ChildandAdolescentDisorders-221029-174223.pdf

Child amd adolescent disorders is family medicine system psychiatry topic

1. MANAGEMENT OF CHILDHOOD
PSYCHIATRIC DISORDERS
Muhammad Zeshan, MD

2. Objectives
■Differentiate ADHD, DMDD, ODD, IED, LD, ASD, ID, Bipolar Disorder, Conduct
Disorder, PTSD
■Identify and treat co-morbid Anxiety, Depression, ASD, substance use, Insomnia,
excessive screen time

3. Risk Factor
Symptoms
Diagnosis

4. Clinical Scenario
10-year-old girl, with vague h/o recurrent anger outbursts, physical and verbal aggression at home and in school. She was brought to outpatient clinic by her mother due to worsening behavioral problems over the past few months which includes following:
■Frequent verbal and physical altercation with the mother and in school-throwing things,
yelling, screaming, saying mean words when get mad, poor frustration tolerance
■Oppositional behavior towards parents, teachers, aunts, uncles
■Tried to choke her 5-year-old brother without any remorse as well being mean to her cat at times
■Chronic suicidal ideation, self-cutting, and occasional threat to hurt her mother
■Problem paying attention, irritability, ”mood swings”, insomnia
■6-8 hours of time on social media, screen, videogame
■Family history is questionable for some mood swings

5. Differential Diagnosis
1.Bipolar Disorder
2.DMDD (Disruptive Mood Dysregulation Disorder)
3.Conduct Disorder
4.ADHD
5.ODD (Oppositional Defiant Disorder)
6.Borderline Personality Disorder
7.Intermittent Explosive Disorder
8.Screen Addiction

6. Other Common Childhood Psychiatric
Disorders
■Autism Spectrum Disorder
■Learning Disability
■Intellectual disability
■PTSD/Reactive Attachment

7. Current Presentation: Tip of Iceberg
Birth
10-year
Pregnancy
Temperament
Milestones
Preschool
School-age
Hobbies
Social Hx
Family Hx

10. Overview of DC:0-5 EA-ASD & ASD
Diagnostic Criteria
1.Social Communication (SC) symptoms:
a.Limited or atypical social–emotional
responsivity, sustained social
attention, and/or social reciprocity
b.Deficits in nonverbal social-
communication behaviors
c.Peer interaction difficulties
2.Restricted/Repetitive Behaviors (RRBs):
a.Stereotyped or repetitive
babbling/speech, motor movements,
or use of objects
b.Insistence on sameness/ritualized
behaviors
c.Restricted interests
d.Atypical sensory behaviors
Deficits
in 2 of 3
SC
areas
Deficits
in all 3
SC
areas
Presence
of 1 of 4
RRBs
Presence
of 2 of 4
RRBs
Early Identification and Diagnosis of Autism Spectrum Disorder: Alicia S Carter, PhD
Early
Identification
and Diagnosis
of Autism
Spectrum
Disorder: Alicia
S Carter, PhD

11. ADHD

12. Disruptive
Mood
Dysregulation
Disorder

16. Bipolar Disorder

17. PTSD (Physical/Sexual/Emotional
Abuse or Neglect)

18. Psychopharmacology

19. Key points for ADHD Treatment
Prior stimulant hx, therapeutic need and compliance
Document prior Meds trials by type, dosage, duration, tolerability, and response of each Trial
Paige Partain at el. New stimulant formulation for pediatric ADHD: A case based approach for the primary care.
Current opinion Pediatrics Feb 2019, Volume 31

20. Key points for Treatment-continues
Divide the day in thirds: morning, afternoon, and evenings
For Long-acting Medication: consider the % immediate release vs. % extender release
Paige Partain at el. New stimulant formulation for pediatric ADHD: A case based approach for the primary care.
Current opinion Pediatrics Feb 2019, Volume 31

21. AMPH vs MPH
Small but significant superiority of AMP-based in decreasing ADHD symptoms
Dose for AMP agents 0.25-0.75mg/kg/day
MPH 0.25-1.5mg/kg per 12 hour day of dl MPH
AMP stimulants greater impact on appetite and weight
Stein MA, Waldman ID, CharneyE, et al. Dose effects and comparative effectiveness of extended release dexmethylphenidateand mixed ampheta-mine salts. J Child AdolescPsychopharmacol[Internet] 2011; 21:581–588.
SoutulloC,BanaschewskiT,LecendreuxM,etal.Aposthoccomparisonofthe effects of lisdexamfetaminedimesylateand osmotic-release oral system methylphenidate on symptoms of attention-deficit hyperactivity disorder in children and adolescents. CNS Drugs 2013; 27:743–751.

22. ADHD &
Depression
Differential between sadness or feeling lonely vs a
major depressive episode
Assess which Dx is more severe and causing more
impairment
If ADHD seems to be the predominant Dx, start
stimulant, titrate the dose and see if there are ongoing Major depressive episode symptoms
despite adequate Rx of ADHD
CBT and or SSRI

23. ADHD &
Anxiety
Differential between feeling anxious, nervous vs an
anxiety disorder (DSM-5 criteria) SCARED rating scale
Assess which Dx is more severe and causing more
impairment
If ADHD seems to be the predominant Dx, start
stimulant, titrate the dose and see if there are ongoing anxiety disorder symptoms despite
adequate Rx of ADHD
CBT and or SSRI

24. ADHD &
Insomnia
Adjust ADHD meds
Sleep hygiene
Melatonin
Alpha agonist

25. ADHD &
Screen Time
■Parenting (How to be a good listener vs Problem
Fixer)
■Collaborative Exploration: total screen time, impact
on eating, sleeping, social and family life; discuss
about participating in some activities (sports,
music, gym) in which child is interested
■Family Media Plan (Resources: AAP, CIMAID)

26. ADHD &
Substance
Use
Assess for frequency, duration, severity of substance use
Untreated ADHD a risk factor for substance use
Stimulant treatment reduces risk of SUD

27. Resources
■www.aacap.org(American Academy of Child & Adolescent Psychiatry-AACAP)
Practice parameters
■www.aap.org(American Academy of Pediatrics)—AAP Family Media Plan
■Harvard University-Boston Children Hospital-Clinic for Interactive Media Use
(www.cimaid.org)