Behavioral Medications in Primary Care Pediatrics

Educational Objectives

The goal of this program is to improve management of behavioral issues in children. After hearing and assimilating this program, the clinician will be better able to:

1. Assess emotional and behavioral issues in children.
2. Manage emotional and behavioral issues in children.

Summary

Attention-deficit/hyperactivity disorder (ADHD): prevalence is 8% to 10%, with high comorbidity rates of anxiety and depression; profound consequences include, eg, suicide; early identification of ADHD, anxiety, and depression can help mitigate severe outcomes; the recommended approach to behavioral health involves several steps, ie, screening for developmental and behavioral concerns, using behavioral symptom rating scales for focused assessments, conducting focused clinical histories, and intervening through, eg, anticipatory guidance, therapy and other services, or medication; if a situation exceeds the pediatrician’s comfort level, refer to a higher level of care

Screening tools: Pediatric Symptom Checklist (PSC) identifies children who need additional screening and assessment; the 17-item and 35-item variations focus on psychosocial issues; the sensitivity and specificity are good, and it is cost-effective; it is used for children 6 to 16 yr of age, with a youth scale starting at 11 yr of age; use lower thresholds for children 4 to 5 yr of age; the PSC includes subscales for internalizing, attention, and externalizing behaviors, guiding the next steps in assessment; externalizing behaviors — the Vanderbilt ADHD Diagnostic Rating Scale is effective for assessing attention and externalizing issues; older children can use either Vanderbilt or the Swanson, Nolan and Pelham Teacher and Parent Rating Scale; internalizing issues — the Screen for Child Anxiety Related Emotional Disorders (SCARED) is useful for younger children; older children can use the Generalized Anxiety Disorder (GAD) scale; young children can use the Moods and Feeling Questionnaire (MFQ) for depression, and older children can use the Patient Health Questionnaire modified for adolescents (PHQ-A), which includes questions about suicidality

Focused history: ask about the onset duration of symptoms, potential alternate diagnoses, eg, drug adverse effects, ameliorating factors, and family and social history; factors (eg, systemic discrimination, adverse childhood experiences, neighborhood adversity) should also be considered; symptom severity is assessed by the rating scales; distress or functional impairment is required for diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5); mnemonics, eg, BLAASSTEDD (behavior, learning, attention, anxiety, sleep, substance use, trauma, elation, depression, developmental) help ensure a comprehensive history; perform risk assessment for suicidality, self-harm, or homicidality; depending on, eg, duration, severity, failure of prior interventions, and degree of distress or impairment, involve a developmental-behavioral pediatrician (DBP), child psychiatrist, or therapist

ADHD assessment: a positive PSC (>7 points for attention or externalizing) or significant parental or provider concerns warrants further evaluation; the Vanderbilt scale helps confirm the diagnosis; 6 of 9 points are required for inattentive or hyperactive-impulsive symptoms (or both), present in ≥2 settings (eg, home and school), along with school or peer functional impairment; the focused history explores physical, emotional, cognitive, and social stressors (PECS); if PECS does not fit the primary etiology for the symptoms, with onset at <12 yr of age, lasting >6 mo, there is stronger consideration of an ADHD diagnosis

Intervention for ADHD: subclinical ADHD may benefit from anticipatory guidance and school support; moderate ADHD may need medications, therapy, or services; severe ADHD may require a behavioral health specialist; school support — includes 504 plans and individualized education programs; medication — include stimulants, α-agonists, and serotonin-norepinephrine reuptake inhibitors (SNRIs); parenting interventions — involve parent training in behavioral management programs; the 2019 American Academy of Pediatrics guidelines emphasize screening for coexisting conditions recognizing ADHD as a chronic condition requiring a “medical home”

Age-based interventions: age 4 to 5 yr — start with parent training in behavioral management; consider medication (eg, stimulants, α-agonists) only if behavioral interventions are insufficient; age 6 to 11 yr — behavioral (parent) therapy and medication are recommended; behavioral therapy at this stage focuses on strategies to help children succeed by structuring their environments rather than psychoanalysis or cognitive behavioral therapy (CBT); age ≥12 yr — medications are the primary treatment, with behavioral therapy being reserved for, eg, excessive parent-child conflict or coexisting anxiety or depression; target medication to the core symptoms (eg, hyperactivity, attention, impulsivity); many clinicians start with stimulants before considering α-agonists or SNRIs; adverse effects of SNRIs include appetite, moodiness, headache, and sleep issues

Medications for ADHD: methylphenidate is ≈50% as potent as amphetamine-based medications; the speaker recommends using a dose for 2 to 3 wk before uptitrating; if the maximum tolerated doses fail or adverse effects are intolerable, revisit the diagnosis, switch medication classes, or refer the patient; α-agonists cause drowsiness and should be started at night to help regulate sleep; a morning dose of a short-acting agent can be added later; long-acting guanfacine (Intuniv, Tenex) and clonidine (Catapres, Kapvay, Onyda) are available; gastrointestinal adverse effects may occur; SNRIs (eg, atomoxetine, vilozaxine) are less effective but have fewer adverse effects

Comorbid conditions: ADHD is often accompanied by learning disabilities, oppositional symptoms, mood and anxiety disorders, or autism spectrum disorder

Anxiety disorders: younger children may experience separation anxiety or selective mutism, while older children often display social anxiety, specific phobias, generalized anxiety, or panic attacks; ≈40% of cases have a genetic cause; introverted children may have more emotional instability; symptoms may be precipitated by substances, medications, and stressors; use the DSM-5 as the basis for diagnosis; start with the PSC (focus on internalizing questions and worries) and, if positive, use SCARED (8-12 yr of age) or GAD-7 (≥10 yr of age), with a focused history if positive; use anticipatory guidance for mild, therapy with or without medication for moderate, and referral for severe cases

Depression: presents in children as sadness or irritable moods plus an autonomic response; differs with age, from disruptive mood dysregulation disorder in younger children (eg, temper tantrums) to persistent depressive disorder or major depressive disorder (MDD) in teenagers; MDD remits and recurs in ≈70%, and ≈20% is chronic; ≈40% is caused by genetics; use DSM-5 for diagnosis; start with the PSC and proceed to the MFQ and PHQ-A, depending on age; if positive, obtain a focused history, focused on safety; therapy plus medication is the most robust option for moderate depression

Treatment for anxiety and depression: CBT is the method of choice, using psychoeducational explanations, cognitive restructuring and reframing, relaxation, and exposure; selective serotonin reuptake inhibitors (eg, fluoxetine, escitalopram, sertraline) decrease amygdala activation and increase serotonin signaling; 3 to 4 mo are needed for full efficacy; monitor for agitation, suicidality, and distress; follow up consistently; use behavioral rating scales to titrate or discontinue (taper over 2-4 wk) to avoid discontinuation syndrome

Readings

Anderson NP, Feldman JA, Kolko DJ, et al. National Norms for the Vanderbilt ADHD Diagnostic Parent Rating Scale in Children. J Pediatr Psychol. 2022;47(6):652-661. doi:10.1093/jpepsy/jsab132; Keeton VF. Pharmaceutical supply chains: A structural determinant of health for children with ADHD. J Pediatr Health Care. Published online November 23, 2024. doi:10.1016/j.pedhc.2024.11.001; Ørnberg J, Mayer A, Dangel O, et al. Comparison of the real-world safety of two different long-acting methylphenidate formulations (Medikinet MR and Concerta) - a Danish nationwide register-based cohort study. Scand J Child Adolesc Psychiatr Psychol. 2024;12(1):84-91. Published 2024 Nov 16. doi:10.2478/sjcapp-2024-0009; Wolraich ML, Hagan JF Jr, Allan C, et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents [published correction appears in Pediatrics. 2020 Mar;145(3):e20193997. doi: 10.1542/peds.2019-3997]. Pediatrics. 2019;144(4):e20192528. doi:10.1542/peds.2019-2528; Zablotsky B, Black LI, Sheldrick RC, et al. Assessing the Validity of the Baby Pediatric Symptom Checklist Using a Nationally Representative Household Survey. Acad Pediatr. 2023;23(5):939-946. doi:10.1016/j.acap.2022.10.022.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Vanderbilt was recorded at the 40th Annual Current Advances in Pediatrics, held October 18-20, 2024, in Irvine, CA, and presented by The American Academy of Pediatrics, Orange County Chapter. For information about upcoming CME activities from this presenter, please visit https://www.aap-oc.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

PD710601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.