Psychopharmacology

Essential Concepts

Medication may be an important component of a multimodal treatment plan for a child suffering from behavioral and emotional problems.
For all psychotropics used, there should be a careful consideration of risks and benefits of the treatment with the family/guardian and education and assent of the child.
Rating forms of symptoms prior to and following the initiation of medication may be helpful in quantifying effectiveness as well as side effects.
Take a careful medical and medication/substance history prior to the initiation of any medication, with laboratory, ECG, or other tests as appropriate.

It is part of the cure to wish to be cured.

—Lucius Annaeus Seneca

General Principles and Clinical Considerations

The essential consideration in using medications for the treatment of psychiatric disorders in children and adolescents is being clear what the diagnosis and target symptoms are, knowing the risks and benefits, and being thoughtful and careful about medication use. While this is important for all of medicine, it is even truer in the treatment of children, whose bodies and nervous systems are not yet fully developed.

Pharmacotherapy should be part of a broader treatment plan in which consideration is given to all aspects of the child’s life. It should not replace psychosocial and educational
interventions. Likewise, medication should not be thought of as the treatment of last resort, when everything else has failed. Realistic expectations of pharmacotherapy based on a clear definition of which target symptoms may be effectively ameliorated as well as what cannot be reasonably expected (e.g., changing the child’s attitude) are the ingredients for successful intervention.

Even as there needs to be care taken in using medication, we also know that untreated disorders (such as depression, mania, and psychosis) have worse prognoses. There is evidence that early detection and medication intervention with prodromal schizophrenia may improve lifetime prognosis and functioning. We also know that children who are unable to pay attention will miss out academically and socially on early developmental tasks. Thus, risks of using medication must be weighed against not only the benefits but also the risk of not treating, which may be chronicity and social incapacitation.

Key Point

Many of the medications used for the treatment of psychiatric disorders in children and adolescents are considered “off-label,” or not approved by the U.S. Food and Drug Administration (FDA) for the pediatric population. For many medications, the intensive testing required for FDA approval has not been sought by the medication manufacturers. For this reason, medications determined to be effective with adults are used with children. Because children are not just “miniature adults,” the medications should be used more judiciously, carefully, and only with clear indications and target symptoms.

Evaluation and Treatment

The sine qua non of all psychiatric care is a thorough evaluation, using multiple informants. This includes ensuring good physical health, and getting baseline laboratory and physical assessment data, as indicated. Table 24.1 highlights the essentials of evaluation prior to the use of pharmacotherapy.

Once the decision has been made that pharmacotherapy is appropriate for the symptoms and functional disability with which the child or adolescent presents, follow the plan for pharmacotherapy outlined in Table 24.2.

Table 24.1. Evaluation Essentials for the Use of Pharmacotherapy

Conduct a comprehensive psychiatric evaluation of the child or adolescent, including information from multiple sources, assessment of the family, and family history of psychiatric and medical disorders.
Provide careful diagnostic and psychiatric symptom review with the patient and caregivers.
Ensure a physical examination.
Collect baseline laboratory and physical assessment data where warranted. Consider baseline rating scales of target symptoms.
Determine indicated nonpharmacologic interventions for the diagnosed disorder.
Consider the risks and benefits of pharmacotherapy.
Consider the risks and benefits of specific medications relevant to the disorder.
Conduct a formal consent procedure with the parent and youth. Give handouts on medications, where appropriate.

Table 24.2. Essentials of Pharmacotherapy

Review the patient’s (and pertinent family) medical history, drug allergies, and past drug reactions.
Identify treatable symptoms and establish treatment goals.
Initiate medications at low doses and assess dosing schedule (for ease, effectiveness, and to minimize side effects).
Monitor therapy regularly.
- Ask patient and parents about presence of adverse reactions and side effects.
- Perform routine physical assessments (blood pressure, height, weight, etc.).
- Use rating scales to assess side effects, as available.
Limit and manage side effects.
- Start medications at low doses and titrate slowly.
- Avoid adding medications that may cause drug interactions.
- Identify need for medications that treat side effects (e.g., benztropine, diphenhydramine).
Determine treatment duration.
- Evaluate effectiveness of medication and dosage after 2–6 weeks.
- Duration of therapy—reevaluate need for medication every 6 months.
Minimize duplicate therapy and polypharmacy.
- Monotherapy is preferred when possible.
- Consider potential drug–drug interactions when combining medications.
Coordinate care with the patient, caretakers, all health care and mental health care providers, and the family pharmacist.

Major Classes of Medications Used in Child and Adolescent Psychiatry

Stimulant Medications

The stimulant medications act to enhance dopamine and noradrenergic transmission. They improve both cognitive and behavioral functioning. They are considered the first-line medications in the treatment of attention deficit hyperactivity disorder (ADHD). Stimulants are the most prescribed psychotropic agents for children in the United States.

The stimulant medications come in short and longer acting preparations. The most commonly reported side effects of stimulant medications are appetite suppression and sleep disturbance. Less frequently, mood disturbance, headaches, abdominal discomfort, increased lethargy, and fatigue or “spaciness” have been reported. There may be increases in heart rate and blood pressure, and monitoring is suggested. Additionally, all stimulants may exacerbate tics. Although the etiology remains unclear, some ADHD children taking stimulants may demonstrate growth delay. “Drug holidays” (summers or other periods of time not taking the stimulant) typically remediate that delay. Table 24.3 gives information relevant to the use of stimulant medication in clinical practice.

Table 24.3. Stimulant Medications

Drug	Chemical Effect	Average Daily Dose Range	Pharmacokinetic Parameters (duration)	Monitoring
Amphetamine Mixtures
Adderall	Blocks reuptake of DA and NE, inhibits MAO	2.5–40 mg 1–3 divided doses	4–6 h	Blood pressure, height, weight
Adderall XR	Blocks reuptake of DA and NE, inhibits MAO	10–30 mg QAM	12 h	Blood pressure, height, weight
Dextroamphetamine
Dexedrine	Blocks reuptake of DA and NE, inhibits MAO	5–40 mg 1–3 divided doses	4–6 h	Blood pressure, height, weight
Dexedrine spansules	Blocks reuptake of DA and NE, inhibits MAO	5–40 mg QD	6–8 h	Blood pressure, height, weight
Methylphenidate
Concerta	Blocks reuptake of DA	18–54 mg QAM	12 h	Blood pressure, height, weight
Metadate CD	Blocks reuptake of DA	20–60 mg QAM	9h	Blood pressure, height, weight
Amphetamine Mixtures
Focalin		5–20 mg 2 divided doses	3–5 h	Blood pressure, height, weight
Ritalin IR		5–60 mg 2–3 divided doses	3–5 h
Ritalin SR		20 mg QD	8 h
Other
Cylert (pemoline)	Blocks reuptake of DA	37.5–112.5 mg QD	6–8 h	Liver enzymes, height, weight
DA, dopamine; NE, norepinephrine; MAO, monoamine oxidase.