1. Obsessive-Compulsive Disorder
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Recurrent obsessive thoughts, impulses, or images that are experienced as intrusive at times.
Repetitive compulsive behaviors or mental acts are performed to prevent or reduce distress stemming from obsessive thoughts.
Obsessions and compulsions cause marked distress, are time-consuming, and interfere with normal routines.
Obsessive-compulsive disorder (OCD) is related to anxiety disorders, but tends to cluster genetically with other compulsive disorders such as compulsive skin picking, trichotillomania (hair pulling) and hoarding. Onset often occurs during childhood, and untreated OCD can have a lifelong course. Males have an earlier age of onset, with childhood cases usually occurring before the age of 10 years. OCD often leads to avoidance of situations that trigger obsessions, and for children and adolescents, this can interfere with development.
Identification & Diagnosis
The obsessions that lead to OCD are defined as recurrent, persistent, intrusive thoughts, urges, or images that cause significant distress. The individual tries to avoid, suppress, or ignore the obsessions or to mitigate them through action or thought. The obsessions and compulsions of OCD consume more than an hour per day. Obsessions vary by individuals, but tend to cluster into the following groups: intrusive “forbidden” images such as sexual, aggressive or religiously taboo images, thoughts of contamination, need for symmetry, fears of harming others, fears of harm to oneself or loved ones. Individuals often experience more than one cluster and types of obsessions can change over time. In addition to compulsive symptoms, youth who are experiencing obsessions may also experience panic, depressive, irritable, and suicidal symptoms. Sudden onset of symptoms should alert pediatricians to screen for Group A streptococcal infections, as pediatric autoimmune disorders associated with these infections have been implicated in the development of OCD for some children.
Caretakers can often identify children who have compulsions, but obsessions can be difficult to recognize because they are experienced internally. Youth who recognize that obsessions and compulsions are strange may not spontaneously reveal symptoms unless specifically asked.
Many individuals with OCD feel that their symptoms are “crazy” or alternatively, they do not want to consider giving up their compulsions as they feel these will lead to intense distress. Psychoeducation is an important first step in treatment of OCD to help put symptoms in perspective and outline treatment progression. OCD is best treated with a combination of CBT specific to OCD and with medications in more severe cases. SSRIs are effective in diminishing OCD symptoms, but higher doses may be needed than those used to treat anxiety disorders or depression. Fluvoxamine and sertraline have FDA approval for the treatment of pediatric OCD. The tricyclic antidepressant clomipramine has FDA approval for the treatment of OCD in adults. Severe cases have been treated with gamma knife brain surgery interrupting the circuit involved in OCD.
OCD often occurs with other compulsive disorders such as trichotillomania (the recurrent pulling out of hair), compulsive skin picking, body dysmorphic disorder, or hoarding. Youth with OCD are at increased risk to have comorbid anxiety, ADHD, depression, and tics. The differential diagnosis includes all of the above as well as eating disorders, psychotic disorders and obsessive compulsive personality disorder. The perseveration of children with autism spectrum disorders can also be confused with OCD.
The combination of CBT plus medication is most effective for patients who do not respond to either treatment alone. It is important to recognize and treat OCD early, as early age of onset and greater impairment are predictors of poor prognosis. Hoarding is particularly difficult to treat.
et al: Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA 2011;306(11):1224–1232
FT: Pediatric obsessive-compulsive disorder: management priorities in primary care. Curr Opin Pediatr 2008 Oct;20(5):544–550
JT: Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatr Clin N Am 2005 Oct;14(4):877–908
JT: Selective serotonin reuptake inhibitor use in the treatment of the pediatric non-obsessive-compulsive disorder anxiety disorders. J Child Adolesc Psychopharmacol 2006 Feb-Apr;16(1–2):171–179
BA: Intermittent abdominal pain in a 6-year-old child: the psycho-social-cultural evaluation. Curr Opin Pediatr 2009 Oct;21(5):675–677
et al: Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches. J Am Acad Child Adolesc Psychiatry 2007 Apr;46(4):469–478
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Recurrent skin picking resulting in lesions despite efforts to stop.
The skin picking causes significant distress or impairment in school, social or other areas of function.
Excoriation disorder (ED), also known as skin picking disorder, or dermatillomania, is one of the newer diagnoses in the DSM-V. This disorder is a subset of obsessive-compulsive and related disorders. As with other additions to the DSM-V, this disorder has been around for over a century, however, it was not included in previous DSMs. There are some that believe that ED is closest to OCD in etiology, however, others believe it is better categorized as an “addiction disorder,” like alcohol and drug use disorders.
Identification & Diagnosis
The disorder is characterized by repeated skin picking leading to multiple lesions on the skin, despite ongoing efforts to reduce or stop this behavior. ED, similar to trichotillomania (TTM), is not associated with obsessions or preoccupations, as in OCD. Diagnosis of this disorder is characterized by clinically significant distress affecting social, occupational or other areas of functioning. Distress includes, but is not limited to experiencing a loss of control, embarrassment, or shame. Symptoms are likely affected by increased stress, anxiety and boredom. In addition, various substances, namely dopamine agonists, for example, methamphetamines and cocaine can lead to skin picking.
Psychotherapy can be beneficial and should be the first line of treatment in most cases. For severe cases, or cases not responding the therapy, there is mixed evidence supporting the use of SSRIs and evidence and evidence for N-acetylcysteine in adults. Comorbid conditions should be identified and treated. Currently, there are clinical trials looking at treating this disorder by targeting other receptors, such as opioid antagonists and glutaminergic agonists, however, these are still in preliminary phases.
The differential diagnosis includes trichotillomania, substance use disorder, major depressive disorders, anxiety disorder, OCD, Tourette’s or tic disorder, body dysmorphic disorder, substance-induced skin picking, psychosis and neurodevelopmental disorders, such as Prader-Willi. There is a high comorbidity with OCD and TTM, in addition to major depressive disorder.
The disorder is much more common in females than males, with about a 3:1 ratio. Typical age of onset is teen years, likely associated with picking of acne. The lifetime prevalence for excoriation disorder in adults is at or above 1.4%. The course is chronic, yet symptoms can wax and wane for months to years at a time.
SW. N-Acetylcysteine in the treatment of excoriation disorder: a randomized clinical trial. JAMA Psychiatry 2016;73(5):490–496.
EA. A systematic review and meta-analysis of psychiatric treatments for excoriation (skin-picking) disorder. Gen Hosp Psychiatry 2016;41:29–37
Posttraumatic Stress Disorder
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Signs and symptoms of hyperarousal and reactivity.
Avoidant behaviors and numbing of responsiveness.
Flashbacks to a traumatic event such as nightmares, intrusive thoughts, or repetitive play.
Follows traumatic events such as exposure to violence, physical or sexual abuse, natural disasters, car accidents, dog bites, and unexpected personal tragedies.
Factors that predispose individuals to the development of PTSD include proximity to the traumatic event or loss, a history of exposure to trauma, preexisting depression or anxiety disorder, being abused by a caregiver, or witnessing a threat to a caregiver. PTSD can develop in response to natural disasters, terrorism, motor vehicle crashes, and significant personal injury, in addition to physical, sexual, and emotional abuse. Natural disasters such as hurricanes, fires, flooding, and earthquakes, create situations in which large numbers of affected individuals are at heightened risk for PTSD. Individuals who have a previous history of trauma, or an unstable social situation are at greatest risk of PTSD.
Long overdue, attention is now being paid to the substantial effects of family and community violence on the psychological development of children and adolescents. Abused children are especially likely to develop PTSD and to suffer wide-ranging symptoms and impaired functioning. As many as 25% of young people exposed to violence develop symptoms of PTSD and children with some symptoms of PTSD can suffer significant distress and functional impairment, even when not meeting full criteria for PTSD.
Identification & Diagnosis
Children and adolescents with PTSD show persistent fear, anxiety, and hypervigilance. They may regress developmentally and experience fears of strangers, the dark, and being alone, and avoid reminders of the traumatic event. For young children with magical thinking, this can involve avoiding objects or events that may not be obviously linked to the traumatic event. Children with PTSD re-experience elements of the events in the form of nightmares and flashbacks. In their symbolic play, one can often notice repetition of some aspect of the traumatic event. Children with a history of traumatic experiences or neglect in infancy and early childhood are likely to show signs of reactive attachment disorder and have difficulty forming relationships with caregivers.
Before considering treatment, it is critical to ensure that the child is living in a safe environment. If there is concern regarding current or past abuse, this must be reported to social services. The cornerstone of treatment for PTSD is education of the child and family regarding the nature of the disorder so that the child’s emotional reactions and regressive behavior are not mistakenly viewed as volitional. The child needs support, reassurance, and empathy. Treatment also includes building a developmentally appropriate narrative of the event to help the child understand their experience. Efforts should be made to establish or maintain daily routines as much as possible, especially after a trauma or disaster that interrupts the family’s environment. In the case of media coverage of a disaster or event, children’s viewing should be avoided or limited. Individual and family psychotherapy are central features of treatment interventions. Specific fears usually wane with time, and behavioral desensitization may help. Trauma-focused CBT is considered first-line treatment for PTSD. There is preliminary evidence that eye movement desensitization and reprocessing (EMDR) may also be useful.
For children with more severe and persistent symptoms, assessment for treatment with medication is indicated. Children who have lived for an extended time in abusive environments or who have been exposed to multiple traumas are more likely to require treatment with medications. Currently, there is not a medication that has FDA approval for treating PTSD for children. Child psychiatrists may choose medications to target specific symptoms (eg, anxiety, depression, nightmares, and aggression). Some of the medications used to treat children with PTSD include clonidine or guanfacine (Tenex), mood stabilizers, antidepressants, and neuroleptics.
Evidence is growing to support a connection between victimization in childhood and problems in adulthood, including health problems, substance abuse, unstable personality and mood disorders. It is important to treat PTSD not only to relieve the suffering of youth with PTSD, but also to mitigate long-term negative sequelae.
The best prognostic indicator for children exposed to trauma is a supportive relationship with a caregiving adult. Frequently caregivers exposed to trauma also have PTSD and need referral for treatment so that they can also assist in their child’s recovery. Timely access to therapy enhances prognosis. Children with more severe PTSD may require intermittent therapy to identify and treat symptoms that emerge during different stages of development.
et al: Physician-reported practice of managing childhood posttraumatic stress in pediatric primary care. Gen Hosp Psychiatry 2008 Nov-Dec;30(6):536–545
AP: Identifying, treating, and referring traumatized children: the role of pediatric providers. Arch Pediatr Adolesc Med 2008 May;162(5):447–452
MS: Posttraumatic stress disorder diagnosis in children: challenges and promises. Dialogues Clin Neurosci 2009;11(1):91–99
DR: Concise Guide to Child & Adolescent Psychiatry. 2nd ed. Washington, DC: American Psychiatric Association; 1999.
L: Psychophysiological characteristics of PTSD in children and adolescents: a review of the literature. J Trauma Stress 2011 Apr;24(2):146–154. doi: 10.1002/jts.20620 [Epub 2011 Mar 24] [Review] Erratum in: J Trauma Stress 2011Jun;24(3):370–372
National Child Traumatic Stress Network. Multiple invaluable resources available at http://www.nctsn.org
. Accessed September 27, 2015.
CH: Reconsideration of harm’s way: onsets and comorbidity patterns of disorders in preschool children and their caregivers following Hurricane Katrina. J Clin Child Adolesc Psychol 2008 Jul;37(3):508–518
Inattentive, Hyperactive, & Combined Type
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Significant impairment in attention or concentration.
And/or significant hyperactivity and impulsivity in excess of that expected for age.
Must be present in two or more settings.
Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly seen and treated psychiatric conditions in children and adolescents. Although there is no definitive cause or cure for this disorder, with adequate screening and monitoring, it can be identified and effectively treated.
Identification & Diagnosis
Symptoms of ADHD fall into two categories: hyperactive and impulsive or inattentive. If a child has a significant number of symptoms in both categories, a diagnosis of ADHD, combined type is given. Functional impairment is required across at least two settings. Accurate diagnosis includes obtaining information regarding symptoms and functional impairment from two sources, typically parents and teachers. Standardized forms in the public domain such as Vanderbilt parent and teacher evaluation and follow up forms are helpful in the process. It is important to keep in mind that intermittent symptoms of hyperactivity and/or inattention without functional impairment do not warrant a diagnosis of ADHD.
Not all hyperactivity and/or inattention can be attributed to ADHD. Some of the most common psychiatric conditions that have similar presenting problems to ADHD include mood disorder (ie, bipolar and depression), anxiety disorders, oppositional defiant disorder, adjustment disorder and PTSD. Learning disorders and other neurodevelopmental disorders can present with symptoms suggestive of ADHD. There are also a number of medical diagnoses with presenting problems similar to ADHD, including head injury, hyperthyroidism, fetal alcohol syndrome, and lead toxicity. Inadequate nutrition and sleep deprivation, including poor quality of sleep, can also cause inattention. It is important to have the correct diagnosis prior to initiating treatment for ADHD.
Medication is a primary treatment for school age children and adolescents with ADHD. For children diagnosed with ADHD under the age of 6, behavioral therapy is the first line of treatment. Stimulants are the most effective and most commonly prescribed medications for ADHD. Approximately 75% of children with ADHD experience symptom improvement when given stimulant medications. Children with ADHD who do not respond favorably to one stimulant may respond to another. Children and adolescents with ADHD without prominent hyperactivity (ADHD, predominantly inattentive type) are also likely to be responsive to stimulant medications. When stimulants are not well tolerated or effective, nonstimulants may be used as an alternative. Among nonstimulant medications, atomoxetine, a selective noradrenergic reuptake inhibitor and guanfacine ER, a central α2A-adrenergic receptor agonist, both have FDA approval for the treatment of ADHD in children. Please refer to tables of stimulants and nonstimulants when considering which medication to use (Tables 7–10 and 7–11).
Table 7–10.Stimulant medication used for treatment of ADHD.a ||Download (.pdf) Table 7–10.Stimulant medication used for treatment of ADHD.a
|Short-Acting Stimulants |
|Drug Name ||Duration ||Dosages ||Stimulant Class ||Usual Starting Dose ||FDA Max Daily Dose |
|Methylphenidate (Ritalin, Methylin) ||4–6 hours ||5, 10, 20 mg ||Methyl. ||5 mg BID 1/2 dose if 3–5 y ||60 mg |
|Dexmethylphenidate (Focalin) ||4–6 hours ||2.5, 5, 10 mg ||Methyl. ||2.5 mg BID ||20 mg |
|Dextroamphetamine (Dexedrine, Dextro-Stat, Dexedrine SA, Pro Centra, Zenzedi) ||4–6 hours ||5, 10 mg tabs ||Dextro. ||5 mg QD-BID 1/2 dose if 3–5 y ||40 mg |
|Amphetamine Salt Combo (Adderall) ||4–6 hours ||5, 7.5, 10, 12.5, 15, 20, 30 mg ||Dextro. ||5 mg QD-BID 1/2 dose if 3–5 y ||40 mg |
|Extended Release Stimulants |
|Drug Name ||Duration ||Dosages ||Stimulant Class ||Usual Starting Dose ||FDA Max Daily Dose ||Editorial Comments |
|4–8 hours ||10, 20 mg tab ||Methyl. ||10 mg QAM ||60 mg ||Generic available. Uses wax matrix. Variable duration of action |
|Concerta ||10–12 hours ||18, 27, 36, 54 mg ||Methyl. ||18 mg QAM ||72 mg || |
Osmotic pump capsule
|Adderall XR ||8–12 hours ||5, 10, 15, 20, 25, 30 mg ||Dextro. ||5 mg QD ||30 mg || |
Beads in capsule can be sprinkled
|Metadate CD (30% IR) ~8 hours ||~8 hours ||10, 20, 30, 40, 50, 60 mg capsules ||Methyl. ||10 mg QAM ||60 mg || |
Beads in capsule can be sprinkled
|Ritalin LA (50% IR) ~8 hours ||~8 hours ||10, 20, 30, 40 mg capsules ||Methyl. ||10 mg QAM ||60 mg || |
Beads in capsule can be sprinkled
|Focalin XR ||10-12 hours ||5 to 40 mg in 5 mg steps ||Methyl. ||5 mg QAM ||30 mg ||Beads in capsule can be sprinkled |
|Daytrana patch ||Until 3–5 hours after patch removal ||10, 15, 20, 30 mg Max 30 mg/9 hr ||Methyl. ||10 mg QAM ||30 mg ||Rash can be a problem, slow AM startup, has an allergy risk, peeling off patch a problem with young kids |
|Lisdexamfetamine (Vyvanse) ||~10 hours ||20, 30, 40, 50, 60, 70 mg ||Dextro. ||30 mg QD ||70 mg ||Conversion ratio from dextroamphetamine is not established |
|8–10 hours ||5, 10, 15 mg ||Dextro. ||5 mg QAM ||40 mg ||Beads in capsule can be sprinkled |
|Quillivant XR ||10–12 hours ||25 mg/5 ml 1 bottle = 300 mg or 60 ml ||Methyl. ||10 mg QAM ||60 mg ||Liquid banana flavor |
|Quillichew ER ||6–8 hours ||20, 30, 40 mg ||Methyl. ||20 mg QAM ||60 mg ||Chewable cherry-flavored tablets |
Table 7–11.Nonstimulant medication used for treatment of ADHD. ||Download (.pdf) Table 7–11.Nonstimulant medication used for treatment of ADHD.
|Drug Name ||Duration ||Dosages ||Usual Starting Dose ||FDA Max Daily Dose ||Editorial Comments |
|Atomoxetine (Strattera) ||All day ||10, 18, 25, 40, 60, 80, 100 mg ||0.5 mg/kg/day (1 to 1.2 mg/kg/day usual full dosage) ||Lesser of 1.4 mg/kg/day or 100 mg (HCA limit is 120 mg/day) ||Usually lower effectiveness has GI side effects, takes weeks to see full benefit |
|Clonidine (Catapres) ||12 h 1/2 life ||0.1, 0.2, 0.3 mg || |
0.05 mg QHS if < 45 kg, otherwise 0.1 mg QHS
Caution if < 5 y
|(Not per FDA) 27–40 kg 0.2 mg 40–45 kg 0.3 mg > 45 kg 0.4 mg ||Often given to help sleep, also treats tics, can have rebound BP effects |
|Clonidine XR (Kapvay) ||12–16 h ||0.1, 0.2 mg ||0.1 mg QHS ||0.4 mg daily ||Lower peak blood level, then acts like regular clonidine (similar 1/2 life). Still is sedating. Approved for combo with stimulants |
|Guanfacine (Tenex) ||14 h 1/2 life ||1, 2 mg || |
0.5 mg QHS if < 45 kg, otherwise 1 mg QHS
Caution if <5 y
(Not per FDA) 27–40 kg 2 mg
40-45 kg 3 mg
>45 kg 4 mg
|Often given to help sleep, also treats tics, can have rebound BP effects |
|Guanfacine XR (Intuniv) ||16 h 1/2 life ||1, 2, 3, 4 mg ||1 mg QD if over 6 years old (full dosage 0.05 to 0.12 mg/kg) ||4 mg daily ||Lower peak blood level, then acts like regular Tenex (similar 1/2 life). Still is sedating. Approved for combo with stimulants |
ADHD comorbidities are common and include anxiety disorders, mood disorders, oppositional defiant disorder, and conduct disorder. While stimulant medication, the first-line treatment for ADHD, has the potential for abuse, individuals who are treated for ADHD are significantly less likely to abuse substances compared to those who have not been treated. Also, a large majority of children and adolescents with ADHD are not formally diagnosed, and of those who are diagnosed, only 55% actually receive ongoing treatment.
Special Considerations Regarding the Use of Stimulant Medication
Common adverse events include anorexia, weight loss, abdominal distress, headache, insomnia, dysphoria and tearfulness, irritability, lethargy, mild tachycardia, and mild elevation in blood pressure. Less common side effects include interdose rebound of ADHD symptoms, behavioral stereotypy, tachycardia, hypertension, depression, mania, and psychotic symptoms. Reduced growth velocity can occur, however, for individual patient’s ultimate height is not usually compromised. Treatment with stimulant medications does not predispose to future substance abuse. Young children are at increased risk for side effects from stimulant medications. Additive stimulant effects are seen with sympathomimetic amines (ephedrine and pseudoephedrine).
Reports of sudden death and serious cardiovascular adverse events among children taking stimulant medication raised concerns about their safety. The labels for methylphenidate and amphetamine medications were changed in 2006 to note reports of stimulant-related deaths in patients with heart problems and advised against using these products in individuals with known serious structural abnormalities of the heart, cardiomyopathy, or serious heart rhythm abnormalities. There continues to be insufficient data to confirm whether taking stimulant medication causes cardiac problems or sudden death. The FDA advises providers to conduct a thorough physical examination, paying close attention to the cardiovascular system, and to collect information about the patient’s history and any family history of cardiac problems. If this scrutiny suggests a problem, providers should consider a screening electrocardiogram or an echocardiogram. Caution should also be taken if there is a personal or family history of substance abuse or addictive disorders, as these medications can be abused. Students attending college/university may be at increased risk to divert their stimulants to peers. Stimulants should be used with caution in individuals with psychotic disorders, as they can significantly worsen psychotic symptoms. Likewise stimulants should be used with caution in individuals with bipolar affective disorder as they can worsen mood dysregulation.
Initial medical screening should include observation for involuntary movements and measurement of height, weight, pulse, and blood pressure. (See also Chapter 3.) Pulse, blood pressure, height, and weight should be recorded every 3–4 months and at times of dosage increases and abnormal movements such as motor tics should be assessed at each visit.
Research indicates that 60%–85% of those diagnosed with ADHD in childhood continue to carry the diagnosis into adolescence. The literature varies greatly about progression of ADHD into adulthood. Most studies show that a majority of adolescents diagnosed with ADHD in adolescence continue to have functional impairment in adulthood, whether or not they meet full criteria for the disorder. While many have devised ways to cope with their symptoms in a manner that does not require medication, about one-third of adults previously diagnosed with ADHD in childhood require ongoing medication management.
JS: Developments in pediatric psychopharmacology: focus on stimulants, antidepressants, and antipsychotics. J Clin Psychiatry 2011 May;72(5):655–670
CJ: Review of ADHD pharmacotherapies: advantages, disadvantages, and clinical pearls. J Am Acad Child Adolesc Psychiatry 2009 Mar;48(3):240–248
et al: Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr 2001;22(1):60–73
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Dysphoric mood, mood lability, irritability, or depressed appearance, persisting for weeks to months at a time.
Characteristic neurovegetative signs and symptoms (eg, changes in sleep, appetite, concentration, and activity levels).
Suicidal ideation, feeling of hopelessness.
The incidence of depression in children increases with age, from 1% to 3% before puberty to around 8% for adolescents. The rate of depression in females approaches adult levels by age 15. The lifetime risk of depression ranges from 10% to 25% for women and 5% to 12% for men. The incidence of depression in children is higher when other family members have been affected by depressive disorders. The sex incidence is equal in childhood, but with the onset of puberty the rates of depression for females begin to exceed those for males by 5:1.
Identification & Diagnosis
Clinical depression can be defined as a persistent state of unhappiness or misery that interferes with pleasure or productivity. Depression in children and adolescents is as likely to be characterized by an irritable mood state accompanied by tantrums or verbal outbursts as it is to be a sad mood. Typically, a child or adolescent with depression begins to look unhappy and may make comments such as “I have no friends,” “life is boring,” “there is nothing I can do to make things better,” or “I wish I were dead.” Behavior patterns change from baseline and can include social isolation, deterioration in schoolwork, loss of interest in usual activities, anger, and irritability. Sleep and appetite patterns commonly change, and the child may complain of tiredness and nonspecific pain such as headaches or stomach aches (Table 7–12).
Table 7–12.Clinical manifestations of depression in children and adolescents. ||Download (.pdf) Table 7–12.Clinical manifestations of depression in children and adolescents.
|Depressive Symptom ||Clinical Manifestations |
|Anhedonia ||Loss of interest and enthusiasm in play, socializing, school, and usual activities; boredom; loss of pleasure |
|Dysphoric mood ||Tearfulness; sad, downturned expression; unhappiness; slumped posture; quick temper; irritability; anger |
|Fatigability ||Lethargy and tiredness; no play after school |
|Morbid ideation ||Self-deprecating thoughts, statements; thoughts of disaster, abandonment, death, suicide, or hopelessness |
|Somatic symptoms ||Changes in sleep or appetite patterns; difficulty in concentrating; bodily complaints, particularly headache and stomachache |
Clinical depression is typically identified by asking about the symptoms. Children are often more accurate than their caregivers in describing their own mood state. When several depressive symptoms cluster together over time, are persistent (2 weeks or more), and cause impairment, a major depressive disorder may be present. When depressive symptoms are of lesser severity but have persisted for 1 year or more, a diagnosis of dysthymic disorder should be considered. Milder symptoms of short duration in response to some stressful life event may be consistent with a diagnosis of adjustment disorder with depressed mood.
The American Academy of Pediatrics recommends annual screening for depression in children age 12 and older using a standardized measure. The Center for Epidemiologic Study of Depression–Child Version (CESD-C), Child Depression Inventory (CDI), Beck Depression Rating Scale, and Reynolds Adolescent Depression Scale and Patient Health Questionnaire-9 modified for teens (PHQ-9) are self-report rating scales that are easily used in primary care to assist in assessment and monitoring response to treatment. Several are available in the public domain.
Treatment includes developing a comprehensive plan to treat the depressive episode and help the family to respond more effectively to the patient’s emotional needs. Referrals should be considered for individual and possibly adjunctive family therapy. CBT improves depressive symptoms in children and adolescents. This includes a focus on building coping skills to change negative thought patterns that predominate in depressive conditions. It also helps identify, label, and verbalize feelings and misperceptions. In therapy, efforts are also made to resolve conflicts between family members and improve communication skills within the family.
Mild to moderate depressive symptoms often improve with psychotherapy alone. When the symptoms of depression are moderate and persistent, or severe, antidepressant medications may be indicated (see Table 7–8). A positive family history of depression increases the risk of early-onset depression in children and adolescents and the chances of a positive response to antidepressant medication. Depression in toddlers and young children is best approached with parent–child relational therapies.
The carefully conducted treatment of adolescent depression study (TADS) is a major source of evidence for clinic guidelines regarding the treatment of depression in children and adolescents. This study found that CBT combined with fluoxetine led to the best outcomes in the treatment of pediatric depression during the first 12 weeks of treatment. Although our knowledge is still evolving, these findings suggest that when recommending or prescribing an antidepressant, the provider should consider concurrently recommending cognitive-behavioral or interpersonal therapy. Providers should discuss the options for medication treatment, including which medications have FDA approval for pediatric indications (see Table 7–6). Target symptoms should be carefully monitored for improvement or worsening, and it is important to ask and document the responses about any suicidal thinking and self-injurious behaviors.
Special Considerations Regarding the Use of Antidepressant Medication
There are some special considerations when prescribing the various classes of antidepressant medication. Table 7–8 outlines the distinct differences between some of the most commonly used antidepressant medications.
A. Selective Serotonin Reuptake Inhibitors (SSRI)
Each SSRI has different FDA indications. Providers can choose to treat with an SSRI that has not received FDA approval for a specific indication or age group. Typical considerations for using a medication without FDA approval include the side-effect profile and/or whether another family member has responded to a specific medication. In these instances, providers should inform the patient and family that they are using a medication off-label.
The therapeutic response for SSRIs should be expected 4–6 weeks after a therapeutic dose has been reached. The starting dose for a child younger than 12 years is generally half the starting dose for an adolescent. SSRIs are usually given once a day, in the morning with breakfast. One in ten individuals may experience sedation and prefer to take the medication at bedtime. Caution should be used in cases of known liver disease or chronic or severe illness where multiple medications may be prescribed, because all SSRIs are metabolized in the liver. In addition, caution should be used when prescribing for an individual with a family history of bipolar disorder, or when the differential diagnosis includes bipolar disorder, because antidepressants can induce manic or hypomanic symptoms.
Adverse effects of SSRIs are often dose-related and time-limited: GI distress and nausea (can be minimized by taking medication with food), headache, tremulousness, decreased appetite, weight loss, insomnia, sedation (10%), and sexual dysfunction (25%). Irritability, social disinhibition, restlessness, and emotional excitability can occur in approximately 20% of children taking SSRIs. It is important to systematically monitor for side effects. SSRIs other than fluoxetine should be discontinued slowly to minimize withdrawal symptoms including flu-like symptoms, dizziness, headaches, paresthesias, and emotional lability.
All SSRIs inhibit the hepatic microsomal enzyme system. The order of inhibition is: fluoxetine > fluvoxamine > paroxetine > sertraline > citalopram > escitalopram. This can lead to higher-than-expected blood levels of concomitant medications. Taking tryptophan while on an SSRI may result in a serotonergic syndrome of psychomotor agitation and GI distress. A potentially fatal interaction that clinically resembles neuroleptic malignant syndrome may occur when SSRIs are administered concomitantly with monoamine oxidase inhibitors (MAOIs). Fluoxetine has the longest half-life of the SSRIs and should not be initiated within 14 days of the discontinuation of a monoamine oxidase inhibitor, or a monoamine oxidase inhibitor initiated within at least 5 weeks of the discontinuation of fluoxetine. One should be cautious of prescribing SSRIs in conjunction with ibuprofen and other NSAIDs for concerns of GI bleeding.
B. Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
Serotonin norepinephrine reuptake inhibitors (SNRIs), which include venlafaxine, duloxetine, desvenlafaxine, and milnacipran, are antidepressants that primarily inhibit reuptake of serotonin and norepinephrine. Desvenlafaxine is the major active metabolite of the antidepressant venlafaxine. It is approved for the treatment of major depression in adults. Contraindications for this class of medication include hypertension, which is typically dose related. The most common adverse effects are nausea, nervousness, and sweating. SNRIs should be discontinued slowly to minimize withdrawal symptoms: including flu-like symptoms, dizziness, headaches, paresthesias, and emotional lability.
Bupropion is an antidepressant that inhibits uptake of norepinephrine and dopamine. It is approved for treatment of major depression in adults. Like the SSRIs, bupropion has very few anticholinergic or cardiotoxic effects. The medication has three different formulations, and consideration for use is based on tolerability and compliance. Bupropion can interfere with sleep, so dosing earlier in the day is paramount to adherence and decreasing side effects. Contraindications of this medication include history of seizure disorder or bulimia nervosa. The most common adverse effects include psychomotor activation (agitation or restlessness), headache, GI distress, nausea, anorexia with weight loss, insomnia, tremulousness, precipitation of mania, and induction of seizures with doses above 450 mg/day.
Mirtazapine is an α2-antagonist that enhances central noradrenergic and serotonergic activity. It is approved for the treatment of major depression in adults. Mirtazapine should not be given in combination with MAOIs. Very rare side effects are acute liver failure (1 case per 250,000–300,000), neutropenia, and agranulocytosis. More common adverse effects include dry mouth, increased appetite, constipation, weight gain, and increased sedation.
Tricyclic antidepressants (TCAs) are an older class of antidepressants, which include imipramine, desipramine, clomipramine, nortriptyline, and amitriptyline. With the introduction of the SSRIs and alternative antidepressants, use of the TCAs has become uncommon for the treatment of depression and anxiety disorders. The TCAs have more significant side-effect profiles and require substantial medical monitoring, including the possibility of cardiac arrhythmias. Overdose can be lethal. TCAs are still used to treat medical and psychiatric issues, such as chronic pain syndromes, headache, or enuresis as well as depression, anxiety, bulimia nervosa, OCD, and PTSD. Imipramine and desipramine are FDA approved for the treatment of major depression in adults and for enuresis in children age 6 years and older. Contraindications include cardiac disease or arrhythmia, unexplained syncope, seizure disorder, family history of sudden cardiac death or cardiomyopathy, and known electrolyte abnormality (with bingeing and purging). Initial medical screening includes taking a thorough family history for sudden cardiac death and the patient’s history for cardiac disease, arrhythmias, syncope, seizure disorder, or congenital hearing loss (associated with prolonged QT interval). Other screening procedures include serum electrolytes and blood urea nitrogen in patients who have eating disorders, cardiac examination, and a baseline ECG. Ongoing medical follow-up includes monitoring pulse and blood pressure (ie, screening for tachycardia and orthostatic hypotension) with each dosage increase, and obtaining an ECG to monitor for atrioventricular block with each dosage increase. After reaching steady state, record pulse, blood pressure, and ECG every 3–4 months. TCAs may potentiate the effects of central nervous system depressants and stimulants. Barbiturates and cigarette smoking may decrease plasma levels while phenothiazines, methylphenidate, and oral contraceptives may increase plasma levels. SSRIs given in combination with TCAs will result in higher TCA blood levels. Please refer to Table 7–13 on upper limits of cardiovascular parameters with tricyclic antidepressants.
Table 7–13.Upper limits of cardiovascular parameters with tricyclic antidepressants. ||Download (.pdf) Table 7–13.Upper limits of cardiovascular parameters with tricyclic antidepressants.
|Heart rate ||110/min |
|Systolic blood pressure ||130 mm Hg |
|Diastolic blood pressure ||85 mm Hg |
|PR interval ||0.2 s |
|QRS interval ||0.12 s, or no > 30% over baseline |
|QT corrected ||0.45 s |
The risk of suicide is the most significant risk associated with depressive episodes. In addition, adolescents are likely to self-medicate their feelings through substance abuse, or indulge in self-injurious behaviors such as cutting or burning themselves (without suicidal intent). School performance usually suffers during a depressive episode, as children are unable to concentrate or motivate themselves to complete homework or projects. The irritability, isolation, and withdrawal that often result from the depressive episode can lead to loss of peer relationships and tense dynamics within the family. Please refer to section on identifying and addressing suicide risk for additional information.
Depression often coexists with other mental illnesses such as ADHD, oppositional defiant disorder, conduct disorder, anxiety disorders, eating disorders, and substance abuse disorders. Medically ill patients also have an increased incidence of depression. Every child and adolescent with a depressed mood state should be asked directly about suicidal ideation and physical and sexual abuse. Depressed adolescents should also be screened for hypothyroidism and substance abuse.
In 2005, the FDA issued a “black box warning” regarding suicidal thinking and behavior for all antidepressants prescribed for children and adolescents. The FDA compiled data from 24 short-term trials of 4–16 weeks that included the use of antidepressants for major depressive disorder and obsessive compulsive disorder. Across these studies, the average risk of suicidal thinking and behavior during the first few months of treatment was 4% or twice the placebo risk of 2%. No suicides occurred in these trials. Although children face an initial increased risk of suicidal thinking and behaviors during the first few months of treatment, there is now substantial evidence that antidepressant treatment, over time, is protective against suicide. For example, following the addition of the “black box warning” for all antidepressants in October 2005, a 20% decrease in prescriptions for those younger than age 20 occurred. During the same time period, there was an 18% increase in suicides. Furthermore, the suicide rates in children and adolescents were lowest in areas of the country that had the highest rate of SSRI prescriptions. This suggests best practice is to educate the family regarding both the risks and benefits of antidepressant treatment and monitor carefully for any increase in suicidal ideation or self-injurious urges, as well as improvement in target symptoms of depression, especially in the first 4 weeks and subsequent 3 months after beginning their use.
A comprehensive treatment intervention, including psychoeducation for the family, individual and family psychotherapy, medication assessment, and evaluation of school and home environments, often leads to complete remission of depressive symptoms over a 1- to 2-month period. If medications are started and prove effective, they should be continued for 6–12 months after remission of symptoms to prevent relapse. Early-onset depression (before age 15) is associated with increased risk of recurrent episodes and the potential need for longer-term treatment with antidepressants. Education of the family and child/or adolescent will help them identify depressive symptoms sooner and decrease the severity of future episodes with earlier interventions. Some studies suggest that up to 30% of preadolescents with major depression manifest bipolar disorder at 2-year follow-up. It is important to reassess the child or adolescent with depressive symptoms regularly for at least 6 months and to maintain awareness of the depressive episode in caring for this child in the future.
et al: GLAD PC Steering Committee Expert survey for the management of adolescent depression in primary care. Pediatrics 2008 Jan;121(1):e101–e107
et al: GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics 2007 Nov;120(5):e1313–e1326. Erratum in: Pediatrics 2008 Jan; 121(1):227
W: Collaborative care for adolescent depression: a pilot study. Gen Hosp Psychiatry 2009 Jan–Feb;31(1):36–45 [Epub 2008 Nov 18]
et al: Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics 2010 Dec;126(6):1117–1123 [Epub 2010 Nov 1]
US Preventive Services Task Force Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics 2009 Apr;123(4):1223–1228. Erratum in: Pediatrics 2009 Jun;123(6):1611
et al: Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics 2009 Apr;123(4):e716–e735[Review]
D, and the GLAD-PC Steering Group: Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007 Nov;120(5):e1299–e1312
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Periods of abnormally and persistently elevated, expansive, or irritable mood, and heightened levels of energy and activity.
Associated symptoms: grandiosity, diminished need for sleep, pressured speech, racing thoughts, impaired judgment.
Not caused by prescribed or illicit drugs.
The symptoms most commonly reported first are depressive symptoms.
Bipolar disorder (previously referred to as manic-depressive disorder) is an episodic mood disorder manifested by alternating periods of mania and major depressive episodes or, less commonly, manic episodes alone. Children and adolescents often exhibit a variable course of mood instability combined with aggressive behavior and impulsivity. At least 20% of bipolar adults experience onset of symptoms before age 20 years. Onset of bipolar disorder before puberty is uncommon; however, symptoms often begin to develop and may be initially diagnosed as ADHD or other disruptive behavior disorders. The lifetime prevalence of bipolar disorder in middle to late adolescence approaches 1%.
Identification & Diagnosis
In about 70% of patients, the first symptoms are primarily those of depression. In the remainder, manic, hypomanic, or mixed states dominate the presentation. Patients with mania display a variable pattern of elevated, expansive, or irritable mood along with rapid speech, high energy levels, difficulty in sustaining concentration, and a decreased need for sleep. The child or adolescent may also have hypersexual behavior. It is critical to rule out abuse, or be aware of abuse factors contributing to the clinical presentation. Patients often do not acknowledge any problem with their mood or behavior. The clinical picture can be quite dramatic, with florid psychotic symptoms of delusions and hallucinations accompanying extreme hyperactivity and impulsivity. Other illnesses on the bipolar spectrum are bipolar type II, which is characterized by recurrent major depressive episodes alternating with hypomanic episodes (lower intensity manic episodes that do not cause social impairment and do not typically last as long as manic episodes) and cyclothymic disorder, which is diagnosed when the child or adolescent has had 1 year of hypomanic symptoms alternating with depressive symptoms that do not meet criteria for major depression.
It is also common for individuals diagnosed with bipolar spectrum disorders to have a history of inattention and hyperactivity problems in childhood, with some having a comorbid diagnosis of ADHD. While ADHD and bipolar disorder are highly comorbid, inattention and hyperactivity symptoms accompanied by mood swings can be an early sign of bipolar disorder before full criteria for the disorder have emerged and clustered together in a specific pattern.
Differentiating ADHD, bipolar disorder, and major depressive disorder can be a challenge, and confusion about the validity of the disorder in younger children still exists. The situation is further complicated by the potential for the coexistence of ADHD and mood disorders in the same patient.
A history of the temporal course of symptoms can be most helpful. ADHD is typically a chronic disorder of lifelong duration. However, it may not be a problem until the patient enters the classroom setting. Mood disorders are typically characterized by a normal baseline followed by an acute onset of symptoms usually associated with acute sleep, appetite, and behavior changes. If inattentive, hyperactive, or impulsive behavior was not a problem in the previous year, it is unlikely to be ADHD. Typically, all these disorders are often heritable, so a positive family history can be informative in formulating a diagnosis. Successful treatment of relatives can offer guidance for appropriate treatment.
In prepubescent children, mania may be difficult to differentiate from ADHD and other disruptive behavior disorders. In both children and adolescents, preoccupation with violence, decreased need for sleep, impulsivity, poor judgment, intense and prolonged rages or dysphoria, hypersexuality, and some cycling of symptoms suggest bipolar disorder. Table 7–14 further defines points of differentiation between ADHD, conduct disorder, and bipolar disorder.
Table 7–14.Differentiating behavior disorders. ||Download (.pdf) Table 7–14.Differentiating behavior disorders.
|Symptom ||ADHD ||Conduct Disorder ||Bipolar Disorder |
|School problems ||Yes ||Yes ||Yes |
|Behavior problems ||Yes ||Yes ||Yes |
|Defiant attitude ||Occasional ||Constant ||Episodic |
|Motor restlessness ||Constant ||May be present ||May wax and wane |
|Impulsivity ||Constant ||May be present ||May wax and wane |
|Distractibility ||Constant ||May be present ||May wax and wane |
|Anger expression ||Short-lived (minutes) ||Plans revenge ||Intense rages (minutes to hours) |
|Thought content ||May be immature ||Blames others ||Morbid or grandiose ideas |
|Sleep disturbance ||May be present ||No ||May wax and wane |
|Self-deprecation ||Briefly, with criticism ||No ||Prolonged, with or without suicidal ideation |
|Obsessed with ideas ||No ||No ||Yes |
|Hallucinations ||No ||No ||Diagnostic, if present |
|Family history ||May be a history of school problems ||May be a history of antisocial behavior ||May be a history of mood disorders |
The Young Mania Rating Scale and The Child Mania Rating Scale may be helpful in eliciting concerning symptoms and educating families and patients, and in aiding timely referral to local mental health resources.
Children and adolescents with bipolar disorder are more likely to be inappropriate or aggressive toward peers and family members. Their symptoms almost always create significant interference with academic learning and peer relationships. The poor judgment associated with manic episodes predisposes individuals to dangerous, impulsive, and sometimes criminal activity. Legal difficulties can arise from impulsive acts, such as excessive spending, and acts of vandalism, theft, or aggression, that are associated with grandiose thoughts. Affective disorders are associated with a 30-fold greater incidence of successful suicide. Substance abuse may be a further complication, often representing an attempt at self-medication for the mood problem.
Most patients with bipolar disorder respond to pharmacotherapy with either mood stabilizers, such as lithium, atypical antipsychotics, or antiepileptic drugs. Lithium, risperidone, aripiprazole, quetiapine, asenapine, and olanzapine have been approved by the FDA for the treatment of acute and mixed manic episodes in adolescents. Other mood stabilizers, carbamazepine and valproate, are less effective. In addition, lithium and aripiprazole are approved for preventing recurrence. It is recommended that primary care providers refer all patients with suspected bipolar mood disorder to a mental health provider for diagnostic clarification and treatment. In situations where bipolar mood disorder is evident, a referral to a psychiatrist is recommended. In cases of severe impairment, hospitalization is required to maintain safety and initiate treatment. Supportive psychotherapy for the patient and family and education about the recurrent nature of the illness are critical. Family therapy should also include improving skills for conflict management and appropriate expression of emotion.
In addition to prescribing medications that have FDA approval for use in children with bipolar disorder (lithium and the atypical antipsychotic medications), providers may choose to use other medications off-label after nonresponse to first-line treatment or because of side-effect profiles. In these cases, it is recommended that a psychiatrist initiate and monitor early treatment. Once the goal of stabilization has been attained, it is reasonable for a primary care provider to provide maintenance therapy.
Physical or sexual abuse and exposure to domestic violence can also cause children to be mood labile, hyperactive, and aggressive, and PTSD should be considered by reviewing the history for traumatic life events in children with these symptoms. Diagnostic considerations should also include substance abuse disorders, and an acute organic process, especially if the change in personality has been relatively sudden, or is accompanied by other neurologic changes. Individuals with manic psychosis may resemble those with schizophrenia. Psychotic symptoms associated with bipolar disorder should clear with resolution of the mood symptoms, which should also be prominent. Hyperthyroidism should be ruled out.
It is not uncommon for the patient to need lifelong medication. In its adult form, bipolar disorder is an illness with a remitting course of alternating depressive and manic episodes. The time span between episodes can be years or months depending on the severity of illness and ability to comply with medication interventions. In childhood, the symptoms may be more pervasive and not fall into the intermittent episodic pattern until after puberty.
3. Disruptive Mood Dysregulation Disorder (DMDD)
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Persistent irritability and severe behavioral outbursts at least three times a week for 1 year or more.
The mood in between these symptoms is persistently negative (ie, irritable, angry or sad), which is observable by others.
The tantrums and negative moods are present in at least two settings.
Onset of illness prior to 10 years old.
Chronological or developmental age of at least 6 years old.
A disruption in functioning in more than one setting (eg, home, school and/or socially).
DMDD is a new diagnosis in the DSM-5. Historically, many of these chronically irritable children would have been diagnosed with some variation of bipolar mood disorder. Studies of the family history, functional brain studies and developmental progression suggest that these children are different from individuals with bipolar disorder. The prevalence is estimated to be 2%–5% and may decrease from childhood to adolescence. Early studies suggest males are at increased risk for this disorder.
Identification & Diagnosis
Children with DMDD experience severe tantrums in addition to chronic irritability. The tantrums must be inconsistent with the developmental age of the child. Currently, this diagnosis cannot be given to individuals over the age of 18. In cases where symptoms overlap between DMDD and ODD, DMDD supersedes ODD. Children who have experienced a manic or hypomanic episode cannot be given this diagnosis. Tantrums that occur only in relation to anxiety-provoking situations, or when routines are interrupted suggest anxiety, ASD or OCD and do not meet criteria for DMDD.
Medication trials are in early stages for this relatively new diagnosis, but identifying and treating comorbid conditions such as anxiety or ADHD may be helpful. Therapy is important for children and their families.
The differential diagnosis for DMDD is similar to other mood disorders. In addition, special attention and consideration should include screening for ADHD, anxiety, trauma, and significant interpersonal and relational deficits. Those with DMDD are at a higher risk than the general population to develop major depressive disorder and anxiety disorders as adults.
Children with DMDD have low frustration tolerance and may misread neutral social cues as threatening. They often function poorly in school and have impaired relations with peers and family. The parents or caregivers of these children are often very distressed and these children are likely to present to mental health clinics. Many parents will decrease the demands and limits placed on these children in an attempt to avoid tantrums. This can include withdrawing their children from developmentally appropriate health promoting activities. Children with DMDD often have dangerous behaviors that lead to psychiatric hospitalization.
With the addition of this diagnosis, researchers are now able to gather data to aid with the diagnosis, treatment, and outcome measures.
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SUICIDE IN CHILDREN & ADOLESCENTS
The suicide rate in young people has remained high for several decades. In 2014, suicide became the second leading cause of death among children and adolescents aged 10–24 years in the United States. The suicide rate among adolescents aged 15–19 years quadrupled from approximately 2.7 to 12.5 per 100,000 since the 1960s. It is estimated that each year, approximately 2 million US adolescents attempt suicide, yet only 700,000 receive medical attention for their attempt. Suicide and homicide rates for children in the United States are two to five times higher than those for the other 25 industrialized countries combined, primarily due to the prevalence of firearms in the United States. For children younger than 10 years, the rate of completed suicide is low, but has also increased. Adolescent girls make three to four times as many suicide attempts as boys of the same age, but the number of completed suicides is three to four times greater in boys. Firearms are the most commonly used method in successful suicides, accounting for 40%–60% of cases; hanging, carbon monoxide poisoning, and drug overdoses each account for approximately 10%–15% of cases.
Suicide is almost always associated with a psychiatric disorder and should not be viewed as a philosophic choice about life or death or as a predictable response to overwhelming stress. Most commonly it is associated with a mood disorder and the hopelessness that accompanies a severe depressive episode. Suicide rates are higher for Native American and Native Alaskan populations than for white, black, and Latino/Hispanic populations. Although suicide attempts are more common in individuals with a history of experiencing trauma, behavior problems, and academic difficulties, other suicide victims are high achievers who are temperamentally anxious and perfectionistic and who commit suicide impulsively after a failure or rejection, either real or perceived. Mood disorders (in both sexes, but especially in females), substance abuse disorders (especially in males), a history of trauma, and conduct disorders are commonly diagnosed at psychological autopsy in adolescent suicide victims. Some adolescent suicides reflect an underlying psychotic disorder, with the young person usually committing suicide in response to auditory hallucinations or psychotic delusions.
The vast majority of young people who attempt suicide give some clue to their distress or their tentative plans to commit suicide. Most show signs of dysphoric mood (anger, irritability, anxiety, or depression). For those who are screened, there is often a history of elevated distress reported on a screening instrument. Over 60% make comments such as “I wish I were dead” or “I just can’t deal with this any longer” within the 24 hours prior to death. In one study, nearly 70% of subjects experienced a crisis event such as a loss (eg, rejection by a girlfriend or boyfriend), public shaming, a failure, or an arrest prior to completed suicide. With ubiquitous social networking technologies and the presence of digital profiles, posting distress messages electronically and aggression in the form of cyber-bullying are important to identify and discuss when conducting risk assessments and gathering information about relationships, supports, and sources of stress.
Assessment of Suicide Risk
Routine screening for children 12 and older now includes questions regarding suicide. If a child or adolescent expresses suicidal thinking, the treating provider must ask if he or she has an active plan, intends to complete that plan, and has made previous attempts. Suicidal ideation accompanied by any plan warrants immediate referral for a psychiatric crisis assessment. This can usually be accomplished at the nearest emergency room (ER).
Assessment of suicide risk calls for a high index of suspicion and a direct interview with the patient and his or her parents or guardians. The highest risk of suicide is among white, adolescent boys. High-risk factors include previous suicide attempts, self-injurious behavior, a suicide note, and a viable plan for suicide with the availability of lethal means, close personal exposure to suicide, conduct disorder, and substance abuse. Other risk factors are signs and symptoms of major depression or dysthymia, a family history of suicide, a recent death in the family, suicide of student at the patient’s school and a view of death as a relief from the pain in the patient’s life.
Suicidal ideation and any suicide attempt must be considered a serious matter. The patient should not be left alone, and the treating provider should express concern and convey a desire to help. If a behavioral health clinician (BHC) is embedded in the practice, the BHC can aid in assessing the patient. Either the provider or the BHC should meet with the patient and the family, both alone and together, and listen carefully to their problems and perceptions. It is helpful to explicitly state that with the assistance of mental health professionals, solutions can be found. The practice should err on the side of caution, in deciding whether further referral or an emergency evaluation is indicated. Similar to reporting suspicion of child abuse, although the practice may not have the expertise or time to determine full suicide risk, primary care providers can determine that further evaluation is indicated. A thorough suicide assessment requires some level of expertise, a considerable amount of time and contact with multiple sources of information. The majority of patients who express suicidal ideation and all who have made a suicide attempt should be referred for psychiatric evaluation and possible hospitalization. Referral for further assessment is always appropriate when there is concern about suicidal thinking and behavior.
Regardless of whether a practice has an embedded behavioral health clinician, it is useful to have a practice-specific algorithm for suicidal youth. The algorithm should include the steps to be taken for youth who need to be sent to an emergency room, youth who need an urgent or less urgent referral, or youth that will be followed in the practice. The algorithm should specify who in the practice is responsible for each step. This should include who will call for emergency transport, if indicated, and who will flag a patient’s record to ensure the patient follows up with care recommendations. Additionally, the primary care practice will need to follow-up and document the outcome of the emergency assessment (eg, hospitalization, community referrals) in the patient’s record and schedule a follow-up visit in the primary care setting as soon as is feasible given the disposition.
Suicide prevention efforts include heightened awareness in the community and schools to identify at-risk individuals and increase access to services, including hotlines and counseling services. Restricting young people’s access to firearms is a critical factor, as firearms are responsible for 85% of deaths due to suicide or homicide in youth in the United States. Other means restriction methods include instructing families to lock up all medications. Many families are not aware that overdoses of over the counter medications such as acetaminophen can be lethal. In addition to increasing public awareness of the issue, media depictions of death by suicide, including news reporting and fictionalized accounts, could serve as a conversation starter for discussion of how an adolescent is understanding and thinking about this social issue. It is important to minimize sensationalism of deaths by suicide and have an open dialogue about what happened. This is particularly critical in communities that have recently experienced a death by suicide where there is increased vulnerability to the occurrence of additional incidents.
Finally, the treating provider should be aware of his or her own emotional reactions to dealing with suicidal adolescents and their families. Providers may be reluctant to cause a family stress or go against their will and require an emergency evaluation. Providers may have unfounded fears about precipitating suicide by direct and frank discussions of suicidal risk. Reviewing difficult cases with colleagues, developing formal or informal relationships with psychiatrists, and attending workshops on assessment and management of depression and suicidal ideation can decrease the anxiety and improve competence for primary care providers.
American Foundation for Suicide Prevention. https://afsp.org
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DISRUPTIVE, IMPULSE-CONTROL & CONDUCT DISORDERS
1. Oppositional Defiant Disorder
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months.
Loses temper, argues with adults, defies rules.
Blames others for own mistakes and misbehavior.
Angry, easily annoyed, vindictive.
Does not meet criteria for conduct disorder.
Oppositional defiant disorder is more common in families where caregiver dysfunction (eg, substance abuse, parental psychopathology, significant psychosocial stress) is present. It is also more prevalent in children with a history of multiple changes in caregivers, inconsistent, harsh, or neglectful parenting, or serious marital discord.
Identification & Diagnosis
Oppositional defiant disorder usually is evident before 8 years of age and may be an antecedent to the development of conduct disorder. The symptoms usually first emerge at home, but then extend to school and peer relationships. The disruptive behaviors of oppositional defiant disorder are generally less severe than those associated with conduct disorder and do not include hurting other individuals or animals, destruction of property, or theft.
Interventions include careful assessment of the psychosocial situation and recommendations to support parenting skills and optimal caregiver functioning. Assessment for comorbid psychiatric diagnoses such as learning disabilities, depression, and ADHD should be pursued and appropriate interventions recommended.
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Disorders of conduct affect approximately 9% of males and 2% of females younger than 18 years. This is a very heterogeneous population, and overlap occurs with ADHD, substance abuse, learning disabilities, neuropsychiatric disorders, mood disorders, and family dysfunction. Many of these individuals come from homes where domestic violence, child abuse, drug abuse, shifting parental figures, and poverty are environmental risk factors. Although social learning partly explains this correlation, the genetic heritability of aggressive conduct and antisocial behaviors is currently under investigation.
Identification & Diagnosis
The typical child with conduct disorder is a boy with a turbulent home life and academic difficulties. Defiance of authority, fighting, tantrums, running away, school failure, and destruction of property are common symptoms. With increasing age, fire-setting and theft may occur, followed in adolescence by truancy, vandalism, and substance abuse. Sexual promiscuity, sexual perpetration, and other criminal behaviors may develop. Hyperactive, aggressive, and uncooperative behavior patterns in the preschool and early school years tend to predict conduct disorder in adolescence with a high degree of accuracy, especially when ADHD goes untreated. A history of reactive attachment disorder is an additional childhood risk factor. The risk for conduct disorder increases with inconsistent and severe parental disciplinary techniques, parental alcoholism, and parental antisocial behavior.
Effective treatment can be complicated by the psychosocial problems often found in the lives of children and adolescents with conduct disorders. These problems may also interfere with achieving compliance with treatment recommendations. Efforts should be made to stabilize the environment and improve functioning within the home, particularly as it relates to parental functioning and disciplinary techniques. Identification of learning disabilities and placement in an optimal school environment is critical. Any associated neurologic and psychiatric disorders should be addressed.
Residential treatment may be necessary for individuals whose symptoms do not respond to lower level interventions, or whose environment is not able to meet their needs for supervision and structure. Juvenile justice system involvement is common in cases where conduct disorder behaviors lead to illegal activities, theft, or assault.
Medications such as mood stabilizers, neuroleptics, stimulants, and antidepressants have all been studied in youth with conduct disorders, yet none has been found to be consistently effective. Each patient suspected of conduct disorder should be screened for other common psychiatric disorders and a history of trauma prior to the initiation of medication. Providers should use caution when prescribing various medications off-label for disruptive behavior. Early involvement in programs, such as Big Brothers, Big Sisters, scouts, and team sports, in which consistent adult mentors and role models interact with youth, decreases the chances that the youth will develop antisocial personality disorder. Multisystemic therapy (MST) is being used increasingly as an intervention for youth with conduct disorders and involvement with the legal system. MST is an intensive home-based model of care that seeks to stabilize and improve the home environment and to strengthen the support system and coping skills of the individual and family.
Young people with conduct disorders, especially those with more violent histories, have an increased incidence of neurologic signs and symptoms, psychomotor seizures, psychotic symptoms, mood disorders, ADHD, and learning disabilities. Efforts should be made to identify these associated disorders because they may require specific therapeutic interventions. Conduct disorder is best conceptualized as a final common pathway emerging from a variety of underlying psychosocial, genetic, environmental, and neuropsychiatric conditions.
The prognosis is based on the ability of the child’s support system to mount an effective treatment intervention consistently over time. The prognosis is generally worse for children in whom the disorder presents before age 10 years; those who display a diversity of antisocial behaviors across multiple settings; and those who are raised in an environment characterized by parental antisocial behavior, alcoholism or other substance abuse, and conflict. Nearly half of individuals with a childhood diagnosis of conduct disorder develop antisocial personality disorder as adults.
HIGH-RISK PATIENTS & HOMICIDE
Aggression & Violent Behavior in Youth
The tragic increase in teenage violence, including school shootings, is of particular concern to health professionals, as well as to society at large. There is strong evidence that screening and initiation of interventions by primary care providers can make a significant difference in violent behavior in youth. Although the prediction of violent behavior remains a difficult and imprecise endeavor, providers can support and encourage several important prevention efforts.
The vast majority of the increase in youth violence, including suicides and homicides, involves the use of firearms. Thus, the presence of firearms in the home, the method of storage and safety measures taken when present, and access to firearms outside the home should be explored regularly with all adolescents as part of their routine medical care.
It is important to note that violent behavior is often associated with suicidal impulses. In the process of screening for violent behavior, suicidal ideation should not be overlooked. Any comment about wishes to be dead, or hopelessness, should be taken seriously and assessed immediately.
Interventions for parents include encouraging parents and guardians to be aware of their child’s school attendance and performance. Parents should be encouraged to take an active role and learn about their children’s friends, be aware of who they are going out with, where they will be, what they will be doing, and when they will be home. Most students involved in school violence might have been identified earlier and potentially may have benefited from interventions to address problems in social and educational functioning in the school environment. Communities and school districts nationwide have increased their efforts to identify and intervene with students whom teachers, peers, or parents recognize as having difficulty.
Threats & Warning Signs Requiring Immediate Consultation
Any and all threats that children make can be alarming. However, it is important to respond to the more serious and potentially lethal threats. These threats should be taken with the utmost seriousness and parents/guardians should see a mental health provider immediately. Such threats include threats/warnings about hurting or killing someone or oneself, threats to run away from home and/or threats to damage or destroy property.
Factors Associated With Increased Risk of Violent and/or Dangerous Behavior
Not all threats signify imminent danger. There are several potential predictors to consider when assessing the dangers of a child or adolescent, such as past history of violence or aggressive behavior, including uncontrollable angry outbursts; access to guns or other weapons; history of getting caught with a weapon in school; and family history of violent behaviors. These are likely predictors of future violent behavior. In addition, children who witness abuse and violence at home and/or have a preoccupation with themes and acts of violence (eg, TV shows, movies, music, violent video games, etc) are also at high risk of such behavior. Victims of abuse (ie, physical, sexual, and/or emotional) are more susceptible to feeling shame, loss, and rejection. The difficulty of dealing with abuse can further exacerbate an underlying mood, anxiety, or conduct disorder. Children who have been abused are more likely to be perpetrators of bullying and engage in verbal and physical intimidation toward peers. They also may be much more prone to blame others and are unwilling to accept responsibility for their own actions. Substance use is another major factor frequently associated with violent, aggressive, and/or dangerous behavior, particularly because it impacts judgment and is often associated with decreased inhibition and increased impulsivity. Socially isolated children also carry a high risk for violent and dangerous behavior. These include children with little to no adult supervision, poor connection with peers, and little to no involvement in extracurricular activities. These individuals may be more likely to seek out deviant peer groups for a sense of belonging.
How Providers & Parents Can Respond to Concerns of Violence and/or Dangerous Behavior
If a provider or parent suspects that a child is at risk for violent and/or dangerous behavior, the most important intervention is to talk with the child immediately about alleged threat and/or behavior. One should consider the child’s past behavior, personality, and current stressors when evaluating the seriousness and likelihood of them engaging in a destructive or dangerous behavior. If the child already has a mental health provider, he/she should be contacted immediately. If they are not reachable, the parent(s)/guardian(s) should take the child to the closest ED for a crisis evaluation. It is always acceptable to contact local police for assistance, especially if harm to others is suspected. Another indication that warrants a crisis evaluation is if a child refuses to talk, is argumentative, responds defensively, or continues to express violent or dangerous thoughts/plans. Continuous, face-to-face adult supervision is essential while awaiting professional intervention. After evaluation, it is imperative to follow up with recommendations from mental health provider(s) to ensure safety and ongoing management.
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SOMATIC SYMPTOM & RELATED DISORDERS
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Medically unexplained symptoms are no longer required for these disorders other than conversion disorder. Most disorders in this category are characterized by focus on symptoms within a medical setting.
Distress and/or functional impairment are present in somatic symptom disorder while functional impairment is more common in conversion disorder.
The category of somatic symptoms and related disorders includes somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder) psychological factors affecting other medical conditions, factitious disorder and factitious disorder imposed by another (Table 7–15).
Table 7–15.Somatoform disorders in children and adolescents. ||Download (.pdf) Table 7–15.Somatoform disorders in children and adolescents.
|Disorder ||Major Clinical Manifestations |
|Somatic symptom disorder, factitious disorder, other specified somatic symptom and related disorder, unspecified somatic symptom and related disorder ||A somatic symptom or symptoms cause significant distress, worry and concern and may take up considerable time and energy. |
|Conversion disorder (functional neurological symptom disorder) ||Symptom onset follows psychologically stressful event; symptoms express unconscious feelings and result in secondary gain. |
|Illness anxiety disorder ||Somatic symptoms if present are mild. Focus is on fear of having or developing an illness leading to maladaptive behaviors. |
|Psychological factors affecting other medical conditions ||Psychological or behavioral factors negatively impact a medical illness. |
|Factitious disorder or factitious disorder imposed on another ||Deliberate false presentation of oneself or another (or causing in oneself or another) signs or symptoms of a physical or psychological problem. |
Patients with these disorders are commonly encountered in primary care and can be conceptualized as suffering; differences in presentation are likely related to cultural, contextual factors, individual experiences (such as trauma) and individual differences such as pain sensitivity. Families and cultures that value physical suffering while devaluing or ignoring psychological distress, reinforce the development of these disorders. Family members who are ill, physically disabled, or suffer from any of these disorders, can serve as models for children. More extreme parental dysfunction can manifest as factitious disorder imposed on another with the child as the victim.
Identification & Diagnosis
Somatic symptom disorder often presents in school age children and adolescents with the somatic symptom of headaches or gastrointestinal distress. Conversion symptoms by definition involve alterations in voluntary motor or sensory function and are often more transient in pediatric patients than adults. Common symptoms include unusual sensory phenomena, paralysis, and movement or seizure-like disorders. A conversion symptom is thought to be an expression of underlying psychological conflict. The specific symptom may be symbolically determined by the underlying conflict and may resolve the dilemma created by the underlying wish or fear (eg, a seemingly paralyzed child need not fear expressing his or her underlying rage or aggressive retaliatory impulses).
Children with conversion disorder may be surprisingly unconcerned about the substantial disability deriving from their symptoms. Symptoms include unusual sensory phenomena, paralysis, vomiting, abdominal pain, intractable headaches, and movement or seizure-like disorders. For both somatic symptom disorder and conversion disorder, the physical symptoms often begin with a stressful event at school, with peers or within the context of a family experiencing stress, such as serious illness, a death, or family discord.
Medical providers are often the first to see the patient and identify these disorders. Many of these patients can be treated within the pediatric primary care setting, utilizing the relationship between the pediatric provider and the family to maximize outcomes. For those who need referral to other settings, ongoing care by the pediatrician can help insure families engage in other indicated treatments.
In most cases, conversion symptoms resolve quickly when the child and family are reassured that the symptom is a way of reacting to stress. The child is encouraged to continue with normal daily activities, knowing that the symptom will abate when the stress is resolved. Treatment of conversion disorders includes acknowledging the symptom rather than telling the child that the symptom is not medically justified and responding with noninvasive interventions such as physical therapy while continuing to encourage normalization of the symptoms. If the symptom does not resolve with reassurance, further investigation by a mental health professional is indicated. Comorbid diagnoses such as depression and anxiety disorders should be addressed, and treatment with psychopharmacologic agents may be helpful.
Somatic symptom disorder patients may respond to the same treatment. If the family structure or the patient cannot tolerate psychological approaches, somatic symptom patients may respond to regular, short, scheduled medical appointments to address the complaints at hand. In this way they do not need to precipitate emergencies to elicit medical attention. The medical provider should avoid invasive procedures unless clearly indicated and offer sincere concern and reassurance. The provider should also avoid telling the patient “it’s all in your head” and should not abandon or avoid the patient, as somatic symptom disorder patients are at great risk of seeking multiple alternative treatment providers and potentially unnecessary treatments. Although, not a DSM disorder, many parents worry about their child developing or having a serious illness. These families may also benefit from the above approach, in conjunction with encouragement for the pediatric patient to engage in health promoting activities such as involvement in sports. Parents who do not feel supported are also at risk to seek alternative opinions and procedures for their child.
Treatment for patients who are suffering from psychological factors impacting illness should be targeted to the underlying problem, such as treatment of anxious avoidance, motivational interviewing to target substance abuse or adherence problems.
Health care providers who suspect factitious disorder imposed on another may need to involve a specialist to confirm the diagnosis. Communication between providers is critical to helping these patients. Child protective services and legal counsel may also need to be alerted. Although parents who are perpetrating factitious disorder imposed on another can appear concerned about the wellbeing of their child, studies have found child victims’ mental health and well-being improved when they were removed from more extreme perpetrating caregivers.
Somatic symptoms are often associated with anxiety and depressive disorders (see Tables 7–7 and 7–15). Occasionally, psychotic children have somatic preoccupations and even somatic delusions.
Children with conversion disorder may have some secondary gain associated with their symptoms. Several reports have pointed to the increased association of conversion disorder with sexual overstimulation or sexual abuse. As with other emotional and behavioral problems, health care providers should always screen for physical and sexual abuse.
Prognosis is dependent on family factors, age, and disorder. Parents who support the view that symptoms can be related to stress can help patients engage in appropriate treatments. Younger patients with conversion symptoms have better prognosis than older patients with somatic symptom disorder. Patients who have had the disorder for a longer period of time may be less responsive to treatment. Psychiatric consultation can be helpful and for severely incapacitated patients, is indicated.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
The precipitating event or circumstance is identifiable.
The symptoms have appeared within 3 months after the occurrence of the stressful event.
Although the child experiences distress or some functional impairment, the reaction is not severe or disabling.
The reaction does not persist more than 6 months after the stressor has terminated.
The most common and most disturbing stressors in the lives of children and adolescents are the death of a loved one, marital discord, separation and divorce, family illness, a change of residence or school setting, experiencing a traumatic event, and, for adolescents, peer-relationship problems. These stressors naturally have a significant impact on children and adolescents.
Identification & Diagnosis
When faced with stress, children can experience many different symptoms, including changes in mood, changes in behavior, anxiety symptoms, and physical complaints. When the reaction is significantly out of proportion to the stressor and a decline in functioning is noted, a diagnosis of adjustment disorder is highly suspected. The two main categories of adjustment disorders include disturbance in emotions (ie, depression and anxiety) and/or conduct.
The mainstay of treatment involves genuine empathy and assurance to the parents and the patient that the emotional or behavioral change is a predictable consequence of the stressful event. This validates the child’s reaction and encourages the child to talk about the stressful occurrence and its aftermath. Parents are encouraged to help the child with appropriate expression of feelings, while defining boundaries for behavior that prevent the child from feeling out of control and ensure safety of self and others. Maintaining or reestablishing routines can also alleviate distress and help children and adolescents adjust to changing circumstances by increasing predictability and decreasing distress about the unknown.
When symptoms emerge in reaction to an identifiable stressor but are severe, persistent, or disabling, depressive disorder, anxiety disorder, and conduct disorders must be considered.
The duration of symptoms in adjustment reactions depends on the severity of the stress; the child’s personal sensitivity to stress and vulnerability to anxiety, depression, and other psychiatric disorders; and the available support system.
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Disorganized speech (rambling or illogical speech patterns)
Disorganized or bizarre behavior
Hallucinations (auditory, visual, tactile, olfactory)
Paranoia, ideas of reference
Negative symptoms (ie, flat affect, avolition, alogia)
The incidence of schizophrenia is about 1 per 10,000 per year. The onset of schizophrenia is typically between the middle to late teenage and early 30s. Symptoms usually begin after puberty, although a full “psychotic break” may not occur until the young adult years. Childhood onset (before puberty) of psychotic symptoms due to schizophrenia is uncommon and usually indicates a more severe form of the spectrum of schizophrenic disorders. Childhood-onset schizophrenia is more likely to be found in boys.
Schizophrenia has a strong genetic component. Other psychotic disorders that may be encountered in childhood or adolescence include schizoaffective disorder and psychosis not otherwise specified (psychosis NOS). Psychosis NOS may be used as a differential diagnosis when psychotic symptoms are present, but the cluster of symptoms is not consistent with a schizophrenia diagnosis.
Identification & Diagnosis
Children and adolescents display many of the symptoms of adult schizophrenia. Hallucinations or delusions, bizarre and morbid thought content, and rambling and illogical speech are typical. Affected individuals tend to withdraw into an internal world of fantasy and may then equate fantasy with external reality. They generally have difficulty with schoolwork and with family and peer relationships. Adolescents may have a prodromal period of depression prior to the onset of psychotic symptoms. The majority of patients with childhood-onset schizophrenia have had nonspecific psychiatric symptoms or symptoms of delayed development for months or years prior to the onset of their overtly psychotic symptoms.
Obtaining a family history of mental illness is critical when assessing children and adolescents with psychotic symptoms. Psychological testing, particularly the use of projective measures, is often helpful in identifying or ruling out psychotic thought processes. Psychotic symptoms in children younger than age 8 years must be differentiated from manifestations of normal vivid fantasy life or abuse-related symptoms. Children with psychotic disorders often have learning and attention disabilities in addition to disorganized thoughts, delusions, and hallucinations. In psychotic adolescents, mania is differentiated by high levels of energy, excitement, and irritability. Any child or adolescent exhibiting new psychotic symptoms requires a medical evaluation that includes physical and neurologic examinations (including consideration of magnetic resonance imaging and electroencephalogram), drug screening, and metabolic screening for endocrinopathies, Wilson disease, and delirium.
The treatment of childhood and adolescent schizophrenia focuses on four main areas: (1) decreasing active psychotic symptoms, (2) supporting development of social and cognitive skills, (3) reducing the risk of relapse of psychotic symptoms, and (4) providing support and education to parents and family members. Antipsychotic medications (neuroleptics) are the primary psychopharmacologic intervention. In addition, a supportive, reality-oriented focus in relationships can help to reduce hallucinations, delusions, and frightening thoughts. In situations where psychosis is evident, a referral to a psychiatrist is recommended. In cases of severe impairment, hospitalization is required to maintain safety and initiate treatment. A special school or day treatment environment may be necessary, depending on the child’s or adolescent’s ability to tolerate the school day and classroom activities. Support for the family emphasizes the importance of clear, focused communication and an emotionally calm climate in preventing recurrences of overtly psychotic symptoms.
Special Considerations Regarding the Use of Antipsychotic Medication
While it is expected that a psychiatrist initiate treatment, primary care providers undoubtedly treat children on antipsychotics and should become familiar with management and potential common and severe side effects of this class of medication. The “atypical antipsychotics” differ from conventional antipsychotics in their receptor specificity and effect on serotonin receptors. Conventional antipsychotics are associated with a higher incidence of movement disorders and extrapyramidal symptoms due to their wider effect on dopamine receptors. The atypical antipsychotics have a better side-effect profile for most individuals and comparable efficacy for the treatment of psychotic symptoms and aggression. Because of their increased use over conventional antipsychotics, the information that follows primarily focuses on safe use of atypical antipsychotics.
Common adverse effects of the atypical antipsychotics are cognitive slowing, sedation, orthostasis, and weight gain. Most side effects tend to be dose related. Less frequent, but important side effects are development of type 2 diabetes and change in lipid and cholesterol profile. The risk-benefit ratio of the medication for the identified target symptom should be carefully considered and reviewed with the parent or guardian. Providers should obtain baseline height, weight, and waist circumference, observe and examine for tremors and other abnormal involuntary movements, and establish baseline values for CBC and LFTs, lipid profile, and cholesterol. Antipsychotics can cause QT prolongation leading to ventricular arrhythmias. Therefore, it is important to obtain an ECG if there is a history of cardiac disease or arrhythmia. Medications that affect the cytochrome P-450 isoenzyme pathway (including SSRIs) may increase the neuroleptic plasma concentration and increase risk of QTc prolongation.
In addition to the above concerns, postmarketing clinical use has demonstrated significant reports of hyperglycemia, and diabetes mellitus. Table 7–16 presents the currently recommended monitoring calendar. Baseline and ongoing evaluations of significant markers are considered standard clinical practice. It is important to mention other side effects, which include irregular menses, gynecomastia, and galactorrhea due to increased prolactin, sexual dysfunction, photosensitivity, rashes, lowered seizure threshold, hepatic dysfunction, and blood dyscrasias.
Table 7–16.Health monitoring and antipsychotics. ||Download (.pdf) Table 7–16.Health monitoring and antipsychotics.
| ||After Initiation ||Thereaftera |
|Baseline ||4 wk ||8 wk ||12 wk ||Quarterly ||Annually ||q5y |
|Personal/family history || || || || ||✓ || |
|Weight (BMI) ||✓ ||✓ ||✓ ||✓ || || |
|Waist circumference || || || || ||✓ || |
|BP || || ||✓ || ||✓ || |
|Fasting blood sugar || || ||✓ || ||✓ || |
|Fasting lipid profile || || ||✓ || || ||✓ |
Other troublesome side effects of antipsychotics include dystonia, akathisia (characterized by an urge to be in constant motion and difficulty sitting still), pseudoparkinsonism, and tardive dyskinesia (TD). These side effects typically occur in a stepwise fashion and are also dose related. The first three are reversible and typically are relieved by anticholinergic agents, such as benztropine (Cogentin) and diphenhydramine, or β-blockers, specifically for akathisia. The risk of TD is small in patients on atypical antipsychotics, and those on conventional antipsychotics for less than 6 months. There is no universally effective treatment. Withdrawal dyskinesias are reversible movement disorders that appear following withdrawal of neuroleptic medications. Dyskinetic movements develop within 1–4 weeks after withdrawal of the drug and may persist for months.
A severe side effect of antipsychotics is neuroleptic malignant syndrome (NMS). NMS is a very rare medical emergency associated primarily with the conventional antipsychotics, although it has also been reported with atypical antipsychotics. It is manifested by severe muscular rigidity, mental status changes, fever, autonomic lability, and myoglobinemia. NMS can occur without muscle rigidity in patients taking atypical antipsychotics and should be considered in the differential diagnosis of any patient on antipsychotics who presents with high fever and altered mental status. Mortality as high as 30% has been reported. Treatment includes immediate medical assessment and withdrawal of the neuroleptic and may require transfer to an intensive care unit.
The patient should be examined at least every 3 months for side effects, including observation for TD using the Abnormal Involuntary Movement Scale quarterly monitoring of blood pressure, weight gain, abdominal circumference, dietary and exercise habits, and, if indicated, fasting blood glucose and lipid panels. In cases of significant weight gain or abnormal laboratory values, patients should either be switched to an agent with a decreased risk for these adverse events or should receive specific treatments for the adverse events when discontinuation of the offending agent is not possible. In general, a child and adolescent psychiatrist should evaluate children with psychosis, initiate treatment and refer back to the pediatrician once symptoms are adequate control.
Antipsychotics are also used for acute mania and as adjuncts to antidepressants in the treatment of psychotic depression (with delusions or hallucinations). Antipsychotics may also be used cautiously in refractory PTSD, in refractory OCD, and in individuals with markedly aggressive behavioral problems unresponsive to other interventions. In some instances, they may be useful for the body image distortion and irrational fears about food and weight gain associated with anorexia nervosa.
Schizophrenia is a chronic disorder with exacerbations and remissions of psychotic symptoms. Generally, earlier onset (prior to age 13 years), poor premorbid functioning (oddness or eccentricity), and predominance of negative symptoms (withdrawal, apathy, or flat affect) over positive symptoms (hallucinations or paranoia) predict more severe disability, while later age of onset, normal social and school functioning prior to onset, and predominance of positive symptoms are associated with better outcomes and life adjustment to the illness.
The American Academy has a practice parameter regarding the use of atypical antipsychotics in youth available at https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf.
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OTHER PSYCHIATRIC CONDITIONS
Several psychiatric conditions are covered elsewhere in this book. Refer to the following chapters for detailed discussion:
Attention-deficit/hyperactivity disorder (ADHD): see Chapter 3.
Autism and pervasive developmental disorders: see Chapter 3.
Enuresis and encopresis: see Chapter 3.
Eating disorders: see Chapter 6.
Intellectual disability/mental retardation: see Chapter 3.
Substance abuse: see Chapter 5.
Sleep disorders: see Chapter 3.
Tourette syndrome and tic disorders: see Chapter 25.