NEUROPSYCHIATRIC DISORDERS IN INFANTS, TODDLERS AND PRESCHOOLERS ... - PowerPoint by M6E8vkJ9

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									     Neuropsychiatric Disorders:
         Mood and Anxiety



               Max Wiznitzer, M.D.


Division of Pediatric Neurology
Rainbow Babies andChildren’sHospital
Cleveland, Ohio
                Topics

 Mood disorders
   Depression
   Bipolar disorder
 Anxiety disorders
   Overview
   Selective mutism
   Obsessive-compulsive disorder
            Depression
 Disturbance of mood with depressive
  feelings and vegetative symptoms
 Types
   Depressive feelings
   Adjustment disorder with depressed
    mood
   Major depressive disorder
   Dysthymic disorder
Depression - Core Features
   Depressed or irritable mood
   Loss of interest in activities
   Concentration problems
   Change in sleep pattern
   Change in appetite
   Lack of energy or excessive agitation
   Suicidal ideation
    Depression Screening
 Adult data corroborated by studies in
  adolescents
 Two questions
   Are you normally happy or not happy?
   Do you get pleasure or enjoyment from
    your favorite activities?
 A “Yes” answer to either question
  merits further investigation
            Depression
        in Preschool Years
 For many years, depression was not
  considered to occur in prepubertal
  children
   “Childhood too happy”
   Emotion and cognition too immature to
    experience features
   Self-concept not well developed
   Poor differentiation of the difference between
    real and ideal self
   Inability to conceptualize guilt (emotion of
    depression)
            Depression
        in Preschool Years
 Research showed greater ability to
  understand and experience depressive
  affects
   Not limited by developmental stage
   Features found in children of depressed
    mothers
   Directly express depressive emotions in
    addition to indirect superficial features of
    somatization or aggression
   Adult DSM criteria, with modification,
    applicable to children
    Depression in Infancy
 Lethargy, fussiness and
  unresponsiveness
 Withdrawal/unresponsiveness to primary
  caregiver
 Poor eye contact
 Poor eating and/or sleeping
 Lack of interest in environment
 Delayed gross/fine motor development
 Failure to thrive
           Depression
       in Preschool Years
 Irritable, angry and aggressive
 Poor peer interactions (friends and
  activities)
 Tantrums/anxiety
 Over- or underactive
 Disturbed sleep patterns (including
  frightening dreams)
 Problems following rules
 Auditory hallucinations
              Depression
         in School Age Years
   Unhappy mood
   Poor self image
   Little interest in favorite activities
   Change in sleeping and eating
   Concentration problems
   Irritability/anxiety
   Physical complaints
   Suicidal ideation
 Depression in Developmental
    Disabilities Population
 Frequently cannot verbalize
  emotions
 Manifestations similar to peers
   “Vegetative” features
   Behavioral observation
     Mood and smiling
     Pleasure or enjoyment of activities
   Screening questions are applicable
         Depression
       Behavior Profiles
 Irritable, oppositional with poor
  functioning in school
 Nonorganic physical complaints and
  disability
 Overactive, impulsive disinhibited
  with aggression and poor insight
 Withdrawn, sullen, unhappy with
  little energy or interests
Depression - Epidemiology
 0.4-8% prevalence in childhood
 Equal prevalence in boys and girls
 Comorbid disorders
     Attention deficit hyperactivity disorder
     Anxiety disorders
     Oppositional defiant disorder
     Conduct disorder
                Depression
 At-risk populations
     Parental divorce
     Death/separation of close family member
     Physical/emotional abuse and/or neglect
     Family member with mood disorder
     Chronic medical condition
     Medication effect
     Learning/language disability
          Suicidal Risk
 Family history of suicide and
  psychiatric disorders
 Male
 Sexual orientation
 Abuse
 Impaired home/living environment
 School/social problems
 Access to firearms
              Suicidal Risk
 Assessment
   Screening scales
   Direct interview
      If possible, without parent present
      Specific questions
           Plan
           Attempt
   Immediate mental health evaluation for high
    risk individuals
      May require hospital admission
             Natural History
             of Depression
 Major Depression
     Mean length of 7-9 months
     Remission in majority within 1-2 years
     5 year recurrence risk of 70%
     Increased risk of bipolar disorder, substance
      abuse, social problems
 Dysthymic disorder
   Average length of 4 years
   Increased risk of depression, bipolar disorder,
    substance abuse
  Treatment of Depression
 Pharmacotherapy
   Serotonin reuptake inhibitors
   Other antidepressants
     Buproprion (Wellbutrin®)
     Venlafaxine (Effexor®)
     Mirtazapine (Remeron®)
     Duloxetine (Cymbalta®)
   Tricyclic antidepressants may be less
    effective
  Treatment of Depression

 Psychosocial intervention
   Individual therapy
   Family education/therapy
   School participation
  Treatment of Depression
 Tx Option   12 wk   18 wk   36 wk

 Comb         73%     85%     86%

 Fluox        62%     69%     81%

 CBT          48%     65%     81%


                                TADS, 2007
      Serotonin Reuptake
           Inhibitors
 Dosing (for older child)
   Fluoxetine, citalopram, paroxetine
      Start 5-10 mg/dy
      Range: 5-40 mg/dy
   Escitalopram
      Start 5 mg/dy
      Range: 5-20 mg/dy
   Sertraline, fluvoxamine
      Start 12.5-25 mg/dy
      Range: 1-3 mg/kg/dy
FDA Mandated Warning
   SSRI & Suicidal Ideation
 Initial analysis has 2% absolute risk (4% vs 2% on
  placebo)
    17/23 studies with no increased risk
    Studies not designed to ID suicidality
    No data from anxiety/OCD studies
 More recent meta-analysis (Bridge et al 2007)
    27 studies (15 MDD, 6 OCD, 6 anxiety disorder)
    Used random effects model and additional studies
    SSRIs effective for conditions
       Anxiety disorder > OCD > MDD
       Fluoxetine beneficial in children under 12 years with MDD
    Benefits outweigh potential risk of suicidal ideation or
     attempt
Suicidal Ideation/Attempt Risk

 TADS, 2007
   Baseline               30%
   Week 12                11%
   Week 36                6.6%
   Suicidal ideation decrease less with
    fluoxetine than with Comb or CBT
   Suicidal events
       Fluoxetine        14.7%
       CBT               6.3%
       Combination       8.4%
   SSRI & Suicidal Ideation
 No reports of completed suicides
 SSRI use associated with decreased suicide rate
 Studies found no association between SSRI use
  and completed suicide
 13% suicidal behavior during psychotherapy
 Decrease in depression diagnosis and SSRI Rx
  rates since warning
    Increased use of fluoxetine
 Suicide rate in children and adolescents since
  warning
    In USA, increased noted, although rates are again
     declining
    In UK, no increase and continued decline through 2005
     despite decrease SSRI Rx from 2003-2005
   Depression – Treatment
 Acute treatment
   Goal is remission
 Maintenance therapy
   No change in medication does
   Continuation for ?
      4-6 month minimum (adult data)
      Relapse factors
          Psychosocial stressors
          School year
          Comorbid disorders
          Depression + dysthymia
          Influence of developmental factors
          Previous relapses
  Depression – Treatment
 SSRI’s & Suicidal Ideation
 What is a physician or caregiver to do?
   Need to weigh benefits and risks of SSRI’s
    vs risk of untreated depression
   Consider using fluoxetine as first choice
   Recommendations are treatment with
    close monitoring
   BECOME AN INFORMED CONSUMER or
    PRESCRIBER – read, discuss and
    understand the issues
     AAP guidelines on Adolescent Depression
               Depression
 Treatment
   Support and monitoring for mild features
   Moderate-severe features → mental health
    referral
   Use of scientifically proven intervention
      Psychotherapy (CBT, IPT)
      Medication (SSRI)
   Monitor response and progress
 Use available toolkit at www.glad-pc.org
   GuideLines for Adolescent Depression in
    Primary Care
                                     Pediatrics Nov 2007
      Bipolar Disorder
       Core Features

 Inflated self-esteem or grandiosity
 Decreased need for sleep
 More talkative than usual or
  pressure of speech
 Flight of ideas or racing thoughts
 Distractibility
 Increased goal-directed activity or
  psychomotor agitation
       Bipolar Disorder
        Core Features
 Excessive pleasurable activities with
  potential for painful consequences
 Functioning
   Mania - marked impairment in
    functioning
   Hypomania - no marked impairment in
    functioning
 Not due to substance effect or
  general medical condition
Childhood Bipolar Disorder
 Rapid mood swings – many short
  episodes between classic ones
 Irritability in addition to euphoria or
  dysphoria
 Comorbid disorders
     ADHD
     Depression
     Anxiety
     Tics
     Psychosis
 Childhood Bipolar Disorder
         Treatment
 Mania
   Classic – Lithium
   Rapid cycling – Anticonvulsant drugs
 Depression
   Lamotrigine
   Bupropion
   SSRI with mood stabilization
 Comorbid ADHD
   Stimulants
Childhood Bipolar Disorder
 Is the diagnosis bipolar disorder in all
  children with rage/tantrums? NO!
 Differential diagnosis is usually:
     ADHD
     Oppositional defiant disorder
     Difficult temperment
     Executive dysfunction (FAS, TBI)
     Autistic spectrum disorders
     Depression
     Anxiety
 Bipolar disorder – about 10% in 1 study
             Anxiety

 Apprehensive anticipation of future
  danger or misfortune (fear, terror)
 Anticipated danger may be internal
  or external
 Somatic features present
 Inability to relax
       Anxiety Disorders
 DSM –III-R
   Separation anxiety disorder
   Overanxious disorder
   Avoidant disorder
 DSM –IV
     Separation anxiety disorder
     Generalized anxiety disorder
     Social phobia
     Specific phobias
        Anxiety
    Physical Features
   Increased heart rate/palpitations
   Shaking and trembling
   Blushing
   Sweating
   Nausea/vomiting
   Headaches
   Dry mouth
   Red ears
   Dilated pupils
            Anxiety
       Screens and Scales
 State-Trait Anxiety Inventory for Children
  (STAIC)
 Revised Children’s Manifest Anxiety Scale
  (RCMAS)
 Fear Survey Schedule for Children-Revised
  (FSSC-R)
 Multidimensional Anxiety Scale for Children
  (MASC)
 Spence Children’s Anxiety Scale (SCAS)
 Screen for Child Anxiety Related Emotional
  Disorders (SCARED)
        Social Anxiety
 Core feature
   Excessive fear of negative evaluation
   Occurs with activity with possible disapproval
    or rejection
 Components
   Cognitive (presituational negative ideation)
   Physiologic (dry mouth, increased heart rate)
   Avoidance
        Social Anxiety
 Situations
     Public speaking
     Public eating
     Writing in public
     Going to parties
     Using public restrooms
     Speaking with authority figures
     School
                                    Beidel & Randall, 1994
        Selective Mutism
 Paucity/lack of speech in one or
  more environments despite the
  ability to speak adequately in other,
  usually more familiar environments
 Usually occrs at school or
  environment with unfamiliar adults
 Meet criteria for social phobia and/or
  avoidant disorder
       Selective Mutism

 Mean age of onset approximately 3
  years
 Prevalence less than 1%
 Probably more common in girls
 Family history of anxiety disorders
        Selective Mutism
          Risk Factors

 Shy, inhibited personality
 Developmental problems
 Language disorder
 Difficulty processing social cues
        Selective Mutism
      Differential Diagnosis
   Autistic spectrum disorders
   Childhood schizophrenia
   Cognitive deficiency
   Post traumatic stress disorder
   Depression
   Oppositional defiant disorder
          Assessment
      of Selective Mutism
 Medical and psychiatric examination
 Hearing evaluation
 Cognitive/learning evaluation
 Speech and language evaluation
           Treatment
      of Selective Mutism
 Behavioral (including naturalistic
  environment)
 Speech/language therapy
 Pharmacotherapy
   Positive effects of fluoxetine
    Obsessive-Compulsive
          Disorder
 Obsession - recurrent or persistent idea,
  impulse or image that is intrusive and
  recognized as being inappropriate
 Compulsion - repetitive behavior based on
  rules and with a stereotypic pattern
  performed to suppress or diminish dysphoria
  related to obsession
 Occur for more than 1 hour daily and interfere
  with functioning
 Recognized as excessive or unreasonable
 Not single thought or action
   Obsessive-Compulsive
         Disorder
 Prevalence        1:200 children
 Pediatric onset   30-50% of
                    population
 Age of onset      10 years
   Boys               Prepubertal
   Girls              Adolescence
 30-50% prevalence in Tourette
  Syndrome
       Features of Obsessive-
        Compulsive Disorder
Common Obsessions                Common Compulsions
   Contamination themes            Washing
   Need to tell, ask, confess      Repeating
   Doubting                        Checking
   Harm to self or others          Touching
   Symmetry urges                  Counting
   Aggressive themes               Ordering/arranging
   Scrupulosity/religiosity        Hoarding
   Forbidden thoughts              Praying
    Obsessive-Compulsive
      Disorder - Causes
 Genetic
 Environmental
   Infectious
 Psychological
   Conditioned responses to anxiety-
    provoking stimuli
   Compulsion as way to reduce anxiety
    Obsessive-Compulsive
          Disorder
 Comorbidity
   Anxiety disorders
   Mood disorders
   Attention deficit hyperactivity disorder
   Learning disorders
   Tics
   Obsessive-Compulsive
         Disorder

 Differential Diagnosis
   Schizophrenia
   Depression
   Evolving mania
   Normal childhood habits and fears
       Childhood Habits
 Preference for sameness in daily
  routine
 Bedtime & mealtime routines
 Arrangement of items
 Distinct likes and dislikes
   Clothing
   Food
 Hair/finger picking
   Obsessive-Compulsive
         Disorder
 Treatment
   Cognitive behavioral therapy
     Difficult to implement in preschool and
      developmentally impaired children
   Medication
     SSRI’s
        Effective in the school age population
        Limited data for preschoolers

								
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