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Other Mental Health Issues that Impact Learning. Stephanie Eken, M.D. Child and Adolescent Psychiatrist David Causey, Ph.D. Clinical Child Psychologist Square One: Specialists in Child and Adolescent Development. Mood Disorders:. Symptoms, Treatment, & Impact on Learning.

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Other mental health issues that impact learning l.jpg

Other Mental Health Issues that Impact Learning

Stephanie Eken, M.D.

Child and Adolescent Psychiatrist

David Causey, Ph.D.

Clinical Child Psychologist

Square One: Specialists in Child and Adolescent Development


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Mood Disorders:

Symptoms, Treatment, & Impact on Learning


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Why Should We Care?

  • Mood disorders are prevalent and recurrent

  • May impact school performance

  • May present with physical symptoms

  • Poor psychosocial outcomes

  • High risk for suicide

  • High risk for substance abuse


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Epidemiology of Depressive Disorders

  • Preschool: <1%

  • School-age: 1-2%

    • Female-to-male ratio 1:1

  • Adolescence: 6%

    • Female-to-male ratio 2:1

  • Cumulative incidence by 18 yrs: 20%

  • Hospitalized children: 20%

  • Hospitalized adolescents: 40%


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Most common stressors leading to youth suicide in Kentucky

Fight with Parent 20%

End of a relationship 12%

Financial problems 10%

Fight with a significant other 8%

Recent move, social isolation 7%

Legal problems 6%

Family Problems 6%

Academic problems 5%

Substance abuse 4%

Homosexuality 3%

Recent abuse 4%

Other stressors 15%


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Etiology of Depression

  • Neurobiology

    • Dysregulation of serotonin & norepinephrine in CNS

    • Influence of sex hormones

  • Personality

    • Negative cognitive style

  • Environmental factors

    • Abuse & neglect

    • Stressful life events

    • Family dysfunction


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Genetics

  • Children with a depressed parent are 3 times more likely to have MDD

  • Children at high genetic risk may be more sensitive to adverse environmental experiences


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Depression in Children

  • Irritability (more common than depressed mood)

  • Boredom (anhedonia)

  • Somatic complaints

    • Stomachaches & headaches most common

  • Anxiety

  • Indecision

  • Temper tantrums & disruptive behavior


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Depression in Adolescents

  • Irritable or sad mood

    • More likely to report a sad/depressed mood

  • Increased sleep and appetite

  • Increased suicidal ideation & attempts

  • Increased impairment of functioning

  • Increased behavioral problems

  • Decreased energy

  • Rejection sensitivity


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Psychosocial Risk Factors for Depression

  • Family problems

    • Conflict, maltreatment, parental loss/separation, parental mental illness

  • Comorbid psychiatric disorders

    • ADHD, anxiety d/o’s, conduct d/o, substance abuse

  • Recent adverse events

    • School, relationships, loss of social support

  • Personality traits

    • Anger, dependence, difficulty regulating affect


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Is he sad or depressed?

  • Feeling sad or “blue”

    • Temporary period in which a child feels sad in response to a major stressor

  • Children may have transient depressed mood states

  • Adjustment disorders to stressors

  • Depression is more severe, lasts longer and impacts functioning


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Adjustment Disorder

  • Behavioral or emotional response to a identifiable cause or stress

  • Symptoms occur within three months of the stressor

  • Symptoms cause marked distress


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Adjustment Disorder

  • Associated with:

    • Anxiety

    • Mixed anxiety and depressed mood

    • Disturbance of mood and conduct

    • Disturbance of conduct


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Impact on Learning

  • May change sleep or eating patterns

  • Difficulty concentrating/focusing

  • Social isolation

  • School behavior – fighting, arguments

  • Academic difficulties can lead to changes in mood

    • Consider an educational evaluation if treatment for depression does not resolve learning issues


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School-based Interventions

  • Acknowledge the student’s feelings

  • Provide a place for students to regroup if they feel weepy or fatigued

  • Allow the student to stop an activity and resume it later when calm

  • Encourage positive self-talk and break tasks down


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School-based Interventions

  • Irritable Mood

    • Model appropriate responses to replace irritable responses

    • Allow the student to take him/herself out of a situation (self-timeout) when irritability is starting to disrupt others

    • May want to work independently

    • Provide opportunities for the student to "fix" problems or inappropriate classroom behaviors

  • Fatigue

    • Provide class notes to the student

    • Identify study partners who can support and assist with assignments

    • Grade the student based on work completed or attempted (rather than work assigned)


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Bipolar Disorder

  • Increasingly diagnosed in children

    • Lifetime prevalence = 1%

  • Risk factors

    • Early onset depression

    • Psychosis

    • Mood lability

    • Seasonal pattern

    • Family history of BD


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Bipolar Disorder

  • Increasingly diagnosed in children

  • Genetics

  • If untreated, children/adolescents are at risk for substance abuse, school failure, accidents, incarceration and suicide


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Bipolar Disorder

  • Neurobiology

    • Neurotransmitters

    • Neuroimaging shows subtle differences in frontal lobe and amygdala volume

  • Genetics

    • One parent with BD = 25% risk

  • Environmental factors

    • May potentiate genetic predisposition

    • Stressors

    • Low maternal warmth


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Bipolar Disorder in Children

  • Mood may shift rapidly

    • Minute-to-minute

    • Day-to-day

  • May present as chronic irritability or explosiveness with no discernible pattern or periods of wellness

  • Different from depression by the presence of mania

    • 20% of depressed children will go on to develop bipolar disorder


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Mania in children

  • Excessive irritability

  • Excessively giddy or silly

  • Aggressive behaviors

    • Extended, rageful tantrums

    • Physically aggressive

  • Restless or persistently active

  • Age-inappropriate sexual interests

  • Grandiosity


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How does it impact school?

  • Fluctuations in cognitive abilities

  • Impaired ability to plan, organize, concentrate and use abstract reasoning

  • Heightened sensitivity to perceived criticisms

  • Hostility or defiance with little provocation

  • Emotions disproportionate to situation


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School-based Interventions

  • Develop a simple explanation that the student and staff can use with peers and teachers

  • Accommodate tardiness

  • Allow the student to complete schoolwork or tests in a less stimulating environment

  • Seat the student where the teacher can monitor, but not where the student is the focal "center of attention"

  • Limit homework to a feasible amount during manic periods

  • Allow the student to have homebound instruction during manic periods

  • Allow children to discreetly and frequently accommodate needs caused by medication side effects


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Treatment for Mood Disorders

  • Psychological interventions

    • Individual therapy (CBT)

    • Parent guidance sessions

    • School-based counseling

  • Biological interventions

    • Medications

      • Side effects may impact learning or behavior when starting medication



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Anxiety Disorders

  • Medical condition that causes people to feel persistently, uncontrollably worried over an extended period of time

  • Limit children’s ability to engage in a variety of activities


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Epidemiology of Anxiety Disorders

  • Most common emotional/behavioral disorder in childhood

  • Incidence 10-15% of children/adolescents

  • Female-to-male ratio

    • Equal in preadolescent children

    • Females are increasingly represented in adolescent years


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Etiology of Anxiety

  • Genetics

  • Biologic

    • Central Nervous System (brain)

      • Abnormal neurotransmitter functioning

        • Serotonin, norepinephrine, GABA receptors

  • Psychological

    • Internal and external stressors overwhelm coping abilities


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Fear

  • Alarm and agitation

  • Caused by expectation or realization of danger

  • A state of dread or apprehension

    Webster’s II Dictionary, Third Ed.


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Fear

  • Immediate alarm reaction

  • Basic, normal emotion

  • Essential to alert to imminent danger

    • Focuses attention

  • Prepare to respond: Flight or Fight

    • Pounding heart, rapid breathing, muscle tension, sweating

  • Consolidate experience to memory

    • To learn appropriate response


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Anxiety

  • Apprehension of danger and dread

  • Accompanied by

    • Restlessness

    • Tension

    • Rapid heart rate

    • Shortness of breath

  • Unattached to a clearly identifiable stimulus


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When is anxiety pathologic?

  • Intensity of anxiety

    • Out of proportion to threat

  • Frequency of anxiety

    • Increase in fear reaction and cannot be “reasoned away”

  • Content of anxiety

    • Seemingly innocuous situation or stimulus


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Children with Anxiety Disorders

  • Risk for developing other types of anxiety disorders/or psychiatric disorders

  • Comorbid psychiatric disorders

    • Young children with GAD can also suffer from separation anxiety

    • Depression can accompany the feeling of generalized anxiety

    • Increased risk for adjustment difficulties in adulthood


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Generalized Anxiety Disorder

  • Worry, worry, and more worry

    • About – family, friends, health of others, natural disasters, school performance, etc.

  • Somatic concerns

    • Headaches, feeling shaky, sweating

  • Not easily reassured

  • May throw tantrums related to anxiety

  • Poor concentration and attention

    • May present for ADHD work-up


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Separation Anxiety

  • Excessive anxiety focused on separating from home or parent figure

  • Most commonly diagnosed in prepubertal children

    • More common in 5-7 and 11-12 year olds with transition into elementary and middle school

  • Typically occurs following a significant change or major life event


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Separation Anxiety

  • Expression varies with age

  • Prepubescent children (5-8 years)

    • Clinging/shadowing behavior

    • Nightmares

    • Fear of loss of loved ones

    • School refusal


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Separation Anxiety

  • Preadolescent (9-12 years)

    • Emotional distress of separation

      • Staying away from home overnight

  • Adolescents (13-16 years)

    • Somatic difficulties

    • School refusal


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Social Phobia

  • Excessive fear in social situations where child is exposed to unfamiliar people/evaluation by others

  • Excessively self conscious/shy

  • Tremendous concern about social failure/embarrassment/humiliation


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Social Phobia

  • Exposure causes significant anxiety/panic

  • Fear excessive and unreasonable

  • Avoidance or endurance with extreme distress

  • Interference in functioning


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Selective Mutism

  • Children either talk minimally or not at all in certain settings or situations that are part of their daily lives (e.g., school)

  • Reflects underlying problems with anxiety

  • Often inadvertently reinforced by other individuals (i.e., parents, friends) in the child’s daily life (e.g., speaking for the child, permitting the use of nonverbal communication, etc.).

  • Considered an extreme form of social phobia


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Panic Attacks

  • Sudden, discrete episodes of intense fear

  • Intense desire to escape

  • Feeling of doom

  • Activation of autonomic nervous system

    • Fight or flight

  • Duration 20-30 minutes


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Panic Disorder

  • Recurrent panic attacks

  • Inter-episode worry about having a panic attack

  • Worry about implications and consequences

  • Changes in behavior

  • More common in adolescents


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Anxiety at School

  • Frequent self-doubt and criticism

  • Seeking constant reassurance from the teacher

  • Difficulty transitioning between home and school

  • Avoidance of academic and peer activities

  • Poor concentration


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School-based interventions

  • Accommodate late arrivals

  • Shorter school days to transition children with separation anxiety

  • Allow extra time for transitions

  • Provide alternative activities for children with somatic complaints

  • Have a “safe” place if child develops increased anxiety or panic attacks

  • Have an anti-worry plan


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Components of a Simple Anti-Worry Plan

  • Anti - Worry Plan

  • *What am I worried or afraid about?

  • *How worried Am I? 2

  • 0 1 2 3

    Not at all A little worried A lot

  • *How do we know that things will be OK?

  • *What can I do to help myself not worry so much?

  • *What can I do to help myself not worry so much?

  • *Is this something that I should worry about?



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Defiance

  • When is defiant behavior not really defiance to an authority figure….Never

  • When is defiant behavior a result of something other than a defiant attitude?...When it’s a coping response to an underlying vulnerability, frustration, or disappointment (“solution” versus problem)


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Two Types of Aggression

  • Proactive Aggression – aggression that is more organized and less impulsive, not necessarily emotional driven, and may be goal oriented.

  • Reactive Aggression – more impulsive and resulting from overwhelming affect; quickly reaches threshold for inability to cope with the demands of the situation.


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Cognitive Distortions in Angry Youth

  • Appraisal of internal arousal

  • Cue Utilization

  • Attributions

  • Social Perceptions (self and others)

  • Generating problem-solving solutions

  • Considering Consequences

  • Implementing Solutions

  • Situational Appraisals


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Adult Issues That May Escalate an Anger Outburst

  • The adult’s mood at that moment

  • Feelings of helplessness in managing difficult situations

  • Expectations (or judgments) about the youth are already determined and influence the adult’s response to the current situation.

  • Not being well prepared for managing the situations.


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Specific adult behaviors that may increase the likelihood of an anger outburst

  • Too quick to say “no”

  • Quick to anticipate a conflict

  • Quick to raise voice or yell

  • Interpret behavior as intentional

  • Don’t set limits when necessary

  • Too strict with limits-can’t follow through

  • Coercive Process


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Situational Factors (Possible Anger Triggers) an anger outburst:

“Antecedents” refers to those factors that precede and trigger a conflict or anger outburst.

“Situation Specificity” refers to specific situations that are likely to raise frustration levels, lower coping thresholds, and make the youngster more vulnerable to the impact of an antecedent.


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Specific student issues that may increase the likelihood of an anger outburst

  • Experiencing frustration and worry – interpret anger

  • The occurrence of a real or perceived threat and/or adverse event

  • Being teased, bumped in the hallway, threatened by another youth, etc.

  • Obstacles to getting or doing what they want or expect

  • Not feeling heard or understood

  • Denied requests – don’t like to hear “no”

  • Feeling unimportant and insignificant – such as being left out of something

  • Some injustice occurs – e.g., the youth gets into trouble for something they didn’t do or didn’t initiate.


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Other “High Risk” Situations an anger outburst

  • Medications wear off

  • Blamed unjustly

  • Academic frustration

  • Embarrassed over a grade

  • Picked on

  • *Angry from home (“Carry Over”)


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Purpose / Process in good anger control plans an anger outburst

  • Better self-regulation

  • Effective use of language

  • “Interactive Coping” – working with the student while maintaining authority

  • “Firm Flexibility” – adult must be firm, clear, and consistent while ALSO being flexible, supportive, and collaborative with the student when appropriate.


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Things to consider, explore, or examine when developing an anger plan

  • Clarification of the concerns or problems

  • What’s behind the anger (feelings, issues)

  • Ideal alternative attitudes and behaviors

  • Benefits to them of positive behaviors and attitudes

  • Costs to them of negative attitudes and behaviors

  • High risk situations, antecedents (people, places, times, etc.)


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Things to consider, explore, or examine when developing an anger plan

  • Things that can be done to prevent frustration when entering a high risk situation

  • Things that can be done when frustration is present and/or escalating (i.e., 3-7)

  • Calm down actions or de-escalation strategies that can and can’t be done

  • Ways the adult can help with high-risk times

  • Reinforcements and consequences if any

  • Regular time to review how things are going

  • Discussion of problem possibilities

  • Completion of problem-solving sheet


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Mistakes adults sometimes make anger plan

  • Setting too many goals at one time

  • Setting goals that are too lofty; it is sometimes better to begin with smaller more attainable goals, than to start with the obvious problem that needs to be eliminated.

  • Measuring success by an absence of the problem, rather than recognizing a reduction in the problem.

  • Scrapping a plan because “its not working”.

  • Assuming the plan isn’t working because the youngster isn’t trying or doesn’t care about doing better.


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Key Parts to a anger planProblem-Solving Plan

  • “High risk” situations

  • Feelings when this happens

  • Angry thoughts that worsen my anger:

  • What to do:

    • Identify the problem

    • Use good self talk

    • Coping strategies

  • What others can do to help

  • Evaluate the process or how it could turn out


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Positive Attention Things anger plan

  • PATs



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Talking with Parents anger plan

  • Need to involved parents when the student experiences significant academic, social or emotional difficulties that interfere with learning

  • Develop a shared understanding of child/adolescent

    • Ask parents if they see concerning emotional or behavioral problems at home

  • Parents may have effective strategies they use at home that can be implemented in the classroom


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When to refer for further evaluation anger plan

  • Impact on learning

  • Effecting social interactions

  • Safety concerns

    • Suicidal statements

    • Threats toward others

    • Concern for abuse/neglect

  • Typical interventions do not work


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Choosing Initial Treatment anger plan

  • Psychotherapy

    • Individual

    • Family – parental educations

  • Psychopharmacologic Intervention

    • Patients unable to participate in therapy due to severity of symptoms

    • Comorbidity with other psychiatric illnesses

    • Symptoms that do not respond to therapy


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Goals of Treatment anger plan

  • Safety

  • Build alliance & instill hope

  • Clarify diagnosis

  • Assess comorbidity (substance abuse, medical illness, other psych d/o’s)

  • Assess motivation for treatment

  • Availability of resources (e.g., partial hospital, day tx programs, outpt. tx)


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Treatment anger plan

  • Treatment is multimodal

  • Pharmacotherapy alone not effective due to psychosocial context of illness

  • Address family, school, peer issues

  • Psychotherapy for mild to moderate mood disorders (CBT, IPT, family therapy, psychodynamic)

  • Consider medications


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Medications anger plan

  • Depression/Anxiety

    • Antidepressants

      • SSRIs

      • Atypical antidepressants

      • TCAs

  • Bipolar Disorder/Mood dysregulation

    • Mood stabilizers

    • Antidepressants


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Antidepressants anger plan

  • Mechanism of Action

    • Modulation of neurotransmitters

      • Increase serotonin at 5-HTreceptor

      • Atypical antidepressants may modulate serotonin, norepinephrine and dopamine

  • Indications

    • Depression (unipolar/bipolar)

    • Anxiety disorders

    • Obsessive Compulsive Disorder

    • Panic Disorder

    • PTSD

    • Bulimia Nervosa


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SSRIs anger plan

First-line medication for depressive and anxiety disorders

No evidence that one SSRI is superior to another

SSRIs take 4-6 weeks to determine efficacy of dose

Fewer side effects than older antidepressants


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SSRIs anger plan

  • FDA approved in children & adolescents

    • Fluoxetine

      • Depression (age 8 and over)

      • OCD (age 7 and over)

    • Sertraline (Zoloft) – OCD (age 6 & over)

    • Fluvoxamine (Luvox) – OCD (age 8 & over)

  • Significant portion of psychiatric medications are prescribed “off-label” for use in pediatric population

  • Off label use

    • Paroxetine (Paxil)

    • Citalopram (Celexa)

    • Escitalopram (Lexapro)


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SSRI Side Effects that May Impact Learning anger plan

  • Common

    • Gastrointestinal – dyspepsia, diarrhea

    • CNS – headache, anxiety, insomnia

    • Increased sweating

  • Uncommon

    • Akasthisia (inner feeling of restlessness)

    • Agitation

    • Mania (may occur in children with BD)

  • May need to add additional agent to manage side effects


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Antidepressant Black Box anger plan

  • The most serious warning possible on drug packaging in the USA

  • To apply to ALL antidepressants for children and adolescents < 25 yrs old

  • Explicit about the increased risk of suicide especially during the early phase of tx

  • No completed suicides in studies reviewed

  • Review of studies showed increased suicidal thoughts (2% to 4%) through adverse event reporting


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Antidepressant Black Box anger plan

  • Children and adolescents must be monitored closely

  • School officials should notify parent if student’s work reflects suicidal themes


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Other Antidepressants anger plan

  • SNRIs

    • Modulate serotonin and norepinephrine transmission

  • Atypical Antidepressants

    • May modulate serotonin, norepinephrine, and dopamine

  • Can be used as single agent or as augmentation strategy with SSRI or other psychotropic

  • Fewer studies in children & adolescents

  • No FDA approved SNRIs in pediatric OCD


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Side Effects anger plan

  • SNRIs

    • Venlafaxine (Effexor)

      • Elevated B/P - diastolic

    • Duloxetine (Cymbalta)

      • Blurred vision, mydriasis (dilated pupils – can affect vision)

  • Atypical Antidepressants

    • Mirtazapine (Remeron)

      • Sedation

      • Weight gain

      • No sexual side effects


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Mood Stabilizers anger plan

  • Indications

    • Early-onset bipolar

    • Anxiety

    • OCD

    • Explosive aggression

  • Mechanism of Action

    • Multiple

      • Enhance GABA

      • Block glutamate

      • Second messengers


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Mood Stabilizers anger plan

  • Depakote

  • Lithium

  • Oxcarbazepine (Trileptal)

  • Gabapentin (Neurontin)

  • Topirimate (Topamax)

    • Migraine prophylaxis

    • Psychiatric indications

      • Mood stabilization

      • Augmenting agent for treatment resistant OCD


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Side Effects that may Impact School anger plan

  • Weight gain or loss

  • Change in appetite

  • Stomachaches

  • Sedation

  • Cognitive impairment

    • Especially Topamax (processing speed)


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Atypical Antipsychotics anger plan

  • Mechanism of action

    • 5HT2A/D2 receptor antagonism

    • Less TD and EPS symptoms than 1st generation

  • Indications

    • Psychosis/psychotic depression

    • Mood stabilization – bipolar, mood dysregulation

    • Aggressive behaviors – autism, MR, DD

    • Augmenting agent for OCD

    • Conduct problems

    • Severe tic disorders


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Atypical Antipsychotics anger plan

  • FDA approved

    • Risperidone (Risperdal)

      • Treatment of irritability associated with autism in children 5 years of age and older

      • Schizophrenia (13 years and older) and bipolar disorder in children (10 years and older)

  • Off label use

    • Quetiapine (Seroquel)

    • Aripiprazole (Abilify)

    • Ziprasidone (Geodon)

    • Olanzapine (Zyprexa)

    • Paliperidone (Invega)


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Side Effects of Anti-psychotics anger plan

Weight gain

Sedation

Dyspepsia

Impaired glucose tolerance

Dyslipidemia – elevated cholesterol

Hyperprolactinemia – gynecomastia, menstrual irregularities

Long-term effects to CNS in children?


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Serious Side Effects anger plan

  • Acute Dystonia

    • Spastic contraction of discrete muscle groups

      • Most common – neck, tongue, eyes

    • Risk factors – young, male, medication initiation or dose increase

  • Extrapyramidal symptoms

    • Related to dopamine blockade in nigrostriatal pathway

      • Akathisia & parkinsonism


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School Role with Medication anger plan

  • Part of treatment team

  • Observations of student during school invaluable

  • Dispense medication

  • Medication or side effects may impact behavior or learning

  • Impact on parent attitude toward medication


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Internet Resources anger plan

  • American Academy of Child and Adolescent Psychiatry (aacap.org)

    “Facts for Families” handouts on many topics

    Latest news on hot topics

  • ParentsMedGuide.org

    Question and answer material about depression, suicide and black box warning

    Links for parents and physicians

    Up-to-date, well-organized, English-Spanish


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Internet Resources anger plan

  • Massachusetts General Hospital School Psychiatry Program

    • www.schoolpsychiatry.org


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Books anger plan

  • One Mind at a Time by Mel Levine


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