4/17/2013. Outline. Brain Development. Brain Development, Effects of Trauma, and Appropriate Use of Psychotropic Medications

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1 Brain Development, Effects of Trauma, and Appropriate Use of Psychotropic Medications An Introduction to Disorders and Drugs Outline Why are we talking about this? Trauma affects normal brain development resulting in symptoms of mental illness Prevalence of psychotropic medication use, concerning use, growing government and public interest Special issues relating to foster youth and mental health/psychotropic medication use Being an effective advocate Working with a prescribing physician at the time of the appointment When to ask questions, and what to ask 2 Brain Development 1

2 Brain Development: Normal Growth Brain size Birth: grams 1 year: grams Adult: grams 90% of brain growth during first 3 years Critical periods Sensory information received important to function development Eye block; blindness Brain Development: Communication Communication by neurons Dendrites: receive messages Axons: transport messages Information transmission Pain, hunger, fear, anxiety, alertness/sedation Brain Development: Normal Growth Rapid creation of communication pathways Childhood through early adulthood Reinforcement and pruning Plasticity: ability to change brain architecture Exponential decrease over time Heavily dependent on early experiences Organizational framework Exposure to language, music, vocabulary Proportional relationship between vocabulary and SES 2

3 Brain Development: Effects of Trauma Important structures Amygdala: emotional responses Hippocampus: memory of new information Prefrontal cortex: executive function; self regulation Brain Development: Effects of Trauma HPA axis Activated by stress Cortisol secreted within minutes; effects for hours Brain Development: Effects of Trauma Early stress fundamentally changes response system Amygdala responsiveness/reactivity increases Hippocampus, prefrontal cortex less impactful response Toxicity of cortisol Effects of chronic, toxic stress PTSD Depression Borderline personality disorder Impaired physical health 3

4 Brain Development: Effects of Trauma Adverse Childhood Events Research terminology, Kaiser Examples: physical abuse, sexual abuse, domestic violence, neglect, household mental illness/incarceration/substance use Effects of prolonged trauma Depends of several factors Length of stressful event(s) Severity of stress Previous stress Health risk Mental illness, physical illness, risky behaviors (substance abuse, promiscuity) Trauma Informed Diagnoses Foster Children, Trauma, and Psychiatric Disorders Many foster children experience trauma Trauma may result in behaviors that can look like psychiatric disorders Treatment for child trauma can take a very different focus than treatment for mental illness 4

5 Trauma and mental health symptoms for youth entering care by age 100% 80% 60% 40% 20% 0% year olds 7 12 year olds year olds 17 and older Both trauma and mental health symptoms Mental health symptoms only Trauma symptoms only No symptoms Overlapping symptoms of child trauma and psychiatric disorders Psychiatric Disorder Anxiety Disorders ADHD Bipolar Disorder Major Depressive Disorder Overlapping Symptoms avoidance of feared stimuli, physiologic and psychological hyperarousal upon exposure to feared stimuli, sleep problems, hypervigilance, and increased startle reaction restless, hyperactive, disorganized, and/or agitated activity; difficulty sleeping, poor concentration, and hypervigilant motor activity hyperarousal and other anxiety symptoms mimicking hypomania; traumatic reenactment mimicking aggressive or hypersexual behavior; and maladaptive attempts at cognitive coping mimicking pseudo manic statements self injurious behaviors as avoidant coping with trauma reminders, social withdrawal, affective numbing, and/or sleep difficulties Overlapping symptoms of child trauma and psychiatric disorders Psychiatric Disorder Oppositional Defiant Disorder Panic Disorder Overlapping Symptoms a predominance of angry outbursts and irritability striking anxiety and psychological and physiologic distress upon exposure to trauma reminders and avoidance of talking about the trauma Psychotic Disorder severely agitated, hypervigilance, flashbacks, sleep disturbance, numbing, and/or social withdrawal, unusual perceptions, impairment of sensorium and fluctuating levels of consciousness Substance Abuse Disorder drugs and/or alcohol used to numb or avoid trauma reminders 5

6 Psychotropic Medications Top prescribed psychiatric medications in 2009 More medication: Increased use of psychotropic medications in the past decade 6

7 Prescriptions or refills dispensed to children or teens in % 0% 0% 11% 27% 7% 6% 49% Asthma ADHD Antidepressants Antipsychotics Antihypertensive Sleep aids Non insulin diabetes Statins Source: IMS Health Psychotropic Medications and Foster Youth ABC News: December 1,

8 Youth in foster care are at higher risk for developing emotional and behavioral disturbances and mental illness than youth from comparable background. Youth in foster care are more likely to have a mental health diagnosis than other youth. In a study of foster youth ages 14 17, 63% met the criteria for at least one mental health diagnosis at some point in their life. Most common diagnoses: Oppositional Defiant Disorder/Conduct Disorder, Major Depressive Disorder/Major Depressive Episode, ADHD, and PTSD. Of youth enrolled in Medicaid, those in foster care are significantly more likely to receive a mental health diagnosis than those not in foster care. Nearly half of youth aged 2 14 with completed child welfare investigations had clinically significant emotional or behavioral problems. Foster children use mental health services at higher rates than other Medicaid eligible children. Foster children... Represent 3.2 percent of children in Medicaid. Represent 12.6 percent of children in Medicaid receiving psychotropic medications. Represent 15 percent of children in Medicaid receiving behavioral health services. Represent 28.6% of Medicaid child behavioral health expenses. 32 percent of foster children receive behavioral health services. 23 percent of foster children receive psychotropic medication. 19 percent of foster children were prescribed 3 or more psychotropic medications, compared to 10% of non foster children. Of children who received psychotropic medications, 42 percent of foster children and SSI eligible Medicaid children were prescribed an antipsychotic, versus 18 percent of TANF eligible children. Source: Pires, Grimes Allen, Gilmer, & Mahadevan (2012). Faces of Medicaid: Child Behavioral Health Utilization and Expenditure Study. Hamilton, NJ: Center for Health Care Strategies. GAO Report: December 2,

9 Youth in foster care are more likely to receive psychotropic medication than youth not in foster care. 45.0% 40.0% 35.0% Percentage of children prescribed a psychotropic medication 39.1% 32.3% 30.0% 25.0% 20.0% 15.0% 22.0% 21.0% 19.7% Foster care Non foster care 10.0% 5.0% 8.2% 10.2% 7.9% 7.1% 4.8% 0.0% FL MA MI TX OR Youth in foster care are more likely to receive multiple psychotropic medications than youth not in foster care. 1.40% Percentage of children prescribed 5 or more psychotropic medications 1.33% 1.20% 1.00% 1.05% 0.80% 0.60% 0.40% 0.20% 0.00% Foster care Non foster care 0.29% 0.11% 0.13% 0.07% 0.03% 0.02% 0.02% 0.01% FL MA MI TX OR Take Home Points Youth in foster care are at higher risk for developing emotional and behavioral disturbances and mental illness than youth from comparable backgrounds. Youth in foster care use mental health services at higher rates than other Medicaid eligible youth. Youth in foster care are more likely to receive psychotropic medication than other Medicaid eligible youth. 9

10 Drugs and Disorders Zoloft commercial: Depression Abilify commercial: Depression 10

11 Drugs and disorders Psychotropic drugs are used to treat psychiatric disorders. Psychotropic drugs are organized into classes based on their mechanism of action and type of disorder treated. Drug and disorder should match. Antidepressants are generally used to treat depression. Antipsychotics should be used to treat psychotic disorder. Nationwide prevalence of psychiatric disorders in adolescents 60.0% 50.0% 51.0% 48.1% 40.0% 38.0% 30.0% 20.0% 10.0% 0.0% 26.1% 23.5% 15.5% 15.9% 7.7% 3.3% 2.6% 13.0% 11.0% 4.0% 2.0% % Females % Males Types of Disorders Anxiety and Depressive Disorders 11

12 What are Anxiety Disorders? Symptoms: Many worries about things before they happen Constant worries or concerns about family, school, friends, or activities Repetitive, unwanted thoughts (obsessions) or actions (compulsions) Fears of embarrassment or making mistakes Low self esteem or lack of self confidence Example disorders: Generalized Anxiety Disorder, Posttraumatic Stress Disorder, Obsessive Compulsive Disorder, Social Phobia, Panic Disorder What are Depressive Disorders? Symptoms: Inability to feel pleasure Feelings of hopelessness Low self esteem or feelings of worthlessness Irritability Decline in school work, social relationships Example disorders: Dysthymic Disorder, Major Depressive Disorder Major Depressive Episode prevalence among youth in Major Depressive Episode w/o Severe Impairment Major Depressive Episode w/ Severe Impairment 12 Percentage Male Female 12

13 Treating Anxiety and Depressive Disorders: Antidepressants Used to treat: Anxiety and Depressive Disorders Examples: Fluoxetine (Prozac) Citalopram (Celexa) Sertraline (Zoloft) Paroxetine (Paxil) Bupropion (Wellbutrin) Possible adverse side effects Suicidal thoughts Sleeplessness or drowsiness Agitation Sexual dysfunction How do Antidepressants Work? Treating Anxiety Disorders: Benzodiazepines Used to treat: Anxiety Disorders Examples: Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Diazepam (Valium) Loreazepam (Ativan) Possible adverse side effects Drowsiness Dizziness Upset stomach Blurred vision Headache Confusion Dependence 13

14 ADHD and Disruptive Behavior Disorders Nationwide prevalence of ADHD and Disruptive Behavior Disorders in adolescents Percent ADHD 12.6 Oppositional Defiant Disorder 6.8 Conduct Disorder 19.6 Any behavior disorder Attention Deficit and Disruptive Behavior Disorders Symptoms: ADHD Inattention, Hyperactivity, Impulsivity Disruptive Behavior Disorders Harming or threatening themselves, other people, or pets Damaging or destroying property Lying or stealing Not doing well in school or skipping school Early smoking, drinking, or drug use Early sexual activity Frequent tantrums or arguments Consistent hostility towards authority figures Example disorders: ADHD, Conduct Disorder, Oppositional Defiant Disorder 14

15 Treating ADHD: Stimulants and Alpha Agonists Used to treat: Attention Deficit/Hyperactivity Disorder Examples: Atomoxetine (Strattera) Lisdexamfetamine dimesylate (Vyvanse) Methylphenidate (Ritalin, Concerta) Amphetamine (Adderall) Dextroamphetamine (Dexedrine, Dextrostat) Possible adverse side effects Decreased appetite Tics Psychosis Bipolar Disorder What is Bipolar Disorder? Mood episodes Major depressive episodes, manic episodes, or mixed episodes Episodes last at least a week (manic) or two (depressive), sometimes longer Major Depressive Episodes Feel very sad Complain about pain a lot, like stomach aches and headaches Sleep too little or too much Feel guilty and worthless Eat too little or too much Have little energy and no interest in fun activities Think about death or suicide Manic Episodes Feel very happy or act silly in a way that s unusual Have a very short temper Talk really fast about a lot of different things Have trouble sleeping but not feel tired Have trouble staying focused Talk and think about sex more often Do risky things 15

16 Treating Bipolar Disorder: Mood Stabilizers Used primarily to treat: Bipolar Disorder Examples: Lithium Divalproex sodium (Depakote) Carbamazepine (Tegretol) Lamotrigine (Lamictal) Oxcarbazepine (Trileptal) Possible adverse side effects Suicidal thoughts Loss of coordination Hallucinations Kidney, thyroid, liver, and pancreas damage Polycystic ovarian syndrome Weight gain Psychotic Disorders What are Psychotic Disorders? Symptoms: Irrational thoughts not responsive to reason (delusions) Hallucinations Disorganized speech Persistent bizarre behavior Social withdrawal Decrease in personal hygiene Example diagnoses: Schizophrenia, Schizoaffective Disorder 16

17 Antipsychotics Used primarily to treat: Psychotic Disorders, Bipolar Disorder Examples: Atypical or Second Generation Risperidone (Risperdal) Aripiprazole (Abilify) Quetiapine (Seroquel) Typical or First Generation Haloperidol (Haldol) Chlorpromazine (Thorazine) Possible adverse side effects Rigidity (muscle tension) Tardive dyskinesia (uncontrollable movements) Diabetes Increased cholesterol Weight gain Neuroleptic malignant syndrome (a life threatening side effect) Nationwide prevalence of psychiatric disorders in adolescents 60.0% 50.0% 51.0% 48.1% 40.0% 38.0% 30.0% 20.0% 10.0% 0.0% 26.1% 23.5% 15.5% 15.9% 7.7% 3.3% 2.6% 13.0% 11.0% 4.0% 2.0% % Females % Males Types of Disorders The NOS Diagnoses Not Otherwise Specified 17

18 Take Home Points Only a few medications have strong data to support their safety and efficacy in youth. Understand the symptoms a medication is meant to treat and the duration of treatment. Understand the potential side effects and ensure a youth on psychotropic medication is properly monitored for potential side effects. Too much, too many, too young: ask questions about medication use that seems concerning. Being An Effective Advocate Working with a child s psychiatrist What should be cause for concern? Too many medications More than one medication from the same class Three or more psychotropic medications at the same time Too much medication Using more than the FDA recommended dose Too young Use of antipsychotic medication for youth under 10 Use of any psychotropic medication for youth under 5 18

19 Working with a child s psychiatrist Your role Provide accurate information about the child s behaviors to the psychiatrist Ask questions. Be sure you understand the psychiatrist s recommendations for treatment. If medication is recommended, be sure you understand its purpose, risks and benefits, and how the child should be monitored for improvement and side effects Before an Initial Appointment Bring support, if necessary The evaluation may be long and require that you speak with the psychiatrist alone. Having someone else present can reduce stress and anxiety for both you and the child. Do not assume that medication will be prescribed There are many reasons why a psychiatrist may not prescribe medication: they may require additional information or assessments, the child may not require medication, or the psychiatrist may recommend interventions other than medication be tried first. Before an Initial Appointment Be ready to talk about the child s behaviors and other symptoms in detail What behaviors have you observed that concern you? Has there been a recent stress in the child s life? How often do these behaviors/symptoms occur? How long do they last How intense are they? What interventions have been tried? What has been successful? How often have you been trying interventions other than medication? What has the child s response been to medications that have been tried? Have there been side effects? If so, how long did they last? If currently on medications, has the child been taking the medications as prescribed? 19

20 Before an Initial Appointment Be sure to bring relevant records Medical records School records (transcripts, IEP) Previous evaluations (psychological, educational) Information about the child gathered from parents and other caregivers Contact information for: primary care physician(s), placement information, therapists, and other care providers At the Initial Appointment You and the psychiatrist should discuss: Diagnosis What does it mean? What are the treatment options (both medication and nonmedication)? What additional support services should accompany treatment? What is the likelihood of improvement, and over what time frame? If medication is recommended: What diagnosis or symptoms is the medication intended to treat? What are the potential benefits of taking the medication? What are the potential risks? What are other possible treatment options, and their risks and benefits? At the Initial Appointment If medication is recommended: What does the medication do? How does it work? How many times a day should it be taken? What happens if a does is skipped? What if the child takes too much? How long will the child need to take the medication before I can expect improvement? How will I know it is working? What are the possible side effects? How long will they last? Can anything be done to minimize them? Is this medication addictive? Can it be abused? Does the child need any blood work or special tests before starting the medication? What about while on the medication? 20

21 Contact information Brent Wilson, MD collaborative.org 21