ADHD
Treatment
Behavior Modification-
Family Support
Pharmacology in preferred order:
Psychostimulants
Alternate psychostimulant
Pemoline
Antidepressant
Alternate antidepressant
clonidine
Psychostimulant dosing
Methylphenidate- starting dosing 5-10 mg before breakfast and lunch, sometimes 3-4pm
Amphetamine/Dextroamphetamine-starting (Adderall) dose 2.5-5mg typically dosed twice daily (morning and noon)
Doses should not exceed 2mg/kg/d for
Methylphenidate and 1mg/kg/day for
Amphetamine/Dexampheramine
What are some causes or factors that may place a child at risk for depression
5% of US children and adolescents have depression
~ ½ with depression do not seek treatment, less than 20% get the help they need
Early onset mood disorders associated with turbulent, dysfunctional lives, poor school performance, impaired peer and family relationships, alcohol/substance abuse, and other psychiatric comorbidities
Depression Screening and what age does this start?
Patient Health Questionnaire Depression Scale (adolescents, age 11) (PHQ-9) - <5minutes
Pediatric Symptom Checklist (PSC-Y) – children and adolescents - < 5minutes
Must determine if depression places patient at immediate risk for: Psychosis, Suicide,Volatile, Extremely aggressive, or at risk for ongoing abuse or neglect if returned to home environment
What we know about autism
Lifelong disability
Characterized by problems in 3 areas: Communication, behavior, social skills
Developmental disability
Occurs mostly in males
Occurs in 1 out of 250 live births
Manifest between age 18 months and 3 years
Charcteristics
Inattention:
Lack of detail orientation, difficulty staying on
track, looses things, difficulty organizing, forgetful.
Hyperactivity:
Cannot sit still, talks excessively, moves often
Impulsivity:
Cannot wait turns, interrupts/intrudes, blurts
out answers.
ADHD Follow up
Have parents keep logs of symptoms
Phone f/u after 1 week. may be needed until dose stable and no longer titrating
See 1 month after starting therapy and monthly until dose stable and no weight loss
Stable visits every 3-4 months.
Remission chances
Once a child experiences depression, he/she is at significant risk for developing another depressive episode in the next 5 years
74% remission in 1 year, 72% with 5 years.
Depression Treatment and what is considered the first line treatment
Psychotherapy plus medications is most effective
Long term success with treatment hinges on appropriate use of psychotherapy.
Cognitive and behavioral therapy
Need referral to a psychiatric specialist trained in pediatrics
First line treatment in children is considered to be therapy
Common Characteristics
Lack of awareness of the existence or feelings of others
Severe impairment in the ability to relate to others
Aloof and distant from others
Appears not to listen when spoken to
Epidemiology
Environmental influences
Maternal tobacco &/or alcohol use, fetal distress, low birth weight.
Altered self-esteem
Genetics are believed to be related to effects on dopamine & norepinephrine
Inattention and distraction seem to be related to
low levels of norepinephrine
Impulsivity and behavior problems appear to be
related to low levels of dopamine
Psychostimulant side effects
Significant side effects include anorexia and insomnia
Can increase/cause tics
Comorbidities
Anxiety disorder
ADHD
Conduct, learning and oppositional defiant disorders
SAD
Eating disorders
Stress
Gold Standard for Assessing Autism
ADOS: Autism Diagnostic Observation Schedule,
Accurately assess and diagnose autism and pervasive developmental disorders across ages, developmental levels, and language skills for toddler to adults, takes aprox. 45 mins
Social Skills
Fails to produce appropriate facial expressions to specific occasions
Avoids eye contact
Difficulty with changes in environment and routine
Does not seek opportunities to interact with others
Unwillingness and/or inability to engage in cooperative play
3 Types of ADHD
ADHD combined type if both criteria for hyperactivity/impulsiveness and inattention in the last 6 months
ADHD Inattention subtype if criteria met for inattention only in last 6 months
ADHD hyperactive/impulsive subtype if
criteria met for this only in last 6 months
Behavior Modification Suggestions
Change classroom seat, office layout
School folders
Chore charts
career planning
Removing stimulation during tasks that require concentration
CBT
Parenting/ family support and education
Diagnosing Criteria and standard test used to identify this criteria.
5 or more symptoms (most of the day, nearly every day) have been present during the same 2-week period, and represent a change from previous function:
Must have 1 of these:
Depressed mood- either subjective report or observations made by others
Marked diminished interest or pleasure in all, or almost all, activities
Significant weight loss when not dieting, weight
gain, or decrease in appetite (in kids-failure to
make expected weight gains).
Insomnia or hypersomnia
Psychomotor agitation or retardation (observable by others)
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death
The PHQ-9 is the standard test
Autism Treatment
Autism is not a disease; therefore there is not a single treatment or therapy
Individualized plans designed to meet the child’s needs
Communication Skills
Difficulties in using and understanding both verbal and non-verbal language
Failure to initiate or sustain conversational interchange
Abnormalities in the pitch, stress, rate, rhythm, and intonation of speech
Poor receptive and expressive skills
May echo words
Mays use screaming, crying, tantrums, aggression, or self-abuse as ways to communicate.
Repeating words or phrases in place of normal, responsive language.
Screening
Vanderbilt scale
Connor rating scales
Psychostimulant treatment assessment and follow up
Need baseline BP, pulse, height and weight to rule out contraindications and for growth and monitoring.
Need annual assessment
Assess weight and objective measurement of loss of appetite at each visit. Also screen for insomnia, headaches, social withdrawal, and tics.
Clinical presentation: Children vs Adolescence
Diagnosis: children
Depressed mood may appear as irritable
mood. Children have more somatic
complaints, comorbid anxiety, agitation,
separation anxiety, and behavioral
problems.
Diagnosis: Adolescents
More antisocial behavior, substance use,
restlessness, grouchiness, aggression,
withdrawal, sexual promiscuity, problems
with family/school, wanting to leave home,
& of not being understood, appreciated.
What disease will you see perianal skin tags on PE?
Chrons disease
Behavioral Skills
Unusual and repetitive movements of the body that interfere with the ability to attend to tasks or activities, such as hand flapping, finger flicking, grimacing.
Marked distress over changes in seemingly trivial aspects of the environment
Laughing or crying or showing distress for reasons not apparent to others.
Unreasonable insistence on following routines in precise detail.