All You Wanted to Know About Medications But Were Afraid to Ask

1. All You Wanted to Know About Medications But Were Afraid to Ask Medications and Potential Side Effects Relevant to the Classroom Nancy Rappaport, MD Harvard Medical School

3. Presentation Goals • To review processes of diagnosis and formulation about kids that may need medication • Relevant information about medications

4. Symptoms of ADHD • Inattentiveness • Distractibility • Impulsivity *Often hyperactivity is considered inappropriate for developmental age children; however, ADHD manifests itself in different ways.

5. ADHD: Core Symptom Areas • Inattention • Impulsivity/Hyperactivity

6. ADHD: Core Symptom Areas • Negative impact on multiple areas of functioning • Social and academic deficits • Patterns of comorbid disorders

7. The Human Brain

8. Genetic Origins CNS insults Fetal alcohol syndrome Drug exposure Serious head injury Infection Prematurity Environmental Factors E.g., Lead poisoning Twin Studies ADHD Studies ADHD

9. Is there a simple test to diagnose ADHD?

10. No “Gold Standard”

11. “How come my son can be so focused when he is playing video games or building a model?” • Observation captures variability • Inefficient performance not an incapacity (lazy)

12. “When children or adults are distracted they are paying attention to something else. Whether it is soap falling into the bathtub, an apple falling from a tree, or the peculiar way an insect walks across the floor, small attractions may lead to bigger ideas. Being distracted, in other words, means otherwise attracted.” Ellen J. Langer, The Power of Mindful Learning

13. How many children and adolescents have ADHD? • Depends who you ask. • Anywhere from 2-12% of children and adolescents, 4.7% of adults, endorsed childhood and current symptoms of ADHD • On average, at least one child in every classroom

14. Is ADHD a “guy thing?”

15. Problems Communicating • Language impairment in a substantial proportion of community and clinical studies of school-age children with ADHD (20-60% in a clinical study)

16. Expressive language impaired - word retrieval problems using nonspecific words • Pragmatics - difficulties in the appropriate timing (too much talk with transitions and play settings) • Decreased ability to express when planning or organization (story-telling, group directions)

17. ADHD and reading disorder (15-30% of ADHD students • More likely with inattention and naming difficulty

18. Game Plan of Evaluation • Core symptoms • Chronicity • Pervasiveness • Impairment and differential diagnosis

20. Treatment • Psychoeducation • What ADHD is and is not • “A challenge, not an excuse.”

21. *School interventions*Medications

22. NIMH MTA Study • Medication treatment alone • Medication management and behavioral treatment • Children did better with ADHD symptoms as long as the medication was taken

23. Stimulant Treatment of ADHD • Ritalin • Dextroamphetamine • Amphetamine mixed salts

24. What Medications Will Improve • Academic performance • Short-term memory • Reaction time • Cognitive impulsivity • On-task behavior • Hyperactivity

25. What Medications Won’t Improve • Mood • Anxiety • Temper • Specific learning disorder (no data on speed, accuracy, or reading comprehension)

26. Management of Common Stimulant-Induced Adverse Effects • Anorexia, nausea, weight loss • Insomnia, nightmares • Rebound phenomena • Irritability • Dysphoria, moodiness, agitation

27. Other Medications • Strattera (stomache ache) • Wellbutrin (antidepressant) - takes up to four weeks to get a response • Clonidine - reduces motor activity and impulsiveness (sedation side effect)

28. Mood Disorders

29. Case Histories

30. Disturbing Statistics Fig 1: Developmental and temporal trends in rates of adolescent suicide. Data from Maguire & Pastore (1999).

31. Statistics (ctd.) Fig 1.2: Developmental trends since 1950 in suicide rates for 15-19 yr old adolescents, by gender. Maguire & Pastore (1999).

32. For young people 15-24 yrs old, suicide is the third leading cause of death, behind accidental injury and homicide – 2,000 adolescents 15-19 commit suicide each year • Persons under age 25 accounted for 15% of all suicides in 1997 • Within schools this statistic translates to (in a district of 8,000 students) one suicide a year

33. Firearms are the most common method for completed suicides, followed by ingestions leading to overdose, and hanging • 65% of completed suicides use handguns. The increase in the rates of youth suicide (and the number of deaths by suicide) over the past four decades is largely related to the use of firearms as a method of destruction • Substance abuse/dependence is the probable reason that adolescence attempts are more lethal

34. There are 400 suicide attempts by teenage boys for every completed suicide in males • Four thousand suicide attempts per every death in females • Who uses the most effective method – Girls or Boys?

35. The Center for Disease Control (CDC) has tracked by school survey since 1991 every two years 12,000 to 16,000 students. • Approximately 20% of students have had suicidal ideation; 10% have made a suicide attempt in a 12-month period; 1-3% of teenagers will receive medical attention for an attempt • .01% will be successful • Ideation is almost always episodic

36. Profile of Children with Completed Suicides • Immature problem solving that translates into more impulsive behavior • Less able to tolerate frustration (adult data shows decreased serotonin) • Unable to plan future actions • Aggressive or violent outbursts • Difficulty making decisions • Less able to assess situations realistically than non-suicidal children

37. Loss of parent before the age of 12 • History of parental abuse

38. Early onset of suicidal behavior (prepubertal) predicts suicidal behavior in adolescents

39. Although suicides are rare in children age 12 and under, suicide attempts are NOT rare in bipolar children age 12 and under (20%)

40. Usually these children are difficult to treat and there is considerable controversy about the criteria as they are referred to as “rapid cyclers and often have mood lability, mood swings, affective storms, irritability and aggressiveness, periodic agitation, explosiveness and severe temper tantrums which can also be in response to trauma and family discord,” (Papolos 1999).

41. Psychological Autopsies • Shaffer studied large numbers of completed suicides at an average age of 16 (170 psychological suicide autopsies) in an ethnically diverse population in 1984-86 interviewing multiple informants with community control subjects.

42. More than 90% of subjects who committed suicide met criteria for at least one major psychiatric diagnosis • Half of these subjects had psychiatric disorder for at least two years • Link between psychopathology and suicide

43. Organized plan, intent, preparation • One in four adolescents that completed suicides show evidence of planning • According to Shaffer the time-honored clinical inquiry about planning is a poor measure of serious intent

44. Important Implications • Need for thorough diagnostic interview • Never discount a threat especially in the context of affective or substance abuse disorders • Importance of aggressive intervention in first-episode affective illness

45. The most common diagnostic groups were mood disorders (52% major depression), disruptive disorders and substance abuse • A child with a mood disorder is four to five times more likely to attempt suicide than a child without a mood disorder

46. Completer Profile • Evenly distributed by the SES, evenly distributed by educated vs. uneducated, Western states highest, 60% of firearms • 50% of completers were never in therapy • 75% of completers communicated thoughts about their suicide aloud to several people months before dying (“natural screeners”)

47. Strategies for Suicide Prevention • Suicide awareness programs • Screening • First step of recognition

48. Adapted from Shaffer & Greenberg, 2002 ACTIVE DISORDER e.g., Mood disorder, substance abuse, anxiety #1 FIND & TREAT #2 STRESS AVOIDANCE/ TOLERANCE STRESS EVENT e.g., In trouble with law/school; loss; humiliation SUICIDAL IDEATION #3 CRISIS SERVICES 2 FACILITATION UNDERLYING TRAIT Impulsive, intense, serotonin abnormality #4 MEDIA GUIDELINES & POSTVENTION ACUTE MOOD CHANGE e.g., Anxiety-dread, hopelessness, anger Strong taboo; vailable support; presence of others; difficult to access method SOCIAL Recent example, weak taboo, isolation INHIBITION 1 #5 METHOD CONTROL i.e. SOCIAL MENTAL STATE Slowed down MENTAL STATE Agitation Method Availability/ Familiarity SURVIVAL SUICIDE

49. Types of Depression • Major Depression Usually begins in the late teens, but has been diagnosed in children as young as four • Dysthymia Chronic, mild depression. Starts in childhood and can last decades • Bipolar disorder Older teens cycle between mania and depression. Younger teens can experience both symptoms at once • Clinical vignettes

50. SIGECAPS Sleep - too little or too much lose Interest or pleasure feelings of Guilt or worthlessness decreased Energy decreased Concentration change in Appetite Psychomotor agitation or retardation Suicidal ideation