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 (TTM; 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 1 hour/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, and 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—occasionally above maximum recommended daily dose—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 (TCA) 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. Some individuals have benefitted from other nonpharmacologic interventions such as neurofeedback and transcranial magnetic stimulation (TMS); however, they are not FDA approved for this condition.
OCD often occurs with other compulsive disorders such as TTM (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.
International Obsessive Compulsive Foundation: https://iocdf.org/
. Accessed June 26, 2019.
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 settings, 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-5. This disorder is a subset of obsessive-compulsive and related disorders. As with other additions to the DSM-5, this disorder has been around for over a century; however, it was not included in previous diagnostic manuals. There are some who 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, like 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 (eg, 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 for N-acetylcysteine (NAC) 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 TTM, 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 ED 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.
Posttraumatic Stress Disorder
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Signs and symptoms of hyperarousal and reactivity.
Negative changes in thoughts and mood.
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. Witnessing events through electronic media does not count as exposure to traumatic events. Individuals who have a previous history of trauma or with 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 typically show persistent fear, anxiety, and hypervigilance. Children may regress developmentally, 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 and adolescents with PTSD are often more irritable and can experience detachment and diminished interest in activities. They reexperience elements of the events in the form of nightmares and flashbacks. In the symbolic play of children with PTSD, 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. A subset of children experience dissociative symptoms such as feeling detached or unreal. The criteria for PTSD for children younger than 6 have been adjusted for development, accounting for a more limited repertoire of emotions and behaviors in younger children compared to older youth. Symptoms must be present for at least 1 month to meet criteria for PTSD but can present months after the event.
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. Treatment of patients with PTSD includes education regarding the nature of the disorder and the many varied symptoms that parents may not recognize as related to PTSD. The child needs support, reassurance, and empathy, and the primary caregiver may also need additional help to provide this. Individual and family psychotherapy are central features of treatment interventions. Treatments differ based on age of child, chronicity of trauma, and access to treatment. Young children may benefit from therapy focused on strengthening the parent child relationship whereas other treatments additionally focus on creating a developmentally appropriate trauma narrative to help the child understand and process their experience. Trauma-focused cognitive behavioral therapy (TF-CBT) has the most evidence for treatment of children and adolescents with PTSD while treatments such as eye movement desensitization and reprocessing therapy (EMDR) have more limited evidence. Pediatricians can help the family 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.
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 have been exposed to multiple traumas are more likely to require treatment with medications. Currently, there are no medications with FDA approval for treating PTSD in 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 anti adrenergic agents (clonidine, guanfacine or propranolol), mood stabilizers, antidepressants, and second-generation antipsychotics.
Growing evidence supports 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.
Many of the symptoms of PTSD can be mistaken for other disorders such as depression, anxiety, primary substance abuse, ADHD, learning disorders, ODD, bipolar disorder, and even psychosis in more severe cases. All behavioral health assessments should include inquiries related to traumatic events. It is important not to miss trauma-related etiology as this may change treatment focus. Traumatic events may not lead to PTSD but may cause grief, an adjustment disorder, depression, or an acute stress disorder (same criteria as PTSD but symptoms last < 1 month). Children with PTSD may have comorbid diagnoses that require treatment. This diagnostic complexity often requires the assistance of the child psychiatrist or other mental health provider.
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.
For resources and evidence-based interventions: National Child Trauma Stress Network: https://www.nctsn.org
. Accessed June 26, 2019.
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 can be very helpful for school age children and adolescents with ADHD. For children diagnosed with ADHD younger than 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 a stimulant from the other class (amphetamines vs methylphenidate stimulants). 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, selective noradrenergic reuptake inhibitors, and central α2A-adrenergic receptor agonists (ie, guanfacine and clonidine) have FDA approval for the treatment of ADHD in children.
A device placed on the forehead overnight to stimulate the trigeminal nerve has FDA approval for treatment of children age 7–12 years who are not also being treated with medication. The effect of treatment with the external trigeminal nerve stimulation (ETNS) system is mild and did not separate from placebo until 4 weeks. Side effects include appetite increase, sleep difficulties, teeth clenching, headache, and fatigue.
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% 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, anxiety tachycardia, hypertension, depression, mania, and psychotic symptoms. Reduced growth velocity can occur, however, for individual patient’s ultimate height is not usually compromised. 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 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. Insufficient data continue 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. Formulations such as the methylphenidate transdermal patch or lisdexamfetamine are more difficult to abuse. 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 and those who don’t meet full criteria for ADHD may still have functional impairment. 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.
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 9% for adolescents, and this is likely even higher in patients seen in primary care. Over the course of adolescence, 20% of individuals will experience depression. The rate of depression in females approaches adult levels by age 15, and the lifetime risk of depression ranges from 10% to 25% for women and 5% to 12% for men. 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. The incidence of depression in children is higher when other family members have been affected by depressive disorders.
Identification & Diagnosis
Clinical depression can be defined as a persistent state of unhappiness or misery that interferes with pleasure or productivity. Children and younger adolescents are more likely to present with an irritable mood state and older adolescents with a sad mood more similar to adults. 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, stomach aches, or musculoskeletal pains.
Clinical depression is typically identified by asking about the symptoms. Adolescents 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), 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. Table 7–13 describes some symptoms of depression as they may appear in children and adolescents.
Table 7–13.Clinical manifestations of depression in children and adolescents. ||Download (.pdf) Table 7–13. 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 |
The AAP recommends annual screening for depression in children age 12 and older using a standardized measure. The Center for Epidemiologic Study—Depression Scale for Children (CES-DC), 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 varies by severity level. Children and adolescents with mild depression should receive close monitoring over several weeks and psychoeducation that includes caregivers. The treatment team (patient, caregiver, and provider) may be able to identify targets for change that may improve depression. See Table 7–14.
Table 7–14.Targets to improve depression. ||Download (.pdf) Table 7–14. Targets to improve depression.
|Positive lifestyle changes (improve sleep hygiene, exercise, nutrition) |
|Positive parenting |
|Increase supports at school |
|Address stressors |
|Support positive peer relationships |
Treatment for moderate to severe depression includes developing a comprehensive plan to treat the depressive episode, help the family to respond effectively to the patient’s emotional needs, and build supports within the school setting if needed. Referrals should be considered for individual and possibly adjunctive family therapy. CBT and interpersonal therapy (IPT) both have evidence for improving depressive symptoms in children and adolescents. CBT 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 7–11). 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 CBT or IPT. 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 7–11 outlines the distinct differences between some of the most commonly used antidepressant medications.
A. Selective Serotonin Reuptake Inhibitors (SSRIs)
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 although many individuals may experience benefit earlier. The starting dose for a child younger than 12 years is generally half the starting dose for an adolescent, but young children may need eventual doses similar to adolescents or adults. Pharmacokinetic studies suggest that SSRIS may be metabolized faster in young children, leading to shorter half-lives. SSRIs are usually given once a day, in the morning with breakfast, but lower doses of sertraline should be administered twice daily. Individuals who experience sedation (1 in 10) or find mornings difficult to remember to take their medication may 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 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, and activation is more likely to occur with preadolescent children. 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 (NMS) 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 or other 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. SNRIs also can increase heart rate. 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. The treatment of resistant depression study in adolescents (TORDIA) compared switching adolescents with depression who had not responded to initial treatment with an SSRI to another SSRI, venlafaxine, or medication plus placebo. Response rates were best for the combination (therapy plus medication) arm but did not differ between the two medications arms. However, the patients treated with venlafaxine experienced more skin problems and elevated blood pressure and heart rate. Duloxetine has been associated with severe skin reactions such as erythema multiforme and Stevens-Johnson syndrome, and venlafaxine has been associated with interstitial lung disease and eosinophilic pneumonia and increased suicidal ideation.
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.
TCAs are an older class of antidepressants, which include imipramine, desipramine, clomipramine, nortriptyline, and amitriptyline. The lack of demonstrated efficacy, high-risk side-effect profile potential, and for lethality with overdose have led steering committees and professional organizations to recommend that primary care providers not prescribe TCAs for depression in children and adolescents. Providers should not be confused by FDA approval of imipramine and desipramine for enuresis in children age 6 years and older.
The risk of suicide is the most significant side effect associated with depressive episodes. In addition, adolescents with depression are at higher risk for substance abuse and engaging 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. 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. Subsequent meta-analysis estimated this risk to be lower. 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. 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. Psychotic symptoms during depression, early-onset depression, and family history of bipolar disorder all increase the risk for bipolar disorder. 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.
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 illness can be difficult to diagnose and challenging to treat. It is generally recommended that children and adolescents who may have this diagnosis should be evaluated by a child and adolescent psychiatrist for diagnosis and further treatment if indicated.
Recent prospective and family studies have helped differentiate children who were previously diagnosed with bipolar disorder due to chronic irritability, as more likely to develop a mood or anxiety disorder later in adolescence or adulthood. A new disorder was created to help describe the presentation and course of these children: disruptive mood dysregulation disorder (DMDD). Diagnosing bipolar disorder (previously referred to as manic-depressive disorder) relies on meeting full criteria for a current or past manic episode (bipolar I disorder) or current or past hypomanic and depressive episode (bipolar II disorder). This change will likely lead to fewer diagnoses of bipolar disorder for children and younger adolescents and decrease the exposure of children to antipsychotic medication. It is still important to be vigilant for bipolar disorder as 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 is 1%–2%.
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, increase in goal-directed activity, difficulty in sustaining concentration, and a decreased need for sleep often including lack of fatigue the following day. 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, but the change from baseline is notable to others. The clinical picture can be quite dramatic, with florid psychotic symptoms of delusions and hallucinations accompanying extreme hyperactivity and impulsivity. Hypomanic episodes, characteristic of bipolar II disorder, are lower intensity manic episodes that do not cause social impairment and do not typically last as long as manic episodes. Although common, the co-occurrence of depression with bipolar I disorder is not a diagnostic requirement, while it is for bipolar II disorder. Cyclothymic disorder 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 depressive or hypomanic episode. Symptoms must be interpreted within a developmental context and differentiated from the normal moods and mood changes that occur in childhood and adolescence. Note that other specified bipolar and related disorder criteria describe youth who have hypomania but have not met full criteria for depression, or youth with shorter duration of manic symptoms (2–3 days).
The Mania Rating Scale (Child, CMRS, Youth YMRS, and Parent P-YMRS) can be useful as an additional tool to help patients and families describe moods, but providers should keep in mind that these are not specific. Parent reports of symptoms are typically more diagnostically helpful than patient or teacher reports.
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. Other levels of care that may be appropriate with less severe presentations include day treatment, intensive outpatient therapy (two to three times per week) in home therapy or routine outpatient therapy. Once the goal of stabilization has been attained, it is reasonable for a primary care provider to provide maintenance therapy preferably with ongoing access to child and adolescent psychiatrist if symptoms worsen.
Pediatricians can help reinforce the need for ongoing treatments, provide additional psychoeducation, health maintenance and surveillance for associated problems such as substance abuse, sexually transmitted diseases, and accessing other supports such as a 504 plan or IEP if indicated.
Psychotherapy and medication are the mainstay of treatment. Medications are chosen based on current symptoms, side effects, family preference, and differ by polarity of symptoms (depression vs mania). The best evidence for treatment for mania is with second-generation antipsychotics, followed by lithium. Nonresponders may require a combination of medications. 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, lamotrigine, carbamazepine, and valproate are less effective. Lithium and aripiprazole are approved for preventing recurrence.
Patients with bipolar disorder experience depressive symptoms that can be challenging to treat. It is generally recommended that patients should be on a mood stabilizer. At least one mood stabilizer is approved for pediatric bipolar depression (lurasidone). Patients with mild depression should receive therapy and other interventions prior to considering adding an antidepressant (refer to depression section) to a second-generation antipsychotic or other mood stabilizer. Choices for additional antidepressants, if the patient fails monotherapy, are similar to depression (refer to that section).
Therapy for children and adolescents with bipolar disorder generally includes psychoeducation, and there is some evidence that psychoeducation alone may have some benefit. More recent studies with youth who met criteria for bipolar I and II disorders found family-focused therapy (FFT) to be effective with outcomes related to bipolar depression and mania. Youth at risk for bipolar disorder, based on parent diagnosis, experienced improved outcomes related to hypomania symptoms. Components of this therapy include (1) psychoeducational activities like monitoring symptoms, recognizing triggers, and the importance of continuing medications, and (2) improving family communication with a focus on problem solving skills, appropriate expression of emotion, and developing and maintaining routines. Other therapies with some evidence include CBT, DBT, interpersonal and social rhythm therapy, and other family therapies.
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. DMDD, ADHD, oppositional defiant disorder, and conduct disorder can be difficult to differentiate from bipolar and related disorders. The timing of onset of symptoms, severity and chronicity of irritability, and relation of oppositional or conduct behaviors to mood symptoms can help with this differentiation. For adolescents who are abusing substances, it is important to differentiate if mood symptoms of bipolar are “driving” the substance abuse or substance abuse is leading to mood symptoms. Individuals with manic psychosis may resemble those with schizophrenia or schizoaffective disorder. Psychotic symptoms associated with bipolar disorder should clear with resolution of the mood symptoms, which should also be prominent. Patients with mood lability may have a developing personality disorder. Many patients with bipolar disorder experience a worsening of anxiety with mood episodes. Further complicating this diagnostic difficulty is the relatively high likelihood of comorbid disorders for youth with bipolar disorder. Providers should not miss medical causes of symptoms such as hyperthyroidism, head trauma, and rare presentations of tumors. This is especially relevant if the change in personality has been relatively sudden or is accompanied by other neurologic changes.
The chance of recovery from the mood episode of a bipolar illness that results in diagnosis (index episode) is high (80%), but many youth will experience a recurrence (60%) most likely in the same polarity (depression or mania) as the index episode, and are likely to be symptomatic 60% of the time. Early onset, low socioeconomic status, co-morbid illness, and family history of mood disorders all are risk factors for worse outcome. Children and adolescents diagnosed with cyclothymia are at risk to develop bipolar I or II disorder, and youth with bipolar I or II disorder may also change diagnostic categories over time.
Children and adolescents with bipolar illness are at risk for poorer academic, social, legal, and health outcomes. 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 and risks associated with substance abuse may lead to further poor outcomes.
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 older than 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 a diagnosis of anxiety, ASD, or OCD, and do not meet criteria for DMDD.
Medication trials for this relatively new diagnosis are few but suggest methylphenidate may be effective in reducing symptoms (open-label trial), and the addition of citalopram to methylphenidate treatment may further reduce temper tantrum severity (randomized placebo-controlled trial). Other recommendations include identifying and treating comorbid conditions and referring patients to therapy that includes a parent component. Therapy is important for children and their families.
The differential diagnosis for DMDD is similar to that for 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 families tend to seek mental health treatment. 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 collect data to aid with the diagnosis, treatment, and outcome measures.
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 15–24 years has increased dramatically from approximately 2.7 to 14.5 per 100,000 since the 1960s, but there has been no increase from 2015 to 2017. 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 obtaining 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 BHC, 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 who 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 increased 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
. Accessed September 15, 2017.
H: Suicide risk in adolescents with chronic illness: implications for primary care and specialty pediatric practice: a review. Dev Med Child Neurol 2010 Dec;52(12):1083–1087 [Epub 2010 Aug 31]
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 increasingly used 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 one-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.
Most 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 and predictors of violent behavior, such as past history of violence or aggressive behavior, including uncontrollable anger outbursts; access to guns or other weapons; history of getting caught with a weapon in school; and family history of violent behaviors. 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) 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 Adults Can Respond to Concerns of Violence and/or Dangerous Behavior
If a provider, parent, or trusted adult (eg, teacher, coach, clergy) 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 or crisis center to evaluate safety and potential need for hospitalization. It is always acceptable to contact local police for assistance, especially if harm to others or lethal means are 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 or 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.
Tips for Adults on How to Talk With Children About Violence
Talking about violence and personal safety is a necessary component of child rearing given the rise in violence in public places, including schools and places of worship. The most important factors to consider when discussing such a difficult topic is to be honest, be their source of information, reassure them that they are safe, and try to keep a routine and address their concerns at an age-appropriate level. Some reputable national websites that provide guidance on how to talk with children about violence and threats to personal safety include:
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 neurologic 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 neurologic 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 GI 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 ensure 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 well-being 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. 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.
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 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, mood disorders, anxiety disorders, and conduct disorders should 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 unspecified psychosis. Unspecified psychosis 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. Most individuals 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 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 or second generation 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, dystonia, 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 hemoglobin A1c (HbA1c), complete blood count (CBC), liver function tests (LFTs), and lipid profile. Antipsychotics can cause QT prolongation leading to ventricular arrhythmias. Therefore, it is important to obtain an electrocardiogram (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 are two FDA-approved medications for TD (ie, valbenazine and deutetrabenazine); however, the recommendation is to either lower the dose of the offending agent or switch to an alternative. 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 NMS. NMS is a very rare medical emergency primarily associated 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 (AIMS), 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. 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.
OTHER PSYCHIATRIC CONDITIONS
Several psychiatric conditions are covered elsewhere in this book. Refer to the following chapters for detailed discussion: