North Dakota Family Based Services Conference - PowerPoint Presentation

North Dakota Family Based Services Conference
North Dakota Family Based Services Conference

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March 31 2022 Linda Jo Volness MS APRN PMHCNS My pronouns are he her hers Quality Life Mental Health and Wellness Center Mood Disorders in Children amp Psychiatric Medications Used to Treat ID: 916810 Download Presentation

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Slide1

North Dakota Family Based Services Conference

March 31, 2022

Linda Jo Volness MS, APRN, PMH-CNS,

My pronouns are: he, her, hers

Quality Life Mental Health and Wellness Center

Mood Disorders in Children & Psychiatric Medications Used to Treat

Slide2

Linda Jo Volness will be discussing off-label use of

medications

in this presentation

Disclosure

Slide3

Objectives

Slide4

Mental Health Diagnosis in Childhood

. Estimates for ever having a diagnosis among children aged 3-17 years, in 2016-19, are given below.ADHD 9.8% (approximately 6.0 million)2

Anxiety 9.4% (approximately 5.8 million)2Behavior problems 8.9% (approximately 5.5 million)2Depression 4.4% (approximately 2.7 million)2

This Photo

by Unknown Author is licensed under

CC BY

This Photo

by Unknown Author is licensed under

CC BY-ND

Slide5

Slide6

Mental Disorders can occur together

Slide7

Slide8

Adverse childhood events (ACE)

Children with

3+

reported ACEs, compared to children with zero reported ACEs,

had higher prevalence of one or more mental, emotional, or behavioral disorder (

36.3% versus 11.0%).

6

Slide9

Statistics

NIMH » Any Mood Disorder (nih.gov)

2

Slide10

Statistics

NIMH » Any Mood Disorder (nih.gov)2

Slide11

Adolescent Mental Health Concerns

15.1% had a major depressive episode.

2

36.7% had persistent feelings of sadness or hopelessness.

2

4.1% had a substance use disorder.

2

1.6% had an alcohol use disorder.2

3.2% had an illicit drug use disorder.2

18.8% seriously considered attempting suicide.

215.7% made a suicide plan.

28.9% attempted suicide.22.5% made a suicide attempt requiring medical treatment.2AdolescentData and Statistics on Children's Mental Health | CDC

Slide12

Slide13

Severe Mood Dysregulation (SMD) HX

Criteria developed by Leibenluft et el. In consultation with investigators at other sights.

Designed to address scientific question: to what degree do children meeting these criteria (DMD) resemble youth with BP on variables used to validate psychiatric disorders?

Children with chronic irritability no distant manic episodes should be differentiated from those with BP and BP-NOS.

Towbin K, Axelson D, Leibuenluft E, Birmaher B.

Differentiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation. J Am Acad Child Adoles Psychiatry. 2013:52:466-481

Slide14

Statistics

Disruptive Mood Dysregulation Disorder

None available

Slide15

DMDD

Slide16

PRIMARY FEATURES OF CHILDHOOD

MOOD DISORDER MOOD CYCLING

vs. CHRONICITY

DEPRESSIVE

SYMPTOMS

“ADHD”

SYMPTOMS

MANIC

incl.

DISTRACTIBILITY-

INATTENTION

MANIC

SYMPTOMS

OTHER

incl.

LATE SLEEP ONSET

RAGE/

? DMDD

RAGE/BIPOLAR

Slide17

UNIPOLARDEPRESSION

? Bipolar I

BIPOLAR DEPRESSIVE SYMPTOMS

HYPOMANIC SYMPTOMS

Mania Mixed

Bipolar II

Disorder

Mood Disorder Spectrum DSM-5

Bipolar NOS?DMDD

? DMDD

Slide18

Slide19

Persistent Depressive

D

isorder

New term in DSM-5, originally known as dysthymia and chronic major depression

For children or adolescents, the

mood

can be irritable instead of depressed

, and the time requirement is 1 year.  For both groups, symptoms cannot be absent for greater than 2 months. In addition to depressed/irritable mood, at least 2 of the following symptoms have to be present.  Poor appetite or overeatingInsomnia or hypersomnia

Low energy/fatigueLow self-esteemPoor concentration/decision makingHopelessness

Slide20

RACING THOUGHTS

LESS SLEEP

GRANDIOSITY

ELATION

RAGE

IRRITABILITY

severe angerwith agitation,

aggression;

Slide21

Disruptive Mood Dysregulation Disorder (DMDD) (F.34.8)

The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property. 2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level. 2013 American Psychiatric Association.

Slide22

DMD Criteria

B. ExclusionExhibits any of cardinal manic symptomsElevated or expansive moodGrandiosity or inflated self-esteemEpisodically decreased need for sleepSymptoms occur in distinct periods lasting > 1 d Hyperarousal of following: insomnia, agitation, distractibility, racing thoughts, or flight of ideas, pressured speech, intrusiveness. Meets criteria for schizophrenia, PDD or PTSD.Meets criteria for substance abuse in pasts 3 months

5. IQ <706. Symptoms due to direct physiological effects of a drug abuse, medical or neurological condition. Towbin K, Axelson D, Leibuenluft E, Birmaher B. Differentiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation. J Am Acad Child Adoles Psychiatry. 2013:52:466-481

Slide23

DMDD

Slide24

DMDD

Slide25

DMDD

J. Criteria (cont.) The behaviors can coexist with other disorderMajor Depressive DisorderADHDConduct DisorderSubstance Use DisorderCan not coexist with Oppositional Defiant Disorder Intermittent explosive disorder Bipolar2013 American Psychiatric Association

Slide26

DMDD

Risk and Prognostic Factors

Many have qualified for Oppositional Defiant Disorder (ODD)

Also often meet criteria for ADHD

Also often meet criteria for anxiety disorders

Some also meet criteria for MDDGeneticsuggested …can be differentiated from children with BP in their family-based riskDMDD do NOT differ from BP familiar rates of anxiety disorders, unipolar depressive disorders or substance abuse.

Slide27

DMDD

Functional consequences

Extremely low frustration tolerance

Difficulty succeeding in school

Often unable to participate in the activates typically enjoyed by healthy children

Family life is severely disrupted

Trouble initiating or sustaining friendships

Both DMDD and BP children

Dangerous behavior

Suicidal behaviors or suicide attempts

Severe aggression

Psychiatric hospitalizations are common

Slide28

Disruptive Mood Dysregulation Disorder

Slide29

Mood Disorders

Slide30

Medications Approved for DMDD

Currently, there are

No

medications approved by the U.S. Food and Drug Administration (FDA) specifically for treating children or adolescents with DMDD.

However, health care providers may prescribe certain medications—such as stimulants, antidepressants, and atypical antipsychotics—to help relieve your child’s DMDD symptoms

Disruptive Mood Dysregulation Disorder: The Basics (nih.gov)

Slide31

FDA Approved Psychopharmacological Treatment for ADHD in Children/Adolescents

AgentsADHD

amphetamine (Adderall = ages 3-12; Adderall XR=6-17 & adults; Mydayis=13-17, 18-55 )atomoxetine (Strattera=ages 6 through adults)

methylphenidate (Ritalin’s includes Concerta, Metadate’s, Quillivant XR, QuilliChew ER, Jornay

PM, Cotempla XR-ODT, Daytrona) ages vary depending on formulations

lisdexamfetamine (Vyvanse=6 yrs old through adults)guanfacine (Tenex, not approved for ADHD, use is off label) immediate release and er not interchangeable

guanfacine er (Intuniv = ages 6-18 yrs)

clonidine XR (Catapress, Kapvay XR ages 6 and above) immediate release and er not interchangeableModafinil (Provigil) not approved off label

bupropion (Wellbutrin) not approved off labelViloxazine (Qelbree =ages 6-17 yrs)

Slide32

ADHD Side EffectsStimulantsInsomniaHeadacheExacerbation of ticsNervousnessIrritability

OverstimulationTremorDizzinessAnorexiaNauseaDry MouthConstipationDiarrheaWeight LossStrattera/atomoxetineSedationFatigueDecreased appetiteRare priapismIncreased heart rate/BPInsomniaDizzinessAnxietyAgitationAggressionIrritabilityDry mouth

ConstipationNausea/vomitingUrinary hesitancy

Slide33

ADHD Side EffectsClonidine/KapvayDry mouthDizzinessFatigueInsomnia

HeadacheMajor depressionHypotensionTachycardiaNervousnessAgitatedNausea, vomitingIntuniv/guanfacine erSedationDizzinessFatigue/weaknessHypotension

Slide34

Slide35

Slide36

MAJOR DEPRESSIVE DISORDER (MDD)

Slide37

Medication approved for Pediatric MDD

Medications FDA Approved to treat pediatric Major Depressive Disorder

Fluoxetine (Prozac)

is the only SSRI approved by the FDA for treatment of depression in children aged 8-18 years

Black Box WarningPediatric Depression. Medscape. Mar 15, 2016

Slide38

FDA Approved Psychopharmacological Treatment for Depression in Children/Adolescents

AgentsDepression

AnxietyOCD

Antidepressants

fluoxetine (Prozac)

+

-

+

citalopram (Celexa)--

-

escitalopram (Lexapro)

-

-

-

sertraline (Zoloft)

-

-

+

mirtazapine (Remeron)

-

-

paroxetine (Paxil)

-

-

+

duloxetine (Cymbalta)

-

+

-

bupropion (Wellbutrin)

-

-

clomipramine (Anafranil)

-

+

venlafaxine (Effexor)

-

-

-

Slide39

Antidepressants Side EffectsSSRI (Prozac, Zoloft, Celexa, Lexapro, Paxil). SNRI (Effexor)Insomnia/Sedation/Headaches/DizzinessDiarrhea/Nausea/Constipated/Dry mouth/SweatingEmotional flattening/apathy

Cognitive slowingSexual dysfunctionProzac Agitation (akathisia)AnxietySwitch to maniaCymbalta (duloxetine)Above plus increase in blood pressureWellbutrin (bupropion)InsomniaTremorAgitationHeadache/DizzinessDry mouth/Constipation/NauseaAnorexiaSweatingRemeron (mirtazapine)Dry mouth/ConstipationIncreased appetite/Weight gainSedation/Dizziness/Abnormal dreams

Flue-like symptomsHypotension Urinary function

Slide40

AMs

PMs

SLOWER low energy

LESS

DEPRESSED

MORE DEPRESSED

Slide41

Differential Diagnosis: Unipolar or Bipolar?

Mania Symptoms

Key Elements

Age of first mania/depression

Time between episodesLength of episodes

History of treatmentMultiple treatment failures?Non-response or erratic response to antidepressants?

Higher rates of mood disorder impairment?

Unevenness in intimate relationships? Distractibility, Insomnia, Grandiosity, Flight of ideas,

Activities, Pressured speech, ThoughtlessnessCourseof Illness

Key Elements

Treatment

Response

Key Elements

Family History

Key Elements

Associated Features

Key Elements

Slide42

Slide43

PRINCIPLE OF BIPOLAR MOOD, SPEED, AND

ENERGY CHANGES DURING DAY

AMsPMs

FASTER high energy

MORE

MANIC

Slide44

Longitudinal Assessment of Bipolar Disorder Is Critical

Hypomania

Mania

Depression

Euthymia

Depression

Subsyndromal

Depression

Polarity of Symptoms

Slide45

CYCLING WITHIN ONE DAY

(ultradian)

INFREQUENT CYCLING

PMs

AMs

SUMMER

mania

WINTER

depression

typical

diurnal

pattern of

childhood bipolar cycling

Slide46

Bipolar DSM-5 Codes

Slide47

Mania DSM 5

Manic Episode

A. A distinct period of abnormally and persistently

elevated

, expansive

or irritable mood and Abnormally increased goal-directed activity or energy

Manic Episode lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is required). Hypomanic Episode lasting 4 consecutive days and present most of the day, nearly every day.2013 American Psychiatric Association

Slide48

PRINCIPLE OF BIPOLAR MOOD, SPEED, AND

ENERGY CHANGES DURING DAY

AMsPMs

FASTER high energy

MORE

MANIC

Manic Bipolar Cycle

B. During the period of mood disturbance and increased energy or activity

Slide49

NEED LESS SLEEP

RACING THTS./

FLIGHT OF IDEAS

GRAND- IOSITY

ELATION

plus three+ of seven others BIPOLAR ILLNESS

IRRITABILITY plus four+

of seven others BIPOLAR ILLNESS

RECKL.

IMPULS.

PRESS.

SPEECH/

MORE TALKATIVE

DISTRACT

-

IBILITY

ii

INCREASE

ACTIVITY

GOAL OR NON

(AGITATION)

MANIC

B. During the period

of mood disturbance and

increased energy

or activity

Slide50

Psychomotor

AccelerationHedonia

Psychosis

IrritableAggression

Dysphoric Mood

Factor Structure of Mania

Cassidy et al. 1998

elation

grandiosity

depression during mania

rage violent aggression

pressured speech

racing thoughts

distractibility

hyperactivity

impulsivity

Bipolar Disorder

Slide51

DIGFAST:

Symptoms of Hypomania and Mania

D Distractibility: poorly focused, multitaskingI Insomnia: decreased need for sleepG Grandiosity: inflated self-esteemF Flight of ideas: complaints of racing thoughtsA Activities: increased goal-directed activitiesS Speech: pressured or more talkative

T Thoughtlessness: “risk-taking” behaviors — sexual, financial, travel, drivingGhaemi. Prim Psychiatry. 2001;8:28-34.

Slide52

RACING THOUGHTS

LESS SLEEP

GRANDIOSITY

ELATION

RAGE

EXPLOSIVEIRRITABILITY

periods of

prolonged excessive silliness

(esp. evenings)

Bipolar Mania Disorder

Slide53

RACING THOUGHTS

LESS SLEEP

ELATION

RAGE

EXPLOSIVE

IRRITABILITYGRANDIOSITY

“tall tales” cocky, entitled,

arrogant attitude;

bossy, bullying;

Bipolar Disorder

Slide54

RACING THOUGHTS

LESS SLEEP

GRANDIOSITY

ELATION

RAGE

EXPLOSIVEIRRITABILITY

“100 miles

per hour”;flying from

subject to subject

Bipolar Disorder

Slide55

(Goodwin and Jamison 1990; Bauer et al. 1991)

*

Rapid speech (racing thoughts) is an almost invariant finding in mania.

LESS SLEEP

RACING THTS.

PRESS.

SPEECH DISTR-ACTIBIL.

HYPER-

ACTIVITY

B2

B4

B3

B5

B6

B7

RECKLESS

IMPULSIVITY

ELATION

GRAND-

IOSITY

A

B1

*

Slide56

overlapping

defining features

TALKS EXCESSIVELY

DISTRACTIBILITY

HYPERACTIVITY

ADHD

IMPULSIVITYexcessive elation

/ irritability grandiosity

excessive bedtime energy

racing thoughts

PRESSURED SPEECH

DISTRACTIBILITY

HYPERACTIVITY

Mania

harmful

IMPULSIVITY

Slide57

Bipolar Disorder Symptoms

RACING THTS.

LESS

SLEEP

GRAND- IOSITY

ELATION

OR IRRIT- ABILITY

“ADHD” MANIC SYMPTOMS PRESSURED SPEECH

DISTRACTIBILITY HYPERACTIVITYRECKLESS IMPULSIVITY

DEPRESSION

RAGE

EXPLOSIVE

IRRITABILITY

EIGHT DSM-IV MANIC SYMPTOMS

Slide58

fidgets, squirms

diff. staying seated

runs inappropr.driven by a motor

blurts out answersdiff. awaiting turninterrupts others

manic

press. speech

careless mistakes

diff. sustaining attn.doesn’t seem to listen

fails to finish tasksdiff. organizing tasks

loses thingsforgets daily activitieseasily distracted avoids difficult tasks

ADHD Inattention Criteria

manic

distract

ibility

ADHD Hyperactivity-

Impulsivity Criteria

loud play

--- is a sx. of mania

talks excessively

manic

hyper

activity

manic

impuls

ivity

Essentially all of the ADHD symptoms are

present when bipolar patients are manic.

Chronically hypomanic children will be

misdiagnosed as having primary ADHD.

Slide59

Behavioral ratings from a large number of studies

indicate that racing thoughts, pressured speech, increased motor activity, and decreased sleep are the most common clinical findings in mania.

Goodwin and Jamison 1990; Benazzi 2003.

RACING THOUGHTS

PRESSURED SPEECH

HYPER- ACTIVITY

LESS

SLEEP

Slide60

ADHD? No.

Probably an atypicalform of bipolar illness.

ADHD criteria met

LESS

SLEEP

RACING THTS.

B2B4B3

B5

B6

B7

ELATION

GRAND-

IOSITY

A

B1

Slide61

mornings

before schoolAT HOME

after school

and evenings AT HOME

SCHOOL DAYS

“ADHD” symptoms

TIRED

SLOW

ANGRY

DEFIANT

“HYPER”

RACING

SILLY

COCKY

Diurnal Bipolar Cycling

(a common childhood bipolar illness presentation)

Slide62

Chronic Mania or Hypomania

HYPERACTIVITY

PRESS. SPEECH

DISTRACTIBILITY

ELATION

GRANDIOSITY

RACING THOUGHTS

PMs

AMs

Slide63

Chronic Mixed State

ADHD

SYMPTOMS

RAGE

DYSPHORIC MOOD LITTLE INTEREST

LOW SELF-ESTEEM

RACING THTS.

LESS

SLEEP

Suicide

Slide64

THE DEVELOPMENTAL PROGNOSIS OF BIPOLAR

CHILDREN IS MADE WORSE BY THE FREQUENT PRESENCE OF MULTIPLE COMORBID PSYCHIATRIC ILLNESSES

Attention-Deficit Hyperactivity Disorder 85% Oppositional Defiant Disorder 75%

Anxiety Disorder(s) 40% Obsessive Compulsive Disorder

Generalized Anxiety Disorder

Substance Abuse (adolescents) 40% Conduct Disorder 2x that of

ADHD Children

ADULT

(ANY) SUBSTANCE ABUSE DISORDER 70% ANXIETY DISORDER(S) 60+%

Slide65

DISTRACTIBILITY

HYPERACTIVITY

DEPRESSIVE SXS.

INCREASING AGE

NORMAL

MANIC SXS.

YOUNG

ADULTHOOD

AGE

3 YRS.

RAGE

VERY RAPID CYCLING

CHRONIC MOOD LABILITY

DEVELOPMENTAL COURSES OF

BIPOLAR AND “ADHD” SYMPTOMS

IMPULSIVITY

Slide66

FDA Approved Psychopharmacological Treatment for Bipolar Disorder in Child/Adolescents

AgentsManic

MixedMaintenanceDepression

OTHER

Carbamazepine ER (

Equetro

TM)-

-––

Oxycarbamazepine--

-

-

Divalproex DR (Depakote®)

-

Lamotrigine (

Lamictal

®

)

-

Lithium (

Lithobid

®

,

Eskalith

®

)

age 12-17

+

Topiramate (Topamax

®

)

-

-

-

-

Slide67

Mood Stabilizer Side EffectsLithiumAtaxia, tremor, memory problems, deliriumPolyuriaDiarrhea, nauseaWeight gainDecrease thyroid function

Acne/rash/hair lossLithium toxicity/life threateningNeed blood workDepakote (valproate), seizure medSedationTremorDizziness/ Ataxia/headacheAlopecia (hair loss)Following controversialPolycystic ovariesHyperandrogenismDecreased bone mineral density

Slide68

Mood Stabilizer Side EffectsLamictal (lamotrigine) seizure medSedationBlurred or double visionDizziness/Ataxia/HeadacheTremor

InsomniaNausea/Vomiting/ConstipationRare serious life threating rashSteve Johnsons SyndromeTopamax (topiramate)Kidney stonesParesthesiasNausea/Appetite loss/wt. lossMood problemsMemory problemsLanguage/speech problemsTaste perversion

Slide69

FDA Approved Psychopharmacological Treatment for Bipolar Disorder in Children/Adolescents

AgentsManic

MixedMaintenanceBipolar

DepressionATYPICALS

a

ripiprazole (Abilify®) age 10-17+

++

–asenapine (Saphris®) age 10-17

++--olanzapine/fluoxetine (Symbyax

®)Age 10-17-

-

-+

lurasidone (Latuda) age 10-17

-

-

-

+

o

lanzapine (Zyprexa

®

) age 13-17

+

+

-

q

uetiapine (SEROQUEL

®

) age 10-17

+

-

-

q

uetiapine XR (SEROQUEL XR

®

) age 10-17

+

+

-

-

r

isperidone (Risperdal

®

) age 10-17

+

+

z

iprasidone (Geodon

®

)

withdrew

from completing study in pediatric mania

-

-

paliperi

done (Invega

®

) age

12-18, for

schizophernia

-

-

-

-

Slide70

Let’s look at the symptom of irritabilityWhat medications FDA approved to treat the symptom irritability?Oct. 10, 2006 ­­ The FDA has approved Risperdal (risperidone) to treat irritability in children and adolescents with autism.It's the first approval of a drug for use in treating behavior ­related problems associated with autism in children. Classified under the

general heading of irritability, these behaviors include aggression, deliberate self­ injury, and temper tantrums.http://www.webmd.com/brain/autism/news/20061010/fda­oks­drug­autism­irritability?print=true Abilify (aripiprazole) indicated irritability associated with autistic disorder age 6-17 years of agehttps://www.abilify.com

Slide71

Prescribing Information for SEROQUEL

Atypical Boxed WarningSuicidality in children and adolescents – antidepressants increased the risk of suicidal thinking and behavior (4% vs 2% for placebo) in short-term studies of 9 antidepressant drugs in children and adolescents with major depressive disorder and other psychiatric disorders. Patients started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. (see Boxed Warning)

Slide72

Metabolic MonitoringThis is suggestion based on American Academy of Child and Adolescent Psychiatry, updated 2013

Slide73

Slide74

Movement Disorder AKATHISIA

Slide75

Movement Disorder Tardive Dyskinesia (TD)

Slide76

Movement Disorder Tardive Dyskinesia (TD)

Slide77

Questions?

Slide78

ReferencesData and Statistics on Children's Mental Health | CDC2. NIMH » Any Mood Disorder (nih.gov)Disruptive Mood Dysregulation Disorder: The Basics (nih.gov)

Suicidality in Children and Adolescents Being Treated With Antidepressant Medications | FDA

Slide79

ReferencesAmerican Psychiatric Association, 2010. Diagnostic and statistical manual of mental disorders, fourth edition. DSM-IV. American Psychiatric Association, Washington, DC. American Psychiatric Association , 2010. Diagnostic and statistical manual of mental disorders, fifth edition. DSM-5. American Psychiatric Association, Washington, DC Cassidy, F., Murry, E., Forest, K., Carroll, B.J., 1998b. Signs and symptoms of mania in pure and mixed episodes. J. Affect. Disord.50, 187-201. Towbin, K.,

Axelson, D., Leibenluft, E., Birmaher, B., Differentiating bipolar disorder-not otherwise specified and severe mood dysregulation. Psychiatry. 2013:52:466-481

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