptive Behavior Vineland Adaptive Behavior

Scales -measure of personal and Scales -measure of personal and social skillssocial skills

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Mental RetardationMental Retardation

(~ 85%)(~ 85%)

(~ 10%)(~ 10%)

(~ 3%)(~ 3%)

(~ 1-2%)(~ 1-2%)

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Treatment ConsiderationsTreatment Considerations

• Family is coping with loss of “ideal” child:Family is coping with loss of “ideal” child: Grief and loss issuesGrief and loss issues

• Appropriate placement and support:Appropriate placement and support: School School setting, day care, group homes, sheltered workshop and relief setting, day care, group homes, sheltered workshop and relief carecare

• Specific problems responsive to medications:Specific problems responsive to medications:e.g. seizures; depression; hyperactivity ; aggressione.g. seizures; depression; hyperactivity ; aggression

• May experience “independent” psychiatric disorders: May experience “independent” psychiatric disorders:

e.g. schizophrenia, bipolar disorder, etc.e.g. schizophrenia, bipolar disorder, etc.

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Pervasive Developmental DisordersPervasive Developmental Disorders

Disorders with severe and pervasive impairment in essential Disorders with severe and pervasive impairment in essential developmental areas:developmental areas:

Reciprocal social skillsReciprocal social skills Language developmentLanguage development Range of behavioral repertoire Range of behavioral repertoire

DSM-IV includes the following under PDD:DSM-IV includes the following under PDD:1.1. AutismAutism2.2. Rett’s DisorderRett’s Disorder3.3. Childhood Disintegrative DisorderChildhood Disintegrative Disorder4.4. Asperger’s DisorderAsperger’s Disorder5.5. PDD, not otherwise specifiedPDD, not otherwise specified

Language Disorders: Autism and Other Pervasive Developmental Disorders, Pediatr Clin N Am 54 (2007) 469–481

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Autism Spectrum Disorders (ASD)Autism Spectrum Disorders (ASD)

ASD are increasingly common neurodevelopment disorderASD are increasingly common neurodevelopment disorder

Characterized by functional impairments in a triad of symptoms:Characterized by functional impairments in a triad of symptoms: (1)(1) limited reciprocal social interactionslimited reciprocal social interactions (2) disordered verbal and nonverbal communication(2) disordered verbal and nonverbal communication (3) restricted, repetitive behaviors or circumscribed interests(3) restricted, repetitive behaviors or circumscribed interests

These behaviors can vary in severity from mild to disablingThese behaviors can vary in severity from mild to disabling IQ:IQ: At least half of all children who have autism haveAt least half of all children who have autism have mentalmental retardation retardation Autism appears in early childhood, often as young as age 2 or 3Autism appears in early childhood, often as young as age 2 or 3 Prevalence rate for all ASDPrevalence rate for all ASD 0.6%0.6% (Am J Psychiatry 2005; 162(6): 1133-41)(Am J Psychiatry 2005; 162(6): 1133-41)

Up to 25% have grand-mal seizures and about 50% non-specific EEG Up to 25% have grand-mal seizures and about 50% non-specific EEG abnormalitiesabnormalities

boys to girls 4:1boys to girls 4:1 Asperger’s disorder 10:1 as many boys to girls Asperger’s disorder 10:1 as many boys to girls Genetic / environment Genetic / environment

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Epidemiology of AutismEpidemiology of Autism

• Prevalence rate of Autism Spectrum Disorders is Prevalence rate of Autism Spectrum Disorders is about 1%about 1%

• Up to 25% have grand-mal seizures and about 50% Up to 25% have grand-mal seizures and about 50% non-specific EEG abnormalitiesnon-specific EEG abnormalities

• 50 to 70% have some degree of MR50 to 70% have some degree of MR

• Boys are effected 3 to 5 times more often than girlsBoys are effected 3 to 5 times more often than girls

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Etiology of AutismEtiology of Autism

• Psychological theories have not been confirmed:Psychological theories have not been confirmed: Not caused by “refrigerator mother” or bad parentingNot caused by “refrigerator mother” or bad parenting

• Heritability over 90%Heritability over 90%

• Association with a variety of disorders: Association with a variety of disorders: Congenital rubella & Postnatal infectionCongenital rubella & Postnatal infection Genetic disorders, including Fragile XGenetic disorders, including Fragile X Metabolic disordersMetabolic disorders Tic disordersTic disorders OCDOCD

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Asperger’s DisorderAsperger’s Disorder

• ““High functioning autism”High functioning autism”

• No delays in language and cognitive developmentNo delays in language and cognitive development

• Stereotypic, repetitive mannerismsStereotypic, repetitive mannerisms

• Lack of interactive play/communicationLack of interactive play/communication

• Impaired communication skillsImpaired communication skills                                                                            

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PDD NOSPDD NOS

When there is no severe and pervasive When there is no severe and pervasive impairment in the development of reciprocal impairment in the development of reciprocal

social interaction, or communication skills, or social interaction, or communication skills, or when stereotyped behaviors and activities are when stereotyped behaviors and activities are

present, but the criteria are not met for a present, but the criteria are not met for a specific pervasive developmental disorder.specific pervasive developmental disorder.

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Interventions in PDD/AutismInterventions in PDD/Autism

Presently:Presently:

No curative treatmentNo curative treatment; early detection and symptomatic ; early detection and symptomatic approachesapproaches

Mainstay:Mainstay:

Structured behavioral and educational programs; speech and Structured behavioral and educational programs; speech and language serviceslanguage services

Medication:Medication:

To control seizures, hyperactivity, SIB, severe aggression, or To control seizures, hyperactivity, SIB, severe aggression, or mood disordersmood disorders

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Externalizing Disorders in Children Externalizing Disorders in Children (ADHD, CD, ODD)(ADHD, CD, ODD)

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Attention Deficit/Hyperactivity Disorder Attention Deficit/Hyperactivity Disorder (ADHD)(ADHD)

• Present before age 7Present before age 7• Persist for at least 6 months and be more frequent and severe Persist for at least 6 months and be more frequent and severe than is typical for children at comparable developmental stagesthan is typical for children at comparable developmental stages• Symptoms in two or more settings• Boys to girls 3 : 1Boys to girls 3 : 1 • DSM-IV-TR distinguishes ADD WITH & WITHOUT hyperactivity, and recognizes a predominantly hyperactive subtype • Persists in some patients into adolescence and AdulthoodPersists in some patients into adolescence and Adulthood

• Normal IQNormal IQ

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INATTENTIONINATTENTION

no attention to detailsno attention to details difficulty focusingdifficulty focusing not listeningnot listening easily distractedeasily distracted forgetful not forgetful not

following throughfollowing through difficulty organizingdifficulty organizing avoids effortful tasksavoids effortful tasks loses thingsloses things

HYPERACTIVITYHYPERACTIVITY

IMPULSIVITYIMPULSIVITY fidgetsfidgets leaves seatleaves seat runs/climbsruns/climbs loudloud on the goon the go excessive talkexcessive talk blurtsblurts can't wait turncan't wait turn interrupts/butts ininterrupts/butts in

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ADHD Low selfesteem

Academiclimitations

Relationships

Smoking andsubstance abuse

InjuriesMotor vehicle

accidents

Legaldifficulties

Occupational/vocational

ChildrenA

du

lts

Adolescents

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ADHD DiagnosisADHD Diagnosis

• ADHD is more difficult to reliably diagnose in early childhood ADHD is more difficult to reliably diagnose in early childhood (age 4-6)(age 4-6)

• Obtain developmental and medical historyObtain developmental and medical history

• Get standardized questionnaires from parents and teachersGet standardized questionnaires from parents and teachers

• Observation in clinic setting may or may not show symptoms Observation in clinic setting may or may not show symptoms described by parentsdescribed by parents

• Psycho-educational testing useful if LD suspectedPsycho-educational testing useful if LD suspected

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الطفل : المستشفى : ........................................ اسم ................العمر : ............................. رقم

:التعليماتالعبارات من واحده كل أمام الطفل وصف يناسب الذي الرقم حول دائرة وضع الرجاء

:التالية  S كثيرا

Sجداكثير

SاSقليًال

أبدSا

الطفل وصف تسلسل

3 2 1 0 مقعده . في يتحرك أو يتململ ما Sغالبا )1(

3 2 1 0 . S جالسا البقاء في صعوبة يجد )2(

3 2 1 0 انتباهه . تشتيت السهل من )3(

3 2 1 0وسط دوره انتظار في صعوبة يجد

أقرانه . )4(

3 2 1 0على االجابة في يندفع ما Sغالبا

تفكير . دون األسئلة )5(

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3 2 1 0 التعليمات . اتباع في صعوبة يجد )6(

3 2 1 0يطلب فيما انتباهه حصر في صعوبة يجد

عمله . منه )7(

3 2 1 0 ، إكماله قبل نشاط من ينتقل ما Sغالبا

آخر . نشاط إلى )8(

3 2 1 0 بهدوء . اللعب في صعوبة يجد )9(

3 2 1 0 بافراط . يتكلم ما sS غالبا )10(

3 2 1 0نفسه يقحم اآلخرين يقاطع ما Sغالبا

عليهم .)11(

3 2 1 0 اإلنصات . عدم عليه يبدو ما Sغالبا )12(

3 2 1 0 ) األدوات الخاصة أشياءه يضيع ما Sغالبا

( S مثًال المدرسية)13(

3 2 1 0دون Sبدنيا خطرة بأعمال يقوم ما Sغالبا

ذلك . عن ينتج لما اكتراث)14(

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ADHDADHD

EtiologyEtiology

NeuroanatomicalNeurochemical

Genetic

CNS insult

Environmental

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NIMH Press Release November 12, 2007 NIMH Press Release November 12, 2007 Brain Matures a Few Years Late in ADHD, Brain Matures a Few Years Late in ADHD,

But Follows Normal PatternBut Follows Normal Pattern

http://www.nimh.nih.gov/science-news/2007/brain-matures-a-few-years-late-in-adhd-but-follows-normal-pattern.shtml

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ADHD Child Home

Behavioural Therapy

MedicationSchool

Treatment

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ADHD TreatmentADHD Treatment

• Psychoeducation essential; medication alone is usually not Psychoeducation essential; medication alone is usually not sufficient for the treatment of ADHDsufficient for the treatment of ADHD

• Parent training in behavioral management and school-Parent training in behavioral management and school-based behavioral interventionsbased behavioral interventions

• FDA approved medications include FDA approved medications include stimulantsstimulants and and AtomoxetineAtomoxetine Note: Stimulant medications improve attention in Note: Stimulant medications improve attention in

normal individuals as well as children with ADHDnormal individuals as well as children with ADHD• Establish communication with teachers/school; potentially Establish communication with teachers/school; potentially

includes accommodations and IEPincludes accommodations and IEP

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The CONCERTAThe CONCERTA®® Formulation Formulation

MPH Overcoat

Tablet Shell

Push Compartment

MPH Compartment

#2

Laser-Drilled Hole

MPH Compartment

#1

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ADHD OutcomesADHD Outcomes

ADHD can be a lifetime disorder, with nearly 2/3 of children ADHD can be a lifetime disorder, with nearly 2/3 of children continuing with symptoms as adultscontinuing with symptoms as adults

Learning disabilities frequently comorbid in children with Learning disabilities frequently comorbid in children with ADHD and not responsive to medicationsADHD and not responsive to medications

Adult outcome studies show more relationship problems, Adult outcome studies show more relationship problems, lower educational and professional achievement, more traffic lower educational and professional achievement, more traffic violations and higher health care costs for cohort members violations and higher health care costs for cohort members with ADHD compared to unaffected controlswith ADHD compared to unaffected controls

Long term outcome strongly influenced by comorbid ODD, Long term outcome strongly influenced by comorbid ODD, CD, and substance abuseCD, and substance abuse

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Conduct /Oppositional Defiant DisorderConduct /Oppositional Defiant Disorder

ODD: …for six monthsODD: …for six months– NegativisticNegativistic

Loses temper, arguesLoses temper, argues DefiesDefies Deliberately annoys/easily annoyedDeliberately annoys/easily annoyed Angry, resentful, spitefulAngry, resentful, spiteful

CD: 3 or more in the last 12 mos.CD: 3 or more in the last 12 mos.– Aggression to people animalsAggression to people animals– Destruction of propertyDestruction of property– Deceitfulness/theftDeceitfulness/theft– Serious violations of rulesSerious violations of rules

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Toilet trainingToilet training Begins 18-30 monthsBegins 18-30 months Most children control urination by day at 2.5 years and at Most children control urination by day at 2.5 years and at

night by 3.5-4 yearsnight by 3.5-4 years Factors that effect refusal include:Factors that effect refusal include:

early trainingearly training excess parent-child conflictexcess parent-child conflict constipationconstipation

Prerequisites:Prerequisites: bowel and bladder regularitybowel and bladder regularity sphincter controlsphincter control psychological ability to delaypsychological ability to delay desire to please adultsdesire to please adults

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EnuresisEnuresis Primary vs Secondary EnuresisPrimary vs Secondary Enuresis Nocturnal vs. DiurnalNocturnal vs. Diurnal DIURNAL enuresis after DIURNAL enuresis after

continence is achieved should continence is achieved should prompt evaluationprompt evaluation

Family history of enuresisFamily history of enuresis Laboratory studies are unlikely to Laboratory studies are unlikely to

be positive unless other clinical be positive unless other clinical findings are presentfindings are present

Treatment with medications and Treatment with medications and behavioral planbehavioral plan

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Selective MutismSelective Mutism Failure to speak in specific Failure to speak in specific

social situations despite social situations despite speaking in other speaking in other situationssituations

Classified as an anxiety Classified as an anxiety disorderdisorder

High association with High association with depressiondepression

A leading cause (2nd or 3rd) of death in adolescents:

12% of teen deaths are suicide

Suicidal ideation very common in adolescents: 20% per year

Suicide attempts: 10% per year a. More common in females b. More often completed in males

What do you say to a teen who reports suicidal feelings?

What are some major worries/ “red flags”?

SUICIDE…SUICIDE…

Treatment ModalitiesTreatment Modalities Individual Therapies (play, behavioral, Individual Therapies (play, behavioral,

cognitive, supportive, dynamic)cognitive, supportive, dynamic) Family Therapy & Parent TrainingFamily Therapy & Parent Training Group Therapy - especially important for Group Therapy - especially important for

adolescentsadolescents Medication therapyMedication therapy

Can be use alone or in combinationCan be use alone or in combination Outpatient or inpatientOutpatient or inpatient

Evidence Based Treatments in Child and Evidence Based Treatments in Child and Adolescent PsychiatryAdolescent Psychiatry

McClellan and Werry, McClellan and Werry, JAACAPJAACAP, 2003;42:1388-1400, 2003;42:1388-1400

Psychopharmacology:Psychopharmacology: Most medication practices for psychiatric illnesses in youth Most medication practices for psychiatric illnesses in youth

based on anecdotal reports and/or adult literaturebased on anecdotal reports and/or adult literature Essentially no literature examining combined therapies and Essentially no literature examining combined therapies and

polypharmacypolypharmacy Limitations include small sample sizes, lack of controls, narrow Limitations include small sample sizes, lack of controls, narrow

diagnostic inclusion criteria and/or short duration of treatmentdiagnostic inclusion criteria and/or short duration of treatment Most prescriptions for psychiatric indications in juveniles Most prescriptions for psychiatric indications in juveniles

considered off-label (non-FDA approved)considered off-label (non-FDA approved) NIH promoting large cooperative multisite trials to address NIH promoting large cooperative multisite trials to address

these concernsthese concerns

Pediatric PsychopharmacologyPediatric Psychopharmacology

Increased Public ConcernIncreased Public Concern– Questions of over-medication and over-diagnosisQuestions of over-medication and over-diagnosis

Since 2003, FDA has issued separate warnings regarding Since 2003, FDA has issued separate warnings regarding – Antidepressants (suicidality)Antidepressants (suicidality)– Atypical antipsychotics (metabolic problems)Atypical antipsychotics (metabolic problems)– Stimulants (potential for sudden death and cardiovascular Stimulants (potential for sudden death and cardiovascular

problems)problems)– Atomoxetine (suicidality)Atomoxetine (suicidality)– Antiepileptics (suicidality)Antiepileptics (suicidality)

Washington State passed a law requiring DSHS to establish a Washington State passed a law requiring DSHS to establish a monitoring system for psychotropic agents in youth (House Bill monitoring system for psychotropic agents in youth (House Bill 1088)1088)

Stimulant MedicationsStimulant Medications

Short Term Effectiveness of Stimulants for ADHD Short Term Effectiveness of Stimulants for ADHD well documentedwell documented> 160 published RCT, including studies with preschoolers > 160 published RCT, including studies with preschoolers

and adultsand adults– 65 – 75 % response rate, compared to 5 – 30 % placebo 65 – 75 % response rate, compared to 5 – 30 % placebo

responseresponse– Most Trials 12 weeks or lessMost Trials 12 weeks or less– Methylphenidate best studied, followed by Methylphenidate best studied, followed by

dextroamphetamine, pemoline and mixed amphetamine dextroamphetamine, pemoline and mixed amphetamine salts (Concerta, Adderall, Metadate, etc)salts (Concerta, Adderall, Metadate, etc)

– FDA approved for ADHD FDA approved for ADHD (age 6 for MPH, age 3 for DEX) (age 6 for MPH, age 3 for DEX) … … now FDA “Black Box” warning for amphetamine salts: now FDA “Black Box” warning for amphetamine salts:

cardiotoxicitycardiotoxicity

Selective Serotonin Re-Uptake InhibitorsSelective Serotonin Re-Uptake Inhibitors

Sampling of the data…Sampling of the data…

FluoxetineFluoxetine– Emslie et al., 1997: Fluoxetine (n = 96)Emslie et al., 1997: Fluoxetine (n = 96)

Moderate to severe depression,Moderate to severe depression, 58% vs 33% placebo response. 58% vs 33% placebo response.

– Emslie et al., 2002: Fluoxetine (n = 219), Emslie et al., 2002: Fluoxetine (n = 219), Significant improvement, but 53% placebo response rateSignificant improvement, but 53% placebo response rate

– Simeon et al., 1990. Fluoxetine (n = 40 adolescents)Simeon et al., 1990. Fluoxetine (n = 40 adolescents) No difference, both groups had ~ 66% response rateNo difference, both groups had ~ 66% response rate

Fluoxetine FDA approved for Depression in Youth (the only Fluoxetine FDA approved for Depression in Youth (the only medication approved for depression in kids)medication approved for depression in kids)

Selective Serotonin Re-Uptake Inhibitors:Selective Serotonin Re-Uptake Inhibitors:other indicationsother indications

OCD/Anxiety:OCD/Anxiety:

–4 Positive RCT’s, including two multisite trials4 Positive RCT’s, including two multisite trials

–Fluvoxamine, Sertraline and Fluoxetine studiedFluvoxamine, Sertraline and Fluoxetine studied

All three agents: FDA approved for OCD in youthAll three agents: FDA approved for OCD in youth

Tricyclic AntidepressantsTricyclic AntidepressantsImipramine, Amitriptyline, Nortriptyline, Clomipramine, DesipramineImipramine, Amitriptyline, Nortriptyline, Clomipramine, Desipramine

the old guard….the old guard….

DepressionDepression: 13 studies, > 300 subjects: none were superior to : 13 studies, > 300 subjects: none were superior to placebo (50 – 60 % placebo response rates)placebo (50 – 60 % placebo response rates)

ADHDADHD: several positive RCT’s, although not as effective as : several positive RCT’s, although not as effective as stimulantsstimulants

Enuresis:Enuresis: several positive RCT’s for Imipramine several positive RCT’s for Imipramine

OCDOCD: 3 positive RCT’s for Clomipramine, 1 RCT found : 3 positive RCT’s for Clomipramine, 1 RCT found Clomipramine helpful for repetitive behaviors in autismClomipramine helpful for repetitive behaviors in autism

Best Indications: Impramine for enuresis, Clomipramine for OCD. Best Indications: Impramine for enuresis, Clomipramine for OCD. Not indicated for Depression/AnxietyNot indicated for Depression/Anxiety

Atypical AntipsychoticsAtypical Antipsychotics

FDA indications for PediatricsFDA indications for Pediatrics

RisperidoneRisperidone Irritability for children and adolescents with AutismIrritability for children and adolescents with Autism Adolescents with SchizophreniaAdolescents with Schizophrenia Adolescents with Bipolar DisorderAdolescents with Bipolar Disorder

AripiprazoleAripiprazole Adolescents with SchizophreniaAdolescents with Schizophrenia Adolescents with Bipolar DisorderAdolescents with Bipolar Disorder

Cognitive-Behavioral TherapyCognitive-Behavioral Therapy DepressionDepression

– At least 10 Positive RCTs for Depression in Children and AdolescentsAt least 10 Positive RCTs for Depression in Children and Adolescents Comparison arms included wait list controls and nondirective Comparison arms included wait list controls and nondirective

supportive psychotherapysupportive psychotherapy AnxietyAnxiety

– Individual and Family CBT approaches found useful for Separation Individual and Family CBT approaches found useful for Separation Anxiety and Generalized Anxiety DisordersAnxiety and Generalized Anxiety Disorders

– Behavioral Strategies useful for PhobiasBehavioral Strategies useful for Phobias

OCDOCD– some positive trials in kids, well established efficacy in adultssome positive trials in kids, well established efficacy in adults– more robust support for more robust support for “combination therapies”“combination therapies”

PTSDPTSD– Positive Trials, includes youth exposed to maltreatmentPositive Trials, includes youth exposed to maltreatment– ““Trauma-focused CBT” – strong momentum as Evidence-based Trauma-focused CBT” – strong momentum as Evidence-based

Treatment (EBT) for children..Treatment (EBT) for children..must customize… must customize…

Other Behavioral StrategiesOther Behavioral Strategies Conduct/Disruptive Behavioral Disorders …Conduct/Disruptive Behavioral Disorders …

Problem-Solving TrainingProblem-Solving Training Anger ManagementAnger Management Assertiveness TrainingAssertiveness Training

ADHD – specific interventionsADHD – specific interventions– Inconsistent Findings with strategies designed to improve self Inconsistent Findings with strategies designed to improve self

controlcontrol– Not much data on “neurofeedback” (fun to think about though)…Not much data on “neurofeedback” (fun to think about though)…– Contingency Management and Behavioral Interventions helpfulContingency Management and Behavioral Interventions helpful

Generally not as effective as stimulants. Generally not as effective as stimulants. Time Consuming, difficulty with complianceTime Consuming, difficulty with compliance Don’t always generalize to other settings or beyond the Don’t always generalize to other settings or beyond the

treatmenttreatment

Parenting Training ProgramsParenting Training Programs

Oppositional/Conduct DisorderOppositional/Conduct Disorder

Interventions Designed to enhance parenting effectiveness, decrease Interventions Designed to enhance parenting effectiveness, decrease coercion and improve parent-child interactions, includingcoercion and improve parent-child interactions, including

– Behavioral Family Intervention (Patterson 1974)Behavioral Family Intervention (Patterson 1974)– Videotaped Modeling Parent Training (Webster-Stratton 1994)Videotaped Modeling Parent Training (Webster-Stratton 1994)

Parenting Interventions and Family Therapy also helpful forParenting Interventions and Family Therapy also helpful for– Anxiety DisordersAnxiety Disorders– Eating DisordersEating Disorders– Early childhood parent-child challenges…Early childhood parent-child challenges…

Go see PCIT (Go see PCIT (Parent Child Interactive Therapy) Parent Child Interactive Therapy) if you can…if you can…

Multisystemic TherapyMultisystemic Therapy Aggressive case management, Comprehensive Psychiatric Aggressive case management, Comprehensive Psychiatric

services and Targeted Family Interventions used to maintain services and Targeted Family Interventions used to maintain youth in their homes and community systemsyouth in their homes and community systems

MST has better outcomes (including reduced substance abuse) MST has better outcomes (including reduced substance abuse) and more cost-effective thanand more cost-effective than– HospitalizationHospitalization– IncarcerationIncarceration

However, effects may dissipate over 12 - 16 months (Henggeler However, effects may dissipate over 12 - 16 months (Henggeler et al., 2003)et al., 2003)

Psychotherapy In Children and Adolescents: Psychotherapy In Children and Adolescents: SummarySummary

Best Evidence forBest Evidence for– CBT for Depression, Anxiety, PTSDCBT for Depression, Anxiety, PTSD– CBT/Behavioral Strategies for Conduct ProblemsCBT/Behavioral Strategies for Conduct Problems– Parent Training for preschool challenges and Conduct Parent Training for preschool challenges and Conduct

ProblemsProblems– MST for Conduct ProblemsMST for Conduct Problems

Despite the availability of these InterventionsDespite the availability of these Interventions– Most Clinicians Not Trained to Use ThemMost Clinicians Not Trained to Use Them– Most Psychotherapy done in Community Settings is Most Psychotherapy done in Community Settings is

supportive in nature, and may not be effectivesupportive in nature, and may not be effective

04/19/2304/19/23 5656

Questions after lecture?Questions after lecture?

Please e-mail ([email protected]) or call Please e-mail ([email protected]) or call (01 467 1717)(01 467 1717)

Interested in learning more about child and Interested in learning more about child and adolescent psychiatry?adolescent psychiatry?– Arrange to attend OPD Arrange to attend OPD – Consider an elective rotation during internship Consider an elective rotation during internship

or otherwiseor otherwise