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Choosing a Psychiatrist: Trust Your Gut

The process of diagnosis and treatment can be extensive, therefore a patient, and if a minor—along with their parent or caregiver--spends a great deal of time working very closely with the doctor. Having a relationship of trust is paramount. Parents are literally putting the well-being of their child in the doctor's hands, with a great deal riding on the outcome. A doctor must take these concerns seriously, and at the same time provide reassurance, but not guarantees. Medications carry side-effects with them, and a cost vs. benefit has to be taken into consideration depending on the severity of symptoms experienced. Often it takes time to find the correct “mix” of medications to treat the unique symptoms a patient presents with. So, for example, one symptom may be reduced, but not another, so perhaps an adjustment in dosage is needed, or the addition of another medication. This requires a great deal of patience and a commitment to the process by all parties involved in order to have the most successful outcome. How do we know if the potential provider is someone we can work with?

First, get a feel for how the practice is managed. Take a look around the office, are people comfortable? Is staff receptive to your questions? Is adequate information provided regarding treatments? Are phone calls returned in a timely manner? How are emergencies handled? Is there someone on call to handle calls after hours, weekends and holidays?

Next, how do you feel around the doctor? Is this someone you feel comfortable discussing personal family issues with? Is this doctor receptive to questions? Speak in language you can understand? Is this someone you can be in a long-term relationship with?

Diagnostics and Examining Treatment Options This section of the presentation examines the diagnostic criteria for Pervasive Developmental Disorder, as well as common co-morbid conditions

Disruptive Behavior Disorders Attention Deficit /Hyperactivity Disorder -Inattentive type -Hyperactive/Impulsive type -Combined type

Oppositional Defiant Disorder Conduct Disorder

Treatment Options Medications -Stimulants – long or short acting (Adderall XR, Metadate CD, Ritalin LA, Concerta, Focalin, Focalin XR, Ritalin, Adderall, Dexedrine) -Antidepressants – (Strattera) -Second Line Drugs – atypical antidepressants, other options (Wellbutrin SR,Wellbutrin XL, Modafinil, Nortriptyline, Tenex, Clonidine) Individual therapy

-Strattera has 2 reported cases of liver failure after 4,000,000 patients treated. FDA did not change label or approved use. -Adderall XR sales have been suspended in Canada (but approval to use the drug has not been revoked!) This suspension resulted from 12 deaths (not in Canada) in children with cardiac abnormalities. FDA does not feel any immediate changes are warranted in labeling or approved use. -Adderall XR reinstated for use in Canada on 8/26/05

Mood Disorders Depressive Disorders -Major Depression -Dysthymia Bipolar Disorders -Bipolar Type I -Bipolar Type II Mood Disorder NOS

Treatment Options Medications -ONLY Prozac is formally “indicated” for children and adolescents with Major Depression. All other medications would be used “off-label” meaning that the drug is being used without formal FDA approval.

ALL antidepressants now have a black box warning …FDA announced October 2004 that all antidepressants must add a “black” box warning to the label to warn the public about the increased risk of suicidal thoughts and behavior in children and adolescents. 4400 children studies, 0 completed suicide, 78 reported suicidal thoughts

Bipolar Disorders -Mood stabilizers (Lithium, Depakote, Topamax, Tegretol, Trileptal, Neurontin, Lamictal) -Individual Therapy -Community Support Groups

Pervasive Developmental Disorders Autistic Disorder Asperger's Syndrome Pervasive Developmental Disorder NOS

Treatment Options Medication usage varies depending on symptomatology -Antidepressants for anxiety (Luvox, Paxil) -Antipsychotics for aggression/out of control behavior ( Abilify, Zyprexa, Risperidol, Geodon, Seroquel) Community Support groups for parents

Risperidol -Only medication formally “indicated” for the treatment of Autism or any autism spectrum disorder -Risperidol has been formally approved by the FDA for the treatment of irritability assoc. with autistic disorder, aggression toward others, self injurious behavior, temper tantrums and quickly changing moods in patients 5 to 16 yrs old -Approval based on two 8 week studies of 156 autistic patients ages 5 to 16

-Most research of any antipsychotic medication – 53 studies to date -Effective in reducing tantrums, aggression and self-injurious behavior -Most important side effects were increased appetite and weight gain

Ziprasidone -McDougle et al (2002) studied 9 patients using Geodon and found that Ziprasidone was safe and effective in autistic adolescents -One other study by Cohen to evaluate effect of switching antipsychotics -10 pt charts reviewed, 9 of 10 patients had profound MR - IQ < 20-25 -Positive effect on behavior, body weight and lipid levels in autistic adults

Olanzapine -Study in progress, study started Sept. 2004 expected completion date December 2009 -Expected Total Enrollment: 78 Sponsored by the National Institute of Mental Health

Aripiprazole -One study by Stigler (2004), 5 male patients studied (1 Asperger's and 4 autistic males) -Significant improvement in aggressive and agitated symptoms -Side effects noted mild somnolence and mild weight gain, no N/V or EPS noted

Quetiapine -Finding et al (2004) studied 9 adolescents with autism, 8 males 1 female -Improvement noted on Aberrant Behavior Checklist -Martin et al (1999) studied 6 males with autism -Mixed results, side effect of weight gain noted -2 retrospective (chart review) studies -Corson et al (2004) studied 20 patients, 10 stayed on Seroquel, 3 discontinued due to adverse effects and 7 stopped due to lack of effectiveness -Harden et al (2005) studied 10 patients, 6 deemed responders to CGI –GI scales used

Anxiety Disorders -Generalized Anxiety Disorder -Social Phobia -Panic Disorder -Obsessive-Compulsive Disorder -Post Traumatic Stress Disorder

Medication options -Antidepressants (Lexapro, Paxil, Prozac, Zoloft, Luvox, Celexa, Anafranil) -Beta-blocking agents (Propranolol, Atenolol) -Benzodiazepines (Klonopin) -Anticonvulsants (Gabatril) Cognitive Behavioral Therapy

Thought Disorders -Schizophrenia (very rare in childhood) -Brief Psychotic Disorder -Psychosis NOS

Medication Options -Antipsychotic medications ( Abilify, Haldol, Zyprexa, Risperidol, Geodon, Seroquel,) Individual Psychotherapy NOT proven effective Group Psychotherapy

Tic Disorders -Tourette's Disorder -Chronic Motor or Vocal Tic Disorder -Transient Tic Disorder -Tic Disorder NOS

Medication options -Antipsychotics ( Abilify, Zyprexa, Geodon, Risperidol, Seroquel, Orap) -Antihypertensives (Clonidine, Tenex)

Elimination Disorders -Enuresis -Encopresis

Treatment Options -Bowel Care/Training protocol -Careful assessment for other diagnoses or covert stressors -Thorough work-up for physical causes -Behavior Management training -DDAVP or Ditropan for enuresis

Other Disorders of Childhood -Separation Anxiety Disorder -Selective Mutism -Reactive Attachment Disorder -Mental Retardation -Eating Disorders -Trichotillomania -Adjustment Disorders Treatment Options -Medication options -Individual Therapy -Family Therapy -Behavioral Management Protocols -Appropriate school placement -Possible respite care

Red Flags: When to get Really Concerned

Main Issue: Safety

Out of Control:

-Increase in number of episodes of extreme anger and rage

-Increase in intensity of out of control episodes

-Increase in duration of out of control episodes

Increased Contacts

-Increased number of phone calls to office

-Increased urgency in parent voice

-Messages from other providers about patient

-Messages from the school or other agencies about patient

Aggression

-Physical aggression toward self or others (even the family dog counts)

-Verbal escalation that evolves into screaming

-Prolonged verbal and physical rages (patient heard screaming in the background of phone calls)

Fear

-Is parent fearful of child and his or her behavior with siblings, peers?

-Listen to your gut (or the hair on the back of your neck!)

Caution

-Always good to warn concerned parents about weapons and ask then to remove sharp objects or firearms from the home

Meanwhile

-Any possibility of speaking with specialist to begin treatment prior to specialist appt.

-Long lag time to appt. due to lack of resources

-When to ask for help and who can help

Warnings

-Need for concern increases when outside sources (teachers, babysitters, etc.) are contacting parent with reports of aggression or other untoward behaviors

Repetition

-Repeated episodes of violence/aggression without provocation

-Extreme reactive aggression out of proportion to the stressor

End of the Road

-Know the resources before the crises hits so you are prepared

-Know your own limitations when you are at the “end of your rope” and need outside assistance

Case Studies

This section of the presentation includes examples of actual case studies involving individuals who present with dual diagnoses. This includes the process of evaluation which includes (but is not limited to):

History of:

Present Illness

Psychological

Medical

Developmental

Family

Social

Educational

Abuse

Alcohol and Drug

Medication Trials

Mental Status Exam

Predisposing factors

Precipitating factors

Perpetuating factors

Protective factors