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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.
Depression
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
Augmentation Strategies
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.
Psychotic Depression
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.
Anxiety
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.
SSRIs
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.
Tricyclics
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.
Benzodiazepines
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.
Antipsychotics
We may use the newer antipsychotics in
treatment-resistant OCD but less often in individuals with other forms of
anxiety.
Mood Stabilizers
These are sometimes used as an augmentation strategy in
individuals with treatment-resistant OCD.
Other medications
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 breakthe
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.
PDD
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
Tourettes
Alpha Agonists
(clonidine guanfacine) These medication sometimes decrease tic frequency and
help with explosive behavior and mood swings.
Antipsychotics
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
Associated Disorders
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.
Newer medications
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.
Bipolar Disorder
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
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.
Anticonvulsants
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.
Antidepressants
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.
Antipsychotics
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.
Early Onset-Schizophrenia
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.
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