Transcript Children and Medications

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
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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)
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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
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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
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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
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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
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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 reuptake blocking action
• powerful in OCD
• difficulty with adverse effects
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constipation
dry mouth
blurred vision
postural hypotension
Risperidone
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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