Child and Adolescent Psychiatry

From The Mind of a Child: Psychiatric Challenges for Today’s Youth, presented by HealthPartners Medical Group and Clinics

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of mental health and substance use disorders in children and adolescents. After hearing and assimilating this program, the clinician will be better able to:

1.   Enumerate the “seven deadly sins” of treatment.

2.   Discuss the long-term effects of stimulants, antidepressants, antipsychotics, and mood stabilizers in children and adolescents.

3.   Explain why adolescents use alcohol and drugs.

4.   Describe the signs of drug and alcohol use in adolescents.

5.   Differentiate between substance use disorders and mental disorders in adolescents.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Reeve indicated that she is on the Speakers’ Bureau for McNeil, and receives grant/research support from Briston-Myers Squibb, Eisai, Pfizer, and GlaxoSmithKline. Dr. Reeve also presented information related to off-label use of medications in children and adolescents. Ms. Adair and the planning committee reported nothing to dis­close.

Acknowledgements

Dr. Reeve and Ms. Adair were recorded at The Mind of a Child: Psychiatric Challenges for Today’s Youth, held No­vember 14, 2008, in Minneapolis, MN, and sponsored by HealthPartners Medical Group and Clinics. The Audio-Di­gest Foundation thanks the speakers and HealthPartners Medical Group and Clinics for their cooperation in the production of this program.

Long-term Effects of Psychotropic Medications

Elizabeth Reeve, MD, Assistant Clinical Professor, University of Minnesota Medical School, Minneapolis, and Medical Di­rector, Psychopharmacology Research Center, HealthPartners Medical Group and Clinics Regions Hospital, St. Paul, MN

“Seven deadly sins”: failure to treat; failure to set specific target symptom; starting medications but not adjusting them; starting medications but adjusting them too often; setting wrong expectations; failure to monitor; continu­ing medications that have no documented efficacy

Bottom line: constant reassessment; set target symptoms; adjust doses thoughtfully; if treatment not working,  pre­scribe something else

Stimulants

Cardiac effects: lack of data to suggest stimulant use leads to sudden death; data do not support need for major change in how stimulants administered; morbidity and mortality associated with failure to treat attention-defi­cit/hyperactivity disorder (ADHD) outweigh potential low risk for cardiac side effects; American Heart Associa­tion guidelines  —  obtain family history of sudden death in individuals <30 yr of age (including sudden infant death syndrome [SIDS]) and personal history of syncope, palpitations, chest pain, or dizziness of unknown etiol­ogy, especially during exercise; obtain baseline blood pressure and pulse rate at first visit and periodically at fol­low-up visits; obtain clinical history; no need for electrocardiography (ECG) or Holter monitor; if family history not available, obtain baseline ECG; other  —  no studies indicate QRS or QTc changes with use of stimulant med­ications; reassure parents that >300 trials involving >500 children and adolescents reported no sudden deaths

Tics: in studies, rates of developing tics and of exacerbation of tics similar in children on stimulants and on pla­cebo; warn parents that tics are possible side effect of stimulants; also explain that these tics do not progress; de­cision to discontinue stimulant medication depends on severity of tic and benefit to ADHD symptoms

Height and weight changes: data suggest that school-age children with ADHD, even those not taking stimulants, tend to have fast growth prepubertally and suppressed growth during puberty; meta-analysis indicated that chil­dren on stimulants had height deficit of 1 cm/yr during first 1 to 3 yr of treatment; recommendations  —  obtain growth records and baseline measurements of height and weight; follow with height and weight measurements every 6 to 12 mo; obtain consultation for patients in whom height or weight decreases >1 standard deviation

Antidepressants

Suicidality: all antidepressants now have Food and Drug Administration (FDA) black-box warning about suicidal­ity; however, validity of findings that antidepressants increase suicidality remains controversial; several studies suggest that use of antidepressants decreased suicide rate in 1990s; recent findings suggest increase in adolescent suicide rate; however, these statistics criticized as premature and inconclusive

Growth: several studies suggest decreased growth in children taking selective serotonin reuptake inhibitors (SS­RIs), but small number of subjects; speaker recommends monitoring height and weight

Antipsychotics

Weight gain: in and of itself, issue for children and adolescents, especially girls; contributes to low self-esteem; in­creases medication noncompliance; increases long-term risk for hypertension, diabetes mellitus, sleep apnea, polycystic ovary syndrome (PCOS), and joint and back pain; literature suggests relative risks for diabetes, weight gain, and elevated lipids greatest for clozapine (Clozaril) and olanzapine (Zyprexa), least for aripiprazole (Abil­ify) and ziprasidone (Geodon); concomitant use of divalproex (Depakote) or lithium may increase risks; with atypical antipsychotics, risk for diabetes independent of that for weight gain; weight gain has additive effect, but is not causal; patients with premorbid risk need more intensive monitoring; recommendations  —  diet and exer­cise help prevent weight gain and metabolic disorders; provide education before starting antipsychotics; monitor regularly to maintain high level of vigilance in patient and parents; avoid other medications that may contribute to weight gain; treatment  —topiramate (Topamax) may prevent weight gain but causes sedation and cognitive dulling; consider prophylactic metformin or modafinil if out-of–pocket expenses acceptable to family; change to antipsychotic with less potential for causing weight gain

Metabolic syndrome: has specific definitional parameters, including abdominal obesity, abnormal lipids, hyperten­sion, and glucose intolerance; in United States, 25% of adults and 5% to 10% of adolescents have metabolic syn­drome; thought to result from insulin resistance, leading to elevated insulin levels; obtain baseline fasting lipid panel that includes fractionated cholesterol and triglyceride levels; 25% to 30% of adolescents have low high-density lipoprotein (HDL) immediately after starting atypical antipsychotic, but unknown how many progress to metabolic syndrome; check laboratory values within 3 mo of starting atypical antipsychotic and, if HDL level dropping, counsel patient and family about need for dietary changes

Elevated prolactin: prolactin secretion inhibited by dopamine; antipsychotics have dopamine antagonist properties and therefore can cause increase in prolactin level; estrogen enhances prolactin responsiveness, so women have greater prolactin elevations than men; risk for prolactin elevation greatest for risperidone (Risperdal), least for ar­ipiprazole (partial D₂ agonist, which may result in prolactin suppression rather than elevation); prolactin levels tend to normalize over time; monitoring prolactin levels not recommended unless side effects, such as galactor­rhea or gynecomastia in boys or menstrual irregularities in girls, become problematic to patient; long-term side effects of hyperprolactinemia include osteoporosis and infertility

Tardive dyskinesia: with older antipsychotics, incidence 4% to 5% per year for first 8 yr, to lifetime maximum of »40%; with newer agents, risk »1% (risk higher with risperidone, lower with ziprasidone and aripiprazole)

Mood stabilizers

Divalproex: side effects include decreased platelet count, liver function abnormalities, weight gain, and PCOS; avoid using in prepubertal girls; if any girl on divalproex has significant weight gain and/or menstrual cessation or onset of menstrual irregularities, evaluate for PCOS

Lithium: assess renal function periodically; monitor for hypothyroidism and diabetes insipidus; can cause acne and weight gain

Lamotrigine (Lamictal): »1% of children on lamotrigine at risk for development of Stevens-Johnson syndrome; di­rectly related to speed at which lamotrigine titrated; follow titration schedule on package insert; divalproex dou­bles lamotrigine levels

Comorbid Mental Health Disorders in Chemically Dependent Children

Leslie Adair, MA, LMFT, Mental Health Clinic Manager, Hazelden Center for Youth and Families, Plymouth, MN

Introduction: »16% of general population and 29% of individuals with mental health disorders meet criteria for sub­stance dependence; »50% of adolescents use illegal drugs before leaving high school; »40% of adolescents who begin alcohol use before 15 yr of age later develop alcoholism; only »10% of youth who need treatment for sub­stance abuse receive it; adolescents more vulnerable than any other age group to developing addictions; »75% of adolescents with substance use disorder have ³1 other mental health disorders; up to 50% of adolescents with sub­stance use disorder also have ADHD; nonmedical use of prescription drugs becoming common

Why do adolescents take drugs? to feel “good” (ie, experience euphoria); to seek internal change (as opposed to adults, who tend to use as social activity or for self-medication); to feel “better” (ie, to lessen feelings of distress caused by, eg, anxiety or depression); pressure to look better or to improve athletic or cognitive performance; curi­osity; peer pressure

Behaviors associated with drug and alcohol use in adolescents: adolescents nearly always use substance to point of intoxication and often beyond; keeping backpack or other bag with them at all times (adolescents have fewer hiding places than adults); stealing or borrowing money from work, home, or friends; shoplifting; selling their be­longings; changing friends or peer groups; physical changes  —unexplained bruises or marks (due to clumsiness secondary to intoxication); glazed or red eyes or dilated pupils

Co-occurring disorders: defined as presence of substance use disorders and coexisting psychiatric disorder; interac­tion between these 2 types of disorders often discounted, but speaker emphasizes importance of acknowledging; physical and psychiatric symptoms of substance abuse may resemble those of mental health disorder; misdiagnosis or unrecognized disorder may lead to inappropriate or harmful treatment; co-occurring disorders suggested by  —presence of psychiatric disorder before onset of substance use; because of interaction between comorbidities, may observe increase or decrease in symptoms of one disorder as function of the other (eg, psychiatric symptoms persist or worsen with abstinence from drug or alcohol use); family history of mental health disorders or chemical depen­dence; use of chemicals as self-medication rather than recreation; difficulty maintaining recovery; relapse of addic­tion (could indicate untreated mental health issues)

Clarifying interaction between substance use and psychiatric symptoms: when did psychiatric symptoms first occur? when did symptoms of substance use disorder first occur? what are subjective effects of substance use on psychiatric symptoms? what effect does abstinence have on psychiatric symptoms? what effect does improvement of psychiatric symptoms have on pattern of substance use?

Masking or mimicking of mental health issues by chemical use and withdrawal: cocaine  —  symptoms can mimic those of bipolar disorder; cannabis  —  symptoms can mimic those of anxiety or depression; benzodiazepines  —  symptoms can mask anxiety and mimic those of ADHD; inhalants  —symptoms can mimic those of impulse-con­trol disorders (eg, inability to manage anger); can cause violent behavior and cognitive impairment; nicotine and caffeine  —  use and/or withdrawal can exacerbate other symptoms

Most common co-occurring mental disorders in adolescents: ADHD most common, then major depressive disor­der, anxiety disorders, bipolar disorder, and posttraumatic stress disorder (PTSD); eg, ADHD symptoms typically include inattention (including difficulty sustaining attention, inability to organize, avoidance of tasks, losing things, forgetfulness, and being easily distracted), hyperactivity (including fidgeting, excessive physical activity, restless­ness), and impulsivity (including difficulty delaying gratification, interrupting others, impatience); also common symptoms of marijuana, cocaine, or methamphetamine dependence

Screening for psychiatric disorders in adolescents who use chemicals: symptoms of psychiatric disorder can be complicated by symptoms of substance withdrawal and intoxication, and by reemergence of “reality”; must differ­entiate among feelings, symptoms, and disorders; if possible, obtain information from parents or significant others who may know of patient’s chemical use

Other factors to consider: patients with substance use disorders typically minimize or strongly deny problem use, deny that physical and psychologic issues relate to substance use, rationalize work and interpersonal problems as cause, not result, of use, and do not recognize link between anxiety or mood disturbances and substance use; in pa­tients who present with acute symptoms of mental health disorder, substance use typically missed; patients who complain of psychiatric problems usually do not offer information about substance use because they do not know that substances can cause psychiatric symptoms (ie, they are ignorant of this fact, not intentionally lying or with­holding information; necessary to inquire about substance use); things to consider in differential diagnosis  —  chaotic home environment; ineffective parenting; parental substance use or mental disorder; insufficient mutual at­tachment and nurturing between patient and family; inappropriate, shy, or aggressive classroom behavior; academic failure; low academic aspirations; poor social coping skills; affiliation with deviant peers; perceived external ap­proval of substance use

Models of treatment: single model  —  treat one disorder as primary disorder and “hope that the other [disorder] gets better” concomitantly; sequential model  —  treat disorders sequentially; parallel model  —  one disorder treated by one individual at one venue, another disorder treated by different clinician at different venue; integrated model  —substance use disorder and mental disorder treated by same team in same facility

Suggested Reading

Aagaard L et al: Opening the white boxes: the licensing documentation of efficacy and safety of psychotropic medicines for chil­dren. Pharmacoepidemiol Drug Saf 18:401, 2009; Anderson KG et al: Impact of relapse predictors on psychosocial functioning of SUD youth one year after treatment. Subst Abus 29:97, 2008; Back SE et al: Treatment challenges associated with comorbid sub­stance use and posttraumatic stress disorder: clinicians’ perspectives. Am J Addict 18:15, 2009; Cleary M et al: The association be­tween substance use and the needs of patients with psychiatric disorder, levels of anxiety, and caregiving burden. Arch Psychiatr Nurs 22:375, 2008; Griesler PC et al: Comorbidity of psychiatric disorders and nicotine dependence among adolescents: findings from a prospective, longitudinal study. J Am Acad Child Adolesc Psychiatry 47:1340, 2008; Hanć T, Cieślik J: Growth in stimulant-naive children with attention-deficit/hyperactivity disorder using cross-sectional and longitudinal approaches. Pediatrics 121:e967, 2008; Hawke JM et al: Stability of comorbid psychiatric diagnosis among youths in treatment and aftercare for alcohol use disorders. Subst Abus 29:33, 2008; Kemp DE et al: A 6-month, double-blind, maintenance trial of lithium monotherapy versus the combination of lithium and divalproex for rapid-cycling bipolar disorder and co-occurring substance abuse or dependence. J Clin Psychiatry 70:113, 2009; Koelch M et al: Ethical issues in psychopharmacology of children and adolescents. Curr Opin Psychiatry 21:598, 2008; Mehler-Wex C et al: Drug monitoring in child and adolescent psychiatry for improved efficacy and safety of psychopharma­cotherapy. Child Adolesc Psychiatry Ment Health 3:14, 2009; Poulton A: Growth on stimulant medication; clarifying the confusion: a review. Arch Dis Child 90:801, 2005; Riggs P et al: Comorbid psychiatric and substance abuse disorders: recent treatment research. Subst Abus 29:51, 2008; Shin L et al: An overview of obesity in children with psychiatric disorders taking atypical antipsychotics. Harv Rev Psychiatry 16:69, 2008; Stein MB et al: Impairment associated with sleep problems in the community: relationship to physical and mental health comorbidity. Psychosom Med 70:913, 2008; Swanson JM et al: Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry 46:1015, 2007; Vesga-López O et al: Gen­der differences in generalized anxiety disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). J Clin Psychiatry 69:1606, 2008; Weintrob N et al: Decreased growth during therapy with selective serotonin reuptake inhibitors. Arch Pediatr Adolesc Med 156:696, 2002; Weiss MD et al: Sleep hygiene and melatonin treatment for children and ado­lescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry 45:512, 2006; Wilens TE et al: Stimulants and sud­den death: what is a physician to do? Pediatrics 118:1215, 2006; Yen CF et al: Comparisons of insight in schizophrenia, bipolar I disorder, and depressive disorders with and without comorbid alcohol use disorder. Psychiatry Clin Neurosci 62:685, 2008.