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Copyright The REACH Institute. All rights reserved. Assessment/Treatment of Aggression in Youth Slide 2 Copyright The REACH Institute. All rights reserved. It is the policy of the University of Arkansas for Medical Sciences (UAMS) College of Medicine to ensure balance, independence, objectivity, and scientific rigor in all provided or jointly provided educational activities. All individuals who are in a position to control the content of the educational activity (course/activity directors, planning committee members, staff, teachers, or authors of CME) must disclose all relevant financial relationships they have with any commercial interest(s) as well as the nature of the relationship. Financial relationships of the individuals spouse or partner must also be disclosed, if the nature of the relationship could influence the objectivity of the individual in a position to control the content of the CME. The ACCME describes relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose will be disqualified from participation in the development, management, presentation, or evaluation of the CME activity. UAMS Disclosure Policy Slide 3 Copyright The REACH Institute. All rights reserved. Disclosures The following planners and speaker of this CME activity has no relevant financial relationships with commercial interests to disclose: Lawrence Amsel, M.D. Suzanne Reiss, M.D. Diane Bloomfield, M.D. Mark Riddle, M.D. Cathryn Galanter, M.D. Jyoti Bhagia, M.D. Harlan Gephart, M.D. Ruth Stein, M.D. Peter Jensen, M.D. Mark Wolraich, M.D. Robert Kowatch, M.D. Rachel Zuckerbrot, M.D. Rachel Lynch, M.D. Elena Man, M.D. Slide 4 Copyright The REACH Institute. All rights reserved. Disclosures The following planner and speaker of this CME activity has financial relationships with commercial interests to disclose: Laurence Greenhill, M.D. Bio BDX Scientific Advisory Board Slide 5 Copyright The REACH Institute. All rights reserved. Learning Objectives To safely & effectively learn the role & use of medications for severe pediatric aggression, participants will learn to: 1) Differentiate among pediatric problems that present with aggression, including depression, ADHD, bipolar disorder, psychosis, and conduct disorder. 2)Create and implement an effective treatment plan by mobilizing existing resources, i.e., delegating tasks to family members and other professional caregivers. 3)Effectively utilize psychopharmacologic approaches for clinical aggression, including: a)Selecting medications for individual patients b)Initiating and tapering dosages c)Monitoring improvements d)Identifying and minimizing medication side effects Slide 6 Copyright The REACH Institute. All rights reserved. Agenda Learn the various types of aggression presenting in clinical settings Observe and discuss a typical case Todd and his parent(s) Learn about the T-MAY guideline and toolkit, and its use in assessing, treatment planning, and managing severe aggression Discuss role and the safe/effective use of atypical neuroleptics in children and adolescents with severe aggression Slide 7 Copyright The REACH Institute. All rights reserved. Hidden Slide: Time Table Total Time: 50 minutes Intro, Goals & Objectives: 3 Role play: Patient returns: 7 26 Slides: 20 Table Exercise: 15 Debrief: 5 Unit L: Assessment and Treatment of Aggression Slide 8 Copyright The REACH Institute. All rights reserved. Hidden Slide: Faculty Directions 1.Ask participants to pull out the MH card and follow along during the next case: Todd and his mother/father. 2.Todd Role Play (L 1.1) - Doctor will use the Mental Health (Aggression) Card. 3.Todd case key points: The doctor has done the best ADHD treatments according to Texas algorithms, but it is not enough. Case illustrates: Omigosh! What do we do now? 4.Use case to walk through the answer to the What do we do now? question via the T-MAY toolkit. Slide 9 Copyright The REACH Institute. All rights reserved. Case Presentation: Your Patient Todd Slide 10 Copyright The REACH Institute. All rights reserved. Slide 11 Case Presentation: Todd continued What would you do? Audience input See Todds scored Vanderbilt (L 1.2& 1.3) in Workbook Slide 12 Copyright The REACH Institute. All rights reserved. Hidden Slide: Faculty Directions Faculty directs the Attendees to refer to Todds scored Vanderbilt (L 1.2& 1.3) in their packet Slide 13 Copyright The REACH Institute. All rights reserved. NICHQ Vanderbilt Assessment Scale: Parent information NICHQ Vanderbilt Assessment Scale: Parent information Copyright The REACH Institute. All rights reserved. Slide 14 NICHQ Vanderbilt Assessment Scale: Parent information NICHQ Vanderbilt Assessment Scale: Parent information Copyright The REACH Institute. All rights reserved. Slide 15 Assessment of Aggression Slide 16 Copyright The REACH Institute. All rights reserved. PTSD Impulse control disorders Bipolar spectrum ADHD spectrum Cluster B personality disorders Tourettes /OCD Conduct Disorder Substance abuse Schizophrenia Spectrum Schizophrenia Spectrum Developmental disorders Autism Spectrum disorders Impulsivity and Aggression Impulsive-Aggressive Spectrum Severe Anxiety Antisocial Borderline Slide 17 Copyright The REACH Institute. All rights reserved. TypeClinical DescriptionRepresentative DSM Dx 1.ImpulsiveUnprovoked, brief, rapid, thoughtless, inability to delay reward/recognize consequences; out of proportion and out of the blue ADHD Bipolar TBI IED 2. Affective Storm/HotExaggerated response to affectively provoked or charged (i.e. difficulty modulating arousal), reactive. Hot blooded aggression. Extended duration (30+ minutes) Bipolar PDD/ID ADHD Subst. abuse MDD/Dysthymia 3. Anxious/hyperarousalOverstimulation, overwehelmed, response to xs anxiety; lash out with relief of tension PTSD PDD OCD 4. Cognitive/disorganizedDistorted perceptions, impaired reasoning, delusions, paranoia Psychosis Bipolar Schizophrenia TBI/FAS/Brain damage Sub. Abuse 5. Predatory/ColdPremeditated, consciously executed, instrumentally motivated, cold blooded CD, ASP Slide 18 Copyright The REACH Institute. All rights reserved. Aggression in Children & Adolescents: Critical Issues Most common reason for psychiatric referral Complicates treatment/leads to poorer outcomes Frequent use of atypical antipsychotics and multiple medications Lack of controlled trials to inform physicians prescribing practices Slide 19 Copyright The REACH Institute. All rights reserved. Slide 20 Managing Aggressive Youth Question 1: True or False? Your first step is to make a valid DSM diagnosis Slide 21 Copyright The REACH Institute. All rights reserved. False! T-MAY Recommendations: 1 - Conduct a thorough assessment. Assessment must include: Engaging the patient and parents (emphasizing the need for their on-going participation and work) 2 - Get a diagnosis (remember the General Principles?) DSM diagnosis is insufficient without understanding the child, the family, and the context within which the child is developing Slide 22 Copyright The REACH Institute. All rights reserved. Initial Evaluation Prior to Pharmacologic Treatment Engage parents & patients at the outset: You cannot do it w/meds alone, nor without the family! Assessment & Diagnostic interview with patient and parent/guardian Contact prior treating physician Review treatment records Contact teachers Identify other medications being taken Assess the childs developmental needs: what is missing? Physical examination Appropriate laboratory studies Slide 23 Copyright The REACH Institute. All rights reserved. Managing Aggressive Youth Question 2: True or False ? Response to treatment can be adequately monitored by using clinical interview and clinical judgment alone. Slide 24 Copyright The REACH Institute. All rights reserved. False! Define target symptoms & behaviors in partnership with parents and child Assess target symptoms, treatment effects and outcomes with standardized measures T-MAY Recommendations Slide 25 Copyright The REACH Institute. All rights reserved. : Standardized Measures Useful For Aggression Include: Vanderbilt Modified Overt Aggression Scale (MOAS) Nisonger Child Behavior Rating Form (N-CBRF) Slide 26 Copyright The REACH Institute. All rights reserved. Hidden Slide: Faculty Directions Ask participants to look at workbook pages L1.9-3.4, so they can see the TMAY handouts for all of the rating scales. Slide 27 Copyright The REACH Institute. All rights reserved. L2.9 Slide 28 Copyright The REACH Institute. All rights reserved. L3.2 Slide 29 Copyright The REACH Institute. All rights reserved. Treatment Planning Conduct a risk assessment & if needed, consider referral to a MH specialist or ER Partner with family in developing an acceptable treatment plan Provide psychoeducation to help families form reasonable expectations Help the family establish community & social supports T-MAY Recommendations Slide 30 Copyright The REACH Institute. All rights reserved. T-MAY Recommendations Psychosocial Interventions: Provide or assist family in obtaining evidence-based parent-and-child skills training Identify, assess, and address the childs social, educational, & family needs, and set objectives & outcomes with the family Enlist & engage the child and family in maintaining consistent psychological & behavioral strategies Slide 31 Copyright The REACH Institute. All rights reserved. MTA Medication Doses: Comb vs. MedMgt Dose by Weight Over 14 Months Copyright The REACH Institute. All rights reserved. Slide 32 Behavioral Principles Involve the parent: I cant do it without you. Pills alone wont give your child the skills he/she needs. Parent training & support Co-opt the youth: Involve child/youth in monitoring and controlling aggressive outbursts Positive approach Positive reinforcement Catch the child being good Dont reward negative behaviors Consistency and follow through Slide 33 Copyright The REACH Institute. All rights reserved. T-MAY Recommendations Medication Treatments Treat the 1 Disorder (underlying condition) first, using recognized guidelines for that disorder. ONLY IF severe aggression persists after adequate psychosocial & medication treatments for the 1 Disorder, add an AP If first AP fails, try another, or consider mood stabilizer If possible, avoid using more than two psychiatric medications simultaneously Use recommended titration schedule and deliver adequate doses before adjusting or changing medications Slide 34 Copyright The REACH Institute. All rights reserved. Atypical Antipsychotics: Optimal Dosing/Titration Strategies for Children and Adolescents Atypical Antipsychotics Starting Daily-Dose Titration Dose, q3-4 day (~Min. days to antipsychotic dose) Usual Daily Dose Range in Aggression** Usual Daily Dose Range in Psychosis CHILDADOLESCENTCHILDADOLESCENT Aripiprazole2.5-5 mg (7-10 days) 2.5-15 mg5-15 mg 5-30 mg Clozapine6.25-25 mg 1-2x starting dose (18-30 days) 150-300 mg200-600 mg150-300 mg200-600 mg * * Olanzapine 2.5 mg for children 2.5-5 mg for adolescents 2.5 mg (10-15 days) NDA 7.5-12.5 mg12.5-20 mg Quetiapine 12.5 mg for children 25 mg for adolescents 25-50 mg to 150 mg then 50-100 mg (18-30 days) NDA 300-600 mg Risperidone 0.25 mg for children 0.50 mg for adolescents 0.5-1 mg (10-15 days) 1.5-2 mg2-4 mg3-4 mg3-6 mg Ziprasidone20 mg 20 mg for children 20-40 for adolescents (18-30 days) NDA NDA; (In adults, 160-180 mg) NDA = no data available. *There is little information to guide dosing strategies for aggression. However, for aggressive children treated with risperidone, doses are about half that of the usual antipsychotic dose. **In treatment resistant schizophrenic adults, a serum clozapine level (of the parent compound) greater than 350mg/dl is generally required for efficacy. TRAAY: Pocket Reference Guide for Clinicians in Child and Adolescent Psychiatry (2004). NYS-OMH & CACMH See WkBk L1.8c Slide 35 Copyright The REACH Institute. All rights reserved. Aggression (Iowa Scale*) Methylphenidate in ADHD/CD: Impulsive Aggression *Sum of 5 items, range 0-15. Klein RG et al. Arch Gen Psychiatry. 1997;54:1073-1080. n =7135367437 472324 P < 0.001 P < 0.003 P < 0.03 Slide 36 Copyright The REACH Institute. All rights reserved. Atypical Antipsychotics in Disruptive Behavior Disorders With Aggression: Levels of Evidence Atypical Antipsychotics Short-Term Efficacy Risperidone Olanzapine Quetiapine Ziprasidone Clozapine Aripiprazole A C D C B* A = >2 randomized, controlled studies; B = 1 randomized, controlled study; C = clinical experience, eg, open studies, case reports, etc., D = no data or negative outcome. * Studies done with aggression/irritability in autism: Based on all available RCTs thru 8/2013 Adapted from Jobson KO, Potter WZ. Psychopharmacol Bull. 1995;31:457-459. Slide 37 Copyright The REACH Institute. All rights reserved. T-MAY Recommendations: Ongoing Management Start low, go slow, taper slow Routinely assess for side effects and drug interactions, including clinically relevant metabolic studies (To be discussed in following session). Provide info to children & parents re: side effects Use E-B strategies to prevent-reduce side effects Collaborate with medical, educational, &/or MH specialists as needed Slide 38 Copyright The REACH Institute. All rights reserved. See WkBk L1.8b Copyright The REACH Institute. All rights reserved. Slide 39 See WkBk L1.9 Copyright The REACH Institute. All rights reserved. Slide 40 T-MAY Algorithm: Assessment & Diagnosis Treatment Planning, Treatment, and Ongoing Management See WkBk L2.1 Copyright The REACH Institute. All rights reserved. Slide 41 Hidden Slide for Table Activity Tell participants that Todds problems are getting more urgent, and the school is threatening expulsion. You have done all the ADHD stimulant treatments, but they are still insufficient Todd and family had behavior management therapy, but he still has impulsive aggression. Give table activity instructions (next slide). Slide 42 Copyright The REACH Institute. All rights reserved. Table Activity 1. Review Todds Vanderbilt scores 2. Calculate his MOAS score? (L 1.4) 3. What type of therapy would you pick? 4. Assume Todd has continuing, severe problems: Which atypical would you use, and at what dose? What rating scale would you use to track response? SCRIBES - Write on your flipchart: 1) MOAS score 2) Therapy choice 3) Atypical choice & dose 4) Rating Scale Slide 43 Copyright The REACH Institute. All rights reserved. Table Activity Debrief MOAS Scores Behavior management? Which atypical, what dose? What rating scale? Slide 44 Copyright The REACH Institute. All rights reserved. Treatment Pearls Use rating scales for symptoms & side effects Engage family and youth - LEAP Form Virtual Team Enlist the family in reading (your lending library?) & problem-solving Diagnose and treat the underlying disorder, especially ADHD/ODD Encourage use of behavioral strategies, new skills If/when all of the above arent enough, consider atypical or other agents! Slide 45 Copyright The REACH Institute. All rights reserved. Treatment Pearls II Start with risperidone Target dose 1-2 mg/day, divided doses Start.25 mg qhs, add 0.25 q.am in 3-4 days if well-tolerated Onset of action: 7 days; full efficacy in 4-6 weeks Side effects: weight gain, sedation, elevated prolactin At baseline: fasting glucose, lipids, BMI, girth, dietary consultation Taper at 6 months See WkBk for T-MAY Tools L1.9-3.4 Slide 46 Copyright The REACH Institute. All rights reserved. REMINDER: REMINDER: Please fill out Unit L evaluation Slide 47 Copyright The REACH Institute. All rights reserved. Atypical Toolbox See WkBk L3.6 Atypical Antipsychotic Start at (mg / day) Target Dose (mg/day) MonitorWatch Out For Risperidone0.25-0.501-3Weight/Height/BMIEPS/TD Aripiprazole2.5-55-20Weight/Height/BMIEPS Quetiapine50-100300-600Weight/Height/BMI Ziprasidone20-4080-160 Weight/Height/BMI ECG Take with food, assess cardiac risk factors Olanzapine55-20Weight/Height/BMICholes/FAs Slide 48 Copyright The REACH Institute. All rights reserved. Hidden Slide: Faculty Directions Following 2 slides contain references for parent resources Use these 2 slides to recommend that they develop a reading library and get comfortable making reading assignments or other tasks to parents, such as attending local parent support groups, or going on-line to learn about other support options. Slide 49 Copyright The REACH Institute. All rights reserved. RESOURCE SLIDE: Examples Your Practice Librarys Behavior Management Books Making the System Work for Your Child with ADHD (Making the System Work for Your Child) by Peter S. Jensen, with input & tips by >100 parents (COI: royalties go to CHADD)Making the System Work for Your Child with ADHD (Making the System Work for Your Child) Your Defiant Child: Eight Steps to Better Behavior by Russell A. Barkley, Christine M. Benton 1-2-3 Magic: Effective Discipline for Children 2-12 by Thomas W. Phelan1-2-3 Magic: Effective Discipline for Children 2-12 The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children by Ross W. GreeneThe Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children L1.7 Slide 50 Copyright The REACH Institute. All rights reserved. Resource Slide: Where you Can Refer Your Parents for Additional Support Parent Support Groups May be available: Child and Adolescent Bipolar Foundation: www.bpkids.org; 847-256-8525. Depression and Bipolar Support Alliance: www.dbsalliance.org; 800-826-3632 (toll-free). Families Together in New York State: www.ftnys.org; 888- 326-8644 (toll-free). Federation of Families for Childrens Mental Health: www.ffcmh.org; 703-684-7710. National Alliance for the Mentally Ill: www.nami.org; 800-950- NAMI (toll-free). National Mental Health Association: www.nmha.org; 800- 784-2433 (toll-free). ADHD Family Support Center: www.adhd.comwww.adhd.com Children and Adults with ADHD: www.CHADD.org L1.8a Slide 51 Copyright The REACH Institute. All rights reserved. RESOURCE SLIDE: T-MAY Resources Complete 38-page Toolkit: go to website to download pdf: www.TheReachInstitute.org (see Footer Resources) www.TheReachInstitute.org (see Footer Resources Knapp P, et al., & the T-MAY Steering Group. Treatment of Maladaptive Aggression in Youth (T-MAY) Guidelines I. Family Engagement, Assessment & Diagnosis, and Initial Management. Pediatrics, 129:e1562-1576, 2012 Scotto Rosato N, et al., & the T-MAY Steering Group. Treatment of Maladaptive Aggression in Youth (T-MAY) Guidelines II. Psychosocial Interventions, Medication Treatments, and Side Effects Management. Pediatrics, 129:e1577-1586, 2012 Pappadopulos E, et al. Treatment of Maladaptive Aggression in Youth (T-MAY). Results from a Consensus Survey of Experts- recommended Best Practices. J Child Adol Psychopharm, 21:505-515, 2011 L3.5 Slide 52 Copyright The REACH Institute. All rights reserved. RESOURCE SLIDE: Risperidone in Autism: Irritability Scale RUPP Autism Group, NEJM, 2002