Mental Illness in the Young Child

1. Cathy Robey-Williams RN PhD c Administrative Director Clinical Operations Aiken Regional Medical Center Mental Illness in the Young Child

2. Objectives • Provide an overview of the key mental illnesses identified in preschool children • Summarize the behaviors identified in making a DSM-4 diagnosis • Review the current evidence-based treatments available for preschool disorders • Provide an overview of the medications used for treatment • Review the side effects to be aware of when caring for children receiving psychotropic medications.

3. Incidence of Mental Illness in Children • Prevalence of mental illness is estimated between 14% and 26.4% of children (Postert et al. 2009). • 80% of foster care children assessed by clinician had at least 1 psychiatric diagnosis (Zima et al. 2000) • 1 in 5 children in community samples of pediatrician offices met criteria for mental illness (Postert et al. 2009).

4. Difficulty in Diagnosis • DSM-4 based on adult criteria • Child research on age 0-3 shows differences in symptoms • Tremendous variation in children and symptoms: • Neurodevelopmental maturation • Environmental circumstances • Wide variation on normal behaviors

5. Escalating use of Medications • Most common medications used for preschoolers • Methlphenidate • Dextroamphetamine • Clonidine • Antidepressants • Antipsychotics • Risk factors associated with children requiring medications • 77% have home instability • 71% parents with emotional problems • 31% removed from their home • 29% experienced abuse

6. Considering Psychotropics for Preschoolers • Reasons to Avoid • Parent training interventions best intervention • Limited research in children and especially this young age • Information on impact of meds on developing brain is limited • Side effects more likely in this age • Long term side effects unknown • Reasons to consider • Serious mental illness does exist in this age group • Parent training may not be possible • Risk of not treating child may outweigh risks of meds • Physical harm to child or others • Disruption of family or foster placement • Potential for abuse of child due to behavior and parent reaction • Stimulants well studied and safe in school age children

7. Disorders Identified in Preschoolers

8. Acute Stress Disorder • Exposure to traumatic event • Experienced, witnessed, or confronted with event or events that involved actual or threatened death or serious injury, or threat to physical integrity of self or others • Response to traumatic event involved intense fear, helplessness, or horror • During or after experience had 3/5 dissociative symptoms • Numbness, detachment, absence of emotional responsiveness • Reduced awareness of surroundings • Derealization • Depersonalization • Dissociative amnesia • Symptoms last minimum 2 days and max 4 weeks occur within 4 weeks of the event • PTSD diagnosis if symptoms persist > 3 months

9. ADHD • History of difficult and uneven development from infancy • Inability to sit still, excessively active runs or climbs nearly all the time. • Acts before thinking, impulsive • Socially aggressive calls out in class, difficulty waiting turn in games or groups • Inability to focus on activity difficulty finishing any activity that requires concentration at home, school, or play • Requires close constant supervision

10. Autism Spectrum • Infants arch back when held don’t cuddle • Poor eye contact lack of attention to facial expressions • In world of own, no interaction with other children • Delay or lack of speech • Behavior problems screaming, temper tantrums, excessive crying, refusal to eat • Head banging, hand flapping, toe twirling

11. Anxiety Disorder • Most common manifestation • Fear to be seperated from parents and home • Refusal to attend school • Most common timeframe transitions • Preschool to elementary school • Primary to secondary school • Phobias or fears that interfere with normal daily routine • Prognosis good with treatment • Persistent anxiety disorder leads to panic disorder in adulthood.

12. Bipolar Disorder • More difficult to diagnose in children • Classic symptoms • Manic episode: 1 week abnormally and persistently elevated, expansive, or irritable mood. (3 of following) • Inflated self-esteem or grandiosity • Decreased need for sleep • Talkative pressured speech • Racing thoughts flight of ideas • Distractibility • Increased psychomotor agitation • Excessive involvement in pleasurable activities • Sexually acting out • Depressive episode: 5 symptoms present for 2 week period • Irritable mood • Decreased interest in pleasure or daily activities • Weight change • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of guilt or worthlessness • Decreased ability to think, indecisive • Recurrent thoughts of death , suicidal ideation, attempt

13. Conduct Disorder • Demonstrate 3 of behaviors over 6 months • Consistently lies other than to avoid physical or sexual abuse • Deliberately sets fires • Deliberate destruction of property of others • Truant from school • Breaking into home, office, or car • Physically cruel to animals &/or humans • Forced someone into sexual activity with them • Used weapon in more than one fight • Often starts fights

14. Depression • Specific symptoms in children • Inability to sit still, fidgeting, pacing, wringing hands • Pulling or rubbing the hair, skin, clothing, or other objects • Self stimulation • Slowed body movements • Outbursts of shouting or complaining or unexplained irritability • Crying • Expression of fear or anxiety • Somatic complaints of aching extremities, stomach, when no cause can be found • Aggression refusal to cooperate, antisocial behavior

15. Munchausen’s by Proxy • Form of physical and emotional abuse where the adult fabricates or induces illness in the child • Victim is most likely preschool child • Perpetrator is usually child’s mother • How to make the diagnosis? • Observe interactions between parent and child • Therapeutic separation results in resolution of the illness • Covert video monitoring • ICU admission for observation • Victim mortality 9-10% • Estimated 5-11% reported SIDS cases may be homicides

16. Obsessive Compulsive Disorder • Recurrent and persistent thoughts, impulses, or images. • Disturbance is intrusive and inappropriate causing marked anxiety and distress • Children • Repetitive behaviors • Rigid routines • Anger/tantrums when routines disrupted • Hoarding

17. Oppositional Defiant Disorder • Behavior pattern of negativity, hostility, and defiance lasting for at least 6 months • 4/6 criteria: • Losing temper • Arguing with adults • Actively defying and refusing adult requests and/or rules • Annoying other people in deliberate manner • Blaming others for mistakes and misbehaviors • Easily annoyed by others or “touchy” • Angry or resentful • Spiteful or vindictive • 30% will go on to develop conduct disorder • 10% may develop antisocial and other personality disorders • Earlier age of onset poorer prognosis

18. Pervasive Developmental Disorder • Difficulty using and understanding language • Difficulty relating to people, objects, and events; for example, lack of eye contact or pointing behavior • Unusual play with toys and other objects • Difficulty with changes in routine or familiar surroundings • Repetitive body movements or behavior patterns, such as hand flapping, hair twirling, foot tapping, or more complex movement • Can also be decline in developmental milestones originally achieved

19. Reactive Attachment Disorder • Serious problem with emotional attachment to others • severe colic and/or feeding difficulties • failure to gain weight • detached and unresponsive behavior • difficulty being comforted • preoccupied and/or defiant behavior • inhibition or hesitancy in social interactions • disinhibition or inappropriate familiarity or closeness with strangers. • ICD 10 criteria • markedly disturbed and developmentally inappropriate social relatedness in most contexts; • the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder; • onset before five years of age; • a history of significant neglect; • an implicit lack of identifiable, preferred attachment figure.

20. Somatoform Disorder • The somatoform disorders are a group of psychological disorders in which a patient experiences physical symptoms despite the absence of an underlying medical condition that can fully explain their presence. • These disorders can be represented by a wide spectrum of severity, ranging from mild self-limited symptoms, such as stomachache and headache, to chronic disabling symptoms, such as seizures and paralysis. • Children and adolescents are more likely to meet DSM-IV criteria for an undifferentiated somatoform disorder or somatoform disorder NOS than for a somatization disorder. The criteria for undifferentiated disorder require only one or more unexplained physical complaints, functional impairment, and duration of 6 months

21. Psychotherapy • Cognitive Behavioral Therapy • Play Therapy • Family Therapy • Intensive Case Management

22. Disorders and Treatment

23. Disorders and Treatment 2

24. Medication Management • Stimulant • Vivance (lisdexamfetamine dimesylate) • a prodrug of dextroamphetamine. After oral administration,lisdexamfetamine is rapidly absorbed from the gastrointestinal tract and converted to dextroamphetamine, which is responsible for the drug’s activity. Amphetamines are non-catecholamine sympathomimetic amines with CNS stimulant activity. The mode of therapeutic action in Attention Deficit Hyperactivity Disorder (ADHD) is not known. Amphetamines are thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space. • Capsules 20mg up to 70 mg • Recommended dosage 30 mg in am (max dose 70 mg) • Children ages 6 to 12: Most common adverse reactions (incidence ≥5% and at • a rate at least twice placebo) were decreased appetite, dizziness, dry mouth, irritability, insomnia, upper abdominal pain, nausea, vomiting and decreased weight. http://www.vyvanse.com/pdf/prescribing_information.pdf

25. Medication Management 2 • Antipsychotic • Risperdal • Blocks dopamine reuptake and increased dopamine release (Stahl) • Some benefit for behavioral problems associated with Autism disorders (Level 1) • Decreased irritability, social withdrawal, hyperactivity, temper tantrums, and stereotypical behaviors • Generally tranquilizes without impairing consciousness. Effective in increasing social relatedness. (Jesner et al) • Dosage 0.25 mg/day (initial dose) 0.25-0.5 mg (titrate q 2 wks) 0.5-3 mg/day (effective dose range)

26. 0.5-4.0mg/day Placebo Adverse Reaction (N=76) (N=80) Fatigue 42 13 Fever 20 19 Central and peripheral nervous system disorders Dystonia* 12 6 Tremor 12 1 Dizziness 9 3 Parkinsonism* 8 0 Automatism 7 1 Dyskinesia 7 0 Gastrointestinal system disorders Vomiting 25 21 Saliva increased 22 6 Constipation 21 8 Mouth dry 13 6 Nausea 8 8 Heart rate and rhythm disorders Tachycardia 7 0 Metabolic and nutritional disorders Weight increase 5 0 Psychiatric disorders Somnolence 67 23 Appetite increased 49 19 Anxiety 16 15 Anorexia 8 8 Confusion 5 0 Respiratory system disorders Rhinitis 36 23 Upper respiratory tract infection 34 15 Coughing 24 18 Skin and appendages disorders Rash 11 8 Urinary system disorders Urinary incontinence 22 20 RisperdalSide Effects Associated with Children Treated for Irritability http://www.risperdal.com/risperdal/shared/pi/risperdal.pdf

27. Medication Management 3 • Antidiruetc • Desmopression (DDAVP) • Available as intra-nasal spray successful in reducing enuresis • Adverse effects: headache, nasal congestion, epistaxis, stomachache (Sadock & Sadock) • GI problems associated with Autism in 46-85% of children • Endoscopic findings inflammation • Esophagitis • Gastritis • Duodenitis • Colitis • Implications for bowel issues

28. Medications

31. Questions????