Behavioral Disorders in Children PDF

Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... Behavioral Disorders in Children All right, so we talked about primarily issues in pharmacokinetics, in general, in p...

Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... Behavioral Disorders in Children All right, so we talked about primarily issues in pharmacokinetics, in general, in pediatrics in the !rst slide set. And in this slide set, I wanted to take just a little bit of time to talk about some of the medications that we most commonly use for behavioral disorders in children, which is the thing that you are most likely to see as a generalist. The world of pediatric psychiatry is its whole own specialty. There really are some very interesting disorders. And we will study them, I believe it's in 6971. I think it's your second-- anyway, one of the three sequence courses that we take for assessment and diagnosis. We will spend a lot more time talking about disorders in children. And like I said, pediatric psychiatry is its whole own phenomenon-- attachment disorders, the consequences of not having an attachment to a caregiver in that !rst year. Even in infancy, there are behaviors that infants do when they don't have an attachment, when they don't have a caregiver in whom they can trust. And all the way through the line-- we look at the developmental theory, like Freud and Erikson and Piaget. And we can see that when children are missing certain key aspects in growth and development, it can produce psychiatric disorders that begin very early, can be very devastating. And it's its whole own area of study. And then of course, there is the rare circumstance in which very young children may present a psychotic depersonalization, derealization. Like it's its whole own area of study. And it's why it gets its own semester a little bit further down the line. But the behavioral disorders, these are things that unless you exclusively practice with adults, if you see adolescents or even school-age children, you will absolutely have to manage behavioral disorders. It is a very common presenting symptom in psychiatry. And that's why we take some time to look at it here, speci!cally with a focus on the medications that we will use. We are using the same medications that we've talked about already for other disorders. There's not a special pediatric medication. It's just that the implications for growth and development safety, adverse e"ects are a little bit di"erent. And they're approved for di"erent things in childhood. Even though we very commonly 1 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... used medications o" label, the thing to keep in mind is that insurance companies-- I mean, they ultimately decide what they'll pay for or not. And sometimes the challenge isn't knowing what you need. You know what you need to prescribe. But the insurer will come back and say, well, that's not approved for that diagnosis in children of this age. And then you have to !gure out how to work around that. And we will talk all about that in the pediatric course. But right now, we're just looking at some of the drug considerations for behavioral disorders in children. First up, from the perspective of the prescriber, what we do is meds. Most psych, mental health MPs, your primary role is prescribing. Your !rst visit with the patient is to do a comprehensive assessment and come up with a diagnosis. And once you come up with a diagnosis, if it is not amenable to medication, you typically refer them to a therapist. And if it is amenable to medication, it's your job to prescribe it. And then subsequent followup visits are really medication visits. Is it working or not? If it's working, leave it alone. If it's not, change it. Is it working, but not well enough? Do we need to tweak the dose? Is it working, but the adverse e"ects are intolerable? Well, then we need to see if maybe we can !nd a better option in the same class that has a lesser adverse e"ect pro!le. But really, our place in the world is medications. Meds is about what we do. And none of us likes prescribing medications for children. I mean, really, none of us likes to have to put children on drugs to manage their behavior. But sometimes it really is necessary. It's what we've got. And sometimes we really have to do it for quality of life for the child. And so one thing to keep in mind is that even though we are the prescribers, and medications is our primary area of expertise, every time we put a child on a medication, we should be encouraging the caregiver, whether it's mom, or a foster family, or dad, or relatives, or whomever, we should always be letting them know that we really, really, really encourage that a therapist be in the child's world. And our goal as prescribers, always, for everybody, is that people aren't on drugs forever. We don't want people on drugs forever. We acknowledge that sometimes it is necessary. And that's what we do. But always, our goal is to try to help people !nd a nonpharmacologic way to manage their symptoms, manage their quality of life, and in children, especially. 2 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... I mean, in children, we just hate to see them on medications for the long haul unless it's clearly necessary. So if you make the determination that medications are appropriate, that's !ne. There are many circumstances in which they are. But always throw in that idea. Like, always give that recommendation about connecting with a therapist. And then !nally, another thing to keep in mind while we're on this particular piece of the topic. We recognize that sometimes it isn't really the child that has the problem. Or even if the child does have a problem, the environment can be making it a whole lot worse. If I had a nickel for every time I said to a therapist, oh, man, I really do not like to be giving this kid meds because they have to get out of that home, they have to get out of that environment, whether it's the natural home, a group home, a foster home. I mean, all of those can be di#cult. There are some excellent foster homes, and there are some very poor foster homes, and everything in between. I wouldn't say many times or often because I don't know what the statistics are. But I feel like the majority of children who present to me for evaluation, it really isn't the child that has the primary problem. It's the parents or the environment. And so then what you're left with is, OK, am I going to medicate this child who is acting out-- I mean, is having behavioral episodes, or is almost a danger to themselves or others as a consequence of their behavior? But I strongly believe that the behavior could be improved upon by removing them from the environment. What do you do with that? Because at the end of the road, it's not up to us to have the child removed. We don't have that authority. I don't know who exactly has that authority. In my world, it would be Youth and Family Services, I suppose. I don't know who it is for all of you that are listening from di"erent parts of the country. But I can tell you that it's not up to us. Nobody is taking a kid out of a home based on our recommendation. And so-- unless you call the police, I suppose, and report that you think the child is in immediate danger. Then they will go out and do an assessment and still, half the time, not remove the child. So the bottom line is, even though when we know in our heart that the environment is a big part of the problem, we really are powerless to change that. 3 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... So then what we're left with is a child who is in a situation where their behaviors are such that it's causing real problems. And the only thing we have to do is medicate them. The only thing we have to o"er is to medicate them. Do you do it? And for me, it's a tough one. There have been times when I have said to the parents-- and it's typically natural parents-- there have been times when I said to them, medicine is not the answer in this circumstance. The answer here is the parenting. You need to set boundaries. You need to set limits. You need to enforce the discipline of the household. You need to reward the positive behavior. You need to discourage the bad behavior. You need to be consistent. Not that I was mother of the year, but sometimes it really is the parenting that is so overt. And they need help with it. They need a therapist, a family therapist, often, that can help them set that up. So there have been times when I have said that to families. And then there have been other times when I know that's not going to happen no matter what I say. So then the question is, well, do I medicate the kid, really, to try to make their lives a little more tolerable and pleasant? It's hard. It really is a challenge. And at the end of the road, you have to decide what you're comfortable with. But remember how I said you always want to manage expectations with your patients? Well, in this circumstance, it's really about managing your own expectations. You might genuinely believe that medicine isn't the primary answer here. But if it's the only answer you have, and it can improve things, sometimes that's just what we do. So on that happy note, let's look at some of the individual conditions that we see that cause behavioral symptoms in children. First up is ADD. And we talked about ADD last week, I think. We talked about it from a drug perspective. And just to try to clear up, there is always a question about is it ADD? Is it ADHD? What's the right terminology? I see it both-- Here's what I can tell you. The DSM-5 has a condition called Attention De!cit Disorder, ADD. And then there is the inattentive type, there is the hyperactive/impulsive type, and then there is the mixed type. So that's the way I document it. And that's the way I code it. And that's the way I present it to you. Because that's what the DSM uses. 4 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... So I guess, strictly speaking, there is ADD hyperactive type. So if you call that ADHD, I don't think it makes any practical di"erence to anybody in the whole wide world except when you are coding to submit your billing. And then, of course, you want to use the right code, which if you have an electronic medical record, it will force you into it. I mean, I always get that question. Is it ADD or ADHD? Which one is right? Which one is right or wrong, who am I to say? All I can tell you is how the DSM-5 categorizes it. And that's it. So that condition is statistically the most common behavioral disorder that causes behavioral disruption in kids. So is it the most common disorder? Or is it the most commonly diagnosed disorder? Like, is it the one that statistically is coded more in the United States than anything else? Sometimes, I wonder. But for right now, what the evidence tells us, what evidence-based practice tells us, is that ADD is statistically the most common cause of behavioral symptoms in children. And you will !nd that it is virtually always the !rst one that anybody considers. So when kids come in, when parents bring in children because of behavioral problems, and we're going through the di"erential diagnoses, ADD is very often at the top of the list because epidemiologically, it is so common. And so it's not the role of this class to go into exhaustive discussions about diagnostic criteria, so I'm not going to. But what I do want to tell you is that with ADD, yes, the patient absolutely presents as behavioral problems. There will usually be complaints from the teachers at school. The child doesn't complete the work, disrupts others, always talking in class, doesn't wait their turn, can't sit in their seat. And in a classroom environment, they're a problem. Even in the home environment, especially if there are other kids in the home, this is the child that may not be able to wait turn, like sit at the table. If the rule is everybody sits at the dinner table till everybody is !nished-- whatever the case may be, these behaviors become more overt at home. Now, in an only child situation, sometimes the parents, without even realizing it, just adjust the environment so that the symptoms aren't as overt. And that's when you'll have parents say, the teacher says this, this, and this, and the teacher says it's a real problem. And I don't notice it. He's !ne at home. It's probably not that he's !ne at home. It's just that at home, since he's the only child, the parents start making allowances. Like, they adjust the environment. They adjust the 5 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... boundaries and such so that it doesn't seem like it's a problem. But anyway, it de!nitely can present as behavioral problems. But what you will notice about the ADD child is that they are not mean. They're not mean. They're not nasty. They are not overtly de!ant of authority just for the sake of being de!ant. For these patients, their symptoms really do come from the fact that they just can't focus on whatever they need to be focusing on, that they are very easily distracted, and that they have impulse control problems. So that's where, like, the blurting out answers, and getting out of their seat, and not sitting still-- it's about impulse control and the inability to pay attention, which is really very di"erent than the kid who is really, truly nasty, de!ant, purposefully annoying people around them. That's a di"erent diagnosis. So children with ADD, one of the things that really stands out of this behavioral disorder from others is that these kids do have good times. When you talk to the parents-- and the parents !rst, of course, they'll tell you about the problems because that's what's on their mind, and that's why they made the appointment. But then you want to say, well, tell me about the good times. Tell me about the last time that you really had a nice, an enjoyable interaction. Where did you go? What did you do? Tell me about the last time that you had some good times. And when the child has ADD, those good times are readily identi!able. The parent will be able to tell you about it right away. When they are not in a situation where they really have to control impulse or control movement, when there's circumstances they don't have to sit still, like, maybe they're at the playground. And while they're at the playground, the parents are sitting at a picnic table, and the children are just o". They're running around all the activities and the-- I can't remember. What is it? What do you call it when it's at a playground? I'm so far removed from having kids at a playground. I can't even think of the right terminology. But I know that there are times where they just-- they can do whatever they want. They can go from thing to thing-- the sliding board, the swings, whatever kids do nowadays. Like, in that kind of environment, there are no behavioral issues. The child will respond to authority. If they're out having, like, a family picnic, even over at a relative's house-- big backyard, there's a swimming pool, and there's fun, the kids are having a great time. Everybody's 6 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... happy. When the parents say, hey, Joey, come here, Joey comes. Like, that kind of stu" is also very characteristic of ADD. The quote, "behavioral symptoms" occur when the child is in an environment where they have to sit still, they have to focus, typically for an extended period, and they can't. And it looks like a behavioral problem. So this is one of the ways that we help distinguish this disorder from other behavioral disorders in childhood. As I say, it is considered the most common cause of behavioral dysregulation. It is one of our leading di"erentials. But one of the easiest ways to rule this out is to get a sense of when these problems occur and when they do not. Find out about the good times. If you deduce that the child really does have ADD, then as we discussed a week or so ago, psychostimulants truly are the drug of choice. They are among the most e#cacious in psychiatry. They will work fast. And if ADD is not the problem, they won't make any di"erence at all. A week later, parent says no, I'm not noticing anything. I swear I'm giving it just the way you said, and it's no di"erent at all. Then it's time to consider another diagnosis. So then, as we discussed last week, if you are really convinced that this is ADD, but for whatever reason, the parents don't want a controlled substance, the side e"ects-- like, the child's not eating at all, maybe they're losing weight and you're worried about that-- for whatever reason, you can't use a stimulant, then you have the other options to choose from. Now, you'll also notice in very young children, like four or !ve or six, that prescribers are more comfortable with guanfacine, like I said. They're just concerned about giving a younger child a stimulant. And listen, at the end of the road, you as the prescriber have to decide what you're comfortable with. But I think I conveyed this last week-- and my approach to the world, for what it's worth, my approach to the world is I don't medicate ADD unless I am really as certain as you can be that it is ADD. And once I decide that ADD is what I'm managing, I know that a psychostimulant is going to give me the best clinical outcome. And the only reason I won't use it is if I am concerned about adverse e"ects, if the parents just absolutely say no, they don't want it, or in older kids if there is any concern about abuse. Or even sometimes, you do have to keep your eyes peeled. Sometimes it's not actually the kid that's abusing it, it's the parent. You give the drug to the children, and then the parents are taking it. So if you have any concerns about any of that, then yes, guanfacine is very commonly 7 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... the next go-to drug for the very young children. But it's just not going to be as e"ective. Anyway, that's ADD in a nutshell. And because we talked more about the other medications, I'm not going to go into any great detail. Now, the things we talked about in the week where we talked about ADD as its own diagnosis-- remember, I also mentioned bupropion and the wakefulness agents. But they're not indicated in children, so they're not an option. ADD in kids, it really does come down to the stimulants, the alpha-2 agonists, or sometimes an old throwback would be an antihistamine. I just totally had a TIA and completely lost track of my train of thought. Well, I forget exactly what I just said. I'm having a neurocognitive impairment. But the thing I wanted to say to you about ADD is that because-- oh yeah, I was saying bupropion and the wakefulness agents are not approved in children. So when it comes to ADD medication in children, all we really have are the psychostimulants and the alpha-2 anti-adrenergic agonists. Another one that is used sometimes in really young children is Atarax or PO Vistaril. And it's sort of, I think, fallen by the wayside a little bit. It can calm down behavior. There has been some concern about prolonged use leading to a tic presentation or a tic phenomenon in children. And it just is one of those things that 30 years ago, it was the !rst thing you ever used. But now, we just have better options that, generally speaking, are safer. But at the end of the road, psychostimulants are your most e#cacious. If you don't want to use that, you go for a less e#cacious drug. And the rest of it, I'll refer you back to week !ve. Now, what about the other behavioral disorders of childhood? Because there are a few. We have the alphabet soup of childhood. We have ADD. And we also have DMDD, Disruptive Mood Dysregulation Disorder. This is the artist formerly known as bipolar disorder. This is the new and improved DSM-5 name for what we used to call bipolar disorder in children. It, too, can present as behavioral outbursts or behavioral dysregulation-- I love that phrase. Behavioral problems is how it presents. But making the diagnosis the diagnostic criteria, if you know what you're looking for, it really is di"erent than ADD. 8 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... This is a disorder of pediatrics. This onsets before the age of 10. But look at what you can expect to !nd in DMDD-- a history of more than 12 months of severe, persistent, irritable, or angry mood with frequent temper outbursts. So the child's baseline state is irritability, irritability and anger. And they have temper tantrums. By de!nition, diagnostic criteria, the temper tantrums or the outbursts occur at a minimum of three times a week. And they are disproportionate to the patient's age. There is a certain point in the toddler where temper tantrums are very typical. And unfortunately, that is just part of growth and development. We don't worry so much about that. But when, say, a seven-year-old who is persistently irritable and angry is having these temper tantrums that look like a two-year-old, that's what's consistent with your diagnostic criteria. So I mean, really, what you're looking for here is a baseline state of irritable and angry with regular, frequent, disproportionate temper tantrums. You see the di"erence with ADD right o" the bat? The ADD child, like I said, the good times, they're easy to identify. The parent will have no problem telling you about the good times. The bad times just occur when they are required to stay focused, and sit still, and control themselves, and they can't. Whereas with DMDD, these kids frankly, they're just not very pleasant to be around. It's much harder for the caregiver or the family unit to identify the good times. This is the kid that will go to the picnic or the park and be miserable the whole time. That's the di"erence in a nutshell. The behavior $uctuates just like bipolar disorder does. It's mood dysregulation. The perpetual, irritable, angry, that's analogous to the depressive piece. And the anger outbursts are analogous to the manic piece. But the real di"erence here is A, the absence of really, really good times, and B, the regularly scheduled temper tantrums that are disproportionate. Like bipolar disorder, this is one that does lend itself to medication. This condition can signi!cantly improve in the patient who is properly medicated. And it really comes down to medicating them for bipolar disorder. So you memorize-- not memorize, recognize-- I told you I'm having cognitive decline here-- you recognize this list of drugs. We talked about all of these when we talked about bipolar disorder. Lithium and Depakote, Lamictal, those are mood stabilizers. Abilify and Risperdal are antipsychotics. And all of them are very commonly used in bipolar disorder in adults. 9 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... Well, they are commonly used in children, too. And so it really just comes down to risk- bene!t analysis-- which of these drugs is safest? Which one has an adverse e"ect pro!le that is least o"ensive in children? And then you pick your poison. Lithium-- amazing drug. But you have to have a child in whom you can regularly draw blood, a parent whom you can really trust to be on top of things like hydration. So there's all of that. Depakote-- so Depakote is a little bit easier to monitor than lithium. But Depakote is hugely associated with weight gain, and even the potential for sedation. And the list goes on and on. Lamictal, I would point out, the business with the rash and the itch, that's actually more common in children than it is in adults. That is an adverse e"ect of concern, I suppose, just because their immune systems are just so awesome. I mean, they will respond to everything in a way exaggerated as compared to adults. So anyway, when we talk about the assessment and management of disorders in children, we'll go into a lot more information about how you discriminate among these, and how you choose one over the other, and what's the mechanism for introduction and follow-up and stu" like that. But for right now, what I really just want you to recognize is that this is a common disorder that presents in children with behavioral dysregulation. And we can treat it very e"ectively with drugs that we use to stabilize mood. So ADD and DMDD both present as behavioral symptoms. They're di"erent diagnoses, but they present with behavioral symptoms. But these are ones that are very chemical. And these really, really lend themselves to good treatment with pharmacotherapeutics. The parent and you, the prescriber, have every reasonable expectation that symptoms can really improve if you get the patient on appropriate medication. Not to be confused with oppositional de!ant disorder. Oppositional de!ant disorder is also a condition of the preschool and school-age child. Notice that this is virtually always diagnosed before the age of eight, after three and before eight. And this one is di"erent. This is not clearly a biochemical disorder. This one, we're not really sure. I mean, this is still in evolution. But the one factor that does seem to be common to children with this disorder is persistent controlling by parents and parental overreaction to displays of autonomy in 10 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... the children. And so I will have to take you back for just a minute to the Eriksonian con$ict of the toddler, which is autonomy versus shame and doubt. And don't worry if none of this rings really familiar or if you forget any of the speci!cs. We have a whole semester in which we'll talk about it. But remember that Erik Erikson described con$icts at every stage in the lifespan, and that basically, if you resolve the con$ict successfully, then this helps to develop positive personality traits going through the lifespan. And if you don't resolve it successfully, then it can lead to psychopathology and negativity through the lifespan. And so autonomy versus shame and doubt is the stage described by Erikson as the time when now, the child can walk. And they're exploring. They're getting to know their world. In infancy, they can't walk, so they're dependent completely on the caregiver. That's your trust versus mistrust stage. But autonomy versus shame and doubt, this is the kid that can be mobile on its own. It can walk from room to room, place to place. It can explore. The child can open drawers and pull stu" out and scribble on walls. And so according to Erikson, the con$ict at this age is autonomy versus shame and doubt. Are they encouraged to be independent, and exploring, and learning new things, and expanding the boundaries of their world? Or are they made to feel ashamed when they do that? Are they berated for doing that? Are they discouraged and yelled at? And this can create a sense of shame and doubt. And so it doesn't surprise me-- and I'm no great theorist, believe me. Theory has never been my strong suit. But I think it's pretty easy to see the relationship here between the parents who do not encourage autonomy and the subsequent development of oppositional de!ant disorder. And so when parents bring in their kids complaining of behavioral episodes or behavioral phenomenon, of course, family history is going to be important, period, for any complaint. But when you can see in the family history that there is this history of persistent controlling by the parents and the discouragement of autonomy, oppositional de!ant disorder cranks right up there as one of your leading di"erentials. And then of course you say to yourself, self, how do I !gure that one out? Well, there's diagnostic criteria. I'm not going to perseverate over that because that's coming in another semester. But really, the nutshell is with oppositional de!ant disorder, the children tend to be very unpleasant. But they're not, like, physically dangerous. And 11 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... they don't have the temper tantrums. There's some similarities here with DMDD. But the absence of those age- disproportionate anger outbursts is one of the things that separates ODD from DMDD. These kids are just not very nice. They are perpetually angry, resentful, spiteful. They blame everything on everybody else. They will blame it on siblings, or parents, or whatever. Very easily annoyed. They don't like rules. They don't like to conform to rules, primarily with the parent. They tend to be not quite as bad in school. But they will argue with adults. And they do lose their temper. They get mad. They might throw things down. But they don't have those temper tantrums that we see with DMDD. These children, we just think of as really perpetually unpleasant to be around. Very much a shame because obviously, it's not their fault. When you're that young, you can hardly be blamed for the traits that you develop. But that's what this is. And this is the di"erence between ADD and DMDD. Like DMDD, the caregivers will really struggle when you ask them to identify the good times. When was the last time you had a really good time, you just did something as a family or whatever, and everybody had a really great day? They're going to have a hard time identifying something that wasn't spoiled by the attitude of this child. But what you do see is the absence of those temper tantrums or those true temper outbursts. Now, these children, though, the good side, the upside is that they are not physically destructive. They don't typically break stu", which DMDD will do during their tantrums. They don't break things. They don't tear stu" apart. They're not dangerous. They're not dangerous to siblings or animals or anything like that. They're just really unpleasant, really. The good news is, look, prognosis is good. But what's really relevant to us is that this is not something that lends itself very well to medication. ADD and DMDD, they will markedly improve with the right medications. ODD will not. ODD is a condition that needs therapy. It needs family therapy. The parents really need to be involved because very often, it is the parents' mechanisms of limit setting and boundary setting that's part of the problem. The parents need to be less controlling. And the child needs to help to develop a way to express their frustrations and 12 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... displeasure with a more positive outlet. So the good news is the prognosis is good, especially if the family unit is amenable to therapy. So that's happily ever after. But sometimes the parents won't acknowledge it. Sometimes the parents are just $at out cannot accept that this has anything to do with them. This is all their rotten kid's fault. And I shouldn't say that. I guess I'm being facetious. If I wasn't so lazy, I would rerecord this slide. But I don't mean to say that we're calling the kids rotten. I'm saying the parents will say that when you suggest that, maybe in the household, maybe there are some patterns that could be better established. And then of course, a common response is, well, what do you mean? Are you suggesting that this is my fault as the parent? And you will say, well, sometimes we think we're doing the right thing by being very strict and very controlling. But it actually isn't the best way. Anyway, you see where I'm going with this. It can take some time for parents to accept that. And sometimes they never do. When they do, great. A therapist can be really helpful. But if they won't accept it, now what you've got is a child who is living in perpetual misery, and probably getting punished and getting in trouble because of the things that are going on in the house. And so sometimes we do have to medicate, really to try to improve quality of life for the child, and on a secondary, improved quality of life on the parent. So what do we do? Well, we don't have a big, long list of mood stabilizers here and stu" like that because this is not a mood disorder. What we've got, if you really feel like you have to medicate behavior, maybe even we're just going to take some time to try to ease the parents into it. But if you have to medicate behavior, these are two options. Risperdal, remember, is an antipsychotic that is very, very commonly used for behavior. We use Risperdal for anger all the way across the lifespan. We use it for the elderly patient with dementia who's having behavioral episodes. We use it in, like, adults who are hypomanic, that's really characterized by anger. We use it for intermittent explosive disorder, which we'll talk about in another semester. When the goal is to control angry outburst, Risperdal really is the !rst line drug. I don't know why. I don't know why that one's any better than any other antipsychotic, but it is. And it's also inexpensive and easily accessible. So Risperdal is our !rst go-to to control the angry behavior. 13 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... Abilify is another option. And the question often is, well, why one or the other? Risperdal seems to be better at controlling anger. So if the problem really is about anger, then Risperdal is the drug. If there is a depressive component, if you think that maybe part of what's going on here is that the child is truly depressed, Abilify is better for that. Interestingly, Abilify is one of those meds that it is approved and indicated by the FDA for DMDD at the age of !ve, but it's not approved for ODD until the age of six or seven. I don't know why, it's just that whoever put together the studies, they didn't put younger kids in it or whatever. I mean, it's kind of silly. We know that Abilify is safe in younger children. It's just not approved for it, which equates to insurance is not paying for it, which can be the rub. But you can deal with all of that after you graduate, and you have to deal with insurance companies approving what you want to prescribe. For right now, my job really is to present to you the best evidence-based options. And for oppositional de!ant disorder, the best evidence-based approach is family therapy. For the patient who is su"ering with these symptoms and for whatever reason can't take advantage of family therapy, if you have to go to medications to manage the symptoms, if the primary symptom is anger, irritability, stu" like that, the answer is Risperdal. If there is a clear depressive component, then you can go with Abilify. And that's all I know about that. Now, conduct disorder-- this is the last of the alphabet soup, I think, that I wanted to talk to you in this slide set. We have ADD, DMDD, ODD, and then CD. So this is a bad one. This is the worst of them all. Clearly more common in boys, more common in children of parents with a Cluster B antisocial personality disorder, which really lends the notion that there perhaps is a genetic component here. Although is it nature or nurture? Is it a genetic component, or is the fact that a parent with antisocial personality disorder is more likely to create an environment for the child that produces conduct disorder? I don't know. I do know that there are some studies looking at genetics here. And it is theorized that there might be a genetic component. But a geneticist can have that conversation with you. What I just want you to know is if you are seeing a child with behavioral symptoms, and you're working mentally through your leading di"erentials, conduct 14 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... disorder is one of them. And one of the things that would support conduct disorder is if at least one of the parents was known to have antisocial personality disorder. So you see the risk factors here-- chaotic parenting, poorly developed sense of empathy. I mean, conduct disorder is almost like-- I probably shouldn't say it quite this way, but really, in practical terms, conduct disorder appears to be the childhood precursor to antisocial personality disorder in adulthood. These poor kids, the parenting is just a mess. It's not even consistent. It's just a mess. Sometimes the parents are overly loving, concerned, involved, give them everything. And then the next thing you know, they don't care, they're disinterested, or they're violent, or whatever. It's just chaotic parenting, poor social involvement, poor social supports, chronic exposure to violence, which in its own right can lead to a total lack of empathy. I mean, it's just the nature of the human condition. The more you are exposed to a thing, the less caustic it is, the less di#cult it is. And so kids that are exposed to violence from a very early age, it doesn't take any time at all before they'll just sit there in front of the TV while the father is beating up the mother, or vice versa, or another child is getting beat, and the kids just sit there and watch TV because they've been so exposed to it. So very horrible, very sad, very dangerous disorder. And how do you tell the di"erence aside from the risk factors and the parental history? So these kids are dangerous. Kids with conduct disorder are dangerous. You'll notice. In terms of diagnostic criteria and clinical features, they just have no respect for the basic rights of others. These children do make major violations. When you look up the diagnostic criteria speci!cally, there is very often some infraction with the law. They have usually had some interaction with law enforcement. These children are dangerous to people. They are dangerous to animals. They will willfully and purposefully destroy property. They steal, they lie, they hurt. Oh, man, I mean, it's bad. I wish I had something positive to say here, but I do not. I also would point out that they can also be very disarming and very appealing. Unlike our kids with DMDD or ODD, which just seemed to be perpetually unpleasant and di#cult to be around, the child with conduct disorder, they just want what they want. And if they can get what they want by being charming and disarming and all of that, 15 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... they will. So it's not like they walk around being little terrors. In fact, when you're !rst being exposed to this or !rst trying to get used to it, you may see a kid-- whether they're in the legal system, or it's the parent, and the parent says, he did this horrible thing. He broke this, he destroyed that. I caught him, like, strangling the puppies. And the kid may sit in your o#ce and cry, I didn't do that. I would never do that. I love puppies. They're so sweet. That puppy was my friend. And they may look cute, and sweet, and charming, and disarming, and say all the right things. That's more typical of conduct disorder. Whereas an ODD or a DMDD child, not so charming. [laughs] Not so charming. So this disorder really is a standout from the others. It is very di#cult to treat. Like, not all of these children do go on to become antisocial personalities in adulthood. Some of them do. It is a risk factor for antisocial personality in adulthood. But there are prognostic indicators. And some will do better than others. And so these are some of the things that are listed here. They are very di#cult to treat. And so early symptoms, mild symptoms, normal intelligence, they all can suggest a better prognosis. That's not to say you're going to have a great prognosis, but the potential is there. And just absolute number one, need to be removed from the home. They need to be removed from the home. And I said to you a few minutes ago that we don't have the power to remove children from the home, and we don't. Nobody's going to remove them just on our say-so. But in a circumstance like this, where you have a child who you are con!dent has a conduct disorder, anything you can do-- if Social Services isn't already in the picture, it's time to consult them. If they are in the picture, reach out. Is there anything you can do? Is there any attestation you can make? Do they need you to go to court? Is there a custody hearing coming up? Like, whatever you can do to get them out of the home, because that's the best chance they have of getting past this. They need multimodal therapy. They need structure. They need rules. They need to learn acceptable behavior. They need a therapist to help transition them to-- the life they are living to the one that they need to live in order to be healthy. They need to be rewarded for the good things. And they need to have negative 16 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... reinforcement for the bad. I mean, it's just so hard. As I'm saying this to you, I'm sitting here cringing. Because at least here, where I practice, mental health services are not the greatest, especially for serious mental health concerns. And so even though I know that these are all the things that we need to do, and indeed-- I mean, I see a number of kids that are in the system. They are in foster care. They are wards of the county. And I work with the therapists and even the custodian from Social Services. But it is really, really hard to do the best thing and get these kids out of the home. But always, we try. Now, I don't think I mentioned this earlier, and I probably should have. These can coexist. They're not necessarily mutually exclusive. And very often, you will see in the literature discussions about ADD as coincident with all of these other conditions. So keeping in mind that you may or may not medicate a primary problem if the primary problem is ODD or conduct disorder, medication might not be the answer to treat the underlying disorder. But if the child has coincident ADD or coincident DMDD, then yes, medications may be appropriate. Now, drug therapy of conduct disorder, really, you're just trying to control behavior. You're trying to control behavior and keep people safe. And so sometimes it needs the mood stabilizer, sometimes an antipsychotic. Risperdal is not on this slide. I'm not sure why. It probably should be. It's just another way of trying to keep the kid under control. But with conduct disorder, keep in mind that the primary treatment is not medication. The primary treatment is getting that kid out of that home and in a very structured environment that can provide the therapeutic interventions and the structure that is necessary. But sometimes we have to introduce a drug just to keep people safe. Because these are kids that will hurt other children. They will hurt their siblings. They will hurt or kill animals. And sometimes we need to keep them medicated to try to keep everyone safe. On that happy note-- I wish I had something uplifting to say. And I guess the most uplifting things I can say is that ODD can be successfully treated. Many of those children can grow up to be perfectly healthy, normal, functioning, having good lives. ADD also is very amenable to treatment. 17 of 18 6/26/24, 9:49 PM Behavioral Disorders in Children Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... DMDD is absolutely amenable to pharmacotherapy. Nonpharmacologic therapy is always an important addition. But some things are very, very well medicated. We get very good outcomes with medication. Conduct disorder, it is the rough one. And it's just really, really hard unless you can get the child out of the environment, and not just out of the one they're in, but into one that can really be supportive of what's going to be a very long, multimodal process. So on that note, we're going to call it a day for this topic of conversation. And I will see you in week seven. Print this page 18 of 18 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... Pediatric Considerations Hello again, and welcome back to Week 6, Pediatric Considerations. Boy, are we certainly on the downslide here. Just a couple of weeks to go. This week, like the slide says, obviously we're going to talk about pediatric considerations. And it is a two-slide set discussion. The !rst slide set really is rather brief compared to my other long winded discussions with you, and it's because it really is an introduction to just some basic foundational principles, some of which will have direct relevance to you on a regular basis and others won't. But they're things that any prescriber should have a general familiarity with. So that's the !rst slide set, and then in the second slide set we're going to look at behavioral, the pharmacologic management of behavioral disorders speci!cally in children. Pediatric psychiatry really is its own specialty, its own area of expertise. And so most of you, unless that is the area in which you will practice, you won't spend a whole lot of time managing the psychiatric disorders of the infant, or the one-year-old, or two-year-old. And they do exist believe me. But even if you work in a very general practice and see, from school age children all the way up to the geriatric population, the one thing that you will encounter are behavioral disorders. And so that's the topic of slide set number 2 because that really does have direct relevance to everybody. But before we talk about medicating children, we do have to look at some pediatric considerations. So as you go through this slide set, if you're thinking to yourself, why do I need to know that? I'm not ever going to prescribe psychotropics for an infant. I'm sure you won't, but there are just some foundational principles that everyone should be familiar with. And on a side note, let me just remind you that while you might not be prescribing for an infant, you may be prescribing for a breastfeeding mother. And in that case, you are essentially prescribing for the infant because if the drug crosses breast milk, which is the !rst thing you need to check on when you prescribe for a breastfeeding woman, then you have to recognize that it's going to be distributed through infant metabolism and excretion. And so some of these things aren't so far-fetched. 1 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... So on that note, I will leave you to it. First slide set is truly the pharmacokinetics of the very young. From the neonate forward. And then the second slide set is about behavioral disorders in children. And like I said, if you !nd yourself thinking, oh, I don't need to know any of this. Who cares if renal excretion reaches adult function by one-year-old. I'm never going to medicate anybody under one years old. Remember, if you prescribe for a lactating woman, yes you will, and these principles become important. So while it doesn't have to be like your number one area of expertise, there are some things we need to talk about. And that is the topic of this slide set, so enjoy. This slide presentation really should be relatively brief, and then I know that every time I say that, I turn out not being brief. And you're probably thinking, OK, here we go again. She promised to be brief and isn't. But the reason, if ever we have a chance at being concise, it's with this slide set. It's because a part of it really is not going to be directly relevant to you in your day to day practice, and I do understand that. So then of course you might be asking yourself, well, if that's true, why are we even talking about it at all? And the answer is that even if there is an aspect of this particular branch of science that you don't do every day, you still should have a basic understanding of some core principles. So that's one reason, and one important reason. Another reason is that even though we are not routinely managing say, infants with psychotropics, we do sometimes prescribe these medications to young children. And so you do want to have at least a background understanding, at least if nothing else recognize what some of the major di"erences are so that you can actually look them up when it's time to do prescribing. So as I say, it's not like something like antidepressants and antipsychotics, which you'll be using all the time. But these principles really are important foundational concepts, and in the less common scenario where you actually do have to apply them, I just want you to remember and think, hey, this is di"erent in kids. I don't remember why, but I know there's some di"erence in kids. Let me look it up before I write the prescription. So that's the foundation of these next few slides that I want to talk about. The !rst one-- In the end, the important thing at any age is bioavailability, right? At the end of the road, no matter how we give a drug, how much of it we give, how frequently we give it, the reason we give it is so that we can achieve a serum level that is bioavailable, 2 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... in other words, free to engage in a biologic response, and we want that serum level to be above the minimally e"ective concentration around the clock, and we want it to be below the minimally toxic concentration around the clock. A drug that is free to engage in a biologic response, whether it's an agonist or an antagonist, needs to always be above minimally e"ective, below minimally toxic, and bioavailable. And so one of the things that does impact viabil-- let me try that again. One of the things that does impact bioavailability is the route of administration because giving things by di"erent routes really does make a di"erence in how much actually reaches serum. Obviously, if you take a drug orally, it's got to get past your salivary enzymes, it's got to get past GI mixing and propulsion with gastric acid as well as other enzymes that are introduced in the stomach. It then has to transmit to the intestine, and that's where you start to see absorption. So a lot happens to a drug before it even gets to the place where it can be absorbed into the blood system. And then things like blood #ow in patients like older patients who are hypertensive, and the vessels are thin and sclerosis, and they don't profuse as well. They won't pick up as much of a drug. All of these things matter, and some of these features in children are di"erent. And that's what I want to talk about for the !rst few slides, the di"erences in routes of administration. Now, IM, intramuscular administration of medication. For kids, we see it most often used for immunizations, but there are-- I mean, it's rare, thankfully, but there are times when young children are so out of control that they need to have something given parenterally. So the thing to consider about IM administration is that when you inject a drug into a muscle it then has to be absorbed from the muscle into the vasculature. That's how it gets into the bloodstream, which is where ultimately, that's where bioavailability is an issue. So intramuscular, it is a bit di"erent than it is in adolescents or adults. So yes, we see it for children. For anybody, I guess. But for children, mostly, most often it's used for emergency scenarios, and a time where you either can't get an IV in or the drug is not authorized for IV administration. Think about your psychotic patients who really are just out of control and there's no way they're going to sit still for an IV, nor are they going to voluntarily swallow a pill. IM is pretty much all you've got. So in children, it's not an especially e$cient mode of administration because-- I mean, little children. I'm talking very young children here. They have decreased muscle tissue 3 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... as compared to adults, so if you don't have as much muscle tissue, you don't have as much vasculature in the muscle and absorption will be impaired. So it really just makes absorption unpredictable. It may be that you need higher doses than you would expect because not as much of the drug is actually getting to the place where it can be absorbed by vasculature. Transdermal topical application. We apply it topically so it's absorbed through the vasculature in the skin and then is distributed through serum. And for many adults, transdermal is a great root because you just pop it on them. You pop on the patch, they don't have to swallow it, you don't have to inject them with it. Sometimes it's great, and yet there are particular issues in kids, like you will see here. One of them is-- well, there's a couple. The !rst one is that kids proportionately have increased skin surface area proportional to the rest of their body more of them is skin because what's inside is smaller. So that can actually increase absorption. Also, the younger you are, the greater the water content in your skin. Water content in pediatrics. Water is huge. They have they have great supple skin, they have typically the best physiology, just the best normal physiologic homeostasis. And so they have a much greater water content as compared to adults and especially older adults. So drug will distribute in water more readily. Thinner stratum chromium. This is one of the layers of the dermis. It's one of the layers between where you put the patch on, and then the medicine has to go through the stratum corneum to get into the dermis where it can be absorbed. And pediatrics have a thinner stratum corneum, which means there's a lesser roadblock. Drug can get to the vascular part of skin much more readily. So all of these things can increase distribution or increase absorption, and then if you put something on top of it. Now, diapers, I don't know of any psychiatric medication that you apply to the bottom, but just in general terms, occlusive dressings period. Diapers is one example, but there are others. Occlusive dressings also just tend to increase the time that the drug is on the skin and increases concentration and absorption. Now, the PO route. So PO, of course, everybody loves PO because it's not invasive. You don't have to inject anything. The PO route is most frequently used in children. And again, in very young children sometimes you run into trouble-- Excuse me. I thought I could hold o" that cough to the end of this slide set, but it was not meant to be. 4 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... Especially with some of with some larger pills or pills in general, getting children to swallow them can be more of a challenge. Liquids do tend to be more often given in young children than pills just for that very reason. Liquids are a more readily absorbed PO form, so that's a plus. But another thing to consider is that anything you give PO has to go through the gut, and the gut is di"erent in children. I feel like your slide says it at some point. I don't know. Well, somewhere it should say, and if it doesn't, I'll mention it now. Very little kids have faster PO transit times. They just have faster gastric transit times. Stu" doesn't sit in the bowel as long. On the #ip side, kids are usually among the very most healthy of the of the population, so they should have very good vascular supply so once the drug is absorbed through the gastric lining, there's lots of blood for it to deposit in. So we can't say that this is absorbed better in kids or this is absorbed worse in children. All we can recognize is that some of the di"erences in pediatric physiology can impact the way drugs are absorbed. Sometimes absorption will be greater, sometimes absorption will be lesser. We just have to recognize that there will be some di"erences, and that's what I mean when I say I don't necessarily expect you to spend hours, and hours, and hours studying this phenomenon because for the most part, most of you probably will not be prescribing a lot of psychotropics for young children. But it's going to happen. Do the job long enough. Unless you work in geriatric psychiatry, there's going to come a time when you need to prescribe something for a four-year-old, or a !ve-year-old, or even a three-year-old. And mostly what I want you to remember is, oh, wait. There's something di"erent. There's some-- I need to consider the di"erences here. Let me research this. And then go look into a pediatric reference speci!cally. Not some generic thing that just gives you a range, but look in a pediatric reference speci!cally to !gure out how the pediatric physiology actually impacts that drug that you are thinking about prescribing. Also, remember that with kids, most doses are typically calculated due to weight in kilograms. So it's not just like-- for an adult, you look it up in a drug book and it says, Oh, dose ranges between 5 and 20 milligrams. Typically start at 10 milligrams unless there's renal impairment, then start at 5. That's not the way it is in kids. With kids it's virtually all milligrams per kilogram, so you really can't make any assumptions based on weight. Kids can be very di"erent weights at the same age, so remember, doses in kilograms is 5 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... not doses in pounds. I've also seen people make this mistake, too. Remember that there's a di"erence. That-- excuse me. 1 pound is 2.2 kilograms. So you don't want to be making those calculations based on pounds if it's supposed to be based on kilograms because obviously there's a clear di"erence. And then the other thing to keep in mind is that while liquids are typically easier for children to swallow, you also have to worry about half of it coming out of their mouth, dripping out of their mouth. So there's just-- there are just di"erent considerations in pediatrics, and that really is the gist of this conversation. Now, gastric motility. I promise not to perseverate over this slide because this and maybe even the next one or two, because this really is about infancy, and I hope that you are not prescribing psychotropics for infants. If you !nd an infant who needs a med, then you want to refer it to the infant who needs meds specialist, and that would not be you. But it is interesting some of the profound changes, and while you may not be prescribing in infancy, remember that the transition to adulthood doesn't happen overnight. So even like a four-year-old or a !ve-year-old for whom you might be prescribing, their GI transit time is not as rapid speed as it is in infancy, but it very often still is faster than it is in the adult. And that means-- I mean, it could mean a few things. When GI transit time speeds up, it means that drug doesn't sit in the gut long enough and maybe won't be absorbed as much, not as much proportionally of the oral dose. Or it could be that if it spends less time in the gut, it doesn't break down as much, it's pH doesn't lower, and that could make it easier to absorb. So the real takeaway story is motility is a factor. In some cases it will speed up absorption, and in some cases, it will slow it down. You just want to remember that it is a factor, and if it ever matters, you're going to check it out. I talked about the skin. Yeah, I don't need to say anything else about this. We talked about transdermal medications and how the skin surface area is so much greater, et cetera. I do remember talking about the stratum corneum being thinner. So yeah. Absorption of topical medication tends to be exaggerated in kids, and then for this other reason patches may not be the best answer. In children in general, the amount of medication that's absorbed from a patch will typically be higher than the percentage absorbed from the same patch in an adult, but also really little kids may eat it. There is an age in which everything goes into the 6 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... mouth, and that's not a good plan either. Now, I also mentioned that in children total body water tends to be appreciably higher than it does in adult. Notice that generally speaking, total body water doesn't reach adult concentrations until about the age of seven. So if you're never prescribing under the age of seven, then it really doesn't matter. But if you are treating children, we will see-- and we're going to talk about speci!c pediatric disorders in the next slide set, but it is very common for you to be presented with children who are three, four, !ve, and six, et cetera, that are having behavioral events that usually the !rst thing that comes to mind for the parent is ADD and that's why they bring them in. And then sometimes it is ADD and sometimes it isn't, but we do see children at that age presenting for psychiatric care. And so things like this do matter. And then of course, on the other end of the spectrum is once you get a drug into the body, we have to consider how it's eliminated. Now, the kidney is the number one place where drugs are eliminated, and as I say, the biggest di"erences here really are in the !rst year of life. So this is here for you to read. I really do think that you should be generally familiar with the concept even if it doesn't apply to your day to day world, but we know that for the most part by the time someone reaches one-year-old typically their renal function is very similar to what it will be the rest of the lifespan. So a little bit more detail about that. And so we don't really worry so much about the di"erences related to pediatrics with elimination because by the time most of us are prescribing their elimination, their renal function is analogous to adults. But do keep in mind, this is a good opportunity to make a plug for the fact that there are some medications in which excretion, renal excretion, and renal function is enormously important. So even if it's not di"erent in children, it's still equally important in children, so don't forget that. And there's two examples on the next slide. These are totally worthy of highlighting on their own. Lithium and valproic acid. These are both indicated in children, and they're indicated in young children. And depending on-- Not infancy, obviously. It's not like-- we're talking about the di"erences in renal function in the !rst year of life. But a lot of medications that we use in psychiatry are not necessarily indicated in the very young population, but these two are. 7 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... And for some of your more challenging children, even if you're not the one prescribing this, you might be the one doing the follow up, you might be the one doing the monitoring. It might be your good luck that day to have to be answering the calls, reviewing the labs, looking at the task box. For whatever reason, these are things that you de!nitely want to know. Lithium and valproic acid are indicated in young children, and they can be extremely toxic and even fatal in high levels, and they are eliminated by the kidney. And lithium in particular can have a really signi!cant renal impact because lithium also has an inverse relationship to sodium. So as renal function starts to alter, the patient who eliminates sodium will have a greater tendency to retain lithium. And as you know from our discussion in mood disorders, lithium can be toxic very, very quickly, so that's why I highlighted here. Now, another-- the last two points of interest actually before we leave this slide set and go to one where we actually talk about managing certain disorders of children. The last two concepts I want to mention are pregnancy and lactation. And the important thing to keep in mind is they're not the same, which I know you know that, but when I say they're not the same I mean it's not like if a drug is safe in pregnancy it's safe for breastfeeding and vice versa. They're two totally di"erent phenomenons. There are medications that are safe to give in pregnancy but are not safe to give when mom is breastfeeding. And conversely, there are medications that are not safe to give in pregnancy and are safe to give when mom is breastfeeding. They're just two di"erent things. Keeping in mind that in the pregnant patient, it's not the baby that is metabolizing and eliminating the drug, it is the mother. And whereas the real issue in the pregnant patient is whether or not the drug can cross the placenta. Some can and some can't. If a drug does not cause cross the placenta, then generally speaking, it's going to be safe in pregnancy. On the #ip side, if the drug can cross the placenta, well, then we have to consider if it's safe for fetal circulation. So bottom line, last bullet point there again, a drug may be safe to give a pregnant woman that is not safe to give an infant or a child and vice versa. One example actually is lithium. Now, I know when we talked about lithium in the week on mood stabilizers I said absolutely no lithium in the !rst trimester of pregnancy, and that is absolutely true. There are data and there are concerns about lithium in the !rst 8 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... trimester of pregnancy, early in pregnancy and a link to congenital heart defects, and it is an absolute no-no. If a woman is planning pregnancy or just found out she's pregnant, you really want to get her o" the lithium because of the risk of congenital anomalies. But after you get past that early stage, in the second and third trimester of pregnancy, lithium is actually considered a safer mood stabilizer than Depakote. So if a woman has to have a mood stabilizer for mania or bipolar disorder in the second and third trimesters of pregnancy, lithium is considered the safer option. Remember, it does cross the placenta, but by second and third trimesters, apparently the impact on fetal development is much less. It's not say it's without risk, because any drug in pregnancy is with risk, but after you get past the !rst trimester, the risk is lesser than other mood stabilizers. So in the second and third trimesters of pregnancy, it is permissible to give it. However, during breastfeeding it's not. Because in breastfeeding, lithium does easily cross into breast milk, and now, remember, the baby has to metabolize and excrete it. And fetal circulate-- or not fetal, rather infant circulation neonate, and infant circulation, and renal function speci!cally is very di"erent than the adult. Renal function in the infant is very vulnerable and lithium toxicity can occur very readily. So this is just one example of a drug that can safely be given in the second third trimester of pregnancy but not during breastfeeding. And this is just the #ip side of what I just said. Some drugs cross breast milk and some don't. And now the issue is if the drug crosses breast milk, the infant has to absorb, distribute, metabolize, and excrete it, and that's when all of those factors that we talked about in the !rst eight or 10 slides do matter. So the real takeaway message here is while you may not be medicating a lot of really little children, you may very well be medicating pregnant women and women who are breastfeeding. And again, even if you don't remember all the details here, what I do want you to remember is that breastfeeding and pregnancy are two very di"erent things. The question is, does the drug cross the placenta or does it cross into breast milk, and that in pregnancy it is mom who metabolizes and excretes, mom's renal function matters. Whereas in the breastfeeding patient, it is baby who metabolizes and excretes, and it's baby's renal function that matters. And then of course, babies have all of those same issues in terms of GI transit time and 9 of 10 6/26/24, 9:49 PM Pediatric Considerations Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2425035-dt-... all of those things that we talked about a few slides ago. So the takeaway message here is the concepts, not the precise details, but oh, boy, the concepts really, really are important. And on that note, we're going to close out this slide set and look at slide set number two, where we do look speci!cally at disorders of childhood. Print this page 10 of 10 6/26/24, 9:49 PM