Principles of Psychopharmacology- PSY 740
Week 7 Course Notes
Child and Adolescent Psychopharmacology
Attention Deficit/Hyperactivity Disorder
DSM Types of ADHD
• Predominantly Hyperactive-Impulsive
• Combined- Both Hyperactive-Impulsive and Inattentive
• Predominantly Inattentive
General Symptoms
• Inattentive Symptoms (Attention Deficit)
• Easily distracted
• Disorganization and careless mistakes
• Trouble listening, following instructions, and completing tasks
• Avoidance of tasks requiring prolonged attention
• Forgetfulness
Hyperactivity and Impulsive Characteristics
• Restless, fidgety, intrusive behavior
• Speaking out of turn
• Impatient and have trouble playing quietly
General Facts about ADHD
• 5% of children reportedly have ADHD.
• Most kids will grow out of the hyperactivity as they reach the teen years or adulthood.
• It is believed that about one-third will out grow it due to maturation of the prefrontal lobes by their early twenties or thirties. 2/3 will have symptoms into adulthood.
• The presumption is that ADHD has a genetic linkage
Differential Diagnostic Issues in ADHD
• This is important because many psychological or mental health issues in kids present with hyperactivity and inattention.
Some children with a kinesthetic learning style may be labeled ADHD.
Some normal children that are highly active may labeled as ADHD.
Some children with attachment trauma, or kids without good parental boundaries may act out and be labeled as ADHD. Some parents don’t have good enough parenting skills and resort to heavy handed discipline or don’t set appropriate boundaries and when the kids act out, they can be labeled as ADHD.
Neurobiological Issues in ADHD
• Impaired frontal lobe function has been seen on PET and SPECT scans.
• Dopamine system irregularities.
• Abnormal brain structures have also been noted, smaller cerebrums (smaller frontal and temporal lobes with less white matter) and cerebellums have been noted.
Treatment
Three classes of drugs are used to treat ADHD
Stimulants
• Stimulants raise dopamine levels in the prefrontal cortex which increases the ability to focus and pay attention.
Stimulants work by inhibiting dopamine reuptake or by stimulating increased release of dopamine (amphetamines).
• Reported 70% response rate. (If diagnosis is correct! PTSD is often misdiagnosed as ADHD) Stimulants will increase attention in normal children, as it does in adults that use it for studying, etc., but the changes in behavior will be less marked than when used in a child in which the diagnosis is correct.
• Stimulants don’t work on Inattentive form- It may be a different syndrome altogether.
2. Alpha-2 Adrenergic Agonists
These decrease norepi levels in the brain. (See the anti-anxiety section)
• Mimic norepinephrine at the alpha-2 receptor, the inhibitory receptors stimulated by norepi.
•The effects of Alpha-2 stimulation are decreased aggression, reduced irritability, and sedation.
• Catapres (clonidine) and Tenex (guanfacine)
• Used in conjunction with stimulants in kids with insomnia.
Antidepressants
• The ones that increase norepi as well as serotonin work the best (tricyclics) but have side effects. Raising norepi sometimes helps with core symptoms of ADHD, i.e. attention deficit.
• SSRI’s will not help the core symptoms, but will help with depression if it is present.
• Wellbutrin (weak norepi and dopamine effects) and Strattera (an NRI) can also be used.
Other Childhood Disorders
Serious depression in kids may be a prelude to major depression or bipolar disorder as
an adult.
• 35% go on to have recurrent major depression
• 49% develop Bipolar Disorder
• Serious depression in children is considered Bipolar Disorder until proven
otherwise.
• Bipolar disorder is very rare in < 6 year-old kids
Suicide attempt rates before age 18
• General population- 1%
• Major Depression- 22%
• Bipolar Disorder- 44%… This is why it is important to correctly diagnose Bipolar if present and not confuse it with ADHD. (see below)
Symptoms of early onset Bipolar Mania
• Nonepisodic (more continuous)
• Mixed mania is most typical with marked dysphoria and extreme irritability
• Intense episodic rages
• Severe oppositional behavior
• Ultrarapid cycling
By age 15 to 16 Bipolar presents like adults
• In Children with Bipolar:
• 70% of first episodes are major depression
• Only 1% have classic mania
• 29% have mixed mania
Symptoms common to Bipolar but not in ADHD
• Decreased need for sleep- 40% vs. 6%
• Hypersexuality- 43% vs. 6%
• Intense prolonged rage attacks 92% vs. 0%
• Morbid dreams
• Flight of Ideas
• Psychotic symptoms
• Family Hx of Bipolar and related characteristics (see Bipolar notes)
Similarities in ADHD and childhood Mania
• Irritability
• Inattention and distractibility
• Hyperactivity
• Impulsivity
• High level of engery
• Pressured speech
• Chronic and non-episodic pattern
Treatment of Biplolar children
• 80% respond to combination therapy:
• Li plus Depakote
• Li or Depakote plus an antipsychotic
Atypical Antipsychotics are used in children with:
• Psychosis
• Aggression (which could be a symptom of PTSD)
• Mania
Stimulants can be added if there is comorbidity with ADHD
Reported Childhood Depression Treatment Responses
• Combo therapy (meds and therapy)- 71% success rates (about same as adults)
• Prozac alone- 61%
• CBT alone- 43%
• Placebo- 35% (adult response about 25%)
• Most respond within 4-6 weeks but may take up to 10-12 weeks.
Suicidality and Antidepressants in Children
• Paxil was reported to increase suicidality (“suicidality” includes suicidal ideation, plans, attempts, and actual suicides).
• Placebo- 1.2% suicidality
• Paxil- 3.4% suicidality
• No actual suicides noted in study
• Three major studies had no actual suicides
• Slight increase in suicidality may be seen however there is typically a marked decrease
in suicidality by 12 weeks on SSRIs. Black Box warnings are on labels of SSRIs after this study, however.
• This has led to a 40% drop in prescribing rates for teenagers and children with severe
depression. (Media has scared parents and doctors.)
• Some of these children will commit suicide that would have been preventable with medication.
Description
Read the attachment and answer the below prompt:
1. What are the key things -the concepts, otherwise thought of as “nouns” in this week’s Notes? (e.g., psychotropic medications would be one such thing). Mention five such things.
2. What are either the faculty’s – or better yet, the field’s – principles, as faculty has conveyed in the Notes (e.g. psychotropic medications can be a good thing and they can be a very bad thing – they are a mixed bag). Mention five such principles.
3. What assumptions do you see between the lines, that the Notes not directly conveyed, but that you suspect lurk in the shadows of the material, whether for good or bad (shadows are not necessarily bad). Mention five such between-the-line possible assumptions.
4. What do you not understand, whether due to lack of time on your part, or because it feels like it’s a mountain of material that you’ve only gotten a through just a bit thus far, or because it feels too complex? Mention at least three things that you don’t, as yet, understand.
5. Search for two references that speak directly to at least two concepts entailed in this week’s Notes. Search for these by utilizing the University’s electronic library databases (ERIC; Dissertations and Theses (PQDT); APA’s PsycArticles; APA’s PsycBooks; and/or APA PsycInfo), cite each one, provide the link for it, and in a sentence or two, summarize it as if you were explaining it to a high school sophomore.
