Catch a Falling Teen



Catch a Falling Teen

Handbook of

Behavioral

Adolescent

Medicine

Henry Berman, MD

Catch a Falling Teen

A Handbook of Behavioral Adolescent Medicine

Third Edition, Dec, 2015

Copyright: Henry S. Berman, M.D.

For internal use only by Division of Adolescent Medicine

Seattle Children's Hospital

Table of Contents

Introduction

The Initial Interview page 3

1. ADHD page 5

2. Oppositional Disorders page 19

3. Anxiety Disorders page 21

4. Depression page 28

5. Bipolar Disorder page 34

6. Schizophrenia page 37

7. Substance Use Disorder (SUD) page 39

8. Insomnia page 42

9. Bullying page 43

10. Difficult Home Environment page 44

11. Sex, Drugs, Rock-n-Roll page 45

Appendix

Handbook of Behavioral Adolescent Medicine

This handbook is designed to help clinicians with the diagnosis and treatment of cases related to what I call “Catch a Falling Teen.” The school performance of these patients is deteriorating, their behaviors are a problem—and sometimes illegal—and there is poor (or no) communication with their parents. They are often referred without much specificity. “Missing a lot of school, behavior problems, referred for consultation and ongoing management” is a typical request on the referral form. The purpose of this handbook is to help clinicians who care for adolescents sort out the possible causes of these kinds of symptoms, and then initiate a treatment plan. The handbook also includes more in-depth information for those who want to follow through on the treatment they initiate, as opposed to referring the patient to a specialist in behavioral adolescent medicine. This is a work in (perpetual) progress. I have updated a good portion of the material in the last month or two and some in the last day or two, as I learn more about the diagnosis and treatment of these problems. I would appreciate questions and/or feedback.

Henry Berman, MD. henry.berman@

For almost all of the disorders discussed, there is at least one question in the Division of Adolescent Medicine’s intake form, the Confidential Adolescent Screen (CAS) that is relevant. The relevant question(s) leads the discussion of the topic.

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Those sections not highlighted are at a level of detail, or discuss an area that would be of minimal interest to most MDs.

The initial interview

Generally I start working with new patients by first seeing them together with their parents. I allocate 90 minutes for a first visit, to give the patient’s parents plenty of time to tell me about the onset of the symptoms that brought them in, any family history of similar problems, previous treatments, etc. I then meet with the teen alone, and subsequently put together a diagnosis and recommended treatment plan. This is presented first to the teen, and then to his or her parents with the teen present.

Over the years I have come to realize that there is another reason to take my time—so the parent can tell his or her story.

“Narrative medicine” is described by Rita Charon, one of the founders of the field, as follows: it is “medicine practiced with the skills of recognizing, absorbing, interpreting, and being moved by the stories of illness. It is a ‘new frame’ for medicine, believing that it can improve many of the defects of our current means of providing (or not) medical care. Caregivers who possess ‘narrative competence’ are able to bridge the ‘divides’ of their relation to mortality, the contexts of illness, beliefs about disease causality, and emotions of shame, blame, and fear.” (NEJM)

Also, emerging evidence suggests that storytelling, discussed in detail in Charon’s book Narrative Medicine, may offer a unique opportunity to promote evidence-based choices in a culturally appropriate context. “Listeners” (interviewers) may be affected if they actively engage in a story, identify themselves with the storyteller, and picture themselves taking part in the action. Every parent has a story about his or her child. It starts with pregnancy (or even before) and ends with today. It is likely that no other clinician has ever taken the time to hear the whole story. By listening to the parent, you learn a great deal and you have earned the trust of the family—because you listened. The parents are much more likely to accept your recommendations, to keep appointments and to expect less of your time on future visits.

The following is an example of how valuable the parent’s story is in understanding the teen’s concerns. At the first visit, the patient’s mother told me about her experience on the second day of her daughter’s life. She was awakened at 7 AM, and asked to bring her baby back to the hospital. Puzzled, she did so. Upon her arrival, she learned that her baby’s urine had grown out strep B, and the doctor was concerned. A retrograde pyelogram showed the ureteral valves did not close, risking a serious kidney infection. She was sent home with a catheter, which her daughter needed for 6 months. After that she needed tests every 6 months until she was 3, at which point she was told her daughter would have no further problems. Two years later, upon starting kindergarten, her daughter could not tolerate her mother leaving her alone. At 16 she still is anxious when she is away from her mother—or is her mother is the anxious one? Her mother told me she had no anxiety after that first 3 years—but she told me about that morning minute by minute.

Several years ago, at a SAHM workshop, Dick MacKenzie said that it is important to ask “What was Humpty Dumpty doing before he was on the wall?” Once he was on the wall, he was at high risk to fall; rather than looking at why he fell, we should look at what was happening in his life that led him to get onto that wall. Why was he on the wall? How did he get there? How long has he been there? If we are catching a falling teen, why is he or she falling? When did it start? What was going on before that? It is critical to ascertain the curve of the problem. If the teen’s performance has been deteriorating slowly, even if it has reached rock bottom, the differential diagnosis is much different than if the change was precipitous.

Once you have heard the parent’s story, you are ready to meet with the teen, asking the parent to wait in the waiting room while you meet with their child alone. (At times this may be inappropriate—a young adolescent or one who has a developmental disorder, for example.) You need to explain to the parent with the teen present that all information will be confidential, unless the teen is a threat to others, a threat to self, or is being harmed by others.

Once you are alone with the teen, it works best to start with an open-ended question—e.g., “so what do you think about that?” Or “how are things?” Or “what’s up?” This approach is more likely to get reticent teens to open up than to start by quizzing them about specific issues. Next it works out well to review our intake form, the Confidential Adolescent Screen, with the teen, following up on responses that interest or concern you. If the CAS is not available (e.g., not filled out, or you are doing an inpatient consultation) use the HEADSS format. Based on the information you have obtained, proceed to explore one or more of the diagnoses discussed in this handbook.

Ros Gallagher founded the field of Adolescent Medicine, in 1951, at Boston Children’s Hospital. This story he tells about one of his patients teaches much of what one needs to know about interviewing adolescents:

Gallagher: “A daughter had been raising Cain at home: out late, dirty, refused to bathe, would come in and disgrace the parents in front of their important friends. They came in and talked to me about this, and I said I would be glad to see her, but she did not sound like the sort of girl who wanted to come in and see me. However, they set a date, and they did literally drag her in. There she was, in my outer office, in dirty blue jeans, hair uncombed, dirty face, filthy fingernails, dirty riding boots. So I greeted her with the usual, ‘Hello, I’m Ros Gallagher.’ She looked at me and said, ‘This is the last time I’ll come in this damn place.’ ‘I often feel that way myself.’ By that time we were in the office.

‘What’s cooking here?’ I said. ‘Whose idea is this visit?’ as though I didn’t know. ‘Whose idea! That old battle-ax,’ and then she was off, and she went on and on and talked for an hour. ‘Well, why don’t you drop in in a few days?’ She said maybe she would. As she was going out she said, ‘I’m sorry about these boots. They dragged me down here and I didn’t have a chance to clean them.’ The boots were important to her: she didn’t want me to think that she went around in dirty riding boots. She hung her pajamas in the middle of the bedroom floor, but everything in the tack room was just right. The next time she came back she had a dress on, an index that maybe things were better.

“What did I do to get the girl to come back? I didn’t do anything. I didn’t say, ‘What do you mean coming in here dressed like that?’ I didn’t say, ‘What is wrong?’ I didn’t pry. I didn’t seem to be shocked or upset by her foul language. I tried to be more interested in her than in her language or her clothing. Perhaps she felt this.”

[“General Principles in Clinical Care of Adolescent Patients.” “The Medical Care of the Adolescent,” Pediatric Clinics of North America, Vol 7, 1, Feb 1960, p. 191]

1. ADHD

The following questions from the Confidential Adolescent Screen (CAS) may be helpful here:

Question 4. What, if any, of the following problems are you having school? Grades / Forgetting homework / Fighting / Getting expelled / Not in school

Question 6. Do you have difficulty organizing tasks or often lose things?

Those who circle “forgetting homework,” or answer “yes” to “difficulty organizing tasks or often lose things,” are highly likely to have inattentive ADHD (they may also have additional diagnoses discussed later).

By the time patients have reached adolescence without a diagnosis of ADHD being made, it is almost certain that their ADHD would be the inattentive, not the hyperactive/impulsive type. It is often present at a younger age, but not noticed, in bright adolescents who skate through elementary school with the same teacher all day, one who knows what they are learning or not learning and is able to support the student.

Retrospectively, these patients were “space cadets” when younger, with their spaciness shrugged off by parents. They do not cause trouble in class (as opposed to those with hyperactive ADHD), and/or teachers themselves are not paying that much attention to quiet students who get much of their work done. Many parents do not know there is such a thing as inattentive ADHD, just the hyperactive/impulsive type, so the diagnosis must be explained. (Understandably they then differentiate between ADD and ADHD, and I sheepishly explain to them that physicians are so weird that we call the inattentive type “Attention Deficit Hyperactivity Disorder without Hyperactivity”).

a. Diagnosing ADHD

The DSM-IV lists 18 questions that need to be asked to make a diagnosis of ADHD. They are divided into two groups: the first 9 relate to inattentive ADHD (aka “ADHD without hyperactivity”); the second 9 relate to the hyperactive/impulsive type. In the DSM, the questions are all worded “Does your child often fail to give close attention etc.” with the parent answering “yes” or “no.” A better approach is to leave out the “does your child often” beginning, and then give the parent 4 choices (never/rarely; sometimes; often; very often). In particular it makes it easier to decide what to say when the answer is unclear—“sometimes” is a good resting place for such answers. Then the “never/rarely” and “sometimes” answers are combined into “no” and the “often” and “very often” answers are combined into “yes.” For each section of 9 questions, a finding of at least 6 indicates a likelihood of ADHD. If both sections have at least 6 questions that are answered “yes,” a diagnosis of “ADHD, combined type” is made. For patients 18 or older, only 5 questions need to be answered “yes” for a diagnosis to be made.

The first step in making the diagnosis of ADHD is to administer the 18-question ADHD Checklist, on the next page. If you see more than an occasional patient who may have ADHD, it will be useful for you to print out a few copies of this checklist. See Appendix for a form that may be more useful for older teens.

Teen Behavior Checklist

Name of Person Being Rated _______________________

Name of Rater, if not Patient _______________________Date____________________

Check the column that best describes the teen’s behavior over the past six months:

Inattention: (updated for DSM-5)

| |Never or rarely |Sometimes |Often |Very often |

|1. Fails to give close attention to details or makes careless mistakes in school | | | | |

|work, at work, or during other activities (e.g., overlooks or misses details, | | | | |

|work is inaccurate) | | | | |

|2. Has difficulty sustaining attention to tasks or activities (e.g., has | | | | |

|difficulty remaining focused during lectures, conversations, or lengthy reading) | | | | |

|3. Does not seem to listen when spoken to directly (e.g.., mind seems elsewhere, | | | | |

|even in the absence of any obvious distraction) | | | | |

|4. Does not follow through on instructions and fails to finish school work, | | | | |

|chores, or duties in the workplace (e.g., starts tasks but quickly loses focus | | | | |

|and is easily distracted) | | | | |

|5. Has difficulty organizing tasks and activities (e.g., difficulty managing | | | | |

|sequential tasks; difficulty keeping materials and belongings in order; has poor | | | | |

|time management; fails to meet deadlines) | | | | |

|6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained | | | | |

|mental effort (e.g. schoolwork or homework; for older adolescents and adults, | | | | |

|preparing reports, completing forms, reviewing lengthy papers). | | | | |

|7. Loses things necessary for tasks or activities (e.g., school materials,, | | | | |

|pencils, books, tools, wallets, keys, paperwork, eyeglasses, phones). Sometimes | | | | |

|loses completed homework. | | | | |

|8. Is easily distracted by extraneous stimuli. (for older adolescents, may | | | | |

|include unrelated thoughts). | | | | |

|9. Is forgetful in daily activities (e.g. doing chores, running errands; for | | | | |

|older adolescents and adults, returning calls paying bills | | | | |

Total: ________

Hyperactivity and Impulsivity:

|Fidgets with hands or feet, squirms in seat | | | | |

|Leaves seat when remaining seated is expected | | | | |

|Runs about or feels restless | | | | |

|Has difficulty doing leisure activities quietly | | | | |

|Is “on the go” or “driven by a motor” | | | | |

|Talks excessively | | | | |

|Blurts out answers | | | | |

|Has difficulty awaiting turn | | | | |

|Interrupts, intrudes, butts into conversations | | | | |

Total: _______

Scoring: if ≥ 6 of the 9 questions [≥ 5 if 18 or older] in either section is answered “often” or “very often,” a tentative diagnosis of ADHD can be made. Confirm with the following:

Present by the age of 12? Yes _____No _____ (sometimes not clear for inattentive ADHD)

Present in at least 2 settings? Home _______School________ Other (could be work)______

Causes significant difficulty in at least one setting? ___________________

In particular, it is helpful to ask about failure to hand in completed homework; a “yes” answer to this question is almost pathognomonic of inattentive ADHD. Since to make this diagnosis the behaviors must occur in >1 setting, you need to have Vanderbilt forms (available on the internet) filled out by teachers. However, many teachers are too busy to notice inattention in their students, so a lack of positives may not be definitive.

If the diagnosis has been made in the past using Vanderbilt forms, or parents have been given feedback from teachers that is clearly consistent with ADHD, this step can sometimes be skipped. (However, the Vanderbilt has other useful questions, including screening for Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), and specifics about academic strengths and weaknesses.)

When parents are asked about “problems sustaining attention,” they often answer “no,” saying that their teen can spend hours at a time focused, giving video games or art as an example. Teens with ADHD often “hyper focus” when they are involved in an activity that interests them. Then they don’t pay attention when they are called to dinner, because they don’t hear that. And all of us pay more attention to something we are interested in.

Occasionally a parent will ask if just asking a few questions to reach a diagnosis is valid. They may have heard of friends who saw a psychologist who spent a number of hours with the teen before coming up with a diagnosis of ADHD. Studies have shown that none of the many tests that a psychologist uses is more valid than the simple (but evidence-based) approach described above. And, rarely, a parent will ask about special brain scans (Daniel Amend fires everyone up). There is no proof those are useful, they cost about $3,000, and are not covered by insurance.

b. Talking to parents about ADHD

Parents are likely to be unfamiliar with inattentive ADHD or they may come in with preconceptions about using stimulants (discussed below). Or their concern is their teen has poor grades, is staying out too late, won’t do anything helpful around the house, and is getting so angry that he or she is smashing walls and it is hard for them to believe all of that can be treated with an ADHD medication. For those who are opposed to medication, I generally go over the effects and the side effects, and recommend that they go home and think about my recommendation. The following 3 pages can be printed out and handed to parents.

FAQ about ADHD

Parents often have a number of questions and concerns about the diagnosis of ADHD and the recommendation for treatment with medication. Questions include:

• Is it a “real diagnosis”?

• Aren’t other treatments are just as effective?

• What are the risks of the medication?

Isn’t it true that ADHD is over-prescribed?

• Aren’t we solving all problems with pills?

• Won’t my teen to go on to use more drugs?

“What is ADHD?”

In the past ADHD was seen as a disorder of hyperactivity and impulsivity. Then it became clear that the disorder caused additional problems—having difficulty with paying attention, focusing, memory and other areas. One expert believes that time sense is one of the key elements; another feels that these patients are delayed in the development of an “inner voice.” [As children we rely on “outer voices” (e.g., parents, teachers), to tell us what to do and what not to do. Eventually we need to develop an “inner voice” to guide us.] Our present understanding is that ADHD is caused by a deficit in the circulation of several neurotransmitters, primarily dopamine. That deficit leads to a delay in the development of executive functions, described below.

“Is it a ‘real diagnosis’?”

The earliest reference to ADHD in the literature is a 1775 article by Melchior Adam Weikard, a German physician. He named the disorder “Mangel der Aufmerksamkeit,” or lack of attention. In 1998 the AMA convened a Scientific Council to study the question of ADHD being a ‘real diagnosis’ that can be treated effectively with medication, comparing it to other mental health disorders. Their conclusion was that of all of the mental health diagnoses, ADHD is the one that is most accurately diagnosed and most easily treated. PET scans show the differences in activity between a normal brain and one of a patient with ADHD, which is much less active. If people with ADHD are treated with appropriate medications, their brains then look normal.

No blood test or radiological procedure or test of the brain has can be used to diagnose ADHD, which contributes to the confusion surrounding the diagnosis. In addition, all the opinions of celebrities, neighbors, and grandparents about ADHD create additional barriers. Fortunately the medications are not at all addictive and act very quickly, so we can tell if they are effective. The patient can stop at any time without risks or side effects. At times the improvement is so quick and so substantial that a parent is amazed, making statements such as “that’s a magic pill.”

This slide is the single most important tool to illustrate to a parent

that ADHD is “really real.”

[pic]

“ADHD is over-diagnosed.”

It is also under-diagnosed—more of the latter than the former. A recent study found that only 30% of children with ADHD were diagnosed with the condition. The diagnosis should be carefully made, starting with a parent interview that includes obtaining answers to 9 specific questions. Since the symptoms must occur in more than one setting to make the diagnosis, information is obtained about school problems and teacher comments (handing in assignments, in particular), and, if needed, having teachers also answer a series of questions. In addition, the symptoms must cause significant problems in at least one setting. It occurs in perhaps 8% of teens, and this prevalence is the same world-wide.

“Aren’t there ways to treat it without using drugs?”

A very large NIMH study studied the effectiveness of different ways of treating ADHD, including medication; behavioral training for parents and children; and a combination of the 2. The study found that medication alone was highly effective in treating ADHD; increasing parenting skills along with behavioral training of their children led to almost no difference compared to a control group. (In this study the parents had 37 training sessions and their children attended a special camp for 8 hours a day, 5 days a week for 6 weeks. They were then supported for the entire school year with weekly sessions with an ADHD coach.) The combination of medication and increased parenting skills was somewhat more effective than medication alone.

“I don’t want my teen on drugs.”

Teens with untreated ADHD are twice as likely to use street drugs as other teens; those being properly treated have the same rate as other teens. Teens not on meds often “self-medicate” in order to feel better, taking stimulants such as meth or cocaine. Many teens like being on the meds—they say “I feel like me.” Some call it their “happy pill.”

• Risks of medication: poor appetite; problems with sleep; difficulty determining most effective medication and best dose.

• Risks of no medication: 4 times the rate of auto crashes; twice the use of street drugs; girls with 10- 20 times the rate of unplanned pregnancy; nearly 50% chance of getting into trouble with the law by age 18; more likely to be school dropout; more likely to change jobs frequently; more likely to be divorced.

“Will my teen need to take medication for the rest of his or her life?”

There are 3 possibilities, all about equally likely. One third “outgrow” it (i.e., their executive functions develop in such a way as to eliminate the issue); one third make decisions that enable them to manage their lives so they do not need meds (e.g., they go into careers that minimize the need to be organized and able to focus at all times—music, art, sports, some computer work—and/or marry a highly-organized person); and one third do need medication their whole lives. This means that there is only a 1 in 3 chance that a teen will need medication indefinitely.

“How does ADHD relate to ‘Executive Functions’”?

The latest thinking about ADHD puts the diagnosis into a broader problem—a delay in the development of the prefrontal cortex, that part of our brain that supplies the “executive functions.” That concept helps us understand why such a wide range of problems—focusing, prioritizing, time management, staying organized, understanding saliency, and others—can all be part of a single diagnosis. Conceptualizing the condition this way also helps us make certain decisions. For example, in the past it was common to have the teen have a “drug holiday,” with no medication during school vacations, summer vacations, etc. But even when there is no schoolwork to worry about, there are many other areas in life in which a deficiency in executive functions makes things difficult. So these days most experts do not recommend such holidays, although many parents choose to eliminate or reduce medication when schoolwork would not be affected.

c. A disorder of executive functions

The problems caused by a delay in executive functions can be decreased by reducing a teen’s “cognitive load.” For example, if parents stick to the “high structure” approach, that reduces the amount of variation the teen needs to manage. The accommodations that that can be requested in school (e.g., more time on tests, less homework, fewer distractions) all reduce the cognitive load. Teens who do not have ADHD can deal more easily with unexpected changes, tight deadlines, and other challenges of everyday life.

Executive Functions

|Emotional Regulation |Activation |

| | |

|Managing frustration |Organizing |

|Modulating emotions |Prioritizing |

| |Activating to work |

|Working Memory |Focus |

| | |

|Accessing recall |Focusing |

|Utilizing working memory |Maintaining attentiveness |

| |Shifting attention |

|Monitoring |Effort |

| | |

|Monitoring efforts |Regulating alertness |

|Self-regulation |Sustaining effort |

| |Processing speed |

Throughout this section of the handbook, I give examples of teens I have seen with a given diagnosis. Reading about these patients may be helpful.

Cases (Inattentive ADHD)

One parent had heard from a friend that “once you start on medication you need to take it the rest of your life.” In addition to sharing the above information, I explained that his son could stop it any day, without any withdrawal symptoms. What the friend probably meant was that you should realize that your child may need it the rest of his life. At the end of the visit I said I was recommending medication, and would like him to go home and think about it. To my surprise he said his son was about to flunk out of school, and was there any reason not to start it right away?

A mother brought her 13-year-old son in because he was struggling in school, despite being very bright and being motivated to do well. When I completed my evaluation and told his mother that he had inattentive ADHD, she said she had been told that 2 years earlier but, not wanting to use meds, had tried dietary restrictions and herbal remedies, without success. I answered her many questions about meds thoroughly, but she was not ready to make a decision. They came in two weeks later, and were ready for a trial of medication. At the next visit, I asked the patient how things were going; he said “good.” I asked him what was good and he answered “I can read boring stuff.” I told him how important that was—that few of us get very far in life if we can’t tolerate reading “boring stuff.”

I was treating a 15-year-old girl for inattentive ADHD with 36 mg of Concerta. It took care of her during school hours but she noted that her attention faded after she got out of school. I prescribed a very small dose of Ritalin (the immediate release form of methylphenidate) which improved her ability to study and, to the surprise of both of us, it also improved her soccer game. She has not realized that some of her errors had been caused by her inability to pay attention to what was happening on the field at times she did not have the ball. After that I watched for such situations and found that athletes in other sports benefited from the stimulant I had prescribed for help with struggles in school.

The clearest example of when a teen who plays sports might benefit from meds is a baseball player who plays right field. It may be that he will need to field the ball only 2 or 3 times in 9 innings—but those few times he will need to know how many outs there are, how many players are on base and how fast they are, etc. Without meds there would be no way he could keep track of that much information. One of my patients was a bit resistant to taking medications until he realized how much his baseball performance improved. He led his team to the playoffs and invited me to come to the championship game—which they won!

Parents may hold other misconception--about addictions, decreased height, etc. [Studies have found, on average, small decreases in height--perhaps 1 cm--in children with ADHD treated with stimulants. However there are no such effects in those who are treated in adolescences.] Presenting these facts and developing an honest and trusting relationship with the parent and the teen, are paramount.

A recent study of more than one million children ages 3-17 found no difference in death rates from sudden death or arrhythmia, or heart attacks or strokes in those on medication for ADHD.

[pic]

First line meds: The two “families” of stimulants, illustrated above, are the most effective medications for ADHD. Since they are equally effective, the choice may be based on the drug the clinician is more familiar with, or on one that has worked (or not worked) in another family member or perhaps in the patient. If there is concern about abuse—either by the patient, or because of the possibility of diversion--it is worth noting that while Adderall XR can be crushed and snorted or injected, that is not possible with Concerta or Vyvanse.

Concerta lasts up to 10 hours, Adderall XR up to 8 hours, and Vyvanse up to 12 hours. The advantages of long-acting drugs are that they do not need to be taken during the school day, and that there is no “up and down” experience like there is with a short-acting drug. Vyvanse takes the longest to reach an effective level, so you may need to prescribe Dexedrine upon awakening if the patient needs a stimulant early in the morning. There is a 70% chance that any of these three will be effective; if it is not, or it causes uncomfortable side effects, switch to another. Between the three meds, it is 85-90% likely that the treatment will be effective.

For all stimulants, parents need to know that a prescription can legally be for only a 30-day supply, and renewals cannot be by phone or by fax. [Once a dose is stable and the patient/parent is reliable, it may be appropriate to write three prescriptions, each dated a month apart.]

Second line: Strattera (atomoxetine). Recommendation: not to be tried until several drugs in each of the above classes have failed. It is not very effective in most patients. However, rarely stimulants don’t work or the side effects are too troublesome, and Strattera does the job. Strattera along with a stimulant can sometimes reduce the dose of stimulant needed. A recent study found that more patients initiated on Concerta (43.9%) achieved treatment stabilization without changing their index medication or dose compared to those initiated on Strattera (8.1%). One advantage of Strattera is that because it is not a stimulant, refills may be provided and also called in.

In one study, one-third of patients on Strattera became mood dysregulated. This included patients who had family or personal histories of mood instability, but also several alarming cases who had no personal or family history of mood instability or mood disorder. Strattera has a risk of inducing mood dysregulation, agitation, aggression and frank mania, including psychosis.

Eli Lilly has recently issued a warning:

|Strattera should not be used in patients with severe cardiovascular disorders whose condition would be expected to deteriorate if they |

|experienced increases in blood pressure or in heart rate that could be clinically important (for example, 15 to 20 mm Hg in blood pressure |

|or 20 beats per minute in heart rate). |

|Strattera should be used with caution in patients whose underlying medical conditions could be worsened by increases in blood pressure or |

|heart rate, such as patients with hypertension, tachycardia, or cardiovascular or cerebrovascular disease. |

|It is recommended that heart rate and blood pressure be measured in all patients before treatment with Strattera is started and |

|periodically during treatment to detect possible clinically important increases. |

|Strattera has an unusual dosing schedule, starting at 18 or 25 mg and increasing the dose every 4 days to 40 mg, then 60, then 80. The |

|highest dose in teens and adults is 100 mg, a level reached, if needed in 1 month. |

|Third line (or perhaps second line): Guanfacine. It may cause sleepiness, so should be taken before sleep. The duration of action is |

|generally about 12 hours, so BID dosing works well. Intuniv is billed as long-acting guanfacine, but its duration is not that much longer |

|and it is MUCH more expensive, and often not covered by insurance. Intuniv is dosed at 1 or 2 mg a day, increasing, if needed, to 4 mg. |

|[Kapvay is the long-acting version of clonidine with similar actions to Intuniv. Kapvay starts at 0.1 or 0.2 mg a day, increasing to 0.3 mg|

|if needed. Intuniv is taken once a day; Kapvay twice a day.] |

A common approach to prescribing

Methylphenidates (Ritalin to Concerta)

For most teens it makes the most sense to start with a long-acting stimulant. Of the two families of stimulants, a clinician would choose the longest-acting drug. Concerta comes in unusual dosages—18 mg, 27 mg, 36 mg, and 54 mg. (Those good at math can figure out how to prescribe 45 mg or 63 mg.) It is unusual for 18 mg to be effective, but since there are likely to be side effects at first (headache, abdominal pain, anorexia, insomnia, anxiety), it is preferable to start with 18 mg, and then increase to 36 mg after one week (or sooner—3 days is often enough) if side effects are minimal. Rarely 27 mg works best.

There are two schools of thought on further increases: one is to prescribe as low a dose as possible, as long as it seems to be effective; the other is to continue to increase the dose until there are significant side effects. Generally 54 mg is adequate; rarely a dose of 72 mg a day is needed.

The patient should be seen in 2 or 3 weeks, to ascertain if the dose is effective, if the side effects are manageable, and to begin the family behavior work. The third visit would usually be in a month, ensuring the medication is working, and getting feedback on the home issues. If necessary behavior changes are being made on the part of both parents and the teen, these problems are likely to be resolving.

After one more monthly visit to ensure this improvement is continuing, one can switch to every other month and eventually every 3 months, providing the parent with the extra prescriptions needed so there is not need to call in, etc. Most teens and their parents need to be seen monthly indefinitely, since there always seems to be a behavior issue or a medication issue to discuss. Studies show that patients with ADHD do best if seen by their medical provider at least 6 times a year.

Although Concerta can last up to 12 hours, it often wears off in 8-10 hours. That would mean the level would be decreasing just as the teen has a need for a stimulant to help him or her focus on homework. If that is the case, prescribe short-acting methylphenidate (Ritalin), 5 or 10 mg as a supplement. That should be enough to get homework done, without interfering with sleep. Similarly, it may take the Concerta up to 2 hours to be effective. In those cases, 5 or 10 mg of Ritalin taken at the same time as the Concerta helps. Side effects are discussed below.

Amphetamines: Dexedrine or Adderall to Adderall XR/Vyvanse

Everything above applies to Adderall XR, except the duration of effectiveness is shorter, so supplementation is more likely to be needed. 10 mg of Adderall XR is equivalent to 23 mg of Concerta so 10 mg would be the usual starting dose, going up to 15 mg after one week and going as high as 30 mg. Alternatives for supplementation, from longest acting to shortest, include a second dose of the Adderall XR at midday; Adderall; or Dexedrine.

There are substantial differences in rates of metabolism from one patient to another, and it may be necessary to prescribe high doses in lower-weight teens if the lower dose is not working. 72 mg a day is generally considered the highest dose one prescribes for Concerta before one would switch to Adderall XR. And if 40 mg of the latter is not effective, one would try Concerta. However, at times it is necessary to go to 81-90 mg a day of Concerta, or to 50-60 mg a day of Adderall XR. Adderall and Adderall XR can be turned into powder to snort or liquid to inject, so are very easily abused—or sold.

Vyvanse (lisdexamfetamine) is a single capsule that is taken each morning. Vyvanse enters the body in an inactive form. As the drug is digested, the body slowly converts it into its active form. The effects can last for up to 14 hours. The initial dose is 30 mg orally once a day in the morning

If necessary, the initial daily dose may be increased by 10 mg to 20 mg approximately once a week up to a maximum daily dose of 70 mg.

Although Vyvanse may last 14 hours, it may also last 4-6 hours. And although the maximum dose is considered to be 70 mg (FDA approved level), occasionally100 mg or even more is needed.

e. Risks and side effects of stimulants

It is important to differentiate between side effects and risks. I clarify that side effects go away as soon as you stop taking a drug; risks make you sorry you ever took the drug. A recent study of side effects of Concerta found the most frequently reported ADRs (adverse drug reactions) were loss of appetite (34.3%), headache (17.9%), mood and emotional problems (14.9%), stomach upset (14.9%), sleep disturbance (10.4%), and rash and other skin problems (5.2%). As noted, decreased appetite and insomnia are the most persistent. Fortunately, there are several ways to minimize these side effects. If patients eat a good breakfast (before the meds have kicked in) and a large dinner (after they have worn off) their weight will generally be stable. A late evening snack would be a good supplement to these meals. Also a morning dose of Periactin or Allegra can act as an appetite stimulant.

As for sleep, see Appendix for sleep tips. In addition, melatonin (1 to 6 mg a day), Clonidine (0.1, 0.2 or 0.3 mg h.s.), guanfacine (1, 2, or 3 mg h.s.) or Trazodone (50 to 100 mg or more h.s.) can also be helpful. And, surprisingly, a low dose of a long-acting stimulant, if taken after the teen is in bed ready to fall asleep, can be a great help. If side effects continue to be a problem, you may need to switch to a different drug. There are other side effects that are less common but stressful to the patients. They can experience anxiety or depression, or feel “loopy” or odd. Some of them say they feel like they are zombies--one of my patients talked about “zombification.”

Risks are close to zero. In 2008, the American Heart Association took the position that an EKG read by a pediatric cardiologist, was necessary prior to starting a patient on a stimulant. This led to a flurry of media pieces at the time and the recommendation was quickly dropped. A recent study of 1,200,438 children from 3 to 17 found that those on stimulants were no more likely to die of arrhythmias, heart attacks or strokes that those who were not on medication. Of course, a very small number of children die suddenly from cardiac events (about 1 or 2 per 100,000, similar to the risks of playing Saturday-morning soccer) but it turned out a higher percentage of those not on stimulants died than those on stimulants. The present recommendation of the American Academy of Pediatrics is to consider an EKG prior to putting a teen on a stimulant if he or she has a history of fainting while exercising, a family history of early sudden death, or known cardiac abnormalities.

Behavior issues at home

It is critical to focus at least as much on issues at home (including doing homework and chores, as well as communication and relationships) as on medications, but until you have the patient on the right dose of the right medication it is pointless to expect much change in behaviors at home. See Appendix for a detailed discussion of ways to work with parents and teens to reduce conflict at home and for more information on medications. There is even a handout on helping parents and teens work together to get the teen’s bedroom tidy!

f. Fellow Travelers of ADHD

In one study, 67 percent of teens with ADHD had at least one other reported mental health or neurodevelopmental disorder, compared with 11 percent of unaffected children. Eighteen percent had 3 or more additional conditions. Many physicians are unaware of this, and treat just ADHD without success. They then refer the patient because the treatment is not effective. Often uncovering one or more additional diagnoses is the key to helping these patients. The most common is anxiety, followed by depression, a learning disorder, tics, oppositional behaviors, bipolar disorder, and substance misuse. National authorities have published all manner of conflicting data on this subject. Some feel almost everything is a form of bipolar disorder, while others feel almost everything is just a severe form of ADHD.  

2. Oppositional Behaviors

The oppositional behaviors are ODD (Oppositional Defiant Disorder) and CD (Conduct Disorder). The Vanderbilt form rates the patient for each symptom for these 2 disorders.

In the judgment of many, ODD is a constellation of symptoms, not a diagnosis. It is a likely outcome of ADHD. Bright students with inattentive ADHD, undiagnosed, find themselves doing much worse in school than classmates they know are not as bright. This blow to their self esteem makes them anxious and angry. They get frustrated in general because of the stress caused by struggling in many areas of life. The impulsivity commonly found in patients with ADHD can also contribute to these behaviors.

The CAS asks the following question:

Question19. Have you ever done something violent because you were angry?

The following are the symptoms of ODD:

• often loses temper;

• often argues with adults;

• often actively defies or refuses to comply with adult requests or rules;

• often deliberately annoys people;

• often blames others for mistakes or misbehavior;

• is often touchy or easily annoyed by others;

• is often angry and resentful; and

• is often spiteful or vindictive.

If at least 4 have been present for at least 6 months, most of the criteria for ODD have been met. If the history is obtained only from a parent, positive responses may be meaningless; many teens, in particular those with ADHD, exhibit these behaviors only at home.

There is no specific treatment for ODD, another reason why I have never been very interested in making this diagnosis. However, stimulants used to treat ADHD also reduce impulsivity, which is the basis for many of the ODD behaviors. One regression analysis predicted 40% of the variance of ODD as a comorbid condition in addition to ADHD. Although the presence or absence of ODD at baseline does not moderate response of ADHD symptoms with treatment, improvement in ODD symptoms was mediated by improvement in ADHD symptoms (P < 0.0001). The researchers commented that the ODD behaviors are often secondary to ADHD and resolve with treatment of that disorder.

CD (Conduct Disorder). The CAS asks the following question:

Question 21. Have you ever had trouble with the law?

Children or adolescents with conduct disorder may exhibit some of the following behaviors:

Aggression to people and animals

• bullies, threatens or intimidates others;

• often initiates physical fights;

• has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun);

• is physically cruel to people or animals;

• steals from a victim while confronting them (e.g. assault);

• forces someone into sexual activity.

Destruction of property

• deliberately engages in fire setting with the intention to cause damage;

• deliberately destroys other's property

Deceitfulness, lying, or stealing

• has broken into someone else's building, house, or car;

• lies to obtain goods, or favors or to avoid obligations;

• steals items without confronting a victim (e.g. shoplifting, but without breaking and entering)

Serious violations of rules

• often stays out at night despite parental objections;

• runs away from home;

• often truant from school

DSM-5 added a specifier for conduct disorder on callous and unemotional traits. Results from more than 30 studies suggest that the presence of callous and unemotional traits predicts a more severe, stable, and difficult-to-treat conduct disorder. This constitutes just a small fraction of all conduct disorder cases. [The callous and unemotional specifier requires at least two of these traits: lack of remorse or guilt, lack of empathy, unconcern about performance, and shallow or deficient affect.]

Like ODD, there is no medical treatment for CD. For most of the CD behaviors “treatment” would be by law enforcement.

Causes of truancy (deliberately skipping all or part of the school day) are many. They can be a symptom of an oppositional behavior disorder, a fear of bullying, the attractiveness of the experiences gained instead of being in school (e.g. watching TV, being one of the cool students, extra attention from parents), and many others, including severe anxiety. Truancy fits into the continuum discussed under “school refusal behaviors” below.

Tourette’s Disorder is discussed in the Appendix.

Part II

3. Anxiety Disorders

The following questions from the CAS are related to anxiety:

Question 31. Do you feel nervous or on edge?

Question 32. Are you able to stop or control your worrying?

Those who answer “yes” to one of these questions may well have an anxiety disorder.

Background on anxiety disorders

These are among the most common of mental illnesses in teens, but an NIMH study found that only 18% of adolescents with clinical anxiety ever receive treatment. Identifying and managing adolescent anxiety can be challenging. Symptoms and the focus of anxiety are varied and are often misidentified in primary care as somatic complaints due to “normal” teenage stress. They frequently become manifest in early adolescence, and can be incapacitating. Any combination of social anxiety, phobias, separation anxiety, agoraphobia, general anxiety, and panic disorder is possible. Early history may show some separation anxiety when the patient first started school.

Some patients are referred because an anxiety disorder is suspected. In many other cases, they are referred for other reasons (e.g., poor school performance, missing school) but turn out to have performance anxiety, social anxiety, or separation anxiety. Other referrals are for patients with somatic symptoms—abdominal pain in particular—who have been worked up for an organic basis, with all tests being normal.

a. Diagnosing an anxiety disorder

To screen for generalized anxiety disorder, start with the SCARED-5 (younger teens), validated for ages 8-18 or the GAD-2 (older teens), validated for all teens. If the score on either of these is ≥ 3, the patient needs a more comprehensive test. A thorough evaluation of anxiety can be done by using the MASC (Multi-dimensional Anxiety Scale for Children—sample form in Appendix. It is self-administered, and brief training is needed to score it. It is validated for ages 8-19, and identifies a number of different kinds of anxiety (e.g., somatic, perfectionism, performance anxiety, social anxiety, and separation anxiety). If these tests do not show anxiety, but that diagnosis still seems possible—especially if there are many somatic symptoms—a Burns Anxiety Inventory is worth doing (see Appendix for the questionnaire).

SCARED-5 [Screening Children for Emotionally-Related Emotional Disorders]

| |Not True or Hardly Ever True |Somewhat True or Sometimes True|True or Often True |

|a. I get frightened for no reason at all. | | | |

|b. I am afraid to be alone in the house. | | | |

|c. People tell me that I worry too much. | | | |

|d. I am scared to go to school. | | | |

|e. I am shy. | | | |

|Totals | | | |

|Scoring | 0 | x 1 = | x 2 = |

|Score: (≥ 3 needs followup) | | | |

GAD-2 [Generalized Anxiety Disorder]

The first two questions of the GAD-7 serve as a screening for general anxiety. If the answers to the first two questions add up to 3 or more, then ask all 7 questions. At times the more extensive MASC is not the best tool for diagnosing GAD, which is characterized by classic anxiety symptoms (e.g., worrying about what will happen to family members, fear of a catastrophe, low self esteem) in combination with more somatic concerns (e.g., difficulty sleeping, being fatigued, difficulty concentrating, headaches or abdominal pain).

GAD – 7

|Over the last 2 weeks, how often have you been bothered by the following |Not at all |Several days |More than half the days|Nearly every day|

|problems? | | | | |

|1. Feeling nervous, anxious or on edge | 0 | 1 | 2 | 3 |

|2. Not being able to stop or control worrying | 0 | 1 | 2 | 3 |

|3. Worrying too much about different things | 0 | 1 | 2 | 3 |

|4. Having trouble relaxing | 0 | 1 | 2 | 3 |

|5. Being so restless that it is hard to sit still | 0 | 1 | 2 | 3 |

|6. Becoming easily annoyed or irritable | 0 | 1 | 2 | 3 |

|7. Feeling afraid as if something awful might happen | 0 | 1 | 2 | 3 |

| | | | | |

|Add columns |___ |___ |___ |___ |

|Total Score ____ | | | | |

If you checked off any problem, how difficult have these problems made it for you to do your schoolwork, take care of things at home, or get along with other people?

Not difficult at all ___ Somewhat difficult ___Very difficult ___Extremely difficult___

Scoring: A total score of ≥ 10 indicates an anxiety disorder

b. Treating an Anxiety Disorder

I often start by noting that some anxiety is necessary (if our ancestors were not afraid of lions, we would not be here today). Mild anxiety disorders that do not appear to be causing problems can be managed with support from the clinician along with non-medication interventions. These include breathing exercises, muscle relaxation, therapeutic imaging, journaling, exercise, and involvement in art or music. There are handouts on these approaches in Child, under Adolescent Medicine/Stress. The book Overcoming Anxiety for Dummies has excellent discussions about different forms of anxiety in general, and about these holistic approaches in particular.

For patients who have moderate anxiety that is causing them some, but not severe, problems, Cognitive Behavioral Therapy is probably the best choice. For patients who are resistant to therapy, medication is helpful. For patients with moderate to severe anxiety, medication is needed. In some cases, the medication can reduce the anxiety enough to enable the patient to be helped by therapy. A study published in The New England Journal of Medicine in December of 2009 found that medication alone (citalopram in this study) was more effective than CBT alone; the two together had an excellent success rate of 81%.

As noted, there are 5 kinds of anxiety: general anxiety, separation anxiety, social anxiety, panic disorder, phobias. Several of these—in particular phobias--respond well to desensitization. Other forms of anxiety are well-treated by encouraging the teen to “avoid the avoidance,” since avoiding the situation that causes anxiety makes it worse.

For example, teens who miss a lot of school because of social anxiety are best treated by working with them to attend school. The actual experience is never as scary as what their brain has come up with, and by the third or fourth day back in school, their anxiety is much reduced. James Baldwin, the renowned African-American writer, said “Find what you are afraid of and walk towards it.” [Thoughts on Fire: Life Lessons of a Volunteer Firefighter. By Dr. Frank McCluskey] More about types of anxiety, also including OCD and PTSD, can be found in the Appendix.

A common approach to prescribing:

SSRI’s and the Black Box Warning

The issue of the Black Box Warning about the risk of suicidal thoughts that may be caused by an SSRI should be discussed with parents and with older teens. A recent study found that whereas a control group of teens showed 2% with suicidal thoughts, the treatment group, all with serious depression, was at 3%. Sharing this information with parents is generally all that is needed to reassure them. If necessary, note that of the almost 4,500 teens studied, there were no suicides, only suicidal thoughts/behaviors. Also those thoughts are most common in the weeks BEFORE the teens sought care, decreased when they found care, decreased further in the next month, and were at a “normal” level thereafter.

c. Summary of dosing SSRIs

| |Dosage form |Usual starting dose |Increase increment |RCT |FDA |Comments |

| | | |(~4 weeks) | | | |

|Fluoxetine |10, 20, 40 mg |5-10 mg/day |10-20 mg |Yes |Yes |Long ½ life |

|(Prozac) | |(60 max) | | |(for OCD) | |

|Sertraline |25, 50, 100 mg |25 mg/day |25-50 mg |Yes |Yes |Prone to SE from weaning |

|(Zoloft) | |(200 max) | | |(for OCD) | |

|Fluvoxamine |25, 50, 100 mg |25 mg/ day |50 mg |Yes |Yes |More SE, more drug |

|(Luvox) | |(300 max) | | | |interactions |

|Paroxetine |10, 20, 30, 40 mg |5-10 mg/day |10-20 mg |Yes |No |Not used if also depression|

|(Paxil) | |(60 max) | | | | |

|Citalopram |10, 20, 40 mg |5-10 mg/day |10-20 mg |No |No |Very few drug interactions |

|(Celexa) | |(40 max) | | | | |

|Escitalopram |5, 10, 20 mg |2 ½ to 5mg/day |5-10 mg |No |No |No generic form |

|(Lexapro) | |(20 max) | | | | |

d. Side effects of some common SSRI’s:

|Adverse effect |Fluoxetine |Escitalopram |Sertraline |Citalopram |

|Nausea | 21 % | 18 % | 26 % |21% |

|Headache |20 |24 |20 |2 |

|Nervous |15 |˂ 10 |3 |5 |

|Sedation |12 |13 |13 |18 |

|Insomnia |14 |12 |16 |15 |

|Dry mouth |10 |9 |16 |20 |

|Diarrhea |12 |8 |18 |8 |

|Weak/Fatigue |4 |8 |11 |5 |

|Anxiety/Agitation |9 |< 10 |6 |4 |

|Sexual Dysfunction |2 |14 |16 |6 |

|Anorexia |9 |3 |3 |4 |

Side effects of SSRIs: insomnia sedation; nausea; diarrhea; change in appetite; headache; restlessness; anxiety; nervousness; agitation; irritability; suicidality

Most studies show that sertraline (Zoloft) is probably the most effective drugs for treating anxiety disorders in adolescents. Fluoxetine is not indicated (see highlighted side effects).

• To prescribe sertraline, start with 25 mg a day (this is rarely enough) and increase to 50 mg after one week. The principle for prescribing any SSRI is “start low, go slow.”

• See the patient in person after 2-3 weeks to discuss any changes in symptoms (probably not), side effects, etc. If the patient has suicidal thoughts, they will usually be in the first 3 weeks. You may want to ask one of our nurses to call the patient after a week to make he or she is OK.

• The most common side effects are noted above. It generally takes 3-6 weeks for any SSRI to be effective.

• If there is no or minimal change after 6 weeks, increase the dose to 75 or 100 mg. Again wait 3-6 weeks and increase to either 125 or 150 mg.

• If not effective at 150 mg, I generally change to a different SSRI.

• Higher doses may be needed for OCD, up to 200 mg a day. In addition, patients with OCD may benefit from benzodiazepines supplementing the SSRI.

If the sertraline is not effective, I generally change to citalopram (Celexa), starting at 10 mg, moving to 20 in a week, then to 40 and then to 60 if needed. (Because of fears of complications of an arrhythmia, an EKG should be done prior to increasing above 40 mg). Other prefer escitalopram (Lexapro). Start at 5 mg, moving to 10 and then to 20 and then to 30 as needed. (EKG prior to exceeding 30 mg)

• If the citalopram is not effective, I sometimes move to a third SSRI, although many do not believe a third SSRI will be effective if the first 2 were not.

• Escitalopram (Lexapro, starting at 5 mg) would be my next choice.

• If still not effective, an SNRI (selective norepinephrine uptake inhibitor)--e.g., venlafaxine (Effexor) or duloxaletine (Cymbalta)--could be tried, or a second-generation antipsychotic like quetiapine (Seroquel) could be considered.

• If an SSRI is partially effective, a small amount of quetiapine (e.g., 50 mg) at bedtime can be added to the SSRI.

For treatment of panic disorder, an SSRI is the drug of choice.

• If panic episodes continue, supplement the SSRI with a benzodiazepine such as alprazolam (Xanax), (starting at 0.25 mg up to tid, and increasing to no more than 1 mg tid); Clonazepam (Klonopin) (starting at 0.25 mg tid, increasing to no more than 1 mg tid) lorazepam (Ativan), (starting at 0.50 mg tid, increasing to no more than 1.5 mg tid). These are abortive agents and should be taken at the first sign of panic. Diazepam (Valium) (starting at 2.5 to 5 mg up to tid) can be taken daily routinely.

• For patients who have panic episodes less often than daily, it often makes sense to prescribe one of these short-acting medications for the patient to take only at the first sign of panic. At times knowing they have medication that will abort a panic attack reduces the likelihood that one will occur. Some parents worry that these are addictive drugs. I acknowledge that it is true, but in doses 10-20 times what I am prescribing (e.g. I start Xanax at 0.125 mg per episode of panic).

Note: it is common for patients to have both ADHD and an anxiety disorder. It is not a good idea to start patients on two medications simultaneously—if there are side effects or no improvement, it becomes difficult to figure out which drug caused what. Since one side effect of stimulants is to increase anxiety, a case can be made for treating the anxiety first. On the other hand, we can tell within a week or two if the stimulant is helping with the ADHD. So the choice is up to the prescribing clinician and the parent/patient.

For patients who want to learn about cognitive behavior therapy, The Feeling Good Handbook, by David Burns, is very useful (one of my patients mistakenly, but accurately, called it The Feeling Better Handbook after she had tried some of the exercises!). It can help bright teens work through many of the issues that trouble them; there are 2 chapters on procrastination that are especially valuable. Other resources are listed in the Appendix.

e. School refusal behaviors

CAS asks

5. Have you missed at least 10 days of school in the past year?

Case

Sara had been traumatized at a young age by watching her parents have violent arguments. She had some difficulty with attending school as a young girl, but enjoyed the social relationships. However, she was bullied in 4th grade. This led to her becoming anxious about attending school and that, in turn, made her over-protective mother shield her from her anxiety by supporting her need to stay home. By the time she was 11, she had stopped going to school completely. Frequent visits to our clinic, small amounts of medication, and periodic counseling have made her somewhat less anxious about this, but her mother continues to exacerbate the problem by keeping her home for minor problems.

“School refusal behaviors” (previously called school phobia or school avoidance) refer to a child-motivated refusal to attend school and/or difficulty remaining in classes for an entire day.  Although it is not classified as one of the anxiety disorders, it is caused by the interaction of several of them, and so is discussed here. The problem may manifest as lengthy absences from school, skipping classes during the day, being late to school, or showing misbehaviors in the morning in an attempt to miss school. Some youths manage to attend school but do so with great dread and distress. 

In addition, extended school refusal behaviors can lead to serious short-term and long-term consequences if left unaddressed.  These consequences include academic problems, social alienation, family conflict and stress, school dropout, delinquency, and occupational and marital problems in adulthood. School refusal is extraordinarily difficult to treat. Most of the time there is also an anxious mother (just about never a father), making it difficult to sort out whose anxiety is the primary problem. In these cases the teens may stay home because their mother can’t tolerate the teen being away. Teens who suffer from both separation anxiety (making it difficult for them to leave for school) and social anxiety (making it difficult for them to be in school) are particularly difficult to help. Also, any of the other anxiety disorders or any combination can potentiate school refusal.

 

Common symptoms include anxiety, depression, withdrawal, fatigue, crying, and physical complaints such as stomachaches and headaches.  More disruptive symptoms may include tantrums, dawdling, noncompliance, arguing, refusing to move, running away from school or home, and aggression.  Children and adolescents with school refusal behaviors may show a wide range of constantly changing behaviors. 

Many youths refuse school to avoid a negative experience (school-related situations that cause substantial distress or painful social and/or evaluative school-related situations). Others do so to have a positive experience (to gain attention from significant others or to pursue tangible rewards outside of school, such as watching TV). Many teens manifesting the above behaviors have been bullied. It is unlikely that progress will be made until that information is uncovered.

One complication in the State of Washington is The Becca Bill. This law is named after a 13-year old girl from Tacoma who missed most days of school. Her adoptive parents went to court, but because she had not committed a crime there was no basis for detaining her. Several months later she was found in Spokane, in a ditch, having been killed by a “john.” The bill requires that certain actions be taken if there is chronic truancy. At times it is a cudgel held over parents and/or teens, with the potential to require the teen to transfer to an alternative school, so clinicians should know a bit about it (information is available on the internet).

A handout on school refusal behaviors can be found in the Appendix.

4. Depression

The CAS asks the following questions:

23. Have you felt sad or down or hopeless during the past 2 weeks or felt as though you had nothing to look forward to? …………Yes No

24. Have you had little interest or pleasure in doing things in the past 2 weeks?..........Yes No

25. Have you ever thought about killing or harming yourself or made a plan to kill yourself?

Overview of depression

Major Depressive Episode (from the DSM-5)

To qualify for major depressive disorder the patient needs to have been experiencing symptoms almost every day for at least two weeks, and they are more intense than the normal fluctuations in mood that all of us experience in our daily lives. The patients needs to have at least five of them to qualify, and one of these five has to be either depressed mood or loss of interest or pleasure in activities.

A. 1. Depressed mood most of the day, almost every day, indicated by your own subjective report or by the report of others. This mood might be characterized by sadness, emptiness, or hopelessness.

2. Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day.

3. Significant weight loss when not dieting or weight gain.

4. Inability to sleep or oversleeping nearly every day.

5. Psychomotor agitation or retardation nearly every day.

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day.

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C. The episode is not due to the effects of a substance or to a medical condition

D. The occurrence is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders

E. There has never been a manic episode or a hypomanic episode

a. Effects of teen depression (from )

The negative effects of teenage depression go far beyond a melancholy mood. Many rebellious and unhealthy behaviors or attitudes in teenagers are actually indications of depression. See the table below for some of the ways in which teens “act out” or “act in” in an attempt to cope with their emotional pain:

| |

|Problems at school |Depression can cause low energy and concentration difficulties. At school, this may lead |

| |to poor attendance, a drop in grades, or frustration with schoolwork in a formerly good |

| |student. |

|Running away |Many depressed teens run away from home or talk about running away. Such attempts are |

| |usually a cry for help. |

|Substance abuse |Teens may use alcohol or drugs in an attempt to “self-medicate” their depression. |

| |Unfortunately, substance abuse only makes things worse. |

|Low self-esteem |Depression can trigger and intensify feelings of ugliness, shame, failure, and |

| |unworthiness. |

|Eating disorders |Anorexia, bulimia, binge eating, and “yo-yo dieting” are often signs of unrecognized |

| |depression. |

|Internet “addiction” |Teens may go online to escape from their problems. But excessive computer use only |

| |increases their isolation and makes them more depressed. |

|Self-injury |Cutting, burning, and other kinds of self-mutilation are almost always associated with |

| |depression. |

|Reckless behavior |Depressed teens may engage in dangerous or high-risk behaviors, such as reckless driving, |

| |out-of-control drinking, and unsafe sex. |

|Violence |Some depressed teens (usually boys who are the victims of bullying) become violent. As in |

| |the case of the Columbine school massacre, self-hatred and a wish to die can erupt into |

| |violence and homicidal rage. |

|Suicide |Teens who are seriously depressed often think, speak, or make "attention-getting" attempts|

| |at suicide. Suicidal thoughts or behaviors should always be taken very seriously. |

b. Diagnosing depression

To make this diagnosis, screen with the PHQ-2; if the answer to either question is “yes,” then administer the full PHQ-9.

Screening for Depression Using Patient Health Questionnaire-2

The following questions from the CAS comprise the PHQ-2 (Patient Health Questionnaire).

25. Have you felt sad or down or hopeless during the past 2 weeks or felt as though you had nothing to look forward to? …………Yes No

26. Have you had little interest or pleasure in doing things in the past 2 weeks? ......... Yes No

If the answer to either is “yes,” proceed with the PHQ-9 (available on the internet):

In the past 2 weeks, have you been bothered by:

| |0 |1 |2 |3 |

| |Not at all |Several days |More than half the days |Nearly every day |

|1. Little interest or pleasure in doing things? | | | | |

|2. Feeling down, depressed, irritable, or hopeless? | | | | |

|3. Trouble falling asleep or staying asleep or sleeping | | | | |

|too much? | | | | |

|4. Feeling tired or having little energy? | | | | |

|5. Poor appetite or overeating? | | | | |

|6. Feeling bad about yourself—or that you are a failure or| | | | |

|let yourself or your family down? | | | | |

|7. Trouble concentrating on things, such as reading the | | | | |

|newspaper, doing homework, or watching television? | | | | |

|8. Moving or speaking so slowly that other people could | | | | |

|have noticed. Or the opposite—being so fidgety or | | | | |

|restless that you have been moving around a lot more than | | | | |

|usual? | | | | |

|9. Thoughts that you would be better off dead, or of | | | | |

|hurting yourself in some way ? | | | | |

|Total each column | | | | |

Total: ________

If you said yes to any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all ___ Somewhat ___ Very ___Extremely ___

Scoring:

0 – 4 No depression symptoms

5 – 9 Mild depression symptoms

10 – 14 Moderate depression symptoms (therapy)

15 – 19 Moderate to severe depression symptoms (therapy and/or meds)

20 or more Severe depression symptoms (therapy and meds)

If the patient responds “yes” to question 9, the risk of suicide needs to be determined and a plan for safety developed.

Suicide Warning Signs

People who kill themselves exhibit one or more warning signs, either through what they say or what they do. The more warning signs, the greater the risk.

Talk

If a person talks about:

• Killing themselves.

• Having no reason to live.

• Being a burden to others.

• Feeling trapped.

• Unbearable pain.

Behavior

A person’s suicide risk is greater if a behavior is new or has increased, especially if it’s related to a painful event, loss, or change.

• Increased use of alcohol or drugs.

• Looking for a way to kill themselves, such as searching online for materials or means.

• Acting recklessly.

• Withdrawing from activities.

• Isolating from family and friends.

• Sleeping too much or too little.

• Visiting or calling people to say goodbye.

• Giving away prized possessions.

• Aggression.

Mood

People who are considering suicide often display one or more of the following moods.

• Depression.

• Loss of interest.

• Rage.

• Irritability.

• Humiliation.

• Anxiety.

Safety Planning Intervention (SPI)

The SPI was developed as an alternative to two interventions often used for suicidal patients whose condition is considered not serious enough for hospitalization: (1) providing the patient with a referral to mental health services (which he or she may not use) and (2) creating a ‘no suicide’ contract (an intervention which has never been rigorously evaluated and shown effective).

What can clinicians and patients look at together?

• What are the warning signs of an impending suicidal crisis? What thoughts, moods, thinking styles, and behaviors are going on when thoughts of suicide occur?

• What are coping strategies that can be done alone, in case there isn’t anyone to turn to immediately?

• When there are people to turn to, who are those people? What social settings could someone go to that might help them feel better? (These social contacts and settings are used for distraction from suicidal thinking, not crisis intervention.)

• When a crisis is imminent, who is a trusted person to be honest with about being in a suicidal crisis?

• What mental health providers are available? How can help be sought?

• What lethal means (or methods for attempting suicide) can be restricted, and how?

See Appendix for more on suicide.

c. Treating Depression

Treatment is similar to that for anxiety disorders, above. Cognitive behavioral therapy and/or medication is indicated for moderate to moderately severe depression, and severe depression is treated with both. The discussion of the Black Box Warning applies even more to teens with depression than it does to those with anxiety, since they are more apt to be suicidal. A large study in the early 2000’s showed that treating depressed teens with medication (fluoxetine) alone was more effective than therapy alone; the combination was the most effective.

• Fluoxetine (Prozac) is the only SSRI approved by the FDA for treating children for depression, so that is usually the drug of choice.

• If there is no improvement at 20 mg after 6 weeks, the dose can be raised as high as 60 mg in steps; if still not effective a different SSRI is used (chosen from those listed under anxiety).

• If 2 or 3 SSRIs have been tried without success,

o buproprion (Wellbutrin) is then the drug of choice (contraindicated if history of seizures); Wellbutrin SR should be started at 150 mg for 4 days, then increased to 150 mg BID, then to 200 BID if needed

For clinicians with adequate training and experience:

• Other drugs that can be tried including an SNRI (venlafaxine (Effexor), 75 mg QD, up to 225 mg or duloxaletine (Cymbalta), 20 mg, increasing to 40-60 mg) or mirtazapine (Remeron), 15 mg (because it causes somnolence in more than half of patients, it should be taken h.s.), up to 45 mg, increasing the dose every 1-2 weeks

• If there is reason to believe that the depression might represent the onset of bipolar disorder (see below), lamotrigine or lithium can be tried.

DISCONTINUATION

Withdrawal effects can occur when any antidepressant is abruptly discontinued. For patients taking SSRIs, abrupt withdrawal can cause malaise, light-headedness, restlessness, sleep and sensory disturbances, and headache. Although not life-threatening, such symptoms can be distressing to the patient, since they may easily be mistaken for symptoms of returning depression.

The severity of SSRI withdrawal syndrome appears to vary according to the half-life of the drug. Fluoxetine, which has the longest half-life of the SSRIs, appears to produce the fewest withdrawal symptoms, while paroxetine produces the most pronounced discontinuation effects. Thus, whereas all SSRIs should be discontinued over a 1-to 2-week period, the smallest stepwise decrements in dose should be used when withdrawing paroxetine.

Half-live of SSRIs

|Drug |Half life |

| | |

|Citalopram |31 hours |

|Fluoxetine |4-5 days |

|Fluvoxamine |15-26 hours |

|Paroxetine |21 hours |

|Sertraline |26 hours |

Fluoxetine is easily tapered. Decreasing the dose by half for a week, then discontinuing it is fine.

For the meds other than paroxetine, reduce the dose by 25% for 3-4 days, then 25% more for another 3-4 days, then, in the absence of side effects, another 25% and then completely. Paroxetine is VERY difficult to taper. 10% per week is recommended. [In my opinion, the better approach is to not prescribe it at all.]

If abrupt discontinuation of any SSRI is medically necessary, patients should be monitored carefully and informed about withdrawal symptoms.

Occasionally, SSRIs may need to be discontinued because of adverse events. In these cases, a long half-life can be problematic. Patients who develop intolerable adverse symptoms while taking fluoxetine, for example, may suffer from these symptoms for several days or weeks while the drug and its metabolites are cleared from the body. In contrast, drug-induced adverse events produced by the other SSRIs most likely will resolve more quickly, since these agents are more rapidly cleared from the body.

SWITCHING SSRIs (“Cross-tapering”)

Selective SSRIs overlap in their mechanism of action, and the new SSRI will usually prevent discontinuation symptoms that may occur when the first SSRI is stopped. Substituting a new SSRI at the relatively equivalent dose of the former SSRI is typically well-tolerated though starting the new SSRI at a lower dose may also be considered since patients occasionally have idiosyncratic side effects to particular SSRIs. At this time, there is no consensus on the best approach. One that is often discussed, and the approach I use, is as follows:

To switch FROM fluoxetine, cease the fluoxetine stat and immediately begin the new SSRI from lowest dose and increase as per usual. To switch from any other SSRI, taper down the SSRI more rapidly than when you are discontinuing it—e.g. over a week—and build up the new SSRI to the lowest effective dose over a week.

Example: patient is taking 40 mg a day of citalopram with no improvement. You decide to switch to sertraline.

Day 1: decrease citalopram to 20 mg and initiate sertraline at 25 mg

Day 4: decrease citalopram to 10 mg and increase sertraline to 50 mg

Day 8: discontinue citalopram and maintain sertraline at 50 mg.

Day 22: increase sertraline to 75 or 100 mg if 50 is not effective.

d. Dysthymic Disorder

Dysthymia can seem to be a mild form of depression. It is a chronic condition characterized by depressive symptoms that occur for most of the day, more days than not, for at least 2 years. The teen is irritable, not depressed, and the symptoms must have been present for at least 1 year. During this period, any symptom-free interval can not have lasted longer than 2 months.

We commonly see impairment in social, occupational, or other important functioning. In addition, this disorder is often associated with impaired school performance and poor social interaction. Teens with this disorder are usually irritable and cranky as well as depressed. They have low self-esteem, poor social skills, and are pessimistic. Also, they are at high risk to develop major depression.

Treating Dysthymia

In general, counseling has been the preferred treatment for dysthymia disorder. However, several recent studies have shown the efficacy of treating the disorder with SSRIs, with one study finding higher success in treating dysthymia than in depression.

Efficacy of antidepressants for dysthymia: a meta-analysis of placebo-controlled randomized trials. (Levkovitz Y, Tedeschini E, Papakostas GI. J Clin Psychiatry. 2011 Apr;72(4):509-14.)

In another study, pharmacotherapy was less effective in 'pure dysthymia' than in dysthymia with a history of major depression or in patients with concurrent major depression. [Versiani M. Pharmacotherapy of dysthymic and chronic depressive disorders: overview with focus on moclobemide. J Affect Disord 1998; 51: 323-332.]

5. Bipolar disorder

What is bipolar disorder?

Bipolar disorder, or manic depression, is a medical illness that causes extreme shifts in mood, energy, and functioning. These changes may be subtle or dramatic and typically vary greatly over the course of a person’s life as well as between individuals. Over 10 million people in the United States have bipolar disorder, and affects men and women equally. BPD is a chronic and generally lifelong condition, with recurring episodes of mania and depression that can last from days to months. BPD often begins in adolescence or early adulthood, and occasionally even in children. Most people generally require some sort of long-term treatment. While medication is one key element in successful treatment of BPD, psychotherapy, support, and education about the illness are also essential components of the treatment process.

What are the symptoms of mania? [The activated phase of BPD]

Criteria for a manic or hypomanic episode

The DSM-5 has specific criteria for the diagnosis of manic and hypomanic episodes:

A manic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). The episode includes persistently increased goal-directed activity or energy.

A hypomanic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least four consecutive days

For both a manic and a hypomanic episode, during the period of disturbed mood and increased energy, three or more of the following symptoms (four if the mood is only irritable) must be present and represent a noticeable change from your usual behavior:

Inflated self-esteem or grandiosity

Decreased need for sleep (for example, you feel rested after only three hours of sleep)

*Unusual talkativeness

*Racing thoughts

*Distractibility

Increased goal-directed activity (either socially, at work or school, or sexually) or agitation

Doing things that are unusual and that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

*can all be found in patients with ADHD

To be considered a manic episode:

The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in social activities or relationships; or to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).

Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

To be considered a hypomanic episode:

The episode is a distinct change in mood and functioning that is not characteristic of you when the symptoms are not present, and enough of a change that other people notice.

The episode isn't severe enough to cause significant difficulty at work, at school or in social activities or relationships, and it doesn't require hospitalization or trigger a break from reality.

Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

The diagnosis of bipolar disorder…”Be afraid, be very afraid” (Geena Davis, The Fly).

a. Diagnosis: “The estimated annual number of youth office-based visits with a diagnosis of bipolar disorder increased from 25 (1994-1995) to 1003 (2002-2003) visits per 100 000 population” Carmen Moreno, MD; Gonzalo Laje, MD; Carlos Blanco, MD, PhD; Huiping Jiang, PhD;Andrew B. Schmidt, CSW; Mark Olfson, MD, MPH. Arch Gen Psychiatry. 2007; 64(9):1032-1039.

There are several theories to explain this phenomenal increase in children (as young as 8 months) and teens being diagnosed with this disorder. Most believe in the concept of “The Selling of a Diagnosis,” created by drug companies selling products that were not profitable because there were too few who needed them. They worked in collusion with physician researchers who accepted funding of millions of dollars to have a fresh look at which patients could benefit from these drugs.

I have diagnosed 4 patients with this disorder in 6 years, in each case having discussed the patient with a consulting psychiatrist. The medications used to treat these patients, discussed in the Appendix, all have substantial side effects, good reason to be “very afraid” before you prescribe them. I recommend referral to a psychiatrist. On the other hand, I accept referrals with a diagnosis of “possible bipolar disorder” because that is seldom accurate.

Case

Peter is an 18 year old boy referred to me because of poor academic performance and social anxiety. On the first visit I learned that he had been diagnosed with ADHD some time ago but every medication tried caused significant side effects. I prescribed guanfacine, which was helpful as I increased the dose. But as I explored the social anxiety (he would not leave the house without his mother), some unusual symptoms came out.

He would have bursts of violence—toward walls, not toward his mother. He confided that he had a dragon in his head that warned him that he would harm his mother unless he struck a hard surface, like a wall. He learned that to get that dragon out of his head, after striking the wall, he needed to work out strenuously for 2 hours, and then do an additional 4 hours of less intensive exercise. Once he explained this to me, I referred him to a psychiatrist, with a tentative diagnosis of schizophrenia. However, he was diagnosed with BPD, and is presently being treated with 6 mg of risperidone.

Treatment: Referral to psychiatry

[Second-generation anti-psychotics, SGAs, are generally the first line of treatment, but because of the serious side effects of these meds, they should not be prescribed by adolescent medicine specialists unless they work very closely with a psychiatrist.]

6. Schizophrenia

Although onset of schizophrenia is rare before the age of 18, it must be considered in a teen who seems to be deteriorating in many areas.

Criteria:

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these should include 1 of the first 3: 

1.      Delusions

2.      Hallucinations

3.      Disorganized speech

4.      Grossly abnormal psychomotor behavior, such as catatonia

5.      Negative symptoms, i.e., restricted affect or avolition/asociality

B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

The first sign of schizophrenia in teens may be social withdrawal, according to a study in the April 1998 issue of the British Journal of Psychiatry. Other common symptoms, in addition to delusions and hallucinations, include the following:

• Trouble distinguishing dreams from reality

• Confused thinking

• Extreme moodiness

• Paranoia

• Severe anxiety and fearfulness

• Severe problems making and keeping friends

• Reduction in emotional expression

• Lack of motivation and energy

• Loss of interest in activities and social interactions

• Flat affect

Case

Brian is an 18-year-old boy who was referred for possible anxiety and some difficulties in school. He presented as a bright, engaging high school senior planning to attend UW in the fall. However he had substantial anxiety, causing him to procrastinate in getting his application finished. I started him on sertraline and we brainstormed some strategies to help him get his application submitted. The sertraline worked very well: he felt much better and subsequently was accepted at UW.

Six months later he was brought to our clinic by his aunt—over the past several weeks he had become more and more upset, and now he could not stop himself from crying. I attempted to talk with him, but he was sobbing and barely using any words. He was under so much distress that I was concerned about suicide, and referred him to the ED. From there he was admitted to the IPU with a diagnosis of anxiety disorder r/o BPD. However during his 18-day admission his diagnosis was changed to schizophrenia.

Treatment

Immediate referral to a child/adolescent psychiatrist.

7. Substance Use Disorder (SUD)

Substance abuse (or substance misuse) can be a co-morbidity of untreated ADHD, a cause of depression, a response to anxiety, or have many other parents and children.

The CAS is a useful first step.

13. Have you ever smoked cigarettes (even if you did not inhale, vaped, or chewed tobacco?

14. Have you ever drunk any alcohol? (beer, wine, liquor, other)

Did you ever get drunk or have a blackout?

15. Have you ever used drugs?

If yes, circle all that apply: Marijuana / Sniffed inhalants / Cocaine / Crack / Heroin / Acid / Speed / Ecstasy / Roofies / Shrooms / Steroids / Hormones / Prescription drugs not ordered for you / Other

16. Have you ever ridden in a vehicle when the driver was under the influence of alcohol or drugs? (This includes when you were the driver or when other people were driving.) Note: This is a red flag question—a positive requires an extensive discussion on the spot.

17. Have you ever been told by a friend or family member that you are using too much alcohol/ drugs?

If a patient answers “yes” to getting drunk; using drugs; having ridden in a vehicle when the driver was high; or being told that he or she is using too much alcohol or drugs, the CRAFFT questions should be asked. It is an excellent screen for these problems, leading to a referral to a substance abuse counselor if indicated.

a. CRAFFT

Part A

Screening for SUD using CRAFFT

During the PAST 12 MONTHS, did you:

|1. Drink any alcohol (more than a few sips)? | Yes | No |

|2. Smoke any marijuana or hashish? | Yes | No |

|3. Use anything else to get high? “anything else” includes illegal drugs, over the counter and prescription | Yes | No |

|drugs, and things that you sniff or “huff” | | |

If you answered NO to ALL (A1, A2, A3), answer only B1 below, then STOP.

If you answered YES to ANY (A1, A2, A3), answer B1 to B6 below.

Part B

|1. Have you ever ridden in a CAR driven by someone who was high or had been using drugs or alcohol? |1. Y___N___ |

|2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? |2. Y___N___ |

|3. Do you ever use drugs or alcohol when you are ALONE? |3. Y___N___ |

|4. Do you FORGET things you did while using drugs or alcohol? |4. Y___N___ |

|5. Do your family or FRIENDS ever tell you that you should cut down your drinking or drug use? |5. Y___N___ |

|6. Have you ever gotten into TROUBLE while using drugs or alcohol? |6. Y___N___ |

|(2 or more positives is significant | |

Four or more positives means the patient most likely has SUD, and a referral to a substance abuse counselor is indicated. For 2 or 3 positives, some judgment is called for. For teens who are using tobacco, smoking marijuana, and/or consuming alcohol, if they believe it is not interfering with their lives they are not likely to have any interest in seeing a therapist. In such cases, they may agree to an educational visit with an SUD counselor, without making a commitment for treatment.

Key areas to explore for alcohol and marijuana use:

• Age at which use began

• Frequency

• Amount

• Is it staying constant or increasing

• In what circumstances (e.g., with friends on weekends versus in bedroom)

• Any trouble with authorities (e.g., DWH, busted for possession, suspended by school, grounded by parents, etc)

• (For marijuana) What is the source

• Deteriorating performance at school or in other important areas

• Dropping activities previously enjoyed (e.g., a sport, an instrument).

It is important to discuss the risks of alcohol and marijuana, and provide information on how they affect the brain. And remember, this is not your (or your parents’) marijuana. Compared to 30 years ago, the marijuana today is at least 4 times as potent.

After discussing these issues, unless you have come to the conclusion that you need to refer a teen for SUD counseling, it is often helpful to ask patients to “talk to themselves,” being completely honest, and then make a determination of whether they want to change their behaviors.

Cases

George is a 17-year-old boy I saw for depression; I also diagnosed ADHD. On the first visit, he told me that he drank a bit—perhaps 10 beers on a weekend night! He felt he was fine, since his older brother drank 15-20 beers at a time (of course, his brother was on his third rehab stint). And his father was an alcoholic. Over the years I worked hard at pushing George into treatment, with no luck. He went off to college, where he added marijuana to his substances. I finally convinced him to see a counselor the next time he was home from college. Then we got a call from George’s mother telling us that he had been busted for dealing cocaine.

Priscilla is a 16 year old girl referred to me for treatment of her depression. I also made a diagnosis of ADHD, and she ended up on Adderall XR. She smoked marijuana a bit—mainly on weekends, just enough to reduce her anxiety (she said). I checked in with her at each visit, and she seemed stable and set to graduate from high school on her way to community college. Then her mother called to tell us that she had been busted for selling the Adderall.

So with these triumphs behind me, I am now much more aggressive in referring these patients for counseling.

See Appendix for more information on effects of substance use.

8. Insomnia

The remaining topics are not behavioral disorders. But problems in these areas have a significant effect on behavioral health disorders, so are included in this Handbook. Sleep is the grease for all aspects of an adolescent’s wheel. If patients do not get enough, they will be tired all the time—leading to falling grades, withdrawal from social contact, irritability. This could because they stay up to 2 AM playing video games; or they stay up to 2 AM texting a girlfriend or boyfriend; or they have anxiety leading to difficulty falling asleep; or they are struggling with writing assignments and stays up to 2 AM trying to complete them, etc.

The CAS asks:

Question 24: Are you having trouble falling asleep? ___ Staying asleep? ___ Waking up? ___

Have you been told that you snore?

For those who have a sleep problem, it is helpful to do a BEARS screen:

BEARS sleep screen:

|Bedtime problems |Do you have any problems falling asleep at bedtime? |

|Excessive daytime sleepiness |Do you feel sleepy a lot during the day? In school? While driving? |

|Awakenings during the night? |Do you have trouble getting back to sleep? |

|Regularity and duration of sleep |What time do you usually get to bed on school nights? Weekends? How much sleep |

| |do you usually get? |

|Sleep-disordered breathing (Parents) |Does your teenager snore nightly? |

Studies have shown that teens need an average of 9.25 hours a night. Since most of them have to be up at 7 AM or earlier to get to school, that would mean a bedtime of 9:30 or so. With the expectations of schools (mandated by the state) of 2-3 hours of homework a night, not to mention the reasonable desire of teens to relax and have some fun, that bedtime is clearly unrealistic. [Athletes, an activity good for health in so many ways, often do not get home until 5 PM or later, making it even more difficult for them to go to bed at a reasonable time.] Other studies show that it is not healthy to sleep more than 2 extra hours on a weekend day to compensate, so “sleeping in” until noon or later is not much of a solution (it plays havoc with their circadian rhythm).

The only good solution would be for school to start at 10 AM, which would fit with the normal teen circadian rhythm. It would also help if nightly homework were reduced to ≤2 hours—that would be more than adequate to “get them into (name your school).” Given our inability to change public policy, the best we can do is to help teens determine what time it is reasonable to go to sleep, and then discuss ways for them meet their goal.

Asking patients to keep a sleep diary is a good first step, and providing them a handout on Sleep Tips can be helpful (see Appendix). If the problem persists, a referral to the Sleep Clinic is indicated.

9. Bullying

Bullying can have a profound effect on its victims. Its effects include significantly higher chances for depression (occurring almost 8 times as often) plus psychosomatic symptoms including headache, sleeping problems, abdominal pain, bedwetting, and feeling tired. In addition, it is often a contributing factor to school refusal behaviors. Interestingly, children who themselves actively bullied did not have a higher chance for most of the investigated health symptoms. Clinicians working with children who report early symptoms of psychosis should inquire about traumatic events such as maltreatment and bullying.

Bullying comes in many forms, including:

• physical

• verbal

• emotional

• being bullied through lies and rumors

• having money or other items taken or damaged

• being socially excluded

• being forced to do things

• cyberbullying

The CAS asks:

Question 22. Has there ever been anyone at home, school or anywhere else, who made you feel afraid, threatened, bullied, or who hurt you? (This includes cyberbullying.)

Certain teens are at increased risk for being bullied (see Appendix). A discussion of the following topics can also be found there.

Frequency of bullying

Who is likely to get bullied?

When to suspect a child is being bullied

Medical consequences of being bullied

What a parent can do if his or her child is being bullied

Cyberbullying compared to traditional bullying

How a clinician can help a teen avoid being cyberbullied

10. Difficult Home Environment

The CAS asks about aspects of family life:

18. Is there anyone who lives in your house who uses drugs or alcohol in a way that worries you?

20. Is there a handgun in your home?

33. Do you have at least one friend who you really like and feel you can talk to?

34. Do you have at least one adult whom you feel you can talk to?

35. Do you think your parent(s) listen to you and take your feelings seriously?

Problems at home can include:

• severe stress caused by divorce;

• overprotection, over-ambition, over-intrusion;

• communications: mixed, inconsistent or confusing messages;

• sexual, physical, or emotional abuse experienced or witnessed;

• parents newly married or newly divorced;

• new sib or step-sib in household;

• death in the family;

• moving to new house or new school;

• financial strains;

• food insecurity;

• substance abuse in parent or sibling;

• developmental disability in sibling;

• mental illness in parent or sibling;

• parent in legal trouble/prison;

• other

Several of these issues are discussed in detail in Appendix.

11. Sex, Drugs, Rock-n-Roll: Understanding Normal Teenage Behavior (thank you, Vic Strasburger)

The CAS asks:

Question 37. Have you ever had vaginal, anal, and/or oral sex?

Has your patient had a girl friend and she dumped him; or he wants to have sex and she doesn’t; or he wanted to have sex and his male partner did not; or she wants to have sex and he doesn’t; or they had sex and he had trouble performing; or they had sex and her period is late, etc.

The CAS asks:

Question 2. Have you had a head injury in the past year that caused headaches, dizziness or other problems?

Perhaps your patient suffered an undiagnosed concussion while playing lacrosse a month or 2 ago.

(Some symptoms of a concussion may be delayed in onset by hours, days, or even longer after the injury. They include concentration and memory complaints, irritability and other personality changes, and psychological problems and depression.)

The CAS asks:

Question 44. What plans do you have for after you graduate from high school?

Has your patient been putting a lot of pressure on him- or herself to do well in school and get into Elite U, because a brother went there (or because a brother was not accepted there)?

Have his or her parents have been pushing them to play elite soccer 12 months a year, to get a scholarship?

Suppose your patient met some cool peers who smoke a little pot, drink a little beer, do a bit of this or that—much more fun than studying or orchestra rehearsals.

Is the adjustment to high school hard right now—and he or she will get A’s and B’s next semester?

Is your patient pushing parental limits, in an effort to separate?

Those of us who care for adolescents, after considering these kinds of issues, should then ask what is it like to be living their life and would they like to change it.

The CAS asks:

Question 45. If you could change one thing about your life, what would it be?

And then ask if you can be helpful.

Ros Gallagher understood adolescents best

I began this handbook with a story told by Ros Gallagher. I am ending it with more of his wisdom. In 1954 he was interviewed by the Saturday Evening Post about the new field he was developing. The article closed with the following:

“You think you can put a brace on the spine of a little child, you can tell an adult that he should go and get one, but if, without inquiry into the state of his spine, you fasten a brace to a sixteen-year-old, you can expect a twisted brace, a warped personality and broken appointments. The neglected adolescent is going to do something, which will bring attention to more than his back. He is more aware of himself than a child, less willing to sacrifice part of himself than the adult, and unwittingly demands the very sort of medical attention that all people should have.”[pic][pic][pic][pic][pic][pic][pic]

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This chart lists the components of “executive functions.”

d. Treating ADHD (more in Appendix)

This chart shows the two prime “families” of medication, as well as the immediate release and sustained release drugs for each family. Medications selected from one of these families are almost always effective—as many as 90% of teens will do well with one of them. Other choices are listed below.

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