Psychopharmacology for Children

Prenatal

• The first trimester is the period of organ formation and thus IF POSSIBLE avoid medications (as much as possible)

• Most drugs cross the placenta, so fetal medication exposure will continue thruout the pregnancy

Childhood

• Many mental illnesses begin in childhood and can markedly interfere with– Social Development – Interpersonal relationships– Academic development– Identity Development– Emotional Maturity (may look or be PD)– Think back to Life Span

Benefits of medication children

• So development continues with out interference of MI

• Reduce subjective distress• Neuroprotective (protect brain against damage

and/or kindling)– Bipolar– ADHD– Schizophrenia– Some Unipolar– Some PTSD

Issues Associated with prescribing

• No REAL informed consent• Parental fears about meds, drug use, addiction

(most children with MI do not abuse prescriptions and those with ADHD are less likely to abuse A&D than those not treated with stimulants)

• Parental fear of stigma• Parental believe pill will FIX child and ignore

family dynamics, social issues, psychological issues, etc

Informed Consent

• Parents who do not wholeheartedly endorse tx will sabotage. Include risks of not medicating

• Children 7 and older– Should be a part of the discussions about treatment

– Which may help instill more positive attitudes toward mental health

– May promote utilization of services as MI may be lifelong

School

• Best if fully involved

• Need information. Problem getting all teachers in secondary/high schools involved

• Stimulants need only be given on schooldays? (controversy around this issue)

Children with Psychiatric Probelms

• Tend to present with motoric restlessness and inattention, thus diagnosis can be difficult.

• ADHD inattentive type appears to be a totally unrelated neurological disorder that does not often respond to stimulants

Titration

• Children have very effective livers; much of an oral dose is lost on first pass metabolism– So doses may be equal or close to adult dosage– This may be counter intuitive to parents, so explain– 2-4 months around entering puberty, metabolism will

slow and dose adjustment is likely to be required

• Be clear about goals. Don’t be satisfied with just some improvement

• Find a way of measuring improvement, possibly a rating scale

Drugs to know

• methylphenidate/dexamphetamine (stimulants)

• SSRIs

• imipramine

• clonidine

• sedative antihistamines

• benzodiazepines

Drugs to be aware of

• Clomipramine (Anafranil)

• propanolol

• risperidone

• other antipsychotics

• mood stabilisers

Things to remember @ Stimulants

• Stimulants may aggravate anxiety disorders- tx anxiety first

• Start with immediate release formulas then move to extended release

• Stimulants only work short period of time so to help with afternoon/evening drop off, may use antidepressant

Stimulant side effects

• Initial insomnia (give early in day or clonidine or trazadone at bedtime)

• Anorexia (only while drug is active, not the disorder)

• Stomachache (add food)• Mild Dysphoria (change stimulant or add

Welbutrin)• Lethary, poor concentration (lower dose)

Methylphenidate (MPH)

• Stimulates many mental functions by blocking dopamine transporter (i.e.re-uptake blockade at synapse)

• Can do this in normal children (abuse by parents? Desperate Housewives (the TV show))

• Not addictive in ADHD treatment• Sustained release preparations popular (school not

involved - not a good thing?)

Methylphenidate (MPH)

• Onset insomnia– do not give too late in the day

– problems with evening behaviour/homework

– can add evening clonidine (ECG first), melatonin, sedative antihistamine

• Growth problems infrequent with immediate release (Ritalin, Equasym), unknown frequency with sustained release preparations (Concerta XL, Equasym XL)

Methylphenidate (MPH)

• Titration• Can start with am dose, contrast am vs pm• Otherwise aim for 3-3.5 hr intervals

– 5,5,5 (2.5) (8.00, 11.30, 3.00, (5.00)– 10,10,5/10 – 15, 15, 15 (5-10)

• Or Concerta XL 18 then 36 etc. • or Equasym XL?

Dexamphetamine

• very slightly longer duration than MPH

• adverse effects generally trickier to handle

• euphoria and misuse more of a problem

• dose is half that for MPH (5mg=10 mg MPH)

• Adderall (dexamphetamine salts) is essentially the same

Atomoxetine

• non-stimulant (?) ADHD treatment

• blocks norepinephrine transporter, especially in frontal lobes

• no insomnia though some reduced weight gain with growth in first 12 months of use

• likely to be non-controlled

Depression

• 20% comorbid with ADHD• Psychotic symptoms more likely associated with mood disorders (but

weight gain and EPS more common in children)• High risk for Bipolar if

– Atypical symptoms (hypersomnia, severe fatigue, increased appetite/weight)

– Seasonal depressions– Hx of Sep/anx disorder– Hx ADHD– Fam hx– Hx of hypomania– Hard to know if ADHD or manic– 20% onset in late childhood and adolescence

Selective serotonin re-uptake inhibitors (SSRIs)

• May take 8-12 weeks to begin working, desipramine associated with heart and sudden death NE)

• fluoxetine• sertraline• paroxetine• citalopram• escitalopram• fluvoxamine

Selective serotonin re-uptake inhibitors (SSRIs)

• differ from each other mainly in adverse effects

• helpful in depression, anxiety, obsessive compulsive symptoms

• may help self-injurious behaviour in severe learning disability and autism

• a few children become silly and socially disinhibited

Imipramine

• useless antidepressant

• outclassed by desmopressin in enuresis

• not much good with anxiety

• moderately effective in ADHD

Clonidine• moderately useful in ADHD, especially

hyperactivity and hostility, can use in evening

• first line in Tourette’s disorder (but often ineffective)

• post-traumatic stress disorder• self-injurious behaviour in autism• sleep problems (though can produce

insomnia and nightmares in a few)

Clonidine

• start low, go slow

• monitor BP, pulse rate (and ECG?)

• warn parents not to stop abruptly

• drowsiness main problem, wears off after 10 days until ceiling at about 200-300 mcg daily

Sedative antihistamines

• widely used for sleep onset problems (diphenhydramine, promethazine, hydroxyzine,alimemazine/trimeprazine)

• unlikely to help child with anger or anxiety symptoms

Benzodiazepines

• rapid tranquillisation (lorazepam)

• panic attacks (alprazolam)

• may cause paradoxical excitement or dysphoria

• best used for brief periods only

Clomipramine

• tricyclic antidepressant with serotonin re-uptake blocking action

• powerful in OCD• difficulty with adverse effects

– constipation– dry mouth– blurred vision– postural hypotension

Risperidone

• reduces aggressive behaviour and rage

• reduces tics

• looks useful in ADHD symptoms in PDDs

• relatively low risk of extra-pyramidal effects but a few dribble

• weight gain a problem

Other antipsychotics

• haloperidol for tranquillisation and tics

• phenothiazines (chlorpromazine etc) for short-term tranquillisation, otherwise best avoided because of extra-pyramidal complications

• olanzapine increasingly popular but weight gain and sugar/fatty acid problems

Mood stabilisers

• mainly carbamazepine, valproate

• lithium less commonly because of – thyroid and renal problems – blood level monitoring needed

Future?

• more use of medication in child mental health problems

• more children with mental health problems that specialist child psychiatric services can manage

• non-specialists likely to be come involved as prescribers