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 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. Influences on Children Biology Reversible Static Congenital Acquired •Down •Head Syndrome injury •Autism •Learning Disabilities Environment •Stroke Medicine Psychiatry •Diabetes •ADHD •High blood pressure •Bipolar •Aids •Fetal Alcohol Syndrome Intellectual property of Josh Newman, MD, Wilder Foundation •Schizophrenia •Depression •Anxiety Positive Influences •Positive parenting Family Changes •Divorce •Divorce •Separation •Separation •Positive •Death •Death community •Frequent support •Frequent moves •Faith community moves School Trauma •Good fit •Abuse •Not good fit •Neglect •Domestic Violence •Natural Disaster 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. 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 Mental illness is a physical (brain) disorder……… Normal brain ADHD Brain Normal brain Autistic spectrum disorder brain Anxious Brain OCD Brain Normal brain Bipolar brain Depressed brain Epidemiology      Rates of prevalence is 14-22 % (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)) Classifications of Medications  Stimulants: Ritalin, Metadate, Adderall, Focalin,  Selective Serotonin Reuptake Inhibitors (SSRI’s):       Dexadrine, Concerta, Daytrana Patch, Vyvanse 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 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 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 Attention Deficit/Hyperactivity Disorder • Inattentive type (ADD) • Hyperactive/Imp ulsive type • Combined type 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 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 Side Effect of Stimulants • Sleeping problems • Give meds earlier • Shorter acting medication • Lots of exercise • Good sleep hygiene • May need medication ADHD medications • Monitor for these: • Depression • Sad, withdrawn, no energy • Anxiety • Irritable • Hallucinations • Talking to self, odd behavior ADHD cont. • Mania • • • • • Won’t sleep Very irritable Talking non-stop “I’m the boss” Stop medication • Irritability • Stop medication School Performance • Positive • • • • • Focused Remember More organized Sit still Less disruptive School Performance • Negative • Increased irritability • Decreased appetite • Sedated Remember • No medication “cures” ADHD. • Often life long struggle • More than not sitting still and paying attention • Executive function • Often associated with learning disabilities. 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) 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. Other antidepressants  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 More on antidepressants:  Black Box warning:    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 (http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugCla ss/ucm096352.htm)  http://www.nimh.nih.gov/health/topics/child-andadolescent-mental-health/antidepressantmedications-for-children-and-adolescentsinformation-for-parents-and-caregivers.shtml 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… 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  More medications for anxiety (cont.) 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.  Trileptal  Seroquel  Buspar 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 Medications and school; negatives  Tired  Irritable  Angry/manic  Suicidal thinking   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  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     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 Same for Anxiety 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  Statistics Approximately 1% of children  More boys than girls especially under the age of 13 years ( Joshi,  B. and Wilens, T. 2008. Comorbidity in Pediatric Bipolar Disorder. Children Adolsec Psychiatric Clinic N AM 18, 291319)  From 1994-2003   2 fold increase in adults diagnosed with Bipolar Disorder 40 fold increase in children (Moreno, C. et al. 2007. National Trends in the outpatient diagnosis and treatment of Bipolar Disorder in Youth. Arch Gen Psychiatry, 64(9), 1032-1039) Difficult to Diagnosis Different in children than adults?  Bipolar I    Full mania Depression Bipolar II  Bipolar, NOS  Mood Disorder, NOS  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. 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 Medications    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 More on medications  Risperdal      Geodon    Weight gain Breast enlargement, lactation Dulling FDA approved for kids in autism spectrum Difficult to use Fewest side effects Clozoril  Seldom used More side effects of atypical antipsychotics  May cause “dulling”  Report to provider may want to decrease dose  Movement  Notify Disorders provider immediately  Eye, shoulder, mouth  Can’t sit still  Stiff walking, moving  Should have Benadryl on hand 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. 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 Yet another  Lithium  Frequent lab draws  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 Medications and School Pay attention  Less irritable, aggressive, reactive  More predictable behavior (more like peers)  May help with social interactions  Pleasant to be around.  Medications and School  Dulled  Difficulty processing  Decreased affect Weight gain  Sleepy  Movement Disorders  May be worse   More  aggressive, reactive, moody Missing school 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) 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 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 Reactive Attachment Disorder  Antidepressants  Atypical antipsychotics Same side effect.  Therapy, intensive long term 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. 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.” Little ones and medication http://youtu.be/MXFMZuNs-Fk 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 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 More tips  Make it easy  Time when convenient  Pill box  Routine part of day  Realistic expectations about independence in taking medications. 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)