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Psych/Neuro EXAM 2
Psych/Neuro EXAM 2 Lubsch Child Psych
28
Pharmacology
Graduate
08/31/2011

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Term
most common mental disorders in children 9-17 years
Definition
estimated ~20% of children ages 9-17 years have mental disorders with at least mild functional impairment

MOST COMMON = ANXIETY DISORDER 13%
disruptive disorder = 10.3%
mood disorder = 6.2%

child mental disorders persist into adulthood
Term
disorders usually first diagnosed in infancy, childhood, and adolescence
Definition
anxiety disorders:
OCD

attention deficit and disruptive behavior disorders

eating disorders:
anorexia nervosa
bulimia nervosa

elimination disorders:
enuresis

mood disorders:
depression
bipolar disorder

pervasive developmental disorders:
autism

schizophrenia

tic disorders:
Tourette's disorder

not uncommon to have more than one disorder (Autism and ADHD, depression and anxiety)
Term
risk factors for mental disorders in children
Definition
biological influences:
injury
infection
poor nutrition during pregnancy
exposure to toxins (i.e. lead)
prenatal tobacco/alcohol use
perinatal trauma
traumatic brain injury
chromosomal syndromes

psychosocial factors:
severe parental discord
parents psychopathology/criminality
large family size/overcrowding
economic hardship
exposure to violence
poor care giving practices
security of parental attachment
exposure to inconsistent discipline

genetics:
children of depressed parents are > 3 x more likely to have a depressive episode
other genetic d/o - bipolar, ADHD, autism, SCZ

parental depression

stressful life events

childhood maltreatment:
physical abuse
psychological maltreatment

peer/sibling influences:
sibling rivalry
Term
treatment of mental disorders in children
Definition
MULTIMODAL THERAPY

psychotherapy:
supportive
psychodynamic
cognitive-behavioral
interpersonal
family systems

psychopharmacology:
many medications used "off label"
monotherapy versus combined treatment
Term
frequently used psychotropic medications in children for ADHD, conduct disorders, bipolar disorder, and OCD
Definition
ADHD: stimulants

conduct disorders: mood stabilizers (valproate and carbamazepine)

bipolar disorder: mood stabilizers (valproate and carbamazepine)

OCD: SSRIs
Term
anxiety disorders in children and treatment
Definition
generalized anxiety disorder
OCD
separation anxiety
social phobia
post-traumatic stress disorder

treatment:
benzodiazepines for acute symptoms
SSRIs are considered 1st line
TCAs are effective but are not first line b/c of ADRs
Term
elimination disorders in children and treatment
Definition
enuresis - repeated voiding of urine into inappropriate places

age > 5 years

treatment:

1st line
nondrug therapy preferred due to intolerability of drug treatment
scheduled bathroom time; limit liquid at night

2nd line
DDVAP (desmopressin) HS - increases water reabsorption in the kidney and decreases urine volume entering bladder
not intranasal - associated with seizures and coma due to Na imbalances

3rd line
TCAs (imipramine)

relapse is common after stopping DDVAP

encopresis - repeated voiding of feces into inappropriate places
Term
depression in children and treatment
Definition
depression - depressed mood, loss of interest or pleasure in nearly all activities, irritability

the most common symptom is headache and stomach ache (somatic complaint), suicide (3rd cause of death in adolescents)

reactive depression is most common (i.e. rejection or loss)

treatment:
SSRIs are considered 1st and 2nd line
TCAs not effective
other antidepressants considered 3rd line
Term
treatment of adolescents with depression study (TADS)
Definition
NIMH sponsored, multicenter

12-17 years old with MDD

compare efficacy of fluoxetine, CBT, combination, and placebo in 36 weeks with 1 year follow up

response rate: combination 71%, fluoxetine 61%, CBT 43%, placebo 35%

fluoxetine and escitalopram are the 2 SSRIs that have data to support use in teenagers

2-3 out of 100 are at risk of suicide with SSRI use in teenagers
Term
bipolar disorder in children and treatment
Definition
manic or mixed episodes usually accompanied by major depressive episode

treatment:
mood stabilizers (valproate/carbamazepine) considered 1st line
antipsychotics may be useful if psychotic features are present (aripiprazole, quetiapine, risperidone)
Term
pervasive developmental disorders in children
Definition
severe and pervasive impairment in several areas of development including reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests, and activities

autism:
markedly abnormal or impaired development in social interaction and communication and markedly restricted repertoire of activity and interests
Term
treatment of autism
Definition
antipsychotics may be effective for aggression/perseveration

antidepressants (citalopram) controversial for anxiety/obsessive-compulsive symptoms
Term
tic disorders in children and treatment
Definition
sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations

occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year. there is never a tic-free period of more than 3 consecutive months.

motor - eye blinking, lip licking, facial twitching, shoulder shrugging, squatting, twirling

vocal - clicks, grunts, barking, yelping, throat clearing, echolalia

Tourette's Disorder: multiple motor tics and one or more vocal tics

treatment:
1st line = alpha-adrenergic antagonists - clonidine, guanfacine
antipsychotics - halodol most effective for controlling tics (but ADRs are bad)
Term
use of SSRIs for:
MDD
anxiety disorders
OCD
autism
tourette's
Definition
major depressive disorder: FLUOXETINE, ESCITALOPRAM

anxiety disorders: fluoxetine, sertraline, citalopram, fluvoxamine, escitalopram

OCD: good amount of research for SSRIs in OCD

autism and Tourette's - more efficacious agents
Term
PK and ADRs of SSRIs
Definition
pharmacokinetics:

fluoxetine, norfluoxetine, sertraline AUC higher in 6-12 years of age

fluoxetine t1/2 8 days, norfluoxetine t1/2 7-19 days: better for non-adherent patients

ADRs:
?suicide
mania/restlessness/agitation (in patients with bipolar)
insomnia
nausea/vomiting/weight loss or gain

avoid abrupt DC
Term
TCA use in children
Definition
many trials demonstrate LACK OF EFFICACY FOR CHILDREN with MDD, plus more toxicity versus SSRIs

anxiety disorders - 3rd line = imipramine, clomipramine

NOCTURNAL ENURESIS - IMIPRAMINE, NOTRIPTYLINE (3RD LINE)
Term
PK and ADRs of TCAs
Definition
pharmacokinetics:
imipramine t1/2 11 hours in children - avoid desipramine (and imipramine) EKG monitoring

ADRs:
sedation
anticholinergic
arrhythmias
unexplained death - sudden cardiac death
Term
use of bupropion in children
Definition
use: ADHD

pharmacokinetics:
biotransformation to 3 active metabolites
adult t1/2 10-21 hours, shorter in children

contraindication: eating disorder

ADRs: seizure, insomnia, weight loss
Term
use of lithium in children
Definition
use: bipolar disorder, conduct disorder

pharmacokinetics:
shorter t1/2, higher clearance

ADRs:
tremor/fatigue/atasia/malaise
leukocytosis
hypothyroidism
diabetes
hairloss
nausea/diarrhea
enuresis

requires serum concentration monitoring, not recommended for non-adherent families
Term
use of mood stabilizers in children
Definition
CARBAMAZEPINE

pharmacokinetics:
boys may have faster clearance
t1/2 8-14 hours

ADRs:
drowsiness/dizziness/vertigo
aplastic anemia
nausea

VALPROATE

pharmacokinetics:
slower response, lower serum levels in adolescents

ADRs:
sedation/tremor
hyperglycemia
hepatic insufficiency
nausea/vomiting
increased appetite/weight gain

VALPROATE HAS THE BEST RESPONSE RATE VERSUS OTHER MOOD STABILIZERS
Term
use of haloperidol in children
Definition
use:
autism
schizophrenia
Tourette's Disorder
conduct disorder
ADHD

ADRs:
usually intolerable
sedation
extrapyramidal effects
tardive dyskinesia

haloperidol is cheap and most effective for Tourette's

atypicals may be more effective for schizophrenia with less ADRs
Term
use of clozapine in children
Definition
use:
schizophrenia

ADRs
sedation
seizure
neutropenia: WBC q week x 6 months
Term
use of atypical antipsychotics in children (olanzapine, aripiprazole, quetiazpine, ziprasidone)
Definition
uses:
bipolar disorder
schizophrenia
autism
Tourette's Disorder

aripiprazole and risperidone are the leading antipsychotics in children
Term
comparison of increased weight ADR of atypicals
Definition
olanzapine > quetiapine > risperidone > aripiprazole
Term
approved SSRIs for children and age of approval
Definition
fluoxetine: 8 yo

sertraline: 6 yo (OCD)

escitalopram: 12 yo

fluvoxamine: 8 yo (OCD)
Term
TCA approved for use in children and age of approval
Definition
imipramine: 6 yo (enuresis)
Term
mood stabilizers approved for children and age of approval
Definition
lithium: 12 yo

carbamazepine: any age

valproate: 2 yo
Term
antipsychotics approved for use in children and age of approval
Definition
haloperidol: 3 yo

risperidone: 5 yo

paliperidone: 12 yo

olanzapine: 13 yo

aripiprazole: 6 yo

quetiapine: 10 yo
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