Pediatric Mental Health: ADHD, Anxiety, Depression, Bipolar Disorder - PDF

Pediatric Mental Health Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025  Objectives: Pediatric Mental Health 1. Summarize the risk factors, clinical presentation and general approach to treatment for the following pediatric mental health diagnoses:...

Pediatric Mental Health Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025  Objectives: Pediatric Mental Health 1. Summarize the risk factors, clinical presentation and general approach to treatment for the following pediatric mental health diagnoses: Attention deficit hyperactivity disorder (ADHD) Anxiety Depressive disorders Bipolar disorders Obsessive-compulsive disorder Autism spectrum disorder Breath holding spells Conduct disorders Talking with Kids HEADSS plus Home Education Eating/Appetite Activities Drugs Suicide Sex Sleep Common Pediatric Mental Health Conditions  ADHD - Attention Deficit Hyperactivity Disorder Symptoms of inattention, hyperactivity & impulsivity, or combination - NOT consistent with development level Cause problems across settings Usually present before age 12 and problematic for at least 6 months ○ Younger kids - hyperactivity and impulsivity ○ Older kids - more inattention but also academic failure, occupational and relationship problems, substance use  ADHD Epidemiology: ~11% of U.S. children diagnosed today Male to female ratio 2-6:1 ○ Male: hyperactive/impulsive ○ Female: inattentive symptoms - more likely to be underdiagnosed Symptoms often persist past childhood ○ 80% have symptoms into adolescence ○ 40% into adulthood  ADHD Differential Diagnosis: May be difficult - ADHD overlaps and intertwines with many other medical conditions (sleep disorders, seizure disorders, substance use, hyperthyroidism, lead intoxication, sensory-processing issues, and vision or auditory deficits). Fragile X and Tourette syndrome in particular  ADHD - Etiology = Multifactorial Environmental: Genetics: Exposure to lead, Variable degrees of genetic organophosphate, pesticides association Damage to CNS from trauma Greater risk of developing or infection ADHD in first-degree relatives Prenatal/perinatal exposures: Genes involving dopaminergic alcohol, tobacco, illicit and noradrenergic substances neurotransmitter systems ADHD - Brain Attention Neuroimaging studies have shown structural and function differences in parts of the brain Hyperactivity Delays in cortical maturation – neuronal networks including frontal to parietal cortical connections Orbital frontal cortex - Impulsivity  ADHD - Evaluation Lab and Imaging Diagnosis and Evaluation Thyroid, blood lead levels, Diagnosis made clinically through genetic studies, anemia HISTORY screening Reports from parents, teachers, ? Brain Imaging self-report - rating scales Psychological testing Physical Exam R/o other developmental problems Language disorder, cognitive impairment, learning disability, autism  ADHD - Treatment Recognize as a chronic condition Anticipatory guidance for patients and families Behavioral Management: establishment of structure, routine, consistency in adult/parent behaviors and appropriate behavior goals Optimal Educational Settings: Individual education plans; work with school psychologists to develops plans for child Stimulant Medications: First-line agents for pharmacological treatment ○ Methylphenidate (Ritalin) ○ Amphetamine compounds  ADHD - Meds cont… Stimulants Methylphenidate (Concerta, Ritalin) & Amphetamine (Adderall, Vyvanse) **Increase dopamine and norepinephrine → improve attention, executive function, decision Alternative making, decrease hyperactivity Alpha-adrenergic agonists - Work quickly! (Clonidine, Guanfacine) ○ Increase norepinephrine Short-, intermediate-, and long-acting forms Better for inattention; probably Side effects occur in ~⅓ of patient ○ Severe enough to indicate change or discontinuation in won’t cover severe impulsivity 15% of patients and hyperactivity ○ Most common: appetite suppression, sleep disturbance (insomnia) Useful for co-occurring tics, ○ Careful monitoring of height and weight at f/u visits ODD/CD, sleep disturbance  Non-pharmacologic Behavioral management is still considered standard of care in preschool- age children Cognitive training for older children: schedules, social skills training Calm environments and opportunities for activities that require age- appropriate levels of focus Interdisciplinary: Medical professionals, teachers, mental health clinicians, families working together for patient  Pediatric Anxiety Sense of uneasiness, excessive worry and apprehension about the future Response is excessive or inappropriate 5-10% of children and adolescents affected; occurs earlier than most mental health disorders Increase mood disorders later in life Tend to be familial May present as fear or worry, but can also make children irritable and angry  Anxiety - 8 specific disorders Separation Anxiety: Inappropriate /excessive stress of separation from caretaker Selective Mutism: Absence of speech in social situations Panic Disorder: Repeated episodes of sudden, expected, intense fear that come with symptoms of heart pounding, difficulty breathing, or feeling shaky, dizzy, sweaty Social Anxiety: Excessive fear/worry about negatively evaluated by others; avoid socializing General Anxiety: Being worried about the future and about bad things happening Specific Phobia: Extreme fear about a specific thing or situations like dogs, insects, or going to the doctor Agoraphobia: Fear of being trapped  Anxiety - Diagnosis Clinical History Rule out other medical conditions…what would be some of these? Screening tools ○ (SCARED, GAD7)  Do NOT give BZD to children; Anxiety - Treatment unless specific situation Complicated: Difficult to treat with just meds - Combined therapy! Family included in treatment plan Meds: ○ SSRIs/SNRIs Refractory treatment: address co-morbidities ○ Sleep: behavior, add sleep aid ○ Co-existent ADHD? ○ Substance use ○ Medication adherence Non-pharmacologic: CBT  Depression in pediatrics Symptoms: Common, runs in families Low mood Increased risk of substance Reduced energy (fatigue) abuse and suicide Decreased activity Disturbed appetite Often recurrent & lasts into Disturbed sleep adulthood Psychomotor slowing Difficulty concentrating Impt to r/o mood disorder and Worthlessness consider comorbidities Low self image Irritability Restlessness Depression and the brain  Depressive Disorders - In Pediatrics New category in DSM-5, divided into several new diagnoses to aid with diagnostic clarity and assist in overdiagnosis of some conditions Major depressive Disorder (MDD) ○ 5sx or more in same 2 wk period ○ Must include either __________________ or __________________ Persistent depressive disorder (formerly dysthymia) ○ Decreased in baseline mood that lasts > 1 year Disruptive mood dysregulation disorder (DMDD) ○ Only in kids 6-18yo; severe irritability and behavior dysregulation for > 12months ○ Can look like conduct disorder or ADHD or autism Premenstrual dysphoric disorder (PDD) ○ Repeated irritability, anxiety and mood lability that presents during premenstrual cycle ○ Remits near onset of menses Unspecified depressive disorder ○ Have symptoms and do not meet other criteria Depression - Diagnosis Clinical History ○ Typical symptoms ○ Academic decline ○ Psychotic symptoms (mood congruent) ○ Suicidal thinking Collaborate history, multiple perspectives Screening ○ ___________ R/o other medical causes: What labs?  Depression - Treatment Mild Depression Mod-Severe Depression Psychoeducation Psychotherapy: CBT +/- Psychotherapy Family therapy Family/school support Psychotropic medication ○ SSRI first line ECT in severe, refractory, life-threatening cases  Depressive disorders - Pharmacologic Treatment Meds:___________ are first-line ○ Treat for 6-9 months after remission of symptoms ○ Recurrent or persistent may need more extended/life time therapy _____________ second-line (recommend 2 rounds of SSRI) Failure = no response at 6 weeks at therapeutic dose Duration: 6-9 months after remission of symptoms  SSRIs - Side Effects…what are some of these? GI distress (usually resolves) Weight Gain Growth Suppression Suicidal Ideation: follow closely in initial 1-4 weeks Activation ○ Disinhibition, impulsivity, irritability, insomnia, restlessness, hyperactivity ○ Usually happens early ○ Decrease SSRI dose or consider another May induce ___________  Bipolar and Related Disorders Another new category in DSM-5, divided into several new diagnoses to aid with diagnostic clarity and assist in overdiagnosis Bipolar I disorder (BD) ○ Episodes of mania lastly at least 7 days: grandiosity, flight of ideas, risk-taking behavior, decreased need for sleep, psychosis ○ +/- Distinct periods of depression Bipolar II disorder ○ Hypomania is not so high and ~4-7 days ○ Distinct periods of depression Cyclothymic disorder ○ Chronic fluctuation of hypomania and minor depression Unspecified bipolar and related disorder Bipolar disorders Bipolar - the brain Bipolar Disorder ADHD occurs in 60-90% of children with BD First-degree relative with BD leads to 10-fold increase in child’s change of BD Higher rates of suicide and SI in BD 40-50% of adolescents with BD attempt suicide  Bipolar - Goals of Treatment Acute Treatment: Stop acute mood symptoms and related functional decline (Lithium) Maintenance Therapy: Prevention of new/future episodes Minimize adverse effects of meds Assure adherence with treatment Patient education: stabilize environment and limit stressors that may precipitate and acute episodes  Med Mgt - BD Mood Stabilizer Lithium Acute manic episodes and maintenance therapy in children and adolescents Anticonvulsants + mood Lamotrigine First-line for adults; stabilizer Valproate (Valproic acid or Not FDA approved but divalproex sodium) have been used effectively in children 2nd Gen. Antipsychotic Aripiprazole Initial therapy for mania and Quetiapine used in maintenance Risperidone Lurasidone  Medication review Lithium LITHIUM TOXICITY - Monitor drug levels - narrow TI - Kidney/thyroid function - EKG - Teratogenic 2nd Gen antipsychotics - QT prolongation - Weight gain - monitor A1C and lipids - EPS Valproate - Monitor drug levels - LFTs and platelet - Teratogenic https://www.emboardbombs.com /  Bipolar - Nonpharmacologic Management Cognitive and behavior therapies are key for pediatric patients and their families Assure med adherence Lessening anxiety/depressive symptoms Ongoing safety assessments Collaboration with school - IEP may be necessary  Obsessive Compulsive Disorder Obsessions: Recurrent intrusive thoughts, images, or impulses Compulsions: Repetitive, non gratifying behavior that a person feels driven to perform in order to reduce or prevent distress or anxiety In children, rituals or compulsive symptoms may predominate over worries or obsessions Linked to disruption in brain’s serotonin, glutamate and dopamine symptoms. Overactivity in the frontal cortex and caudate nucleus have been implied  OCD Obsessions Compulsions Fears of contamination, dirt or germs Grooming rituals (hand washing, Need for orderliness/precision showering) Ordering Repeated doubts Checking Aggressive thoughts Requesting/demanding reassurance Praying Counting Repeating words silently  OCD - Risk Factors 50% of your with OCD have at least one other psychiatric illness ○ Mood and anxiety disorders ○ Behavioral disorders (ADHD and oppositional defiant disorder) ○ Tic and hoarding disorders “Moderately heritable” - twin studies suggest genetic link Streptococcal infection causing inflammation of basal ganglia ○ “Pediatric autoimmune neuropsychiatric disorders associated with streptococcal” (PANDAS) infection ○ OCD after strep infection ○ Antibiotic therapy  OCD - Clinical Presentations Generally a gradual onset More commonly diagnosed between 7 and 12 years of age PE: ○ Rough, cracked skin ○ Missing hair from pulling ○ Skin excoriations ○ Persistent fear of illness ○ Concerns regarding health of family members Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)  OCD - Differential Diagnosis Psychotic disorders: ○ OCD typically present with clear obsessions/compulsions that are distinguishable from delusions and OCD lacks hallucinations OCPD: ○ OCD is true obsessions or compulsions. OCPD is preoccupation with orderliness, perfectionism and control ○ OCPD is “egosyntonic” - not distressing to patient ○ OCD is “egodystonic” - distressing to patient  OCD - Management CBT — what is this again? ○ Involves exposure and response prevention ○ Maybe better than medications? ○ Gradual exposure to fear/obsession paired with strategies that target preventing the unwanted ritual/compulsion Med management ○ SSRIs: Fluoxetine, Fluvoxamine, Sertraline ○ TCA: Clomipramine Deep Brain Stimulation - reserved for very severe cases ○ Stimulation of the basal ganglia ○ Surgical implanted electrodes and surgical interventions As many as ⅓ young people refractory to treatment  Autism Spectrum Disorders Previously Autism, Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorder. Lifelong marked impairments in ○ Social relatedness ○ Communication/play Restricted interests and activities **Distinct from intellectual disability** Risk factors: genetic component w/ increased risk in siblings ○ No known methods for primary prevention  ASD - Presentation symptoms Symptoms include: ○ Absence of social smiling ○ Social withdrawal ○ Solitary play ○ Communication/speech delay - Echolalia, perseveration, pronoun reversal, nonsense rhyming ○ Self-injurious behavior ○ Stereotypes or motor mannerisms ○ Hyper/hyporeactive to environment  ASD - Presentation Can see signs at 3-6 months AAP recommends screening at 18-24 months ○ Numerous screening methods ○ M-CHAT-R/F Screening tool Often diagnosed by 3 years old With higher cognitive ability, may be older as they have compensated Males:females 4.5:1 ASD - Evaluation (in additional to screening measure) Hearing test for language delays Chromosomal testing ○ Fragile X ○ Metabolic disorders EEG abnormalities may be seen but are not diagnostic Awareness of underlying medical concerns esp. with non-verbal pts ○ Hunger pain, cerumen impaction, constipation, dental  ASD - Management: Non-pharmacologic No pharmacologic treatments for core symptoms Treatment and education aimed at decreasing morbidity and maximizing function Behavioral Training: multiple interventions ○ Family support groups and individual support for parents Special ed services Occupational, speech and physical therapy Referral for disability services and support  ASD - Management: Types of therapy Social/Communication Sensory Speech Sensory integration therapy Social Skills Programs Occupational Therapy ABA (Applied Behavior Analysis) Feeding therapy Music Therapy Aquatic therapy RDI (Relationship Development Intervention) Music therapy Behavior Motor ABA OT/PT DIR (Developmental, individual-differences, Aquatic therapy relationship based model) Chiropractic therapy RDI Hippotherapy CBD (Cognitive Behavior therapy) Feeding therapy Muscle therapy Verbal behavior Behavioral Interventions - ABA Applied Behavior Analysis Behaviors are affected by their environment. Behaviors can be strengthened or weakened by its consequences. Behavior changes are more effective with positive instead of negative consequences. Interdisciplinary: Board Certified Behavior Analyst  ASD - Management: Pharmacologic ADHD ○ Alpha agonists (guanfacine) ○ Less likely to respond to stimulants (maybe if hyperactive and inattention) Anxiety ○ SSRI - low dose ○ Alpha agonists (guanfacine, clonidine) Irritability or aggression ○ Antipsychotics: (risperidone or aripiprazole) Sleep Dysregulation ○ Melatonin  ASD vs ADHD ADHD: Hyperfocus on immediate ADHD: inattention d/t environment and distraction by change rapidly Attention environment/daydreaming Special Interests Autism: Difficulty Autism: Hyperfocus on shifting attention b/c special interest tends getting stuck or to be more unique and repetitive; difficulties persistent with social cues ADHD: Impulsive, intrusive, interrupts ADHD: Social Hyperacusis Interaction Autism: Difficulty with Sensory social cues and Autism: Difficulty language with textures, fabrics, foods, noises  Disruptive, Impulse-Control, and Conduct Disorders Conditions involving problems with self-control of emotions and behaviors Manifested as behaviors that violate the rights of others or pose significant conflict with societal norms or authority figures In the DSM-V-TR broken down into… ○ Oppositional Defiant Disorder (ODD) ○ Intermittent Explosive disorder ○ Conduct Disorder ○ Pyromania ○ Kleptomania ○ Other and unspecified disruptive, impulse-control and conduct disorders Oppositional defiant disorder (ODD) & Conduct Disorder (CD) Syndromes defined by patterns of behaviors that lead to conflict with adults and/or peers and associated with impairment in home, school and/or community settings. Conduct Disorder Oppositional Defiant Disorder Severe chronic behavior problems Chronic irritability (low frustration including insensitivity to other people’s tolerance, frequent temper outbursts) needs or feelings Behavior problems (persistent defiance & Serious rule violations and infringing on obstinance beyond what is expected for right of others age) Typically begin in adolescence and may Typically appear in preschool and child precede ____???_____ in adulthood years and may precede development of CD  ODD/CD - Evaluation Rule out substance use R/O physiologic effects of a medication condition Consider other psychiatric conditions  ODD/CD Treatment ODD: Focus on diminishing the persistent irritable mood CD: Focus on diminishing maladaptive behavior and developing empathy =============================================================== Psychosocial intervention +/- pharmacologic management Family training is crucial Meds: ○ Lithium: Shown to decrease bullying, fighting, temper outbursts ○ SGA: Improve aggression and irritability ○ Divalproex: Shown to reduce temper outbursts and mood lability =============================================================== Treat co-occurring disorders (ADHD, mood or anxiety)  Breath Holding Spells Age: Typically occur in children 6 months - 24 months of age Timing: Most children have 1-6 episodes/week; some have multiple episodes/day Event: Triggered by emotional insult such as pain, anger, or fear ○ Cyanotic: breath holding → cyanosis and LOC ○ Pallid: LOC occurs before breath holding (due to bradycardia); less common ○ Brief posturing or tonic-clonic motor activity may occur Etiology: ○ ? Possible dysfunction of autonomic nervous system ○ Can be associated with IDA Treatment: ○ Iron supplementation if IDA ○ Theophylline (respiratory stimulant) ○ Anti-seizure meds are NOT helpful Prognosis: Clinically course usually benign - spells usually stop by 5 year of age Case: Thank you!