Dr. Hinlicky's Practice  
     
     
Frequently Asked Questions
Frequently Asked Questions

Attention Deficit Hyperactivity Disorders

As a physician trained in child/adolescent psychiatry and pediatrics, I evaluate and treat many patients with suspected and diagnosed ADHD. I am a strong believer in holistic approaches to managing problems. Therefore, I attempt to find the most effective combination of treatments that suits a patient's sensibilities. In ADHD, this approach usually involves family, child, school and community. It encompasses educational work directed toward patient and family, behavioral treatment when needed, dietary and lifestyle adjustments when appropriate, psychotherapy, and includes the possibility medication and other remedies. Psychoeducational evaluation may also be recommended and utilized to direct treatment.

Learning Differences and Disabilities

As part of my training, I spent a year at the Kennedy Krieger Institute. After completion of training, I spent more than 10 years at Kennedy, working as psychiatric consultant to the Kennedy School and to the School problems evaluation team. I am therefore interested in and familiar with the presentation and evaluation of "school problems," which frequently includes learning differences. I enjoy the team approach to evaluation and treatment. I am also sensitive to emotional and other difficulties that living with learning differences can invoke, and enjoy working with people to minimize the impact these problems have on their lives.

Asperger's Disorder Information


Asperger's Disorder

Definition and Description:

Asperger's Disorder was first described in the 1940's by Hans Asperger who observed autistic-like behaviors and difficulties with social and communication skills in boys who had normal intelligence and language development. Although Asperger's is similar to Autism, and indeed is "an autistic spectrum disorder," it differs from Autism in severity of symptoms and absence of language delays. Children with Asperger's may be only mildly affected and frequently have good language and cognitive skills. A child with Asperger's may, on the surface, seem like "just a normal child behaving differently," but this is not the case.

Individuals with Asperger's are not aloof as many children with Autism are. They usually want to fit in and interact with others,they just don't have the inherent knowledge of how to interact. So they are frequently socially awkward, often cannot understand conventional social rules, and seem to lack empathy. This discrepancy between wanting to be social and being unable to do so successfully often creates sadness and heartache for the Asperger's child and his family.

Children with Asperger's usually have obsessive interests in particular subjects. They may like to collect things, such as rocks or baseball cards. They often are unusually proficient in knowing extensive bits of information, such as baseball statistics. Although they often have unusually strong rote memories, they often have difficulty with abstract concepts, which can perplex parents and teachers of these children, who seem so bright in many ways. This tendency toward obsessiveness is also called "perseveration," a symptom present in other neurologically based disorders as well.

In Asperger's (unlike in Autism) there is no speech delay. Asperger's children often have quite good language skills, but they may use language in different ways. Speech patterns may be unusual, lack inflection or have a rhythmic nature. Or speech may be too formal, too loud or unusually pitched. In addition, the subtleties of language, such as irony and humor, may be lacking in children with Asperger's; and these children often lack the give and take (reciprocity) of conversation, which clearly impacts social relationships.

Given the above characteristics, children with Asperger's may:
-engage in one-sided long-winded conversations, without noticing if the listener is listening or trying to change the subject
-display unusual nonverbal communication, such as lack of eye contact, few facial expressions, or awkward body postures or gestures
-show an intense obsession with one or two specific narrow subjects
-appear not to understand or empathize with others' feelings
-have a hard time "reading" other people
-speak in a voice that is unusual
-move clumsily
-have an odd posture or gait

General cognitive ability is preserved in Asperger's, but may be seriously impaired in Autism. The definition of Asperger's requires normal intelligence. Some children with Asperger's also have associated problems including Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and one or more specific learning problems.

Children with Asperger's often display motor difficulties as well; they are usually clumsy or awkward, and may have specific motor skill delays.





Diagnosis:

Formal diagnosis of Asperger's Disorder is usually made by a child psychiatrist or pediatrician, and requires documentation of a symptom set as described in the DSM or Diagnostic and Statistical Manual of Mental Disorders. Basically, this requires specific symptoms under two general categories, including: 1. qualitative impairment in social interaction, and 2. Restricted repetitive and stereotyped patterns of behavior, interests and activities.

Further details of diagnostic criteria can be found in the DSM IV Manual.

Treatment:

Asperger's is a difficult disorder to have and to live with as a parent or teacher. There are no medications that "cure" Asperger's, although several types can help control some of the symptoms associated with the disorder.

If the child has ADHD, the usual medications for ADHD may help these symptoms.

I child who has difficulties with perseveration can be extremely frustrating and exhausting. Parents often find this symptom one of the hardest to cope with in their child with Asperger's. No medication has been shown to effectively "cure" this symptom, but some children have experienced improvement with the use of an SSRI (selective serotonin reuptake inhibitor) like Prozac, Zoloft or its relatives.

Recently, another group of medications has been approved for use in children with autism and related disorders. This is the group called "atypical antipsychotics" and includes risperidone, Zyprexa and Abilify. This group of medications has some additional side effects, so should be discussed in detail with your care provider.

Treatments other than medication are also suggested. Social skills training is a type of therapy that can be very helpful but is difficult to find in the community. In addition, it is hard to generalize gains made in the group to life outside the group. Age-appropriate psychotherapy can range from play therapy in younger children to supportive and cognitive behavior therapy in older patients, and can be very helpful, especially as the child or teenager begins to understand the social difficulties that emanate from his disorder. Family work can also be very helpful, and can facilitate understanding and coping strategies.

Educational support and intervention is also important in optimal treatment. Full psychoeducational evaluation is necessary to clarify the specific child's strengths and weaknesses, in order to effectively engineer a unique set of accommodations and remedial strategies. Not all Asperger's children have the same set of problems, so individualization is essential educational strategies should include in addition a few simple interventions: it can help to notify the student ahead of time about upcoming transitions and changes in routine. Sometimes a child can benefit from a quiet place to retreat to in case of overstimulation or excessive frustration. The educational ramifications of executive dysfunction are wide and serious. This group of symptoms includes the organization and planning that increases with each step in the school process. Deficits in this area lead to missed assignments, late completion of longterm projects, inadequate preparation for tests due to poor study skills or just not knowing when a test is scheduled. Executive dysfunctions are extremely handicapping, but can also be greatly ameliorated by relatively minor, simply interventions. These can include: routine agenda/planner monitoring, emails between student/parent and teacher to facilitate knowledge about assignments, upcoming tests, and projects, the need to complete makeup work, etc. The goal should be increasing a student's independence in this area. But parents and teachers need to be sensitive to the fact that these skills are often very delayed and not under the student's complete control. So problems in the executive area are not necessarily poor or oppositional behavior. In fact, many students want to do well but simply cannot organize themselves adequately to accomplish their work.

Asperger's disorder is an increasingly diagnosed disorder that is frustrating for patient, family and community. It is not well understood, but our knowledge is increasing rapidly. These children are truly impaired and suffer from their impairments, as to their families. Optimal growth for a given child requires the coordinated work and support of family, school, community and medical/psychological professionals.


Sources of Information:

www.aspergers.com
www.ncpamd.com (Asperger's Disorder section of ncpamd written by Carol Watkins, M. D.)
www.autism-society.org
Facts for Families from the American Academy of Child and Adolescent Psychiatry (www.aacap.org)
Diagnostic and Statistical Manual of Mental Disorders fourth Addition, DSM-IV.


NOTE: I have attempted to paraphrase information from all of the above sources in order to compile a set of definitions and recommendations that I think best explains and typifies Asperger?s Disorder. All of the above sources are public, most are on the web, and available to all readers for further details.

Depression


DEPRESSION


The following is my synopsis of the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive disorders. There is some solid information about causation, clinical presentation, comorbidity, differential diagnosis, and treatment, including medication pros and cons. I have added some personal comments as well.

Depressive disorders are some of the most commonly seen problems in child and adolescent psychiatry, and have the potential to cause severe dysfunction in the child and the family. Young people with depression have problems in family, social and academic functioning and run the risk of suicide, substance abuse and persistent depressive symptoms.

Epidemiology The prevalence of Major Depressive Disorder (MDD) is about 2% in children and 4-8% in adolescents; male to female ration in childhood is 1:1; in adolescence is 1:2. Another 5-10% of children have some depressive symptoms but not enough to meet stringent diagnostic criteria.

Clinical Presentation It is important to remember that the symptoms of depression range along a continuous spectrum from very mild to very severe. Also the symptoms of depression should represent a change from the child or youth's normal baseline. Depressive symptoms can include, among others:

*Depressed or irritable mood
*Loss of interest and pleasure
*Wishing to be dead
*Thought of suicide or attempts
*Change in appetite and/or weight
*Change in sleep patterns
*Decreased activity
*Decreased concentration
*Low energy
*Low self worth
*Exaggerated sense of guilt
*Change in school functioning, drop in grades
Children and adults are similar but not identical in their presentation of depression. For example, children can present with irritability and temper tantrums instead of saying they feel depressed. It is important to know that depression can masquerade as many other problems, so it is important to ask for help from a professional if there is any doubt.

Comorbidity Many children with depression have other disorders. As many as 40-90% have comorbid disorders?that is, coexisting problems. The most frequent of these are anxiety disorders, disruptive disorders, Attention Deficit Hyperactivity disorder (ADHD) and substance use.

Differential diagnosis Several medical and psychiatric disorders may mimic depression and may need to be ruled out before making a diagnosis of depression. These may include:

*anxiety
*Oppositional defiant disorder
*Pervasive developmental disorder
*substance use/abuse
*hypothyroidism
*mononucleosis
*anemia
*autoimmune disorder
*premenstrual dysphoric disorder
*chronic fatigue syndrome

Treatment Treatment of depression needs to include psychoeducation, support, family and school involvement at every level of treatment. Treatment is also divided in acute, continuation and maintenance phases. The acute phase is geared to achieving symptomatic remission, the continuing phase is geared toward consolidating the gains made in the acute phase, and the maintenance phase is geared toward maintaining improvement and preventing relapse.

Psychoeducation refers to education of patient and family about all the aspects of depression and risks associated with the illness and its treatment. The goal is to make treatment transparent; hopefully patient, family and doctor will develop a team approach toward management of this disorder. Supportive treatment should be individualized, depending on the specific needs of the patient and family. Supportive treatment may include active listening, restoration and maintenance of hope, problem solving, coping skills and strategies for management and planning.

Family involvement is key since most parents are intimately and anxiously involved in their child's successes and problems, and the child's welfare is intimately intertwined with the parents and siblings, who provide support, motivation for treatment, transportation to therapy, communication with school and community, and countless other roles in the child's life. Formal family therapy may or may not be necessary in a given clinical situation.

School is also a key element in treating depression, as a child spends the greatest part of his/her waking hours involved at or with school. It is often hard for school personnel to understand the difference between depressive symptoms and difficult behavior since they may look very similar. Understanding depression strongly colors a school's reaction to a patient. Appropriate supports and accommodations can mean the difference between success and failure in school, and are therefore vital to a child's self image and life success.

There have been many studies and discussions of what type of treatment works best for depressed children and youth. Studies seem divided as to whether medication or psychotherapy or the combination achieves the best remission and maintenance of remission. Confounding the picture is the wide range of psychotherapy techniques that have been used in the various studies. My sense is that the clinician must do as in-depth an evaluation of the child and family as possible; and make a deliberate effort to recommend the combination of treatments that seems to best fit the specific child and family. My sense is that most patients do best with some combination of psychotherapies, and many require the addition of antidepressant medication as well.

The question of medication often comes up when a child is being treated for depression. In mild or short-lived depression, education, support and management may be sufficient treatment. In more severe or protracted cases, medication may become a recommendation. More and more, the medical community turns quickly to the use of antidepressants?an issue which has sparked great debate among medical personnel and patients and families
.
SSRI's (selective serotonin reuptake inhibitors) are the most commonly prescribed antidepressants for children and teens. This group includes Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluoxetine), Celexa (citalopram) and Lexapro (escitalopram). Other frequently used medications include Effexor(venlafaxine), Cymbalta (duloxetine), Wellbutrin(buproprion) and the tricyclic andidepressants, which have become second line choices because of concern about side effects.

There is a current debate among psychiatric professionals as to whether there is demonstrable evidence of actual effectiveness of the SSRI's and other antidepressants in children. There is a paucity of studies, and their results are divided. It is reasonable to question the literature in this regard, and families are advised to raise these questions with their treating professionals. My feeling, based on experience and not on the data, is that antidepressants, especially SSRI's, can be an effective and relatively safe intervention that can help certain children immeasurable. Judicious dosing and careful follow up are essential to a positive outcome and avoidance of negative side effects.

One note of caution: many psychoactive medications have not yet been fully tested in children and teenagers, and are not formally approved by the DEA for use in younger people. The standard of care in the field allows and encourages their use in a disciplined well-monitored manner. This is the current state of child psychiatry?that the medications we use are usually tested in adults and approved in older people long before they are approved in children; and they are already in common use, based on adult response, before the formal approval is achieved. This is another point to be discussed in full with your treating professional.

The SSRI's have been well-tolerated in children, with a minimum of bothersome side effects. The can include gastrointestinal symptoms, sleep changes (insomnia or somnolence, vivid dreams, nightmares), restlessness, sweating, headaches, appetite changes and sexual dysfunction. A small percentage of children develop impulsivity, agitation, irritability, silliness and "activation." The noradrenergic antidepressants (not the SSRI group, but includes
Effexor, Cymbalta) have a different set of side effects, and may cause elevation in BP and heart rate, as well as other side effects. Wellbutrin carries a caution about possible seizures in doses greater than 400 mg/day. This is by no means a complete list of side effects of all these medications. It is intended to discuss some of the more common ones, and should be a jumping of point for discussion with your doctor.

There has been a recent discussion in the press and psychiatric literature about a possible increase in suicidal thinking that might occur with SSRI use. This question continues to be investigated. There appears to be a small but statistically significant elevation in suicidal thoughts with antidepressant use in children. My feeling is that, because the increase is real but small, it should not be a deterrent to antidepressant use, but should be an important point of discussion and monitoring in all patients, and needs to be discussed as a precaution in all patients.

Once medication is started and the patient responds, it is generally recommended to continue the medication course for about a year. This is also a point of ongoing research, and recommendations may change as additional data becomes available.

The diagnosis and treatment of depression in children is a complex topic, and the above information is just a beginning in investigating the topic. The AACAP has released a full discussion of depression in children entitled : Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. It can be located in the Journal of the American Academy of child and Adolescent Psychiatry, November 2007 issue. JAACAP 46:11, November, 2007.