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In this first chapter we address a number of general issues that are important to consider prior to discussing diagnosis and treatment, which we’ll cover in the chapters that follow.

Until just recently, in child psychiatry there appeared to be an assumption that children with psychiatric disorders were quite similar, if not identical, to adults with respect to both diagnostic and pharmacological treatment issues. The recommended approach was to diagnose and treat as you would with adults, although generally starting treatment with lower doses of medications. Even though there is some degree of symptomatic overlap between adult- and childhood-onset disorders, there are also significant features that distinguish psychiatric syndromes as well as pharmacological treatments in children and adults. It must also be kept in mind that the target of psychiatric drugs (the central nervous system) is continuously undergoing maturational changes throughout childhood and adolescence. Certain neurotransmitter systems are not fully online in children, and some brain structures have not reached full development. In a sense, using psychotropic drugs with younger clients is like shooting at a moving target. Likewise, there are significant differences between adults and younger people in the way the drugs are metabolized. Kids are not just smaller versions of adults.

It is likely that the majority of emotional suffering experienced by youngsters is related to situational stress and responds best to nonmedical, psychological treatments (e.g., family therapy). However, it is also becoming increasingly clear that many major mental illnesses begin in childhood (for example, 33 percent of obsessive-compulsive disorder cases and up to 25 percent of bipolar disorder cases have childhood or early-adolescent onset). Not only do these disorders cause considerable suffering in young children, but they can also markedly interfere with normal social and academic developmental experiences. For example, more than one-half of children experiencing major depression continue to be symptomatic for more than 2 years. During depressive episodes, many experience significant social withdrawal and academic failure, often due to an impaired ability to concentrate. Even if they recover, many of these children find it hard to ever catch up academically or socially.

Increasing evidence also shows that some psychiatric disorders are subject to progressive neurobiological impairment if they go untreated (the kindling model of disease progression). Toxic levels of neurotransmitters, such as glutamate, or stress hormones, such as cortisol, may damage neural tissue or interfere with normal patterns of neuromaturation (see figure 1-A). Pharmacological treatment of these disorders may be not only successful in improving symptoms but also neuroprotective (in other words, medication treatment may either protect against brain damage or promote normal neuromaturation; in some instances, medications may promote the regeneration of nerve cells, a process calledneurogenesis).

Disorders with Evidence of Progressive Neurobiological Impairment

• Figure 1-A

  Informed Consent and Addressing Parental Concerns

  In addition to clinical considerations, other unique challenges arise in the prescribing of psychotropic medications for children. Children cannot give trueinformed consentsince parents are the ones who usually decide whether or not to allow medication treatment. This presents at least four concerns: (1) fears about drug use (or possible addiction) may lead parents to withhold treatment from some children who need it; (2) some parents may see psychiatric disorders simply as chemical imbalances, believe that pills will fix the problem, and ignore psychological factors (such as dysfunctional family dynamics) as a focus for treatment; (3) parents may use medications primarily for behavioral control despite detrimental side effects (for example, excessive doses of stimulants may markedly reduce hyperactive behavior in children with attention-deficit/hyperactivity disorder, even causing lethargy and sedation and, if doses become too high, decreased cognitive functioning); and (4) the young person is left out of the loop, perhaps not consulted about how he or she feels about medication treatment.

  Most pediatric clinicians agree that children should be included in discussions about psychiatric medication treatment (especially for children ages seven and older whose cognitive development has proceeded enough that they can understand some information regarding medication treatment). Providing information is important in order to encourage the child to voice concerns about treatment, since many children conclude that if they need medicine, they must be very ill or “crazy.” Also, these early experiences with psychiatric treatment, if perceived to be beneficial by the child, may go a long way toward instilling positive attitudes about mental health treatment (this is a critical point, since many of the more severe disorders that warrant medical treatment during childhood are the first manifestations of what may be lifelong mental illnesses). Including the child in discussions regarding medication treatment can often give him or her a feeling of respect and thereby foster a positive relationship with the therapist or physician.

  Because parents who do not wholeheartedly endorse treatment will often sabotage it, professionals need to devote a good deal of time to addressing all of their concerns about drug treatment. Informed consent should also include the risks of not treating certain disorders.

  Parental Fears Regarding Drug Addiction

  Many parents are understandably concerned about the use of habit-forming drugs to treat their children. It is important to talk openly with parents about these concerns (even if they do not initiate the conversation). Among psychiatric medications, only two classes encompass potential drugs of abuse: stimulants (such as Ritalin) and benzodiazepines (antianxiety drugs such as Xanax). However, the vast majority of children with psychiatric disorders do not abuse these medications. Although stimulants can be abused by those genetically predisposed toward substance abuse, such drugs generally do not produce euphoria in ADHD children. In fact, many children with ADHD experience mild dysphoric effects from stimulants. Additionally, current data strongly indicates that among those with ADHD, the use of stimulants actually decreases the risk of substance abuse by about 50 percent in comparison to drug abuse rates among nontreated ADHD subjects (Biederman, et al., 1999; Kuczenski & Segal, 2002; Mannuzza, Klein, & Moulton, 2003).

  Substance abuse by children and adolescents is a common and serious concern in our society. It must also be kept in mind that untreated mental illnesses result in significant emotional suffering and contribute to a much higher likelihood of drug abuse down the line. Low self-esteem, depression, anxiety, and a sense of alienation often prompt the use of illicit drugs as a form of self-medication. Thus any risk-benefit assessment of medication treatment and drug abuse must certainly take into consideration the risks of failure to treat the psychiatric disorder.

  Medications and the Media

  Research studies and clinical experience certainly influence prescribing practices. However, in recent years the media has had a profound effect on public opinion and ultimately on clinical practice. Public opinions are often influenced by both drug companies’ marketing efforts (and thus their profit motives) and news headlines, an example of which is the recent concern over antidepressant use in children and its possible relationship with increased suicidality, an issue discussed in more detail in chapter 2.

  In the late 1980s negative attention was focused on the drug Ritalin, a widely prescribed stimulant used to treat ADHD. Andrew Brotman (1992), summarizing the work of Safer and Krager (1992), states, “The media attack was led by major national television talk show hosts and in the opinion of the authors, allowed anecdotal and unsubstantiated allegations concerning Ritalin to be aired. There were also over twenty lawsuits initiated throughout the country, most by a lawyer linked to the Church of Scientology.”

  In a study conducted in Baltimore, Maryland, examining the effects of this negative media and litigation blitz, Safer and Krager found that during the 2-year period just following the negative media attention, prescriptions for Ritalin had dropped by 40 percent. What were the consequences? Of those children who discontinued use of Ritalin, 36 percent experienced major academic maladjustment (such as failing grades or suspension) and another 47 percent had mild to moderate academic problems. During this time there was a 400 percent increase in the prescription of tricyclic antidepressants (TCA), which were then being used in place of Ritalin (studies had demonstrated that tricyclics were somewhat effective in treating ADHD symptoms but clearly much less effective than stimulants). Further, tricyclics are considerably more toxic, have much higher rates of side effects, and have been associated with sudden cardiac-related deaths in six children. Clearly, parents had heard the negative reports about Ritalin in the media and approached their pediatricians with concerns about the drug. As a result, many children were taken off the stimulant and put on a class of drugs that are less effective and considerably more dangerous.

  Media attention is important in that it can alert consumers and professionals (including the Food and Drug Administration [FDA]) to possible problems with certain medications. When this leads to more thorough investigations, sometimes drugs are found to be problematic or unsafe. However, it can also lead to unwarranted fears and ultimately to clinical decisions that may not be in the best interest of our clients. The point is that media-driven concerns raised by our clients and their parents can be significant, and we as clinicians must be aware of and sensitive to such concerns.

  Drug Research and Outcome Studies

  As important as efficacy studies are, there is a relative paucity of good studies in child psychopharmacology (with the notable exception of the numerous well-controlled studies of the treatment of ADHD with stimulants). In the past, pharmaceutical companies did not conduct tests of psychiatric drugs on children. However, in 1998 the Food and Drug Administration mandated that safety studies be carried out for new psychiatric drugs with child subjects, and has recently begun offering financial incentives (in the form of extensions of patents) for conducting efficacy studies with children. Thus, in very recent times, better-controlled studies have been initiated, although many of these are not yet published and some suffer from significant methodological flaws. It is hoped that in the next few years the number of well-done studies will increase significantly.

  Another concern is that many studies do not include severely ill children (the reason being that it is not considered ethical to expose severely disturbed children to placebos over a period of months). Thus, in some child psychiatry studies involving random assignment and the use of placebos, groups of subjects often include only mild to moderately severe cases. Information about treatment outcomes for severely ill kids is often limited to that which comes from clinical experience and case studies. It is important to keep these research limitations in mind when evaluating the outcomes of medication studies.

  A third area of concern, both for clinicians and parents, is the effect of very long-term use of psychiatric medications in children. Short-term side effects are well documented and will be discussed in detail in subsequent chapters. However, there is relatively little hard data that indicates the risks associated with long-term treatments. Yet, for many of the disorders discussed in this book, including bipolar disorder, ADHD, and psychotic disorders, long-term medication treatment is strongly recommended. It is our belief that when this topic arises in discussions with patients and their parents, the clinician’s only appropriate response is to be completely candid about the lack of knowledge regarding long-term drug exposure, but to also be clear about the risks of not treating certain disorders. Deciding whether to use medication is always a matter of evaluating risk versus benefit, and parents need to be offered as much information as possible so they can make informed choices.

  Medication Metabolism in Young Clients

  The normal rate of hepatic (liver) metabolism is high in children until the time of puberty. The result is that most medications are aggressively metabolized in the liver and rapidly excreted. Because what ultimately matters is how much of the drug enters the bloodstream, treatment of prepubertal children may require doses that approach or equal those for adults. (The use of seemingly high doses for young children may seem counterintuitive to many parents, and thus it will be helpful for clinicians to explain the role of increased rates of drug metabolism.)

  During the 2 to 4 months surrounding the entry into puberty, the rate of hepatic metabolism significantly slows. For this reason, youngsters who have been on a maintenance dose of psychiatric medication and tolerating it well may begin to show increasing side effects when this change in metabolic rate occurs and more of the drug begins to escape the liver and enter circulation. Dosage adjustments may then be required to minimize side effects.

  Approved Drugs and Off-Label Use

  Currently very few psychiatric drugs are approved by the FDA for use in treating children and young adolescents. Yet these drugs are also in widespread use in child psychiatry. It is very common practice in the field, and in general medicine, to prescribe drugsoff label,meaning the use of drugs that are approved by the FDA for treatment of certain conditions but are being used to treat other conditions. For example, the anticonvulsant medication Tegretol (carbamazepine) is FDA approved for the treatment of epilepsy but not bipolar disorder. However, Tegretol has been used for a number of years to treat some cases of mania. Since clinical and scientific research supports the use of this drug in treating mania, its use is considered to be in keeping with medical standards of practice, and thus neither illegal nor unethical. Likewise, many drugs approved for use in adults (but not in children) are used to treat child psychiatric patients. For example, only one antidepressant (fluoxetine, or Prozac) has been approved by the FDA for the treatment of major depression in children, yet many other antidepressants are used to treat childhood-onset depression.

  Some drug classes, most notably antidepressants, have been found effective in treating a host of disorders other than depression, such as panic disorder, OCD, social anxiety, and so on. We will discuss the use of antidepressants in more detail in chapter 2, and in later chapters we will address how such drugs play a role in the treatment of other disorders.

  Attitudes and Realities Regarding Psychopharmacology with Children and Adolescents

  Despite the fact that some of the disorders discussed in the following chapters are deemed to be due largely to a primary neurobiological cause and require drug treatment, we categorically state, as we did in the introduction, that no child should ever be treated with psychiatric medications without concurrent psychotherapy. It is common for pediatricians to diagnose and prescribe psychotropic medications, and in very rare cases pediatricians have both appropriate training for diagnosing and treating psychiatric disorders and enough time to conduct a comprehensive evaluation. Yet the reality is that most primary care doctors are overwhelmed with patients and have grossly inadequate amounts of time to devote to taking careful histories and conducting thorough diagnostic evaluations. We strongly believe that children with serious mental illnesses should be evaluated and treated by mental health specialists.

  Where We Go from Here

  In the chapters that follow we will discuss specific classes of psychiatric disorders. The initial focus of each chapter will be on important issues regarding diagnosis, highlighting new developments in the diagnosis of childhood disorders. This will be followed by an overview of medications that are commonly used to treat particular disorders, and then specific treatment guidelines. Please note that the appendix of this book includes general information sheets regarding six common classes of psychotropic drugs that may be given to patients or used by caregivers. We believe that it is very important for consumers to become knowledgeable about treatment options and the risks and benefits of medications. Please feel free to make copies of these sheets and use them as handouts in your practice.