Common BehavioralHhealth Disorders

Common Behavioral Health Disorders

of Children

& Adolescents

Daniel Castellanos, MDFounding Chair, Department of Psychiatry & Behavioral Health

Professor of Psychiatry & Behavioral Health and PediatricsHerbert Wertheim College of Medicine, Florida International University

Disclosures

No relevant financial disclosures

Castellanos FIU/HWCOM Intl Med Congress 2015

Objectives

Identify the most common psychiatric disorders in children and adolescents

Recognize the appropriate pharmacologic management of the common psychiatric disorders:

ADHD

Disruptive Behavior Disorders

Anxiety Disorders

Major Depressive Disorder (maybe if time permits)

NOTE: Focus of this presentation will be on identifying behavioral health issues in primary care


Adults lifetime

prevalence

Source: Kessler, et al, National Comorbidity Survey, 2005

Any substance use disorder

14.6%

Any anxiety disorder

28.8%

Major depression16.6%

ADHD8.1%


PTSD6.8%

Bipolar Disorder

3.9%OCD1.6%

An estimated 15 million children have a mental disorder.


Children aged

3-17 yrscurrently

had:

Source: MMWR, 2013

ADHD 6.8%

Behavioral or conduct

disorder 3.5%

Anxiety3.0%

Depression2.1%


Lifetime Prevalence of Mental Disorders Adolescents

Source: Meriknagas,et al, 2010


ADHD

Behavior Disorders (Oppositional Defiant Disorder, Conduct Disorder)

Anxiety Disorders Depressive Disorders (Major Depressive Disorder and

Persistent Depressive Disorder/ FKA Dysthymic Disorder)

Substance Use Disorders (mainly adolescents). Schizophrenia is not commonly found in childhood.

Most Common

Behavioral Health

DisordersChildren

& Adolescent


What makes a

mental health problem clinical

(need for treatment)?

ImpairmentSeverity


Levels of Scientific Evidence

Randomized controlled trials

Non-randomized controlled trials; large

meta-analysis

Observational studies with controls

Observational studies w/o controls; case series

Case reports; anecdotal reports; clinical consensus

Source: Adapted from US Dept of Health and Human Services; http://www.ahrq.gov/

Highest

Lowest


Attention-Deficit/Hyperactivity

Disorder(ADHD)

FIU

Psychotropic Medications

Training


Age of onset raised from 7 years to 12 years Studies indicate later detection/identification Onset criterion has been changed from “symptoms that caused

impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”

Slight modification of criteria to accommodate Adult ADHD Five or more of 9 inattention and/or >5/9 hyperactivity

symptoms (instead of >6/9)

Cross-situational requirement has been strengthened to “several” symptoms in each setting


ADHD

Specifiers: Subtypes have been replaced with presentation

specifiers that map directly to the prior subtypes: Combined Predominantly Inattentive Predominantly Hyperactive

Severity: based on # and severity of symptoms, and impact on function: mild/moderate/severe

If in partial remission

A comorbid diagnosis with autism spectrum disorder is now allowed


ADHD

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development as characterized by (1) and/or (2):

1.Inattention

2.Hyperactivity and Impulsivity


ADHD

1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

b. Often has trouble holding attention on tasks or play activities.

c. Often does not seem to listen when spoken to directly.

d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

e. Often has trouble organizing tasks and activities.

f. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

g. Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

h. Is often easily distracted

i. Is often forgetful in daily activities.Castellanos FIU/HWCOM Intl Med Congress 2015

ADHD

2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

a. Often fidgets with or taps hands or feet, or squirms in seat.

b.Often leaves seat in situations when remaining seated is expected.

c. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

d.Often unable to play or take part in leisure activities quietly.

e. Is often “on the go” acting as if “driven by a motor”.

f. Often talks excessively.

g. Often blurts out an answer before a question has been completed.

h.Often has trouble waiting his/her turn.

i. Often interrupts or intrudes on others (e.g., butts into conversations or games


ADHD

B. Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

C. Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

E. The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).


ADHD

Groups:

Stimulants: Usually first line/choice meds Controlled substances Amphetamine basedMethylphenidate

Non-stimulant medications:NOT controlled substancesAtomoxetine (Strattera®)Clonidine, clonidine ER (Kapvay®) & guanfecine,

guanfecine ER (Intuniv®)Others (typically off label)

Medications Used

to Treat

ADHD


FDA Max FDA Approved for ADHD

Generic Name Brand Name® per day Children & Adol Adults

Mixed Amphetamine salts Adderall 40 mg Yes No

Mixed Amphetamine salts XR Adderall XR 30 mg Yes Yes

Clonidine Catapres * 0.4 mg No No

Methylphenidate Daytrana Patch 30 mg Yes No

Methylphenidate ER

Concerta

Metadate CD

Ritalin LA

Quillivant XR

72 mg

60 mg

60 mg

60 mg

Yes Yes

Dextroamphetamine Dexedrine 40 mg Yes No

Dexmethylphenidate Focalin 20 mg Yes No

Dexmethylphenidate XR Focalin XR 30 mg Yes Yes

Guanfecine ER Intuniv 4 mg Yes No

Clonidine ER Kapvay 0.4 mg Yes No

Methylphenidate Ritalin; Methylin 60 mg Yes No

Atomoxetine Strattera 100 mg Yes Yes

Guanfecine Tenex * 4 mg No No

Lisdexamphetamine Vyvanse 70 mg Yes Yes

Bupropion Wellbutrin SR/XL* 300 mg No No

Meds Used to Treat ADHD

Castellanos FIU/HWCOM Intl Med Congress 2015* Off label use for ADHD

Meds Used to Treat ADHD - Duration of Effect


Time (hours)

05 10

0

15

20

Mean

pla

sma

leve

ls(n

g/

mL

)

Absorption &

Duration

5

10

MethylphenidateMethylphenidate ER (Concerta®)Mixed amphetamine salts (Adderall XR®)Lisdexamphetamine (Vyvanse®)

Effective concentration


ADHDThe Bottom Line

1a. Psychostimulant monotherapy (methylphenidate class or amphetamine class, either short or long acting).

1b. If first choice is ineffective try alternate preparation (see table of ADHD medications). If supplementation of long acting with short acting

psychostimulant required for sufficient coverage, stay within same drug class.

2a. Atomoxetine (Strattera®)or monotherapy with extended release alpha-2 agonist (Intuniv® or Kapvay®).

2b. If partial stimulant response, consider combination of extended release alpha-2 agonist with psychostimulant.

3. Immediate release alpha-2 agonist or

Diagnostic reconsideration if none of the above agents result in satisfactory treatment.


All Medication Guidelines

can be

accessed at:

http://medicaidmentalhealth.org/


Disruptive Behavior

Disorders

Meds Used to Treat

Major Depression

FIU


Training


Oppositional Defiant Disorder

Conduct Disorder

Disruptive Behavior

Disorders


Oppositional Defiant

Disorder

Meds Used to Treat

Major Depression

FIU


Training


Symptoms grouped into three types: angry/irritable mood argumentative/defiant behavior vindictiveness.

Frequency: ODD behaviors occur commonly in normally developing

youth. Frequency of behaviors is important to determine if they are symptomatic of the disorder.

Severity: Degree of pervasiveness of symptoms across settings is

an important indicator of severity.

Conduct Disorder

Meds Used to Treat

Major Depression

FIU


Training


More serious behavioral problems than ODD.

Addition of a conduct disorder specifier called “with limited prosocial emotions”Applies to those with conduct disorder who show a callous

and unemotional interpersonal style across multiple settings and relationships. Based on research showing that individuals with conduct

disorder with limited prosocial emotions tend to have a relatively more severe form of the disorder and a different treatment response.

Oppositional Defiant Disorder &Conduct Disorder --

No known medications to address the core pathology.

Meds can be helpful with associated symptoms (eg, severe aggression).

Disruptive Behavior

DisordersThe Bottom Line


Anxiety Disorders

Meds Used to Treat

Major Depression

FIU


Training


Most common are fear based anxiety disorder ---

Separation Anxiety Disorder

Social Anxiety Disorder (FKA Social Phobia)

Generalized Anxiety Disorder

Specific Phobias

Meds Used to Treat

Major Depression

FIU


Training


Anxiety Disorders

Anxiety Disorders

The Bottom Line

1. Sertraline (Zoloft®) or Fluoxetine (Prozac®)

2. Switch to one above not used-Fluoxetine (Prozac®) or sertraline (Zoloft®)

3. Switch to citalopram (Celexa®) or escitalopram (Lexapro®)

No current meds are FDA approved for treatment of anxiety disorders in children


Anxiety Disorders


Substance Use

Disorders

Meds Used to Treat

Major Depression

FIU


Training


High School Students Who Reported Current Alcohol Use, 2011

Meds Used to Treat

Major Depression

FIU


Training


Source: National Youth Risk Behavior Survey, 2011

* Had at least one drink of alcohol on at least 1 day during the 30 days before the survey.

Substance Use

Disorders

Meds Used to Treat

Major Depression

FIU


Training


Nonmedical use

of prescription

drugs

Meds Used to Treat

Major Depression

FIU


Training


The 2011 National Youth Risk Behavior

Survey (YRBS) found that 1 in 5 high

school students in the US have ever taken a

prescription drug, such as OxyContin,

Percocet, Vicodin, Adderall, Ritalin, or

Xanax, without a doctor’s prescription.

Source: www.cdc.gov/yrbss

Percentage of High School Students Who Ever Took Prescription Drugs Without a Doctor's Prescription,* by Type of

Grades Earned , 2009

Meds Used to Treat

Major Depression

FIU


Training


Source: United States, Youth Risk Behavior Survey, 2009

Major Depressive

Disorder

Meds Used to Treat

Major Depression

FIU


Training


Most of this area will be covered by subsequent presentation by Aramys Barzaga, MD

A few points to highlight will follow

Meds Used to Treat

Major Depression

FIU


Training


Major Depressive Disorder

Diagnostic Criteria:

Essentially unchanged except removal of the “bereavement exclusion.” Allows clinicians to now exercise their professional

judgment as to whether someone with a major depressive disorder and grieving should be diagnosed with MDD. The 2-month timeframe required by DSM-IV suggests an

arbitrary time course to bereavement that is inaccurate. Individuals experiencing both conditions can benefit

from treatment but are excluded from diagnosis under DSM-IV.

Meds Used to Treat

Major Depression

FIU


Training



Diagnostic Criteria:

Added:Persistent Depressive Disorder

Disruptive Mood Deregulation DisorderSpecifiers:

“With anxious distress”

Meds Used to Treat

Major Depression

FIU


Training



Major Depression

The Bottom Line

1a. Fluoxetine (Prozac®) or 1b. escitalopram (Lexapro®)

2. Switch to one not used- escitalopram (Lexapro®) or Fluoxetine (Prozac®)

3. Refer to psychiatrist or

Switch to sertraline (Zoloft®), bupropion (Wellbutrin®) or venlafaxine (Effexor®)


A thorough evaluation- it all starts here:

Ensure an appropriate evaluation before beginning psychopharmacological interventions.

This usually implies meeting the criteria for a disorder (not just being a anxious or sad).

Severity & Impairment: As a general rule, meds are indicated for disorders with moderate to severe symptoms and impairment.

Use meds with the strongest evidence base.

Caution with extrapolating from adult literature to justify the use in children.

Take Home Points


Typically begin with meds that are FDA approved for that indication or have the strongest evidence base:

ADHD: Multiple

Anxiety Disorders: Sertraline (Zoloft®) or

fluoxetine (Prozac®)

Insomnia: Melatonin

Major depression: Fluoxetine (Prozac®) or

escitalopram (Lexapro®)

Take Home Points


Parting Thoughts

“If you want happiness for an hour, take a nap.If you want happiness for a day, go fishing.

If you want happiness for a month, get married.If you want happiness for a year, inherit a fortune.If you want happiness for a lifetime, help others.“

Anonymous Chinese Proverb


Documents

Common BehavioralHhealth Disorders