PHM%20456H%20Introduction%20to%20Pediatric%20Pharmacy%20Practice%202004%20Drug%20Related%20Issues%20in%20Pediatric%20Psychiatry - PowerPoint PPT Presentation

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PHM%20456H%20Introduction%20to%20Pediatric%20Pharmacy%20Practice%202004%20Drug%20Related%20Issues%20in%20Pediatric%20Psychiatry

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At the end of this presentation, the student will: ... careless mistakes, can't sustain attn, distractible, forgetful, disorganized, ... – PowerPoint PPT presentation

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Title: PHM%20456H%20Introduction%20to%20Pediatric%20Pharmacy%20Practice%202004%20Drug%20Related%20Issues%20in%20Pediatric%20Psychiatry


1
PHM 456HIntroduction to Pediatric Pharmacy
Practice 2004Drug Related Issues in Pediatric
Psychiatry
  • Claire De Souza BSc MD FRCP(C)
  • November 4th 2004

2
Audience Survey
  • Experience with pediatric psychiatry
  • medications?
  • patients?

3
Learning Objectives
  • At the end of this presentation, the student
    will
  • be familiar with the spectrum of psychiatric
    illness in the pediatric population and the
    assessment involved
  • have a greater understanding of
  • pediatric depression
  • ADHD
  • any others?

4
Outline
  • Starting Principles
  • Spectrum of Psychiatric Disorders in the
    Pediatric Population
  • Review of Pediatric Depression
  • Review of ADHD

5
Principles
  • accurate diagnosis
  • biological, psychological, social contributors
  • informs a comprehensive management plan
  • biological, psychological, social interventions
  • medications used depending on diagnosis,
    symptoms, and severity
  • antidepressants - SSRIs
  • anti-anxiety - benzodiazepines
  • anti-psychotics atypical
  • start low, go slow

6
Spectrum of Psychiatric Disorders
  • Mood Disorders
  • Anxiety Disorders
  • Psychotic Disorders
  • Substance Use Disorders
  • Personality Disorders
  • Disruptive Behavioural Disorders
  • Elimination Disorders
  • Eating Disorders
  • Tic Disorders
  • Somatoform Disorders
  • etc.
  • Reference DSM-IV

7
Depression
8
Depression
  • 2 children, 4-8 teens (? ? 21)
  • suicide attempt - 9 of teens
  • symptoms for 2 weeks
  • mood bored, irritable
  • cognitive SI, guilt, worthlessness,
    concentration
  • physical - change in sleep?, appetite?, energy,
    psychomotor
  • interpersonal change in interest level
  • change in functioning (social, academic) / xs
    distress
  • other features
  • anxiety - phobias, separation anxiety
  • behaviour - tantrums, oppositional, aggression
  • somatic complaints
  • psychosis auditory hallucinations
  • range in severity

9
Depression continued
  • contributing factors (B/P/S)
  • biological ie genetics, history of depression
  • psychological ie loss, trauma, separation
  • social ie interpersonal, SES, academic
  • comorbidity anxiety, substance use, behaviour,
    etc
  • prognosis recurrence
  • 20-60 recurrence in 2 yrs 70 within 5 yrs
  • episodes become more frequent, more severe, last
    longer
  • 20-40 ? bipolar disorder within 5 years

10
Depression continued
  • Assessment
  • interview with family
  • interview with child/teen
  • interview with parents
  • collaterol information from school etc as
    required

11
Depression continued
  • Differential Diagnosis extensive
  • Adjustment Disorder, Dysthymic Disorder, Bipolar
    Disorder, Anxiety Disorder, Eating Disorder,
    Psychotic Disorder, Disruptive Behavioural
    Disorder, Personality Disorder, Substance use
    Disorder, General Medical Condition (thyroid,
    anemia, mono etc), Bereavement etc.

12
Depression continued
  • Management (B / P / S)
  • Psychoeducation
  • Medications
  • Therapy individual (CBT, IPT), family
  • School Intervention
  • Resources / References
  • websites http//www.mooddisorders.on.ca/mdao.asp
  • http//www.aacap.org/ (Facts for Families)

13
Depression continued
  • Medications
  • duration 9 months or more
  • 1st line SSRIs (ie Prozac, Zoloft, Celexa)
    off-label
  • start low, go slow increase as tolerated as
    required
  • Controversy
  • Efficacy limited evidence - Prozac
  • Safety Health Canada warning
  • ? MD to monitor SI, disinhibition, agitation,
    akathisia
  • off-label use based on limited studies,
    experience, adult studies
  • drug interactions cytP450
  • Medications added as required (Sx, Rx
    resistance)
  • ie BZDs, atypical antipsychotics

14
Depression continued
  • Red Flags
  • requesting script renewals
  • appearing dysphoric, suicidal, hypomanic,
    psychotic
  • non-compliance withdrawal, worsening symptoms
  • stockpiling medications, buying OTCs
  • medical problems cytP450 drug interactions

15
Depression continued
  • Approach
  • review Health Canada warning
  • discuss need for monitoring by MD
  • advise them not to stop medication suddenly
  • questions / concerns ? MD
  • advise them about what to look for
  • ie. restlessness, disinhibition, aggression,
  • anxiety, worsened depression
  • direct them to resources
  • if concerned about patients safety refer to ER
  • Reference FDA website, Health Canada, NIMH
    websites

16
Attention Deficit Hyperactivity Disorder
17
ADHD
  • 5-9 of children ? ? 41 (NB ?under-Dx)
  • symptoms 2 settings, onset lt age 7
  • inattention careless mistakes, cant sustain
    attn, distractible, forgetful, disorganized,
    loses things, doesnt listen, doesnt complete
    tasks, avoids time/effort-consuming tasks
  • hyperactivity fidgets, leaves seat, ?
    runs/climbs, on the go, xs talking, cant play
    quietly
  • impulsivity- blurts out, interrupts, problems
    waiting turn
  • interferes with functioning academic, family,
    social
  • diagnosis
  • subtypes 1) inattentive, 2) hyperactivity
    impulsivity, 3) combined
  • reference DSM-IV

18
ADHD continued
  • etiology - DA mediated problems with inhibitory
    executive control
  • factors
  • biological FHx, difficult temperament
  • psychological - self-esteem
  • social - interpersonal, academic, poor social
    skills
  • comorbidity
  • learning disorders (in 40 with ADHD),
    behavioural problems (ODD, CD), substance abuse,
    depression, anxiety
  • prognosis
  • 65 ? adulthood

19
ADHD continued
  • Assessment
  • Interview with
  • family
  • child / teen
  • parents
  • Questionnaires
  • ie Connors Rating Scale parent / teacher form
  • Information from school
  • Psychoeducational testing

20
ADHD continued
  • Differential Diagnosis extensive
  • Learning disorder
  • General Medical Condition (hearing, vision,
    thyroid, congenital, genetic, lead poisoning,
    head injury etc)
  • Adjustment Disorder, Dysthymic Disorder, Bipolar
    Disorder, Anxiety Disorder, Psychotic Disorder,
    Disruptive Behavioural Disorder, Personality
    Disorder, Substance use Disorder, etc.

21
ADHD continued
  • Management (B / P / S)
  • Psychoeducation
  • Medications
  • Social skills training
  • Parent management
  • () reinforcement, structure
  • School Intervention
  • classroom modifications, individual education
    plan (IEP)
  • Resources / References
  • websites www.adrn.org
  • http//www.aacap.org/ (Facts for Families)

22
ADHD continued
  • Medications
  • stimulants - 1st line
  • short acting Ritalin, Dexedrine
  • long acting ie Concerta, Dexedrine SR
  • Blinded placebo / stimulant trials
  • to determine dose, acceptability
  • coordinated with objective scale ie Connors
    Rating Scale
  • restricted use limited scripts
  • abuse potential
  • other medications for co-morbidity ie
    depression, anxiety, tics
  • Use for school day primarily also, during
    weekend summer if problems (social, academic)
    off meds

23
ADHD continued
  • Red Flags
  • requesting script renewals
  • non-compliance
  • substance abuse
  • stockpiling medications
  • medical problems - epilepsy

24
ADHD continued
  • Approach
  • controversy
  • over-diagnosed
  • concerns about long-term side effects
  • problems if no treatment
  • academic, social, family
  • comorbidity
  • advise them to direct their questions / concerns
    ? MD

25
Questions / Cases
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