Term
| Psychiatric disorders in children |
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Definition
• Children are not just “miniature adults”
• Developmental level impacts manifestations of social-emotional-behavioral disorders
• Psychiatric disorders are multifactorial developmental disorders
• Genetic potential;
• Biological capacities;
• Nurturing environment |
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Term
| Psychiatric Evaluation in children, starting out |
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Definition
• A comprehensive initial evaluation is the cornerstone of effective treatment planning
• Use multiple sources
- Parents
- School
- PCP
• Child or adolescent
- Goal is to understand the child’s inner world and perspective - Use developmentally appropriate interview tools---
talking, drawing, playing with toys, observation, etc. |
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Term
| Psychiatric Evaluation in children, performing |
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Definition
• The evaluation is typically initiated by and adult--it is essential to engage the child, as well.
- Make sure child understands purpose and process of the evaluation
• Inventory strengths, as well as deficits/ areas of need
• An assessment of parent and family functioning is integral to the evaluation |
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Term
| Psychiatric Evaluation in children, diagnosis |
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Definition
-Diagnoses are more complicated in children
• Presentation varies by age
• The disorder may be still evolving
• Lack of diagnostic and etiological specificity for many symptoms (e.g. impulsivity and aggression)
• Diagnoses may change over time |
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Term
| Common Pediatric Psychiatric Disorders |
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Definition
• Autism Spectrum Disorder
• Attention Deficit Hyperactivity Disorder
• Separation Anxiety Disorder
• Depressive Disorders
• Oppositional Defiant Disorder
• Conduct Disorder |
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Term
| Autism Spectrum Disorder diagnosis |
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Definition
Clinical/ CARS/ ADOS
• Persistent deficits in social communication and social interaction
• Restricted, repetitive patterns of behavior, interests or activitiesSymptoms must be present in early developmental period
• Symptoms cause clinically significant impairment
• Not explained by developmental delay or Intellectual Disability |
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Term
| autism spectrum disorder etiology |
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Definition
• About 1% of population (has been increasing)
• Male 4: Female 1 (girls with more severe ID)
• Often also has intellectual and language impairment
• Often higher cognitive than adaptive functioning
• Motor deficits or clumsiness common |
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Term
| Autism Spectrum Disorder pathophysiology |
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Definition
• Often see developmental regression between 12-24 months, esp in social and language skills
• Prenatal, non-specific risk factors of advanced parental age, low birth weight, fetal exposures
• Heritability: 37% - 90% (15% known mutation)
• Larger brains, ventricular enlargement, cerebellar hypoplasia, inactive fusiform gyrus
• Neurotransmitter abnormalities |
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Term
| Autism Spectrum Disorder differential diagnosis |
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Definition
• Rett syndrome– severe developmental regression between ages 1-4; girls>boys
• Language disorder
- Selective mutism– appropriate communication skills, but only uses them in certain settings
- Social (pragmatic) communication disorder– lack of restricted or repetitive behaviors
- Verbal apraxia – can communicate nonverbally
• Intellectual Disability
• Reactive Attachment Disorder
• ADHD
• Psychotic Disorder |
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Term
| Autism Spectrum Disorder treatment |
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Definition
- Early detection and intervention
- Multidisciplinary intervention
• Behavioral: Applied Behavioral Analysis (ABA)
• Speech and language services
• OT/PT
• Social stories
• Medication to target secondary symptoms (e.g. ADHD, agitation, anxiety) if necessary |
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Term
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Definition
Anxiety is Developmentally Expected
• Stranger anxiety: starting in the first year of life
• Separation anxiety: toddlers and preschool
• Fears at night: "monsters in the closet", avoiding going to sleep, nightmares, fear of sleeping alone: toddlers, preschool and beyond
• Fear of injury or death: preschool and beyond |
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Term
| Anxiety is a Disorder When a Child: |
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Definition
• Is anxious too much of the time
• Is so anxious that it interferes with age- appropriate functioning in family, social, school, or others areas of life
• Is anxious about things that do not represent real threats |
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Term
| Signs of Anxiety in Children |
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Definition
- BEHAVIOR: Child avoids things that other children do: • Sleeping alone
• Being away from parent
• Speaking with other people
• Fear of animals
• School, social activities
- EMOTION: Emotional reactions are out of proportion to the situation
• Fear
• Anger
• Lack of interest in social or other activities |
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Term
| Epidemiology of childhood anxiety |
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Definition
• Between 10-20% of children suffer from a diagnosable anxiety disorder at some time;
- 1-2% for Separation Anxiety
• Tends to run in families: Heritability estimates are between 20-65%
• Child temperament is important;
• Symptoms vary by developmental level of child;
• May develop in context of environmental adversity/ trauma, high anxiety household (parental modeling);
• Is exacerbated by accommodation(parents and others attempting to help the child avoid the situations that make them anxious). |
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Term
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Definition
neuroimaging and anxiety disorders
Anxiety, what we think is that there is definitely neuroimaging differences. This is a little bit of a complicated slide, but I will just summarize the basics of the neuro. What we think is that individuals with anxiety disorders have a more fluid fear pathway. So it seems to be the same amygdala, right and left amygdala, and insula, all of the areas of the brain that we think of as being more emotional, and maybe more fight or flight fear reaction kinds of areas, do tend to light up more when you do functional neuroimaging of these kids and adults with anxiety. And what we think is that the pathways then become more instantiated. And it is more difficult then to treat it if it goes on for a very long period of time. So early treatment can be helpful. |
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Term
| childhood anxiety assessment |
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Definition
- Screening tools:
• NICHQ Vanderbilt Assessment Scale-PARENT
• Questions 41- 47
• Screen for Child Anxiety Related Disorders (SCARED)
• Generalized Anxiety Disorder (GAD-7) Scale
- Research tool:
• Anxiety Disorder Interview Schedule for Children
• Rule out physical causes(e.g.hyperthyroidism, medication side-effects, caffeine drinks, substance use, migraines or other headaches, etc.)
• Get data from multiple sources (such as home, school, and child)
• Family history--especially of anxiety, depression, substance use
• Child/adolescent interview–longitudinal history (when did it start?), trauma, substances, stressors |
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Term
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Definition
• Not wanting to go to school is common, and maybe developmentally expected
• Refusing to go to school or excessive worry, physical symptoms, or sleep problems, can be a serious disorder |
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Term
| Functions of School Refusal Behavior |
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Definition
-escape from negative emotion
-attention seeking
-escape from social evaluation
-tangible reinforcements |
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Term
| steps to Get student back to school quickly |
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Definition
Set a specific expectation ->
Stay matter-of-fact and supportive ->
Avoid giving medical excuses ->
Practical advice: e.g. invite friend to accompany student ->
Formulate plan with school, family, child, MH providers, PCP
->
Remove temptations of staying home |
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Term
| Major Depressive Disorder in children |
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Definition
• 2 week periods of depressed mood or loss of interest (in adolescents, may be irritability)
• Diminished interest and pleasure
• Weight change (or failure of child to gain wt)
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Poor concentration or indecisiveness
• Recurrent thoughts of death or suicidality
• Never been a manic episode |
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Term
| Major Depressive Disorder in children facts |
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Definition
• Common: Up to 20% of adolescents (peak age 20)
• Annually,8.3%oftheadolescentpopulationwillbegin exhibiting signs of depression
• Females>Males
• Associatedwith:
– academic and social impairment
– psychosis
– suicide (3rd leading cause of death in adolescents) – increased risk for depression in adulthood |
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Term
| Biomarkers for major depressive disorder |
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Definition
• Thinning of right cortex
• Reduction in right medial orbitofrontal cortical volume (for adolescent girls that went on to develop MDD within 5 years) with 70% accuracy
• Foland-Ross, et al., 2015
• HPA axis hyperactivity
• Functional abnormalities in neural systems supporting emotion processing, reward seeking, emotional regulation (frontal cortex, anterior cingulate cortex, insula) |
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Term
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Definition
Cortical thickness predicts the first onset of major depression in adolescence
Fig. 1. Average feature weight ranks across support vector machines (SVMs) from all individuals from each of 50 subsamples for all 32 cortical regions included in our anatomical mask. Features with the greatest contributions toward classifier accuracy ..
This is a graphic-- a little hard to see, I'm sorry-- but the red areas are the areas that you might see, it's not as obvious, but it is statistically significant areas that are thinning when one does imaging, neuroimaging, on these kids. And they're mainly adolescents and into adulthood. The big study for adolescent depression is the TADS, the Treatment of Adolescent Depression, this was almost 500 adolescents that had a diagnosis of major depression. |
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Term
| Treatment of Adolescent Depression: TADS |
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Definition
• 439 adolescents with major depression
• 71% percent responded to the combination of fluoxetine and CBT.
• 60.6 percent response to fluoxetine-only
• 43.2 percent response for CBT-only
• 34.8 percent for placebo group |
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Term
| FDA approved mediation for pediatric anxiety and depression |
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Definition
| escitalopram (12-17y), fluoxetine (8-17y) |
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Term
| Externalizing childhood Disorders |
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Definition
• ADHD
• Oppositional Defiant Disorder
• Conduct Disorder |
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Term
| Attention-Deficit/Hyperactivity Disorder diagnosis for inattention |
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Definition
6+ sx/ 6+ mo (CALL FOR FrEd)
• Careless mistakes
• Attention difficulty
• Listening problem
• Loses things
• Fails to finish what he/she starts
• Organizational skills lacking
• Reluctant to do tasks requiring sustained mental effort
• Forgetful in routine activities
• Easily distracted |
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Term
| Attention-Deficit/Hyperactivity Disorder diagnosis for hyperactive-impulsive |
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Definition
6+ sx/ 6+ mo (RUNS FASTT)
• Runs or is restless
• Unable to wait for his/her turn
• Not able to play quietly
• Slow– oh no, on the go
• Fidgets with hands or feet
• Answers are blurted out
• Staying seated is difficult
• Talks excessively
• Tends to interrupt |
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Term
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Definition
| An individual can have what we call ADHD inattentive type, ADHD hyperactive-impulsive type, or ADHD combined. And, typically, it's the combined that we might see. But the kids with inattention are the kids that maybe aren't hypermotoric at all. They're just sitting there kind of daydreaming, looking out the window at school, and they're missing a whole lot, but they're not causing anyone else distress because they're quiet about it. |
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Term
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Definition
| It used to be thought that people grew out of it. And now what we see, when you look at the longitudinal trajectory, is that the inattention oftentimes doesn't go down much as someone ages, but the hyperactive and impulsive symptoms do. So these are individuals that may not be running around as much, but they may still have a lot of difficulties both with organizational skills and paying attention. |
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Term
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Definition
• Around5% (up to 11% in some studies) of school-age children identified in epidemiological studies to meet criteria for ADHD
• Boys>Girls
- Especially for Combined or Hyperactive- impulsive type
(2+:1 ratio)
- Inattentive Type (Girls>=Boys)
• Primary reason for referral for mental health services (30-50% of referrals) |
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Term
| ADHD overlap of symptoms and diagnoses |
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Definition
| Now, here's the problem. Hyperactivity and inattention can overlap with a whole lot of things. For example, if you're really anxious, you might be fidgety, you might have trouble sleeping, you might be impulsive, all of those things. If you have a learning disability, you can have a lot of those areas, being oppositional because you don't want to be embarrassed that you can't read, for example. And then oppositional defiant disorder as well has a lot of similar symptoms, and it's not uncommon for the two actually to go together in terms of being diagnosed together as well. |
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Term
| ADHD and waht can co-occur |
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Definition
So what does co-occur? Well, it's pretty common to have something co-occur. Oppositional defiant disorder is the most common co-occurring disorder. Anxiety and mood. So just because you have an externalizing disorder doesn't mean you can't have an internalizing disorder.
Additionally, learning difficulties are common and should be inquired about, tested for, because what we tend to see is, oftentimes, kids will act out if they have learning disabilities because they're embarrassed that they can't do the work, and so they'd rather sort of cause problems than have people think that they can't do it.
Conduct disorder is also fairly common and really needs to be intervened and separately. Language disorder. Tic disorders.
Disruptive mood dysregulation disorder is a fairly new diagnosis. These are kids that tend to have very little frustration tolerance. So little frustrations ends up with sort of big temper tantrums. And it's possible that those also co-occur fairly frequently.
Kids with autism spectrum disorder do have, more commonly, ADHD. And PTSD and trauma also can. About half of the kids actually have more than one diagnosis or more than two diagnoses. |
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Term
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Definition
• Complex genetic determinants
- Family history of ADHD, SUD, Mood
Disorders, Antisocial Personality
- Chromosomal abnormalities
• Prenatal insults
- Toxins, VLBW, viral and other illness
- Early environmental abuse/neglect
- Abnormal cross-brain neuronal network interactions |
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Term
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Definition
So here's a brain on ADHD. What we think the tracts are that maybe have some inefficiencies are cortical, striatal, thalamic, cortical. So that would be a loop.
The cortices-- so something comes in. It goes to the cortex to be processed. Then it goes to the areas such as the striatum and the thalamus. That would be sort of an activating area. If it then goes to the frontal lobe, the frontal lobe sort of tamps that down, decides what to do about this new input, and then makes a good decision. If there's inefficiencies in that cycle, we think that the child is at increased risk for attention-deficit/hyperactivity disorder.
ADHD children demonstrate functional abnormalities in
cognitive/attention circuits
Cortical-striatal-thalamic-cortical loops |
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Term
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Definition
| This is a beautiful picture. And it's a connectome. So this DTI connectome is to show that the tracts-- these are myelin tracts that have been sort of made to look in different colors-- that the tracts are not as efficient for kids who have these disorders. And so their connectome, if we were sophisticated enough to see the micro tracts, would probably look different. |
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Term
| Why is it important to identify & treat ADHD? |
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Definition
• Interferes with the child’s learning
• Interferes with the learning of others
• Disrupts social development
• Reduces instructional time
• Adds to stress for all involved
• Drains resources
• Not having an effective strategy can maintain or exacerbate ADHD behaviors |
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Term
| Assessment and Diagnosis of childhood ADHD |
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Definition
- Mental Status Exam/Child Interview
• Assess for other disorders, traumas, stress
• May not appear overactive in a structured or 1:1 setting
- Physical Exam
• Height, weight
• Look for tics, neurological soft signs, hearing or vision problems
• R/O lead exposure, thyroid problems, etc, as appropriate |
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Term
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Definition
• Parent or guardian interview of present symptoms and functional impairment
• Pregnancy, birth and developmental history
• Medical history and OTC medications
• Substance use history
• Family history
• Educational history and teacher evaluation— talk to school |
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Term
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Definition
• Multimodal Treatment of ADHD Study (MTA)
• Individualized Multimodal Treatment Plan
- Core symptoms of inattention, hyperactivity
and impulsivity: Medications most effective
- Behavioral symptoms: Environmental modification, Parent Management Training
• Academic deficits: Psychoeducational services • Preferential seating, less distractions • Behavior plan • Increased individual teacher attention • Organizational aids and homework plan • Self-contained or highly structured classroom
• Relationship issues: Parent counseling and psychotherapy, social skills group, structured peer activities |
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Term
| Stimulant medications for ADHD |
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Definition
• First-choice medication in nearly all cases
• Over 100 controlled trials of medication demonstrating efficacy and overall safety
• About 70+% may improve |
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Term
| Algorithm for Medication Treatment of ADHD |
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Definition
-ADHD without comorbid psychiatric disorder
• Stimulant (70% response)
• Another stimulant
• Atomoxetine (Straterra)
• Alpha agonist (clonidine or guanfacine) • Tricyclic antidepressant:
• Secondary amine Nortriptyline
• Requires serum levels and cardiovascular monitoring
• Bupropion |
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Term
| Oppositional Defiant Disorder (ODD) |
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Definition
act like
REAL BADS
• Resentful
• EasilyAnnoyed
• Argues with adults
• Loses temper
• Blames other for his/her misbehavior
• Annoys people deliberately
• Defies rules or requests
• Spiteful |
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Term
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Definition
behaviors are BAD FOR A BUSINESS
• Bullying
• Animal cruelty
• Destroying others’ property
• Fighting
• Out late at night
• Running away from home
• Actively forcing sex
• Being cruel to people
• Using a weapon
• Setting fires
• Into someone’s house, building or car
• Not going to school
• Everyday lying or conning others
• Stealing while confronting a victim
• Stealing without confronting a victim |
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Term
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Definition
• Point prevalence around 5%
• Lifetime prevalence:
• ODD = 13% boys; 9% girls
• CD = 12% boys; 4% girls |
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Term
| Risk Factors for Conduct Disorder |
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Definition
• CHILD FACTORS
• Male, genetic, non-specific CNS
• Temperament and low autonomic arousal:
• Neuropsychological deficits (executive functioning problems)
• Low CNS transmission of serotonin
• Academic difficulties
• Comorbidity: ADHD, Mood Disorders, Substance Abuse, LDs and others
PARENT AND FAMILY FACTORS
• Pre- and perinatal complications
• Psychopathology and criminal behavior in the family (genetic loading)
• Family history of ADHD, mood disorder, antisocial personality
• Poor parenting, poor supervision, lack of family warmth
• Patterson’s coercive process
• Large family, marital discord, older brother with antisocial behavior
• Socioeconomic disadvantage
• Exposure to media violence characterizing the perpetrator as likeable |
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Term
| Protective Factors for Conduct Disorder |
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Definition
• Supportive adults who play an important role (outside of family)
• Authoritative parenting
• Good school environment and appropriate treatment of ADHD, LD, etc
• First born
• Perceived by mothers as affectionate
• High self esteem and locus of control |
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Term
| Evaluation and Treatment for conduct disorder |
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Definition
• Multiple sources
• Decrease child/youth embarrassment and humiliation during interviewing: parents and child separated for part of interview
• Always screen for PTSD, abuse
• Co-morbid disorders
-LD
- ADHD
- Substance use
- Internalizing and other disorders |
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Term
| conduct disorder Treatment is Multimodal |
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Definition
• PsychosocialRx
• Parent Management Training • Multisystemic therapy
- Home-based and 7 days weekly for 4 mo
• Families and Schools Together (FAST Track)
- Early intervention in home and school
• Individual Therapy: Coping, social problem- solving skills
- Treat co-occurring disorders, such as ADHD
• Group Therapy
- Anger management
- Coping Skills (Coping Cat, etc)
- Social and problem-solving skills
• Positive Environment and Activities
- Mentor
- Sports, music, etc
• Therapeutic foster care
• Wilderness/boot camps– evidence less robust
• School– special education, therapeutic school, appropriate RX of LDs, ADHD, etc
• Residential treatments
• Medication
- Antipsychotics (Most ev. Risperidone)
- Mood Stabilizers– esp. lithium
- Stimulants (with co-morbid ADHD) • Treat other primary disorders
- Appropriate RX of LDs, ADHD, etc |
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Term
| overall takeaways about pediatric psychiatry |
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Definition
• Child and adolescent psychiatric disorders are common
• Early detection and intervention can improve prognosis
• Preventive interventions include ensuring safe neighborhoods, appropriate nutrition and family support
• Always look for the spark in each child to find the strengths that can be built upon |
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