PSYCHIATRIC CONDITIONSPSYCHIATRIC CONDITIONSPSYCHIATRIC CONDITIONSPSYCHIATRIC CONDITIONS
Chapter 13
Psychiatric Conditions
13.1 Attention Defi cit Hyperactivity Disorder
General Ref Pediatrics
• 2000;105:1158–1170, AAP Evaluation Guidelines Pediatrics
• 2001;108:1033–1044, AAP Treatment Guidelines Pediatrics
• 2004;113:754–776, MTA Study Pediatric Annals
• 2008;37(1), entire issue N Engl J Med
• 2005;352(2):165–172
Def
Most common neuropsychiatric condition of childhood,
•
characterized by defi cits in the domain of inattention/focusing and/or hyperactivity/impulsivity
Pathophys
Thought to be a genetically transmitted problem stemming
•
from neurophysiologic imbalance rather than behavioral or psychodynamic etiology
Epidem
Current cross-cultural studies show 3–5% prevalence globally.
•
Higher male prevalence; females have higher proportion of inattentive subtype.
Dx typically made in school-age children, although recent
•
increase in preschool dx.
Dx
AAP guidelines outline current standard of care. Gather infor-
•
mation from multiple sources, especially teachers and parents;
impairment should be noted in multiple settings. Diagnostic criteria specify that sx have been noted before age 7 yr.
Dx includes
• DSM criteria and behavioral questionnaires (AAP Vanderbilt forms); screening questions for oppositional behav- iors, anxiety, and so on; items to estimate degree of impairment.
The dx interview is also important to catalog current or po-
•
tential psychiatric comorbidities (learning disabilities, anxiety, depression, oppositional defi ant disorder [ODD], conduct dis- order, enuresis, encopresis, tic disorder, sleep disorder, sensory issues, explosive behavior).
Physical Exam
Typically normal, although child may demonstrate impulsivity
•
and intrusive speech even in the offi ce setting.
Exam should focus on complicating medical conditions:
•
document normal vision and hearing; oral exam for untreated caries or tonsilloadenoidal hypertrophy suggesting possible obstructive sleep apnea syndrome (OSAS); cardiac exam to assure no unrecognized congenital heart defect that would increase theoretical risk of stimulants; abdominal exam for stool retention.
Lab
None recommended, although consider EKG before starting
•
stimulants.
AAP considers careful H
• P adequate for cardiac screening.
Indications for Rx DSM
• -based questionnaires map out elements in both domains of inattention and hyperactivity; 6 of 9 positive responses in
13.1 Attention Defi cit Hyperactivity Disorder 271
PSYCHIATRIC CONDITIONSPSYCHIATRIC CONDITIONSPSYCHIATRIC CONDITIONSPSYCHIATRIC CONDITIONS
either or both domains, with documentation of impairment in multiple settings, suggest need for rx.
If diagnostic interview uncovers multiple comorbid diagnoses,
•
consider referral to specialty center for complete diagnostic profi le before initiating rx.
Using Stimulants
The MTA study demonstrated that medications are more ef-
•
fective in alleviating core ADHD sx than behavioral inter- ventions. The other fi nding from the study is that careful dose titration improves outcome.
AAP guidelines recommend initiating treatment with one
•
stimulant, titrating dose, and watching for side effects. About 80% of pts respond to this technique. Side effects include ab- dominal discomfort or headache; interference with appetite and sleep. Titration based on effect, not weight. ADHD is a lifelong condition. Frequent visits to monitor HR, BP, and weight along with sx scores are useful for maintaining compliance. Currently no established limits for HR and BP changes allowed; cardiac consultation may be useful for reassurance.
Stimulant preparations vary both by class and by kinetics. Some
•
children respond to short-acting preparations; others have better response (or fewer side effects) to time-released formula- tions. Some children show higher levels of stimulant tolerance.
Alternatives to Stimulants
Most commonly used nonstimulant medication is atom-
•
oxetine, a norepinephrine uptake inhibitor marketed and approved for ADHD. Alpha-agonists have also been used, more typically to decrease hyperactivity and aggression than to improve attention. Bupropion is thought to have some ac- tivity against core sx. Titrating nonstimulant medications are more challenging; may take wk after initiation to see maximal effect.
Tics and Stimulants
Tic disorders are frequently present with ADHD; some
•
children carry Tourette’s dx. Presence of tics is not con- traindication to stimulant rx; tics may come and go in the absence of pharmacologic exposure, although baseline may increase in some children on stimulants. Clinician and family should assess if improvement in ADHD sx bal- ances exacerbation of the tic. Pharmacotherapy for tics is unsatisfactory.
ADHD and Mental Retardation
Children with mild MR can have comorbid ADHD and gen-
•
erally do well on stimulants.
Autism spectrum disorders:
•
Not a contraindication to stimulants. Behavioral sx in this
•
context are notoriously diffi cult to categorize; however, and the impulsivity or inattention may have an alterna- tive etiology. Caution should be applied if medications are used because associated anxiety and “sensory issues” may be exacerbated by stimulants.
Goals of Therapy
Increased volume and quality of academic output, decrease
•
disruptive behavior, increased self-esteem, increased indepen- dence, enhanced safety. Long-term studies show decreased substance abuse issues, motor vehicle accidents.