Child Psychiatry: Clinical Challenges

1. Mick Storck, MD storck@uw.edu (206)469-6282 University of Washington Child Psychiatry: Clinical Challenges “you suffer captivity…but you will have contributed a word to the poem…” Inferno 1, 32 Jorge Luis Borges

2. Objectives This slide set is “over-inclusive”…this is a big topic…and has, historically, been allotted two hours in the clerkship. My goal is that these slides are semi-academic and semi-intriguing… and that you stay forever young. Mick Lecture goals: • Discuss problem/risk prevalence • Discuss explanatory and intervention challenges in child mental health • Review research status of interventions • …Augmenting the Andreason/Black textbook chapter on Child Psychiatry

4. Peds Psych …OLD Diagnostic Categories (DSM-IV) • Autistic Spectrum Disorders • Autism, Asperger’s Disorder, Pervasive Developmental Disorder • Learning Disorders • Reading Disorder, Mathematics Disorder, Disorder of Written Expression • Disruptive Behavior and Attentional Disorders • ADHD • Oppositional Defiant Disorder, Conduct disorder • Mood and Anxiety Disorders • Major depression, Dysthymic Disorder, Bipolar Disorder • Post Traumatic Stress Disorder, Obsessive Compulsive Disorder • Generalized Anxiety Disorder, Panic Disorder, Social Anxiety, Specific Phobias • Somatoform Disorders • Conversion Disorder, Pain Disorder, Body Dysmorphic Disorder, Somatoform Disorder • Eating disorders • Anorexia Nervosa, Bulimia Nervosa, Eating Disorder Not Otherwise Specified • Thought Disorders • Schizophrenia, Schizophreniform Disorder, Psychotic Disorder • Substance Use Disorders • Abuse, Dependence, Intoxication, Withdrawal

5. Peds Psych NEW Diagnostic Categories (DSM-V) • Neurodevelopmental Disorders • Intellectual Disabilities • Autistic Spectrum Disorder • Learning disorders • Attention-Deficit/Hyperactivity Disorder (removed from “disruptive” disorders) • Schizophrenia Spectrum and Other Psychotic Disorders • Schizophrenia, Brief Psychotic, Schizotypal Disorder, Psychotic Disorder due to medical conditions • Bipolar and Related disorders, Depressive disorders • Anxiety Disorders Generalized Anxiety, Panic Disorder, Social Anxiety, Specific Phobias • Obsessive Compulsive Disorder • Trauma- and Stressor-Related Disorders (now a separate category from anxiety disorders) • Somatic Symptom and Related Disorders • Illness Anxiety Disorder, Conversion Disorder • Feeding and Eating Disorders • Anorexia Nervosa, Bulimia Nervosa, Avoidant/Restrictive Food Intake • Disruptive, Impulse Control, and Conduct Disorders • Oppositional Defiant Disorder, Intermittent Explosive Disorder, Conduct disorder • Substance Related and Addictive Disorders • “Other Conditions That May Be a Focus of Clinical Attention”… • Abuse, neglect, parent child problems, partner violence, educational, housing, discord with a lodger, personal history of …, wandering associated with a mental disorder… Other DSMV categories…that areNot so central for kids: sleep-wake, sexual dysfunctions, dissociatiive, neurocognitive, personality, paraphilic disorders

6. Symptom Clusters,Diagnoses & Treatment Probes • Thoughts & Thought Organization • YOUTH • Attention & Impulse Regulation • Mood & Mood Regulation • Acting Out • & • Social Relating

7. Childhood differences (from adult dx)… Symptoms & Frequent Comorbidities (using pediatric depression as an example) • Pediatric Depression • Irritability: often 1º symptom • Temper tantrums • Mood lability • Low frustration tolerance • Somatic complaints • Guilt • Low self-esteem • Suicidal ideation (60%) • Suicide attempts (30%) • Oppositional • Social isolation • Additional Symptoms • 40% - 70% with Comorbid Diagnosis • Anxiety disorders: 20% - 40% • Substance misuse: 20% - 30% • Disruptive behavior and neruodevelopmental disorder (incl. Conduct disorder /ADHD/learning disorders): 10% - 80% • Natural History: • Median episode: 1 – 8mo • Recurrence: 20% - 60% • Bipolar Disorder: 20% - 40%

8. Nonspecific Symptoms (example of continua and overlap between sx…) Mania • Irritability • Increased Energy • Pressured Speech • Reckless Behavior • Grandiosity • Distractibility • Decreased Sleep ADHD • Grumpy • Hyperactive • Talking Fast • Reckless Behavior • Bragging • Distractibility • Restless Sleeper

9. Undercurrents: Historical Trauma(as an example of an ecologic variable… and the importance in medicine of grasping the generational nature of patient’s narrative) • Collective and cumulative emotional wounding across generations that results from cataclysmic events targeting a community • The trauma is held personally and collectively and is transmitted over generations • Distress generated from historical trauma is often unrecognized, misunderstood, ignored, marginalized, or invalidated Brave Heart (1995); Yellow Horse Brave Heart (2000)

10. Child Psychiatry: 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

11. The Youth Risk Behavior Surveillance System (YRBS): • National probability sample of public and private schools • Total sample size = 16,410 • School-level response rate = 81% • Student-level response rate = 88% • Overall response rate = 71% • National survey every two years Some of “what kids are up to…” www.cdc.gov/yrbs/ (look this up for great national data on youth…)

12. Priority Health-Risk Behaviors and Outcomes Monitored by YRBSS • Behaviors that contribute to the leading causes of mortality and morbidity • Unintentional injuries and violence • Tobacco use • Alcohol and other drug use • Sexual behaviors • Unhealthy dietary behaviors • Inadequate physical activity • Obesity • Asthma

15. Percentage of High School Students Who Watched 3 or More Hours/Day of Television,* 1999 – 2009† * On an average school day. † Decreased 1999–2009, p < 0.05. National Youth Risk Behavior Surveys, 1999–2009

16. Percentage of High School Students Who Exercised to Lose Weight or to Keep from Gaining Weight,* 1995 – 2009† * During the 30 days before the survey. † Increased rapidly 1995–2001, increased less rapidly 2001-2009, p < 0.05. National Youth Risk Behavior Surveys, 1995–2009

17. Percentage of High School Students Who Used an Indoor Tanning Device,* by Sex† and Race/Ethnicity,‡ 2009 * Such as a sunlamp, sunbed, or tanning booth one or more times during the 12 months before the survey. Not including a spray-on tan. † F > M ‡W > H > B National Youth Risk Behavior Survey, 2009

18. Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* 1991 – 2009† * Among students who had sexual intercourse with at least one person during the 3 months before the survey. † Increased 1991–2003, no change 2003–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/

19. Juvenile delinquency …. participation in illegal behavior by minors (juveniles) (individuals younger than the statutoryage of majority). …Between 60-80% percent of adolescents, and pre-adolescents engage in some form of juvenile offense.[2] These can range from status offenses (such as underage smoking), to property crimes and violent crimes. …Better or worse than “conduct disorder”? (adult delinquency?…cutting and pasting from Wikipedia)

20. Percentage of High School Students Who Texted or E-mailed While Driving a Car or Other Vehicle,* by Sex† and Race/Ethnicity,§ 2011 * On at least 1 day during the 30 days before the survey. † M > F § W > H > B National Youth Risk Behavior Survey, 2011

21. Percentage of High School Students Who Carried a Weapon on School Property,* 1993 – 2011† * For example, a gun, knife, or club on at least 1 day during the 30 days before the survey. † Decreased 1993–2003, no change 2003–2011, p < 0.05 National Youth Risk Behavior Surveys, 1993–2011

22. Percentage of High School Students Who Reported Binge Drinking,* 1991 – 2009† * Had five or more drinks of alcohol in a row within a couple of hours on at least 1 day during the 30 days before the survey. † No change 1991–1997, decreased 1997–2009, p < 0.05 National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/

23. Percentage of High School Students Who Drank Alcohol for the First Time Before Age 13 Years,* 1991 – 2009† * Other than a few sips. † No change 1991–1999, decreased 1999–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/

24. Percentage of High School Students Who Ever Used Marijuana,* 1991 – 2009† * Used marijuana one or more times during their life. †Increased 1991–1999, decreased 1999–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/

25. Percentage of High School Students Who Ever Took Prescription Drugs Without a Doctor’s Prescription,* by Sex and Race/Ethnicity,† 2009 * Took prescription drugs (e.g., Oxycontin, Percocet, Vicodin, Adderall, Ritalin, or Xanax) without a doctor’s prescription one or more times during their life. † W > H > B National Youth Risk Behavior Survey, 2009 www.cdc.gov/yrbs/

26. Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* 1991 – 2009† * Among students who had sexual intercourse with at least one person during the 3 months before the survey. † Increased 1991–2003, no change 2003–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/

27. Youth Risk Behavior Survey questions about mood… “The next 5 questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life. “ 24. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? 25. During the past 12 months, did you ever seriously consider attempting suicide? 26. During the past 12 months, did you make a plan about how you would attempt suicide? 27. During the past 12 months, how many times did you actually attempt suicide? A. 0 times B. 1 time C. 2 or 3 times D. 4 or 5 times E. 6 or more times 28. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse? www.cdc.gov/yrbs/

28. Percentage of High School Students Who Felt Sad or Hopeless,* 1999 – 2009† * Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities during the 12 months before the survey. † No change 1999–2007, decreased 2007-2009, p < 0.05 National Youth Risk Behavior Surveys, 1999–2009 www.cdc.gov/yrbs/

29. Percentage of High School Students Who Made a Plan About How They Would Attempt Suicide,* 1991 – 2009† * During the 12 months before the survey. †Decreased 1991–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/

30. Percentage of High School Students Who Attempted Suicide,* 1991 – 2009† * One or more times during the 12 months before the survey. †No change 1991–2001, decreased 1991–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/

31. SUICIDE… • 1. 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 • 4. Suicide attempts: YRBS says 6% per year…wow! • a. Attempts are much more common in females • b. Suicides are much more often completed in males • 5. What do you say to a teen or any patient who reports suicidal feelings? • (next slide) • 6. What are some major worries/ “red flags”? 7. Suicide attempts: 3 days (avg. period of contemplation for elders) 1 day (avg. period of contemplation for a young adult) Hours… (avg period of contemplation for a teen…especially males)

32. at the moment of despair/hopelessness…(appreciate the near universality of at least transient wishes to “give up”) After the “first rules of first aid” are followed : (approaching “the scene” safely, surveying the “ABCs”-attending to acute medical risks – e.g. lethality variables, imminent threats etc) Remember that providing health care is about fostering a renewed sense of hope and efficacy) -ask kids (and any of our patients) questions like…: -where did they think they would go? -did they imagine starting over? -Who did they think about? Were they among the living? An elder? A compadre? -What kind of appeal to a “higher power” did they make? -?What kind of appeal did the “higher power” make to them? -Did anyone notice? -At what point did they think they’d “turned the corner” (in either direction) and decided to try to live/die? -What tools came into view? The buddy system: Who will you turn to? Who turns to you? This list is certainly not meant to be a script or the only ways to approach this…we just want our patients to have the chance to not feel so alone or that the health care world isn’t strong and safe enough to give them a place to reflect.

34. Suicide Rate, 15-24 year-olds 29% decline Total Firearm SuffocationPoison Other From 1994-2003, the youth suicide rate dropped by about 29%, driven almost exclusively by a drop in firearm suicide. Suffocation (hanging) suicides increased, poisonings declined in the late ‘80s but were flat in the late 90s/early 2000s, and all other methods showed no change. Catherine Barber: Harvard Injury Control Research Center

35. PediatricPsychopharmacotherapy Evidence • Majority based on anecdotal reports and adult studies • Minimal literature examining combined therapies and polypharmacy • Limitations include small sample sizes, lack of controls, narrow diagnostic inclusion criteria and short duration of treatment • Most prescriptions for psychiatric indications in juveniles considered off-label (non-FDA approved) • NIH promoting large, cooperative, multisite trials to address these concerns

36. “Mind” influences Body It is more than just the pills “Body” Influences Mind Sleep hygiene Activities change cortisol & testosterone levels, etc Fresh air and romping around Diet Biofeedback –yoga,sports Thoughts about actions The phone call from grandma Songs Meal milieu Media images The meaning of the medication to The youth The parents The teachers The peers

37. FDA APPROVED- Peds psych meds • Attention-deficit Hyperactivity Disorder • All amphetamine and methylphenidate formulations (≥6yo) • Dexedrine IR (≥3yo) • Atomoxetine • Guanfacine ER • Clonidine ER • Aggression • Risperidone & Aripiprazole for aggression associated with autism • Major Depression • Fluoxetine (≥8yo) • Escitalopram (≥12yo) • Obsessive-Compulsive Disorder • Sertraline (≥6yo) • Fluoxetine (≥7yo) • Fluvoxamine (≥8yo) • Clomipramine (≥10yo) • Bipolar Disorder • Risperidone (≥10yo) • Aripiprazole (≥10yo) • Quetiapine (≥10yo) • Lithium (≥12yo) • Olanzapine (≥13yo) – acute treatment only • Schizophrenia • Risperidone (≥13yo) • Aripiprazole (≥13yo) • Quetiapine (≥13yo) • Olanzapine (≥13yo)

38. Regarding the Cary/Storck“Pediatric Psychopharm Charts”….( a separate attachment from the lecture handout) Dear Psychiaty Clerkship students, These slides are meant as, hopefully, an enjoyable quick reference for perusal for psychopharm agents that we use in child psychiatry… notthe level of detail that you are expected to know for the clerkship. I will include some slides from these charts during my presentation then try to hypontize you so that you don’t think that you should memorize them. Please Email me if you have questions… Mick

39. A kid drew this a few years ago, probably could reverse the labels lots of times…

40. Epidemiology • Dramatic increase in prescriptions over last 20 years ? Over-medication ? Over-diagnosis ? Enhanced appreciation • Since 2003, FDA has issued separate warnings regarding increased • Suicidal Ideation: • Antidepressants • Atomoxetine • Antiepileptics • Metabolic Disease • Atypical antipsychotics • Recent data has resulted in the removal of FDA warnings: • Potential for sudden death and cardiovascular problems with stimulants • AAP no longer recommends routine pre-treatment cardiograms • Washington State House Bill 1088 • DSHS required to monitor psychotropic use in youth

41. Stimulants • Short Term Effectiveness of Stimulants for ADHD well documented • Over 200 published Randomized Control Trials (RCT), including studies with preschoolers and adults • Methylphenidate best studied, followed by dextroamphetamine and mixed amphetamine salts • 65 – 75 % response rate, compared to 5 – 30 % placebo response • All stimulants equally effective • Except methylphenidate more effective if comorbid autism • FDA approval for ADHD • Age 6 for all, age 3 for DEX • FDA Black Box Warning for amphetamine salts due to cardiotoxicity  removed • Extended-release preparations • Transdermal methylphenidate • D-threo methylphenidate • Lisdexamfetamine • (Meth)amphetamine meanings?

42. α – Adrenergic Agents for “Autonomic Reactivity”-for kids who can’t “pull” their punches-hypervigilance-overarousal • α2 – Adrenergic Agonists: Several small RCTs show efficacy in ADHD Tx • Clonidine/Guanfacine • FDA recently approved long-acting guanfacine and clonidine for ADHD • (…why not the short-acting…which have been available for years and are much cheaper?... “marketing” not clinical issues…) • α1 – Adrenergic antagonist: primarily case report data… • Prazosin • PTSD nightmares

43. Uses for Selective Serotonin Re-Uptake Inhibitors in Youth • Depression • Dysthymia • Bipolar Depression • Generalized Anxiety • Separation Anxiety Disorder • Panic Disorder • Obsessive Compulsive Disorder • Post-Traumatic Stress Disorder • Autism Spectrum Disorders • Chronic Headaches or Pain

44. SSRIs for Depression • Response rates 40-70% and Placebo rates 30-60% • Fluoxetine: First studied, Most consistent positive results • Only FDA-approved medications for pediatric depression: • Fluoxetine ≥ 8yo • Escitalopram ≥ 12yo • FDA Black Box Warning: Increased suicidal ideation • Increased risk of suicidal ideation during the first few months of treatment • 4% for active medication vs 2% for placebo • No increase in suicide attempt • Debatable - ?increased suicide attempts concurrent with reduction in SSRI prescriptions • FDA monitoring recommendations: • All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

45. SSRIs for OCD • 4 Positive RCT’s, including two multisite trials • Fluvoxamine, Sertraline and Fluoxetine all found effective • All FDA-approved for Tx of pediatric OCD

46. Tricyclic Antidepressants Imipramine, Amitriptyline, Nortriptyline, Clomipramine, Desipramine the old guard….not used much now • Depression: 13 studies, > 300 subjects: none were superior to placebo (50 – 60 % placebo response rates) • ADHD: several positive RCT’s, although not as effective as stimulants • Enuresis: several positive RCT’s for Imipramine • OCD: 3 positive RCT’s for Clomipramine, 1 RCT found Clomipramine helpful for repetitive behaviors in autism • Best Indications: Impramine for enuresis, Clomipramine for OCD. • Not FDA approved for Depression/Anxiety – but still can be an option

47. Understanding The Trials Combination of pharmacotherapy and psychotherapy most effective treatment for both moderate to severe depression and OCD • Mild symptoms typically remit within 4-6wks with psychotherapy alone • High placebo response rates • Expect spontaneous remission when treating mild depression • “Placebo” is not equivalent to “no treatment” • Limited long-term data • Bias in pharmaceutical industry sponsored studies

48. Treatment of Pediatric Anxiety Walkup, et al. N Engl J Med. 2008 Dec 25; 359(26):2753-66. Example of growing data on “combined” therapies….

49. Treatment for Adolescents with Depression Study TADS team. Am J Psychiatry 2009; 166:1141-1149

50. Mood Stabilizers • Lithium • One RCT (Geller et al., 1998) found lithium improved bipolar mood symptoms and substance abuse • Two positive, one negative RCTs for Disruptive Behavior/Aggression • Large Open Label Trial (Kafantaris et al., 2003) (n = 100) had a 63% response rate in adolescents with Bipolar I Disorder • Open trials of combination lithium plus other mood stabilizers or antipsychotics support benefit (Kafantaris et al., 2001; Findling et al., 2003, Pavuluri et al., 2004) • NICHD funded Multisite COLT Trial underway for youth with Bipolar I Disorder (ages 7 – 17) • Lithium FDA approved for Bipolar (ages 12 years and older)