Medication For Children with Psychiatric Disorders
It is important for the clinician discuss the initiation of medication versus a specific type of psychotherapy with the informed consent of the parents or guardian. It is also important to inform and involve the child or adolescent to the extent that it is developmentally appropriate. As the child or adolescent gets older he or she should be increasingly involved in the treatment decisions. When choosing a specific medication, one should consider what the child has responded to in the past and which medications have worked well in close relatives. One often has to address family, school and community concerns about medication.
Medication Treatment of Children and Adolescents with Major Depression
Medication algorithm for treating children and adolescents who meet DSM-IV criteria for major depressive disorder. The Children’s Medication Algorithm Project algorithms are in the public domain and may be reproduced without permission, but with appropriate citation. The authors bear no responsibility for the use of these guidelines by third parties.
SSRI = selective serotonin reuptake inhibitor;
BUP = bupropion;
MIRT = mirtazapine;
NEF = nefazodone;
TCA = tricyclic antidepressant;
VLF = venlafaxine;
ECT = electroconvulsive therapy.
Adapted from Crismon et al. (1999).J Am Acad Child Adolesc Psychiatry 1999 November;38(11):1442-1454 Copyright © 1999 American Academy of Child and Adolescent Psychiatry. All rights reserved Published by Lippincott Williams & Wilkins
SSRIs (Selective Serotonin Reuptake Inhibitors–sertraline, paroxetine etc.) have brightened the outlook for the medication treatment of child and adolescent depression. The side effects are not as annoying as those of the older medications. These medications are somewhat less toxic in overdosage. Controlled studies have shown that the SSRIs are better than placebo for depression. As compared to adults, adolescents are a bit more likely to become agitated or to develop a mania while they are taking an SSRI. These medications can decrease libido in both adolescents and adult. Minimal anticholinergic or cardiac side effects Anxiety and agitation may occur when starting or increasing the dose of an SSRI. If the dose adjustment is done gradually, many people develop tolerance to this side effect develops. Behavioral side effects have included motor restlessness and behavioral disinhibition. Decreased sex drive and delayed orgasm are common side effects. Other potential side effects include insomnia, headaches, nausea, and diarrhea. In my own experience I see somewhat more restlessness and disinhibition and a bit less of the sexual side effects in children and adolescents. Fluoxetine, sertraline, citalopram and escitalopram are commonly used as an initial medication. Fluoxetine now has FDA approval for the treatment of depression in children and adolescents. The other SSRI medications do not as of yet have FDA approval for depression in children. These last two have fewer interactions with other medications. In mid 2003, the FDA recommended that paroxetine (Paxil) not be used in children or adolescents under 18.
Bupropion (Wellbutrin) This medication can be helpful for depression and AD/HD but is less effective for comorbid anxiety. It does not seem to cause weight gain.
Tricyclics: (impramine, desipramine, nortryptiline) There is not a lot of good research data showing tricyclic antidepressants working better than placebo in children and adolescents. However, many of us have seen children and adolescents who have clearly benefited from these medications. There are a number of good studies showing good antidepressant effect in adults. Thus we still use these medications if the SSRIs and bupropion do not work. Because the tricyclics are more likely to cause rhythm changes in children, consider baseline and periodic EKGs. Side effects may include dry mouth, dry eyes (problem if contact wearer) dizziness, EKG, pulse and rhythm changes. One may consider a tricyclic earlier if the individual has anxiety comorbid with AD/HD or enuresis because the tricyclics can help these conditions.
We may add an augmenting medication if the child has had a partial response to the initial medication has occurred in prior treatment or when there is the possibility of drug-drug synergy. Advantages of augmentation include the fact that one need not stop the initial SSRI, the lack of a response lag, and the possibility of drug-drug synergy. Medications used to augment the SSRIs include Lithium, buspirone stimulants, and bupropion. Some clinicians also use thyroid hormone to augment antidepressants, but there is limited data to support this.
Combine SSRI or another antidepressant with an antipsychotic. If multiple medications fail, one may need to consider ECT.
One may need to do a more thorough work up. Examine the family history to look for a history of bipolar disorder. If there is suspicion that this is a manifestation of a bipolar disorder, one may also consider treating the patient with an antipsychotic alone or with an antipsychotic along with a mood stabilizer.
Cognitive behavioral therapy is often a good first choice. If this fails or if anxiety is severe, medication can be effective.
Medication is more effective for: OCD, Generalized anxiety, School Phobia and Separation anxiety, Panic attacks and agoraphobia. Medication can be effective in Selective Mutism, Social phobia (Generalized and specific) Medication is often less effective in simple phobia. The use of medication is controversial in a simple adjustment disorder.
Fewer side effects than many other medications. Less likely to cause serious medical problems if there is an overdose. Minimal anticholinergic or cardiac side effects Anxiety and agitation may occur when starting or increasing the dose of an SSRI. If the dose adjustment is done gradually, many people develop tolerance to this side effect develops. Behavioral side effects have included motor restlessness and behavioral disinhibition. Decreased sex drive and delayed orgasm are common side effects. Other potential side effects include insomnia, headaches, nausea, and diarrhea. In my own experience I see somewhat more restlessness and disinhibition and a bit less of the sexual side effects in children and adolescents.
Consider these if two or more SSRIs fail. Because the tricyclics are more likely to cause rhythm changes in children, consider baseline and periodic EKGs. SIde effects may include dry mouth, dry eyes (problem if contact wearer) dizziness, EKG, pulse and rhythm changes. One may consider a tricyclic earlier if the individual has anxiety comorbid with AD/HD or enuresis because the tricyclics can help these conditions. Clomipramine (Anafranil) is quite effective in individuals with OCD.
These medications can be used on a short-term basis to control severe anxiety while waiting for SSRI or tricyclic to take effect. Sedation is a side effect. Use caution in adolescents with a history of substance abuse. They can have an additive effect with alcohol. Clonazepam lasts longer and is less likely to have a withdrawal effect than a shorter-acting drug like Xanax.
We may use the newer antipsychotics in treatment-resistant OCD but less often in individuals with other forms of anxiety.
These are sometimes used as an augmentation strategy in individuals with treatment-resistant OCD.
Beta blockers are useful for peripheral aspects of anxiety, shakiness, palpitations, good for performance-related anxiety, May need EKG or BP check in some cases. They may help break the vicious cycle in which the peripheral aspects of anxiety increase the person’s perception of an impending panic attack.
Buspirone (BuSpar): Relatively little in the way of controlled studies that show that it works as a primary medication for anxiety. May help in mild, non-panic cases, or as an add-on to the SSRIs. May need higher doses.
Medications may be useful for symptoms which interfere with participation in educational interventions or are a source of impairment or distress to the individual. The medications are not specific to autism and do not treat core symptoms of the disorder and their potential side effects should be carefully considered. The neuroleptics, selective serotonin reuptake inhibitors, tricyclic antidepressants, lithium and mood stabilizers, and anxiolytics have been used in these patients with varying degrees of success.
Dietary and other alternative treatments are not clearly established as being efficacious. Families should be helped to make informed decisions about their use of alternative treatments. Treatments that pose some risk to the child and family should be actively discouraged
Alpha Agonists (clonidine guanfacine) These medication sometimes decrease tic frequency and help with explosive behavior and mood swings.
The tics often respond to typical and atypical antipsychotics. However because of the long and short-term side effects of these medications, we often try other medications first. These may include clonidine or guanfacine. There is some new data supporting the use of baclofen and botulinum toxin for some tics. Behavioral techniques are sometimes useful. Tics in Tourette syndrome: New treatment options.
Tourettes often coexists with AD/HD, OCD and other disruptive behavior disorders. Each individual must be evaluated on a case-by-case basis. Treat the symptoms that are the most distressing. The tics may not be the most distressing symptom. We used to avoid stimulants in individuals with tics and AD/HD. Now we will treat these individuals but will follow the tics with Tourettes tic checklists.
J Child Neurol 1999;14:316-319
Baclofen and botulinum toxin type A were each effective in treatment of tics in Tourettes syndrome, according to this large open study. A total of 450 patients with tics in Tourettes syndrome, who had either inadequate response or intolerable side effects to conventional treatments, were enrolled. Two hundred sixty-four patients received baclofen at a mean dose of 30 mg/day. of these, 250 experienced a significant decrease in severity of motor and/or vocal tics, as measured on the Yale Global Tic Severity Scale. One hundred eighty-six patients received BTX-A injection in affected muscles of the neck, face, and extremities. Of these, 31 required small doses of baclofen for complete control of vocal tics, and 4 required vocal cord injections of BTX-A to achieve even partial control of vocal tics.
Controlled studies in Neurology 2001 showed some benefit but not at impressive as the 1999 study. They concluded that these treatments might be useful if other treatments have failed. Children got up to 60mg of baclofen per day.
Post Traumatic Stress Disorder (PTSD)
Marmar et al. (1993) and DeBellis et al. (1994a) suggested but did not empirically evaluate the possibility that an -2 adrenergic agonist such as clonidine might be more effective than psychostimulants for ADHD symptoms in sexually abused and other children with comorbid PTSD. Horrigan (1996) reported a single case study in which a long acting -2 agonist, guanfacine, was successful in reducing nightmares in a 7-year-old child with PTSD. Harmon and Riggs (1996) reported a decrease in at least some PTSD symptoms in all seven children included in an uncontrolled clinical trial using clonidine patches. Brent et al. (1995) suggested that antidepressants may be helpful for some children with PTSD, particularly those with a predominance of depressive or panic disorder symptoms. To date, there have been no empirical studies of antidepressants for PTSD in children.
At this time there is inadequate empirical support for the use of any particular medication to treat PTSD in children (March et al., 1996). Drawing from the adult literature, it appears that the use of conventional psychotropic medication for PTSD is at most mildly effective (Davidson and March, 1997). Due to the lack of adequate empirical data, clinicians must rely on judgment to determine the appropriateness of psychopharmacologic interventions in children with PTSD who have prominent depressive, anxiety, panic, and/or ADHD symptoms. As a general practice medication should be selected on the basis of established practice in treating the comorbid condition (e.g., antidepressants for children with prominent depressive symptoms). Because of their favorable side effect profile and evidence supporting effectiveness in treating both depressive and anxiety disorders, SSRIs often are the first psychotropic medication chosen for treating pediatric PTSD. Imipramine also is used frequently with children with comorbid panic symptoms.
Due to the lack of empirical studies evaluating efficacy of treatment for PTSD in children, it is premature to recommend a hierarchy of interventions. However, outpatient psychotherapy is generally considered the preferred initial treatment, with psychotropic medications used as an adjunctive treatment in children with prominent depressive or panic symptoms.
Although the research on medication treatment of early-onset bipolar is limited, most clinicians feel that psychopharmacological intervention is a necessary part of treatment. Many of the current recommendations are based on studies of adults. We use medications to deal with acute We also use medication between acute episodes to prevent relapse. It is important to educate the child and family to understand the importance of continuing treatment even when the child feels fine.
In the acute phase, an anti-manic medication should be given at a therapeutic dose for at least 4 to 6 weeks before we can tell if it will be effective. We try to avoid multiple medication changes/additions, because this can confuse the clinical picture and usually does not improve the outcome.
Current evidence suggests that the relapse rate is quite high for early-onset bipolar disorder. Substance abuse is common in these individuals. Drug screens may be important. Some patients develop a more treatment-resistant form of bipolar disorder if effective medication is stopped.
Lithium is more effective in individuals with less than 4 episodes per year. Early-onset bipolar disorder is more likely to have rapid cycles. Can cause acne tremor, frequent urination (bathroom pass and permission to carry a water bottle may be necessary in school) and weight gain. Periodic lab tests are necessary.
Depakote (less likely to cause stomach upset than divalproex sodium) It may be better than lithium for those with rapid cycling mania and depression. It can cause weight gain and sedation. Dizziness and tremor may occur early in treatment. One must check lab tests for blood level and check for lowered white blood cell count and for elevated liver studies. Neural tube defects can occur if it is taken during pregnancy.
Lamotrigine (Lamictal) can cause a rash which is sometimes serious. The rash is more common in younger children. I do not use it in individuals under 14. If the dose is raised gradually, it is less likely to cause rash. If combined with Depakote, one must raise the dose even more slowly. There is good data to support the use of this medication in adults with bipolar disorder. Lamotrigine is approved for adults with bipolar disorder.
Carbamazepine (Tegretol) Interacts with birth control pills and with a number of other medications. It is much less likely to cause weight gain. It may be helpful for those with rapid cycling bipolar disorder. Extended release Tegretol is approved for adults with bipolar disorder.
Oxcarbamazepine (Trileptal) This relative of carbamazepine does not require blood tests and is less likely to interact with as many other medications as carbamazepine.
Neurontin does not require blood tests and does not interact with as many medications. It is quite sedating. It do not find it particularly effective.
If two or more anticonvulsants have not been sufficiently effective, we may combine anticonvulsants or add an antipsychotic.
The anti-manic medications are often not as effective for bipolar depression, so we may add an antidepressant. These may speed up the rate of cycling so we use them with caution.
Prepubertal depression may is sometimes the first manifestation of a bipolar depression. Sometimes treating a child with an antidepressant may precipitate a manic or rapid cycling phase. It is important to ask about a family history of bipolar disorder.
If a child is depressed and has a strong family history of bipolar disorder, we may start treatment with a mood stabilizer before starting an antidepressant. We warn the parents to look for signs of a developing mania.
These may be useful for acute mania because they work fast. We also use them in psychotic depression. The atypical antipsychotics can be effective by themselves in mania. The FDA has approved risperidone for children and adolescents with aggressive, agitated behavior associated with autism. There is some suggestion that children and adolescents may be more susceptible weight gain associated with these medications.
This is a relatively rare diagnosis. Children or young adolescents who appear to have schizophrenia should receive an thorough neurological, medical and psychiatric evaluation. The older antipsychotics, such as haloperidol and thioridazine have been effective treatments but have significant short-term and long term side effects are problematic. Early-onset side effects included extrapyramidal symptoms (muscle stiffness and rigidity.) Long term side effects included abnormal movements, called dyskinesias. Sometimes these abnormal movements could become permanent. Further, the older antipsychotics were helpful for the positive symptoms of schizophrenia such as agitation and hallucinations. These older medications were not as good at addressing the negative symptoms social withdrawal and emotional blunting. The newer, atypical antipsychotics include risperidone, olanzapine and others. They are less likely to cause the stiffness and the abnormal movements. However, their side effects include sedation and weight gain.
Intermittent Explosive Disorder
It is important to look carefully at this diagnosis. Does this child have bipolar disorder, AD/HD, Pervasive Developmental Disorder or another diagnosis? Is there a neurological cause?
We may use a mood stabilizer, a stimulant or an antipsychotic. Response to a mood stabilizer does not mean that the individual has a bipolar disorder and response to a stimulant does not mean that the individual has AD/HD.