Term
| Multimodal Evaluation of Child Pt with possible Psychiatric Illness |
|
Definition
ESSENTIAL for correct diagnosis;
1) Take extensive pt history (prenatal, developmental, family hxs);
2) Medical Evaluation - lab tests (Chem-7, LFTs, TFTs, endocrine tests), Radiologic (head - premature fusion, signs of abuse), PhEX (chronic illness, abuse), Genetic Testing (inborn errors);
Psychatric Eval (DSM-IV criteria, "caveats", educational abilities);
Determine Baseline Characteristics & level of impairment (Pt-specific, Family information, School information) |
|
|
Term
| Patient Information required for Evaluation |
|
Definition
age-dependent;
self-assessment or observation of behavior away from clinic;
developmental history;
current signs & symptoms;
medical evaluation;
psychiatric testing |
|
|
Term
| Family Information required for Evaluation of Child pt |
|
Definition
beneficial for determining longitudinal observations;
MAY BE BIASED;
able to provide hx of other family members: diagnosis, successful tx plans;
identifies pt's relationships & coping skills;
strengths & weaknesses |
|
|
Term
| School Information required for Evaluation of Child pt |
|
Definition
academic work/performance w/ comparative hx to past performance;
social relationships w/ peers;
teachers may or may not be less biased;
may observe pt during age-appropriate activity |
|
|
Term
|
Definition
education is essential (pt, parents, family);
behavioral therapy - ALWAYS attempted 1st & preferably as MONOTHERAPY, maintain even if pharmacotherapy is required;
Pharmacotherapy - LAST LINE: best results when combined with behavior & education therapy |
|
|
Term
| Issues to Discuss w/ Pt & Family Prior to initiating Therapy |
|
Definition
1) proposed medications/options;
2) MoA - if "unknown" be honest;
3) Risk vs. Benefit - results of trials including abuse potential, known SEs, drug interactions; requirements of therapy - duration, timing of doses, withdrawal issues, food requirements;
4) EVERYONE should agree prior to implementing plan |
|
|
Term
| Attention-Deficit/Hyperactivity Disorder (ADHD) |
|
Definition
most common childhood psychiatric disorder; occurs more commonly in males;
Cause (proposed): officially unknown but significant link to genetics and environmental factors;
MoA: deficiency of NE & DA at synapse in frontal & neostriatial systems;
Main Signs: inappropriate inattention, impulsivity, hyperactivity |
|
|
Term
| Inappropriate Inattention |
|
Definition
| main sign of ADHD; involves not finishing tasks, not seeming to listen, being easily distracted, having difficulty concentrating on schoolwork, difficulty sticking to play activity |
|
|
Term
|
Definition
main sign of ADHD;
Manifests as: acting before thinking, shifting excessively from one activity to another, difficulty organzing work, increased need for supervision, frequent calling out in class, difficulty awaiting turns in lines |
|
|
Term
|
Definition
main sign of ADHD;
Manifests: excessive running or jumping, difficult staying seated, excessive movement during sleep |
|
|
Term
| Common comorbid states that are seen in pts w/ ADHD |
|
Definition
| anxiety disorder, clinical depression, learning disabilities, Tourette's Disorder |
|
|
Term
|
Definition
ALWAYS start w/ non-pharm therapies (educational & behavioral therapies);
1st line agents --> CNS stimulants (methylphenidate, mixed amphetamines, dexmethylphenidate, dextroamphetamine, methamphetamine) --> most widely used, treatment of choice unless C/I --> Start w/ 1 agent in class - if it fails, try another stimulant agent |
|
|
Term
| Managment Plans for ADHD Medications |
|
Definition
1) start w/ short-acting agent;
2) dose titrate to desired effect or max dose;
3) if max dose is reached and:
a) pt has NO PERCEIVED BENEFIT, switch to a different stimulant (pharmacodynamic failure) OR
b) if pt has SOME IMPROVEMENT but med ends too quickly or "waxes and wanes", try a LONG-ACTING agent w/ same active ingredient (Pharmacokinetic failure);
5) for short-acting stimulants, dose BID or TID to reach da |
|
|
Term
|
Definition
| occurs when pt HAS NO PERCEIVED BENEFIT from medication --> switch to a different stimulant |
|
|
Term
|
Definition
| if pt has SOME IMPROVEMENT on med but it ends too quickly or "waxes and wanes" --> try long-acting agent with same active ingredient |
|
|
Term
| amphetamine + dextroamphetamine (Adderall) |
|
Definition
CNS stimulant for tx of ADHD;
For 3-5 yr olds:
Initial - 2.5 mg
Max - 40 mg
For >= 6 yrs:
Initial - 5 mg
Max = 40 mg
Duration of Action: 2-6 hr |
|
|
Term
| dextroamphetamine (Dexedrine, Dextrostat) |
|
Definition
CNS stimulant for tx of ADHD;
Dosing:
3-5 yrs old:
Initial - 2.5 mg
Max - 20 mg
>= 6 yrs old:
Initial - 5 mg
Max - 40 mg
Duration of Action: 3-8 hrs |
|
|
Term
| methylphenidate (Ritalin) |
|
Definition
CNS stimulant for tx of ADHD;
Dosing:
3-5 yr olds:
Initial - 5 mg OR 0.3 mg/kg/dose BID or TID;
Max - 0.6 mg/kg/dose OR 60 mg
>= 6 yrs:
Initial - 10 mg OR 0.3 mg/kg/dose BID to TID;
Max - 60 mg OR 0.6 mg/kg/dose
Duration of Action: 3-6 hrs |
|
|
Term
| dexmethylphenidate (Focalin) |
|
Definition
CNS stimulant for tx of ADHD (children >= 6 yrs old):
Dosing:
Initial - 5 mg
Max - 20 mg
Duration of Action: 6 hrs |
|
|
Term
| methamphetamine (Desoxyn) |
|
Definition
CNS stimulant for Tx of ADHD (children >= 6 yrs);
Dosing:
Initial - 5 mg
Max - 40 mg
Duration: 6-12 hrs |
|
|
Term
| Long-acting CNS stimulants - Adderall XR, Dexedrine Spansule, Vyvanse, Metadate ER, Methylin ER, Ritalin SR, Metadate CD, Concerta, Daytrana (patch) |
|
Definition
Allows for once daily dosing;
newer forms incorporate immediate release form with sustained release mechanism allowing for continuous release; |
|
|
Term
| Side Effects of CNS Stimulants |
|
Definition
| HA, decreased appetite (take w/ food, increased with long-acting), GI complaints - nausea, stomach pain (take w/ food), insomnia (avoid late day dose, increased w/ longer-acting), exacerbates tics (C/I w/ Tourette's), delayed growth (give drug holidays, monitor height & weight), increased HR & BP (monitor), patch can irritate skin (Daytrana) |
|
|
Term
| Contraindications for Stimulants |
|
Definition
| pre-existing cardiac abnormalities (monitor ECG), agitation, hypersensitivity, suicidal ideation (BLACK BOX WARNING!) |
|
|
Term
|
Definition
used only if stimulants fail or are contraindicated; possibly first line product;
nonstimulant, noncontrolled substance;
MoA: SNRI - selective NE reuptake inhibitor;
Metabolized via CYP 2D6 --> genotyping for rapid or slow metabolizers;
Similar efficacy to CNS stimulants;
Additional SEs:
snomonlence, anorexia |
|
|
Term
|
Definition
MoA: DA agonist w/ long half-life (once daily dosing);
Adv: similar efficacy, Sched IV instead of Sched II;
Disadv: fulminant hepatic failure (UNPREDICTABLE - BLACK BOX WARNING) --> reason for NOT being 1st line |
|
|
Term
| tricyclic antidepressants (TCAs) - imipramine, nortriptyline, desipramine |
|
Definition
well documented efficacy;
NOT as successful as stimulants;
good option if stimulants are C/I OR for comorbid states (depression, agitation);
MoA: unknown;
Disadv: significant SE profile, must titrate on and off, cardiac risk w/ d |
|
|
Term
|
Definition
minimal studies done but SOME results indicate efficacy;
NO FDA indication;
SEs: minimal, exacerbates tics |
|
|
Term
|
Definition
only studied in adults;
MoA: SSNRI - selective serotonin & NE reuptake inhibitor;
SEs: mild nausea, dose-dependent increase in BP |
|
|
Term
|
Definition
| good efficacy BUT diet restrictions /possible rxn preclude its use |
|
|
Term
|
Definition
alpha-adrenergic agonists that have been used to tx ADHD with success
SEs: sedation, BP control difficult to manage in pediatric pts |
|
|
Term
|
Definition
chronic familial disorder characterized by multiple motor tics w/ 1 or more vocalization tic;
motor tics may be twitching, jerking, rapid mouth;
vocal tics --> 98% have phonic tic (grunting/barking), 2% have coprolalia (swearing) |
|
|
Term
|
Definition
1) must have tic for 1 yr or more
occurs more often in boys;
Comorbidities: ADHD, OCD |
|
|
Term
|
Definition
1st line = behavioral & psychotherapy;
2nd line = pharmacotherapy as needed - haloperidol [Haldol], pimozide, clonidine; |
|
|
Term
|
Definition
FGA (first generation antipsychotic) FDA approved for tx of Tourette's;
Dosing: give doses qHS, titrate slowly over 2-3 wks to prevent EPS & sedation;
Symptom regression starts within 48-72 hrs |
|
|
Term
|
Definition
comparable efficacy to haloperidol; FGA approved to tx Tourette's;
Dosing: give initial qHS, titrate over 2-3 wks to limit EPS & sedation, give once daily (long half-life); |
|
|
Term
|
Definition
comparable efficacy to haloperidol; FGA approved to tx Tourette's;
Dosing: give initial qHS, titrate over 2-3 wks to limit EPS & sedation, give once daily (long half-life); |
|
|
Term
|
Definition
effective in only 50% of Tourette's pts;
Pts & Family counseled on risk associated with noncompliance & withdrawal --> flare-up rxn --> HTNsive CRISIS!!!
Dosing:
Start at test dose of 0.025-0.05 mg AM, gradually titrate every 4-7 days to therapeutic dose: 0.15-0.25 mg/day;
Maintenance dose may need to be divided; Onset of effect is slow --> 3 wks to a few months;
WATCH BP CLOSELY! |
|
|
Term
|
Definition
| repeated involuntary or unintentional voiding of urine by day or night which is not caused by a physical disorder |
|
|
Term
|
Definition
1) 2 episodes per wk for at least 3 months;
2) significant distress;
3) impairment of social, academic, or other important functioning;
4) child must be at least 5 yrs old |
|
|
Term
|
Definition
| indicates child has NEVER established urinary continence |
|
|
Term
|
Definition
| follows an ESTABLISHED period (3-6 months) of urinary continence |
|
|
Term
| Treatment Approach for Enuresis |
|
Definition
1) EDUCATION is KEY
2) discourage punishment
3) behavioral & conditioning methods - bed alarms, no fluids after 6 pm, set wake up patterns in night - 70% effective
4) Drug therapy is 2nd line - if attempted, try D/Cing every 3-6 months to assess for spontaneous remission - drugs used: imipramine, desmopressin |
|
|
Term
|
Definition
TCA best known and indicated to tx enuresis;
Efficacy: 70-85% - half will have complete resolution while other half will have decreased episodes;
Dose:
Initial - 25 mg qHS w/ increases of 25 mg per wk
Avg dose - 75 mg (children) & 150 mg (teens)
Dose that is initially effective will be INEFFECTIVE in 2-6 wks, need to reestablish control by titrating dose up |
|
|
Term
| desmopressin acetate (DDAVP) |
|
Definition
synthetic analog of natural ADH;
Forms: tablets, nasal spray, rhinal tube;
Efficacy: 70%, better results in children OLDER than 9;
Duration: 6-24 hrs
ADRs (infrequent):
nasal irritation, epistaxis, rhinitis, nasal congestion, HA, chills, dizziness, nausea;
COUNSELING PTS:
Evening fluids should be limited to 8 oz to PREVENT HYPONATREMIA or WATER INTOXICATION |
|
|
