Attention
Deficit Hyperactivity Disorder
Symptoms must be present prior to age 7, last longer than 6 months, and impair functioning to receive the diagnosis. For children, this generally means difficulty achieving or maintaining appropriate behavior in school. Boys are often referred at an earlier age due to hyperactivity; Girls are often “silent sufferers” because they have less hyperactivity or impulsivity and go unrecognized. Must consider developmental levels in making the diagnosis (e.g., differentiating normal activity levels). It was once felt that all children outgrow ADHD by adolescence, however we now know that approximately 50% continue to evidence symptoms into adulthood.
¨ Difficulty sustaining attention
¨ Easily distracted
¨ Careless or sloppy schoolwork
¨ Difficulty following directions or multiple instructions
¨ Fails to finish work or follow through on chores
¨ Difficulty organizing tasks and activities
¨
Frequently loses things or is forgetful
¨ Fidgets or squirms
¨ Difficulty remaining in seat
¨ Runs about or climbs excessively
¨ Difficulty playing quietly
¨ Always “on the go”
¨ Talks excessively
Medications
Commonly Used To Treat Attention Deficit Hyperactivity Disorder
Short Acting Long Acting
Ritalin Ritalin
LA
Dexedrine Concerta
Cylert Dexedrine
Spansule
Focalin Adderall
XR
¨ Short acting forms begin working in 20 minutes and last 3 – 4 hours. Short acting forms are used when appetite and weight gain are an issue They have the added stigma of children having to leave class to take the medication, they have to be dosed multiple times a day, and symptoms of ADHD increase as medications are wearing off and prior to the next dose (e.g. kids are often under-medicated during the last class before lunch, cafeteria time, and last class of the day).
¨ Long acting forms begin working in 20 minutes and last throughout school and homework time/afterschool program (8 – 12 hours). They are gradually released over time and you avoid the peaks and lows. The downside is that kids will have a very poor appetite for the entire time that the medication is in their system.
Side Effects
¨ Appetite suppression
¨ Growth suppression
¨ Increased Blood Pressure
¨ Rebound irritability: occurs when the medication is wearing off. More likely to occur with short acting forms; Includes crying, irritability, personality changes, and clingy behavior.
¨ Tics: may be “unmasked” in children who are at risk.
¨ Headaches: usually only within the first week, responds to aspirin.
¨ Stomachache: if taken on an empty stomach.
¨ Cylert may cause fatal liver problems
Straterra
¨ Antidepressant class of medication
¨ Takes 4-6 weeks to gain maximum effectiveness
¨ Requires daily intake for effectiveness
¨ Reduced rate of appetite suppression and other side effects
¨ May improve mood
¨ An antidepressant rarely used to treat depression because of the side effects if used in higher doses. Also used to treat bedwetting. May also be used for sleep in lower doses.
¨ Treats attentional symptoms but not hyperactivity symptoms.
¨ Less effective than stimulants, but often used when stimulants are contraindicated (eg. tics, weight loss). Effectiveness develops over 3 – 4 weeks.
¨ Side Effects: Sedation, dry mouth, low blood pressure, blurred vision, constipation, cardiac problems.
¨ Commonly used in the treatment of anxiety and depression. Effective in 3 to 4 weeks.
¨ Works better on concentration and attention span than on hyperactivity. The sustained release formula appears more effective.
¨ Marketed under a different brand name (Zyban) for smoking cessation
¨ Appears helpful in mood changes in substance abusing children
¨ Side Effects: Generally well tolerated with few side effects (stomach upset); Increased risk of seizures in those who have a seizure disorder or an eating disorder.
Clonidine
¨ An anti-hypertensive medication commonly used for hyperactivity and aggression. It does not work well for attentional symptoms. Also available in a patch. Effect increases over time (weeks).
¨ Side Effects: May affect heart rate and rhythm along with blood pressure; Headaches, dizziness, dry mouth, constipation, fluid retention, and nervousness.
Major Depression
The average age of onset is in the mid-20’s, however the age has been decreasing over the past decade. The lifetime is 10-25% in females and 5-12% in males. Depression is twice as common in adolescent and adult females than males, however pre-pubertal rates are equal in boys and girls. Most episodes recover within a year but 60% of people who have experienced one episode of depression will have another episode in their lifetime. Depression affects health status with more people experiencing pain and physical illness. Up to 15% of individuals with severe depression successfully complete suicide. To receive the diagnosis 5 or more of the following symptoms must be present for at least 2 weeks, and symptoms must impair functioning.
Symptoms
¨ Depressed mood, nearly every day (mood can be irritable in children)
¨ Lack of interest in pleasurable activities
¨ Weight loss or appetite reduction/ weight gain or increased appetite
¨ Insomnia or hypersomnia
¨ Psychomotor agitation or retardation
¨ Fatigue or loss of energy
¨ Feelings of worthlessness or excessive guilt
¨ Difficulty concentrating
¨ Recurrent thoughts of death
Tricyclic Antidepressants (TCA’s)
¨ Increases Norepinephrine (NE) levels
¨
Nortyptylline, Amitryptylline, Imipramine,
Desipramine, Clomipramine, Sinequan, and Trazadone
¨ Effective in treating chronic pain syndromes and migraine headaches
¨ Rarely used in children for depression; often used for insomnia
¨ May require blood levels if used in higher doses. Can become toxic at higher levels and may cause death. Effective in 3 – 4 weeks.
¨ Side Effects: Sedation, dry mouth, orthostatic hypotension, blurred vision, constipation, cardiac problems.
Selective Serotonin Reuptake Inhibitors (SSRI’s)
¨
Prozac, Paxil, Zoloft, Celexa, Lexapro
¨ Safer, well-tolerated, requires no blood ministering, non-fatal in overdose
¨ Often used to treat anxiety related disorders (Panic Attacks, Phobias, Post-Traumatic Stress Disorder, Generalized Anxiety) in higher doses
¨ Effective in 4 –6 weeks
¨ Side Effects: Headaches, nausea, agitation, sexual dysfunction;
Flu-like symptoms if discontinued rapidly; Serotonergic crisis with increased temperature, blood pressure, and heart rate occurs when used in combination with similar agents, or may be dose related.
¨ Paxil recently received an FDA warning in
children
¨ Increases levels of Norepinephrine and Serotonin
¨ May take 3-4 weeks for effectiveness to develop
¨ Generally well tolerated with few side effects (similar to SSRI’s).
¨ Serzone: relatively new; Black Box Warning for liver abnormalities
¨ Effexor: may lead to increased blood pressure
¨ Remeron: Sedating, used for sleep a lot, available in a dissolving tab
¨
See above information under ADHD
MonoAmine Oxidase Inhibitors
¨ Parnate, Nardil, Marplan
¨ Increases levels of Norepinephrine, Serotonin, and Epinephrine
¨ May cause a fatal hypertensive crisis if used with other antidepressants and anxiolytics, or foods that contain tyramine
¨ Requires strict dietary requirements and therefore used only in treatment resistant depression
The lifetime prevalence of Bipolar Disorder is 0.4 to
1.6%. Average age of onset is 20. Disorder is equally common in men and women,
though the first episode is more likely to be depression in women and mania in men.
Individuals must have at least one episode of depression lasting at least 2
weeks and one episode of mania lasting at least a week to meet criteria. The
first manic episode may emerge as a result of antidepressant treatment.
Children often present as “rapid cyclers”. Approx. 95% of children with the
disorder have a pre-morbid history of ADHD. There is a high co-morbidity with
drugs and alcohol, and completed suicide occurs in 10-15% of cases. DSM-IV
includes types I and II; DSM V may include Types I-VI.
Manic Symptoms
¨
Inflated self-esteem or
grandiosity
¨
Decreased need for sleep
¨
Increase in
goal-directed activities
¨
Excessive talking with
rapid speech
¨
Racing thoughts or
flight of ideas
¨
Distractibility or poor
attention span
¨
Excessive involvement in
pleasurable activities (e.g. buying things, hypersexuality)
¨
Mood is often irritable
in children and behavior can be aggressive
¨ Engaging in high risk or dangerous activities
¨ Psychotic symptoms may be present
Dysthymia
¨
Chronic depressed mood
that lasts for 2 or more years (1 year in children), has at least two of the
symptoms in Major Depression but does not meet full criteria
¨
Prevalence rates of 6%;
occurs equally in both sexes
¨
Children evidence low
self-esteem, poor social skills, irritability, and pessimism
Cyclothymia
¨
Fluctuating mood with
hypomanic and depressive symptoms for a period of at least 2 years (1 year in
children)
¨
Prevalence rates of .4% to 1%; occurs equally in both sexes
¨
15 to 50% risk of
developing Bipolar Disorder
Intermittent Explosive Disorder
¨ Several discrete episodes of aggression that result in assault or destruction
¨ Aggressive acts are out of proportion to the precipitating stressor
Medications Commonly Used To
Treat Bipolar Disorder, Impulse Control Disorders and Aggression
Lithium
¨ A natural salt; mechanism of action unclear. May take 1 –3 weeks to become effective.
¨ Requires frequent blood monitoring of therapeutic levels (weekly, then every 3-6 months)
¨ Therapeutic levels are affected by salt and water intake, urinary output, and sweat. Important to monitor in children.
¨ Common Side Effects: nausea, diarrhea, weight gain, headache, fine hand tremor, acne, and skin rashes
¨ An anti-convulsant. May take 1-3 weeks to become effective.
¨ Requires monitoring of blood levels (weekly, then every 3-6 months)
¨ Side Effects: nausea, vomiting, weight gain, sedation, clumsiness, decrease in blood cells, liver damage, and polycystic ovarian disease
¨ An anti-convulsant. May take 1-3 weeks to become effective.
¨ Requires monitoring of blood levels (weekly, then every 3-6 months)
¨ Side Effects: sedation, dizziness, clumsiness, blurred or double vision, hair loss, nausea, and increased sensitivity to the sun. Serious side effects include liver and kidney damage, lung irritation, dramatic drops in blood cells, and severe skin rashes.
Trileptil
¨ An anti-convulsant; may take 1-3 weeks to achieve effectiveness
¨ Does not require monitoring of blood levels
¨ May cause dizziness, sedation, abdominal discomfort, fatigue, abnormal gait, and double vision
Topomax
¨ Does not require monitoring of blood levels
¨ May cause nausea, tremor, fatigue, dizziness, abnormal gait, sedation, psychomotor slowing
¨ Attractive to many patients due to gradual weight loss
¨ An anti-convulsant. May take 1-3 weeks to achieve effectiveness.
¨ Does not require blood levels
¨ Relatively new and side effects not well known
¨ May cause agitation
¨ An anti-convulsant; may take 1-3 weeks to achieve effectiveness.
¨ Relatively new; may cause agitation and rashes; other side effects not well known.
Keppra
¨ An anti-convulsant; may take 1-3 weeks to achieve effectiveness.
¨ Does not require monitoring of blood levels
¨ May cause tingling sensations, dizziness, sedation, and infection
Prevalence rates of 0.5-1.5%. with a slightly higher incidence in men. First degree relatives have a 10x greater risk of developing the illness. Age of onset is between the late teens and mid-30’s. Prognosis is poor, with a decline in functioning after each psychotic episode, shortened life span, 10% successfully complete suicide, and 60-70% never marry. Factors that improve prognosis include: good pre-morbid adjustment, acute onset, later age of onset, being female, mood disturbance, medication initiation soon after onset, medication compliance, brief duration of active phase symptoms, good inter-episode functioning, absence of brain abnormality, normal neurological functioning, family history of a mood disorder, and no family history of Schizophrenia. Symptoms must be present for at least 6 months (may include prodromal and residual phases) and impair functioning for diagnosis.
Symptoms
¨ Delusions (persecutory and referential are most common)
¨ Hallucinations (auditory most common)
¨ Disorganized Speech (loose associations, tangential, incoherent)
¨ Disorganized or catatonic behavior (childishness, poor hygiene or dress, oddities, rigidity, agitation)
¨ Negative Symptoms (flat affect, slow thought processes and speech, lack of initiation in activities)
Helpful in a variety of psychiatric illnesses to target symptoms of psychosis, aggression, agitation/low frustration tolerance, thought disorganization, impulsivity, and sleep disturbance.
Older
Neuroleptics
¨ Low Potency: Thorazine and Mellaril may cause orthostatic hypotension, urinary retention, blurred vision, sedation, and constipation.
¨ Mid Potency: Stelazine, Trilafon, and Navane may cause a mixture of side effects from high and low potency medications, usually they are less severe
¨ High Potency: Haldol and Prolixin may cause EPS symptoms: shuffling gait, stiffness in the neck, tongue, and limbs, rigidity, difficulty eating or swallowing; flat affect, dry mouth, sedation, restlessness, and a decrease in the seizure threshold
¨ Benadryl, Cogentin, or Artane are often used in conjunction with these medications to prevent side effects
¨
Zyprexa, Risperidol, Seroquel, Geodon, and Abilify
¨ Much safer and fewer side effects than older neuroleptics.
¨ May cause weight gain, breast enlargement, breast “discharge”, and decrease the seizure threshold. Risperidol has been shown to cause EPS symptoms at higher doses.
Obsessive-Compulsive
Disorder (OCD)
Prevalence rates of 1 to 2.3% in children. Childhood onset occurs more frequently and earlier in males (age 6-15) than females (age 20-29). There is a high association with Learning Disorders, Disruptive Behavior Disorders, and body concerns in children. A subset of children develop acute pre-pubertal symptoms associated with Streptococcal infections. 20-30% have a current or past history of tics. Children must engage in the symptoms for greater than one hour a day, and are not required to experience symptoms as ego-dystonic (as in adults). Symptoms are more likely to present themselves at home than in public. The course is “waxing and waning”, with symptoms remitting and changing over time.
Obsessions
¨ Recurrent, intrusive thoughts, images or impulses that are not merely everyday worries or concerns
¨ Person attempts to ignore or suppress the thoughts (ego-dystonic)
¨ Person recognizes the thoughts as a product of their own mind (not always true in children)
¨ Most common obsessions are about contamination, repeated doubts, need to have things in order, aggressive or horrific impulses, and sexual imagery
Compulsions
¨ Repetitive behaviors or mental acts
¨ Behaviors are aimed at reducing distressing or to avoid a dreaded event or situation
¨ Most common compulsions involve washing and cleaning, counting, checking, requesting or demanding reassurances, repeating actions, and ordering
Medications Commonly Used To
Treat Obsessive-Compulsive Disorder (OCD)
¨ Serotonergic agent, well tolerated, with few side effects.
¨ Marketed specifically for OCD, main effects in 4-6 weeks.
¨ See above section under TCA’s.
¨
Rarely used now that other med’s are available due to
side effects.
¨ Usually require higher doses (see above section under depression)
Generalized Anxiety Disorder
Formerly referred to as Overanxious Disorder of Childhood. Prevalence rate of 5%. More common in women. Children tend to be shy and inhibited, perfectionistic and overly conforming, to worry about their performance in school and sports, have excessive concerns about punctuation and often redo tasks, and seek constant reassurance. The course is generally fluctuating, worsening during periods of stress. To receive the diagnosis a person must have excessive anxiety and worry for 6 months, find it difficult to control the worry, and have at least 3 of the following associated symptoms.
Symptoms
¨ Restlessness or feeling “keyed up”
¨ Easily fatigued
¨ Difficulty concentrating or mind going blank
¨ Irritability
¨ Muscle tension
¨ Sleep
disturbance
Social Anxiety Disorder
Lifetime prevalence rates of 3-13%. SAD accounts for 10-20% of all anxiety disorders and is more common in women than men. The avoidance, anxious anticipation, or distress must impair functioning and last for at least 6 months.
¨ Marked and persistent fear of one or more social or performance situations
¨ Person fears humiliation or embarrassment
¨ Must include fear of age-appropriate relationships in children
¨ Exposure to the situation causes increased anxiety or panic symptoms (may include crying, tantrums, or “freezing”
¨ Person recognizes the fear as unreasonable (not necessary in children)
¨ Feared situations are avoided
Associated Symptoms of SAD in Children
¨ Fear of rejection and hypersensitivity to criticism
¨ Difficulty being assertive
¨ Low self esteem and feelings of inferiority
¨ Poor social skills
¨ Decline in academic performance or school refusal
¨ Avoidance of age appropriate social activities
¨ Crying, tantrums, freezing, clinging to familiar people
¨ May lead to mutism since children are often unable to avoid feared situations