Pediatricians as Primary Mental Health Professionals 5 Essential Drugs Dr. M.K.C.Nair Director, Child Development Centre Medical College, Tvpm Dr. Paul Russell Professor &Head Child & Adol. Psychiatry Division Christian Medical College, Vellore

Treatment modality as recommended by WHO or based on evidence MedicationCBTFamily therapy LD a --- ADHD a yes - Tics a yes Depression a yes Psychoses a yes- Schizophrenia a yes- Autism b yes-- Anxiety b yes Conduct disorder b yes Substance abuse b yes- Eating Disorders b yes Attachment disorders b --yes

4 Hierarchy of Diagnosis & Treatment Organic brain syndromes Psychoses/ Pervasive Dev.l Disroders Mood disorders / ADHD Anxiety disorders Tic / Enuresis / Conduct Disorder

Medication: Antipsychotic Org.Brain Syndromes Dose 1 st -line drugRisperidone (Atypical antipsychotic)0.25-1mg/day 2 nd -line drugHaloperidol (Typical antipsychotic)0.25-1mg/day Organic Brain Syndromes H/O: Temporal correlation with a demonstrable general medical condition, CNS pathology, drugs and medication MSE: attention, orientation, memory impaired.

Psychosis PsychosesDose 1 st -line drugRisperidone (Atypical antipsychotic)2-4mg/day 2 nd -line drugHaloperidol (Typical antipsychotic)0.03 – 0.08mg/kg/day 1.Hallucinations 2.Delusions 3.Catatonic symptoms 4.First Rank Symptoms Medication: Antipsychotic

Autism Symptoms Hyperactivity, impulsiveness, inattention – Atypical antipsychotic Rigidity, rituals– Atypical antipsychotic Aggression, self injury – Atypical antipsychotic Anxiety, Affective symptoms– Atypical antipsychotic Review of 19 articles (Barnard et al, J Psychopharmacol 2002) 1. Deviant/ delayed social interaction 2. Deviant/ delayed communication 3. Restricted-repetitive behaviour Medication: Atypical antipsychotic - Risperidone: Dose: 0.25 – 2mg/day

Mood disorders - Medication of choice Depressive episode 1.Mood 2. Behaviour 3. Cognition 4. Biological symptoms o Worthlessness o Hopelessness o Helplessness o Suicidal ideation (Antidepressant - Fluoxetine (10-20mg/day) Bipolar & Hypermania (Mood stabilizer & Antipsychotic) Pediatrician: Valproate Na (20-30mg/Kg) / Carbamazepine (8-12 mg/L) Psychiatrist: Lithium ± AP (0.6-1mmol/L)

9 Attention Deficit Hyperactivity Disorder MedicationLine of choiceDoseDosing schedule CNS stimulants Methylphenidate1 St line1mg/kg/dayTwice /thrice daily SNARI ( Serotonin NorAdrenergic Reuptake Inhibitor ) Atomoxetine 2nd line/ 1 st ? mg/kg/dayOnce/twice daily 6 symptoms of attention deficit 6 symptoms of hyperactivity/impulsivity 2 settings 6 months <7 years Medication: CNS stimulants / SNARI

Symptom to Disorder Transition 1. Symptoms out of proportion to cause 2. Definite body symptom (eg. Depression: Eating, sleeping, libido affected) 3. Impairment of functions

1.Irrational fear 2.Avoidance Anxiety Disorders 1.Phobic anxiety disorder 2.Overanxiety disorder of childhood 3.Seperation anxiety disorder 4.Obssesive compulsive disorder 5.Post-traumatic stress disorder Medication: Antianxiety

1.Obsessions 2. Compulsions 1.Catastrophic trauma 2.Intrusive recollection 3.Autonomic arousal 4.Avoidance 1. Obsessive compulsive disorder 2. Post-traumatic stress disorder (PTSD) Disorder1 st -line drug Dose OCD Fluoxetine10-40mg/day PTSD Generalized anxiety disorder (GAD) Phobia Medication: Antianxiety drugs

Conduct Disorder Dissocial Defiant Aggressive Conduct DisorderDose 1 st -line drugCarbamazepine8-12 mg/L 2 nd -line drugRisperidone1-2mg/day Medication: Mood stabiliser

14 Tic Disorder Dose 1st-line drugRisperidone (Atypical antipsychotic) Haloperidol (Typical antipsychotic) mg/day 0.2-2mg/day 2nd-line drugFluoxetine10-20mg/day Motor Vocal Combined Medication: Atypical antipsychotic

Enuresis Involuntary voiding > 4 yrs CA EnuresisDose 1st-line drugImipramine0.3mg/kg/day 2nd-line drugDesmopressin  g/I.nasal Medication: TCA

ConclusionMedicationDisorderDose/DayDosing/DayEvidence 1RisperidoneOrg.Brain Syndromes0.25-1mgOD-TIDLevel IIa RisperidonePsychoses2 - 4mgOD-TIDLevel Ib RisperidoneAutism0.25 – 1 mgOD-BDLevel Ia RisperidoneTic mgOD (dinner)Level Ib Risperidone ± Valproate Na Mania2-4mg 20mg/kg OD-TID OD (dinner) Level IIa 2Valproate NaConduct disorder20mg/kgOD (dinner)Level Ib 3FluoxetineDepression10-20 mgOD (breakfast)Level Ia FluoxetineAnxiety disorder (OCD, PTSD, GAD, Phobia) mgOD (breakfast)Level Ib 4AtomoxetineADHD mg/kgOD-BD (break fast, lunch) Level Ia 5ImipramineEnuresis0.3mg/kg/BWOD (dinner)Level Ia