Jane Marie Sulzle, DNP, CNS, MS PrairieCare Medical Group, Edina

Transcription

1 Children, Mental Health, and Psychiatric Medication: Empowering parents with information on how to talk to their children about medication and how the medication may impact school performance. Jane Marie Sulzle, DNP, CNS, MS PrairieCare Medical Group, Edina

2 Clinical Nurse Specialist Masters level preparation National certification 5 areas of competency: research, direct care, education, leadership and consultation Scope of practice is to diagnosis and treat (meds and therapy) people with mental health disorders.

3 Influences on Children Biology Environment Static Reversible Positive Influences Family Changes School Trauma Congenital Down Syndrome Autism Learning Disabilities Fetal Alcohol Syndrome Acquired Head injury Stroke Medicine Diabetes High blood pressure Aids Psychiatry ADHD Bipolar Schizophrenia Depression Anxiety Positive parenting Positive community support Faith community Divorce Divorce Separation Death Death Frequent Frequent moves moves Good fit Not good fit Abuse Neglect Domestic Violence Natural Disaster Intellectual property of Josh Newman, MD, Wilder Foundation

4 Medications Typically only a part of the treatment plan. Therapy is most often recommended. Philosophy of less is more and try to wean off if possible later.

5 Medication is not To make children good To make them easy to parent To make them easy to educate To get them to go to bed They help them sleep Something providers do lightly

6 Mental illness is a physical (brain) disorder Normal brain ADHD Brain Normal brain Autistic spectrum disorder brain

7 Normal brain OCD Brain Anxious Brain Bipolar brain Depressed brain

8 Epidemiology Rates of prevalence is % (1 of 5) Girls are diagnosed most frequently with internalizing disorders (depression, anxiety), boys with externalizing (ADHD, ODD) Age makes a difference re: diagnosis and treatment Culture/ethnicity makes a difference in both identifying and treating the problem (under control vs over control) (Mash and Dozois, 2003))

9 Classifications of Medications Stimulants: Ritalin, Metadate, Adderall, Focalin, Dexadrine, Concerta, Daytrana Patch, Vyvanse Selective Serotonin Reuptake Inhibitors (SSRI s): Prozac, Celexa, Lexapro, Zoloft, Paxil, and Luvox, in order of least to most sedating Dual Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRI s): Effexor and Cymbalta Norepinephrine Dopamine Reuptake Inhibitor) (NDRI): Wellbutrin Sleepers or anti-anxiety: Clonidine, Tenex, Intuniv, Trazadone, Remeron, Benadryl, Melatonin, Seroquel Atypical Antipsychotics: Abilify, Risperdol, Seroquel, Geodon, Zyprexa Mood Stabilizers (anticonvulsants): Depakote, Lamictal, Topamax, Trileptal, Lithium which is not an anticonvulsant. Benzodiazepines: Ativan, Xanax, Klonopin, Valium

10 Symptoms of ADHD Inattentive type: Details/careless mistakes Trouble paying attention Doesn t follow directions, fails to finish homework or tasks Trouble with organization Avoids tasks that take concentration Loses things Distracted Forgetful

11 Hyperactive/Impulsive type Fidgets Doesn t stay in seat Runs or climbs when not OK Trouble with quiet games Driven by a motor Talks a great deal Blurts answers Trouble waiting turn Interrupts

12 Attention Deficit/Hyperactivity Disorder Inattentive type (ADD) Hyperactive/Imp ulsive type Combined type

13 Medications for ADHD Theory states works on dopamine (DA) and norepinephrine (NE) in pre-frontal cortex. Stimulants are often first choice, especially if has combined or hyperactive. Adderall, Concerta, Daytrana patch, Focalin, Metadate, Ritalin, Vyvanse, Dexadrine approved. Strattera is predominantly used for inattentive type or if parents are concerned about using stimulants. Clonidine, Intuniv, Tenex, Wellbutrin

14 More on ADHD medication Weight loss Add extra fat and protein to diet Eat breakfast then medication Tell kids protein and dairy at lunch Cars can t run without gas Little ones explain to trick the brain

15 Side Effect of Stimulants Sleeping problems Give meds earlier Shorter acting medication Lots of exercise Good sleep hygiene May need medication

16 ADHD medications Monitor for these: Depression Sad, withdrawn, no energy Anxiety Irritable Hallucinations Talking to self, odd behavior

17 ADHD cont. Mania Won t sleep Very irritable Talking non-stop I m the boss Stop medication Irritability Stop medication

18 School Performance Positive Focused Remember More organized Sit still Less disruptive

19 School Performance Negative Increased irritability Decreased appetite Sedated

20 Remember No medication cures ADHD. Often life long struggle More than not sitting still and paying attention Executive function Often associated with learning disabilities.

21 Anxiety Disorders Separation Anxiety Disorder (SAD) Generalized Anxiety Disorder (GAD) Social Anxiety Disorder (Social Phobia) Phobias Obsessive Compulsive Disorder (OCD) Post Traumatic Stress Disorder (PTSD)

22 Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI s) Prozac, Celexa, Lexapro, Zoloft, Paxil, Luvox Can cause sexual dysfunction Change medication Nausea (Prozac especially) Give with food If necessary change medication Sedation Give at night Give it a little more time, often goes away Activation Stop medication and change May trigger mania Stop medication.

23 NDRI: Wellbutrin Can cause irritability Activation Does not have the sexual side effects Plays well with others SNRI: Effexor and Cymbalta Effexor tough to get off Same as others Other antidepressants

24 Black Box warning: More on antidepressants: FDA put the Black Box warning on all medications used for depression All those medications whether for depression or anxiety Study 4,400 children Pooled studies, nine antidepressants, MDD, OCD, and others 4% had suicidal thinking and attempts on medication 2% without the medication ( ss/ucm htm)

25 Information about the Black box warning Parents, you will see the difference Suicidal thinking is temporary May not happen on a different medication To the kids: If you had a rash If you got a stomach ache If you start thinking about hurting yourself

26 Other medications for anxiety For children Tenex, Clonidine, and Intuniv (all are anti-hypertensives) work well. Clonidine offers a patch. Tenex is less sedating, works better for inattentive ADHD vs hyperactive Intuniv is long acting (24 hours) Both can cause dulling, slowed thinking Can cause sedation Can cause depression Helps with reactive anxiety

27 More medications for anxiety Benzodiazepines: Klonopin, Ativan, Xanax Can create dependency Don t stop abruptly, can cause seizures. Can cause more aggression Only treats anxiety. Help to sleep Typically for short term use. (cont.)

28 Cont. Trileptal Seroquel Buspar

29 Medications and school; positives Able to concentrate, can sit still Less worried Much less reactive Able to complete homework Doesn t need to be perfect Able to concentrate Can do presentations Able to work on having friends

30 Medications and school; negatives Tired Irritable Angry/manic Suicidal thinking

31 Often are fidgety, rearranging themselves in their chairs. Low energy, Withdrawal from friends, family, more time alone Less caring about what they look like Less motivation for grades, social life I don t care Suicidal thinking Hopelessness Worthlessness See much of the world negatively

32 Sad, irritable look similar in children vs adolescents Adolescents look more like adults For children may just be for a day or two and then better Adolescents may look not act depressed around friends. Sleep disturbances, both getting to sleep and staying asleep Too much sleep Unusual sleep patterns Fatigue Even when getting plenty of sleep. Flat affect, serious or somber mood, poor eye contact Seldom smiles No enjoyment

33 The majority of the time SSRI s are used with children. Secondarily NDRI then SNRI. Black box warning Side effects as above Use of Abilify or Seroquel Both Atypical Antipsychotics Often only need a small dose Lithium if others have not worked

34 Same for Anxiety

35 Bipolar Disorder Between 20-25% of children who first present with MDD will eventually prove to have bipolar. ADHD on speed Less controversy over whether this diagnosis exists in children, but diagnosis varies Very difficult to diagnosis/treat Often takes many medications

36 Statistics Approximately 1% of children More boys than girls especially under the age of 13 years ( Joshi, B. and Wilens, T Comorbidity in Pediatric Bipolar Disorder. Children Adolsec Psychiatric Clinic N AM 18, ) From fold increase in adults diagnosed with Bipolar Disorder 40 fold increase in children (Moreno, C. et al National Trends in the outpatient diagnosis and treatment of Bipolar Disorder in Youth. Arch Gen Psychiatry, 64(9), )

37 Difficult to Diagnosis Different in children than adults? Bipolar I Full mania Depression Bipolar II Bipolar, NOS Mood Disorder, NOS

38 What does Bipolar Disorder look like? Don t need much sleep, Goes from very sad (irritable) to wild and crazy in a flash, Grandiosity is seen as I don t have to, you re not the boss of me. I don t need directions Scary risk takers, Can rage for hours.

39 Medication for Bipolar Disorder Atypical antipsychotics Abilify, Seroquel, Risperdal, Zyprexa, Geodon, Clozoril Side effects: Weight gain Exercise and healthy eating Metabolic Syndrome Lab work, initially, 3 mo and 6-12 there after Weight should be monitored High cholesterol Lab work

40 Abilify Middle range for weight gain Helps with frontal lobe functioning Akathisia, can t sit still Seroquel Sedation, calming Weight gain Great to help with sleep Zyprexa Most significant for weight gain, but works well Really helps with aggression Medications

41 More on medications Risperdal Weight gain Breast enlargement, lactation Dulling FDA approved for kids in autism spectrum Geodon Difficult to use Fewest side effects Clozoril Seldom used

42 More side effects of atypical antipsychotics May cause dulling Report to provider may want to decrease dose Movement Disorders Notify provider immediately Eye, shoulder, mouth Can t sit still Stiff walking, moving Should have Benadryl on hand

43 More Medications Mood stabilizer Anti-seizure medications Depakote, Weight gain Frequent lab draws Dulling Polycystic Ovary Disease Pancreatitis What to do? Diet and excerise Do the lab work If has stomach pain needs to be seen.

44 More on mood stabilizers Trileptal Nausea, vomiting Sedation Activation No lab work Lamictal Rash No change in diet, soaps, et al. Have to go slowly

45 Lithium Frequent lab draws Yet another Very narrow window between helpful level and toxic Drink lots of fluids Can cause thyroid to stop functioning Tremors, increased need to urinate, headache Takes time and most often stops Weight gain Diet and exercise Tough on thyroids

46 Medications and School Pay attention Less irritable, aggressive, reactive More predictable behavior (more like peers) May help with social interactions Pleasant to be around.

47 Dulled Medications and School Difficulty processing Decreased affect Weight gain Sleepy Movement Disorders May be worse More aggressive, reactive, moody Missing school

48 Autism Spectrum Disorder (ASD) Autism Asperger s Syndrome Pervasive Developmental Disorder (PDD) Rett s Disorder Normal until 5 mo, only females Poor gross motor coordination Head growth slows down between 5 and 48 mo Severe problems with receptive, expressive language Childhood Disintegrative Disorder Normal until 2 yrs of age, but changes occur before 10 yrs of age Most often severe MR Regression in all areas Martin, A., et al. (2003)

49 Review of Medications Stimulants for hyperactivity, impulsivity and inattention Often are not as effective as in non-asd kids Intuniv or Tenex has been helpful SSRI for anxiety Prozac is most commonly used, but could try any Zoloft, Celexa, Luvox, Paxil, Lexapro May cause increase in agitation For aggression may need atypical antipsychotic Risperdal, Abilify, Seroquel, Zyprexa, Geodon Or may benefit from mood stabilizer Depakote, Lamictal, Trileptal

50 Reactive Attachment Disorder(RAD) Disrupted attachment Adopted Mother with difficulties attaching Depression Anxiety On a continuum Lying, stealing, hording Not impacted by consequences Unable to regulate their mood

51 Reactive Attachment Disorder Antidepressants Atypical antipsychotics Same side effect. Therapy, intensive long term

52 Getting young children to take medications Find liquid form if pills/capsules are hard Some medication comes in sprinkle form Some can be crushed, but be sure to talk to pharmacist Extended release should not be cut or crushed! Have special food for after Take with special food Keep liquid medications in fridge Use FlavoRx, some pharmacies have it.

53 Young kids and meds Coat spoon with chocolate syrup and put pill on it. Set-up a routine Let them make choices If necessary, You can take it the hard way or the easy way.

54 Little ones and medication

55 Getting older children to take medication Ask what their reluctance is? Don t want to take drugs Call them medications Don t not want to be themselves Won t change them, but allows them to be them Makes them different Insulin analogy

56 Older kids and medications Attitude is Everything Your attitude matters Simpler is Better If possible once/day Listen to Your Child regarding side effects Most often can make a change so less side effects

57 More tips Make it easy Time when convenient Pill box Routine part of day Realistic expectations about independence in taking medications.

58 THOUGHTS Any child can tell you that the sole purpose of a middle name is so he can tell when he's really in trouble. (Dennis Fakes) Raising kids is part joy and part guerilla warfare. (Ed Asner) There is always a moment in childhood when the door opens and lets the future in. (Graham Green)