|
by William Beute, M.D.
About 20% of the U.S. child and adolescent population
has a diagnosable psychiatric disorder. Some of this population
may benefit from medication. The purpose of this article is to discuss
practical aspects of child and adolescent psychopharmacology.
However, before getting to specific disorders and medications, I would
like to share a few of my general principles regarding medication.
- If medication is not indicated, it shouldn’t be prescribed.
- Use the lowest effective dose of medication.
- If there are adjunctive or preferred treatments, they should be discussed.
- Whenever possible, medication should be dispensed at home by parent(s)
(i.e., not at school, daycare, or by sitters, etc.).
Some medications are approved by the Federal Drug Administration (FDA)
for certain uses. Because a medication is not approved does not mean it
is disapproved. It only means that studies have either not been done with
children and/or adolescents, and/or the medication trials were ineffective
for treatment of the condition identified. However, most of the medications
to be discussed are commonly used in the child and adolescent population
for the same reasons they are used in adults.
ADHD
The medications used to treat Attention Deficit/Hyperactivity Disorder
are the stimulants. These are all FDA approved for use to treat ADHD.
They are all controlled substances, meaning they are potentially habit
forming. Misuse occurs but usually with students who are not the prescription
holders. These medications may be dispensed for 30 days only. They may
not be called into pharmacies, nor are refills allowed. Stimulant side
effects may include decreased appetite (and sometimes weight loss), insomnia,
and tics (especially eye blinking, sniffing, snorting, and throat clearing).
Stimulants range in length of benefit. How long do they last?
Ritalin 3-4 hours
Ritalin SR (Methylin ER, Metadate ER) 6-8 hours
Metadate CD 8-10 hours
Concerta 10-12 hours
The amphetamine products are:
Dexedrine 3-5 hours
Dexedrine Spansules 6-9 hours
Adderall 8-10 hours (generally)
Adderall XR 10-12 hours.
There are no liquids or chewables in use. Cylert, which has a chewable
tab, is rarely used today since it has a liver warning and requires lab
work every 2 weeks.
There are times when stimulants either don’t help enough or cannot
be used. What do we do? We may try other medications singly or as add-ins.
Wellbutrin, an antidepressant, is the best non-stimulant for treatment
of ADHD. In many cases it is as effective as stimulants. It is given twice
a day as an SR (Sustained Release) product. It takes 3-4 weeks to deliver
its ADHD benefit, if it works. For students with depression and ADHD,
it may be the medication of choice. It should not be prescribed if there
is a history of a seizure or an eating disorder.
Clonidine and Tenex are used to treat high blood pressure
and tic disorder. They can be helpful adjuncts in ADHD. A common side
effect is tiredness. Clonidine does best if given 3-4 times daily. Tenex
lasts longer and school medication is not necessary.
BuSpar, a minor tranquilizer, can also be a helpful adjunct. It
is given three times per day (8-12-4) and can cause tiredness. ADHD with
conduct difficulties (assault, destruction, and out of control behavior),
may benefit from the addition of a neuroleptic which will be discussed
later.
Affective Disorders
Depression is a more common experience in the child and adolescent population
than one might expect. In fact, the U.S. Department of Health and Human
Services indicates that one in every 33 children may be clinically depressed.
That number goes up to one in eight when looking at the adolescent population.
Selective Serotonin Reuptake Inhibitors (SSRI) have revolutionized psychiatry.
They are safe, effective medications providing relief for depression,
anxiety, OCD (Obsessive-Compulsive Disorder), and PTSD (Post Traumatic
Stress Disorder). There are few side effects. They generally take 3-6
weeks to develop a level in the blood sufficient to treat the disorder.
They come as capsules, tablets, and liquids, making them convenient to
use. They are given once a day at breakfast. Celexa, Paxil,
Prozac, and Zoloft are commonly used. Luvox is typically
used for OCD but it can be effective for anxiety and depression. Unfortunately,
it significantly enhances caffeine effects and can cause insomnia and
decreased appetite if caffeinated soft drinks are commonly consumed.
Other antidepressants are also used. Remeron is given at bedtime
and promotes sleep. Effexor is effective in both anxiety and depression,
but usually has to be given twice a day unless the dose matches one of
the three sizes of XR (Extended Release) capsules. Serzone is also
given on a twice-a-day dosing schedule. Wellbutrin is good for
depression and also has ADHD benefits for many. Studies show it may also
treat anxiety. Tricyclic antidepressants (TCA) and monoamine oxidase inhibitors
(MAOI) are generally no longer in use for the child and adolescent population.
MAOIs were never popular because of accompanying food prohibitions, especially
cheese. TCAs (Trofranil, Elavil, Pamelor) require lab work, ECGs
and have been associated with cardiac concerns.
Fortunately, bipolar disorder is an uncommon disorder in the child and
adolescent population. There are three FDA approved medications for acute
mania: lithium, Depakote, and Zyprexa. Lithium is the only
FDA approved medication for maintenance in this disorder. Lithium requires
regular laboratory work because of potential side effects relating to
blood counts, chemistry studies, kidneys, thyroid gland, and the heart
(ECG is needed). We measure the blood level to remain in the therapeutic
zone and to develop a therapeutic blood level. Lithium comes as regular
tablets, longer acting products, and elixir.
Depakote is an antiepileptic drug (AED). It also requires lab
work because of changes in the blood count and potential liver/pancreas
problems. Blood levels are measured for the reasons noted above. Depakote
has tablets as well as “sprinkles” which can be opened and emptied
into food for the small child.
Tremors and weight gain can occur with both of these medications. These
medications require great vigilance on the part of all: family, patient,
and physician.
Zyprexa is a neuroleptic or major tranquilizer. It requires no
laboratory work. Side effects can include tiredness and increased appetite.
A rare disorder, tardive dyskinesia, can also occur and may be irreversible.
Zyprexa has a new product, Zydis, which is dissolvable.
Risperdal is a neuroleptic, similar to Zyprexa but without
FDA approval for bipolar disorder. It has similar side effects. Its advantage
is that it comes in smaller sizes, making it easier to use for children.
It also comes as a liquid, but is too concentrated to be of much use with
children.
Another AED is Tegretol. It has limitations and requirements noted
above for Depakote. Trileptal, a variant of Tegretol, requires
no laboratory testing. Studies are being done to assess its effectiveness
in bipolar disorder. Other AEDs that may prove to be helpful for bipolar
disorder include: Lamictal, Topamax, Neurontin, Gabitril. None
of these has approved efficacy yet.
A potential but not commonly discussed problem associated with AEDs is
“cognitive dulling.” These medications can result in less effective
school performance. If this is suspected, the physician needs to be notified
and further assessment by school, parents, and student may result in the
need to change medication.
Anxiety
The U.S. Department of Health and Human Services has found that “as
many as one in 10 young people may have an anxiety disorder.” Anxiety
disorders include generalized anxiety, social anxiety, phobia, OCD, and
PTSD. The SSRIs have proven very effective in this group. OCD is a particularly
difficult disorder to effectively treat with SSRIs and may require extraordinarily
high doses, much higher than for depression or anxiety. As noted earlier,
Luvox has been effective for OCD. It is usually given twice a day.
Anxiety can also be treated with minor tranquilizers, all of which (except
BuSpar) are controlled substances. While they are potentially habit
forming, the prescriptions can be called to pharmacies and refills are
allowed. These are not long-term medications. These medications include
Ativan, Klonopin, Valium, Librium, and Xanax. As many of
you know, these medications have been misused by many adults with devastating
results. Thus, while not as controlled as stimulants, their potential
damage is so insidiously achieved that problems can occur before realization
of this happens. BuSpar is the exception to the above. It is not
controlled and will develop a blood level. It may produce tiredness, as
all minor tranquilizers may do.
Schizophrenia and Psychosis
Schizophrenia and psychosis can be devastating in presentation and outlook.
While rare in children under 12, the U.S. Department of Health and Human
Services notes that schizophrenia affects about three out of every 1,000
adolescents. Fortunately, we have newer, effective medications with fewer
side effects than the older neuroleptics (Thorazine, Stelazine, Mellaril,
Haldol, Navane). In the newer group, Risperdal and Zyprexa
are the more commonly used. Seroquel is also used. Clozaril is
seldom used because of required laboratory work. The newest medication,
Geodon, has FDA approval but a cardiac warning. Weight gain is
a common concern with Risperdal and Zyprexa, less so with
Seroquel. Geodon is weight neutral. These medications can
have beneficial effects within minutes but all develop blood levels to
try to effectively maintain progress. Neuroleptics come as tablets, capsules,
liquids, and injectables but not for each product.
Insomnia
A very common concern is insomnia. If it is a symptom associated with
anxiety or depression, the physician may choose not to treat it to further
assess the benefit of the medicine for anxiety or depression. However,
if we do use “sleepers,” they can include: Benadryl (an
antihistamine), minor tranquilizers (Ativan, Klonopin), or specific
sleeping preparations (Dalmane, Ambien, Sonata). Generally, these
are all controlled substances and are intended for short-term use only.
Clonidine has been used to promote sleep, as has Trazodone
(Desyrel). They and Benadryl are not controlled.
Autism and Pervasive Developmental Disorder
Autism and Pervasive Developmental Disorder (PDD) occur in about 1% of
the child and adolescent population. There are no specifically approved
medication treatments. However, SSRIs offer the most potentially beneficial
treatment and have been helpful to many of these students.
A Final Word
Medications only work with an effective physician/patient and family relationship.
The single biggest reason for medication ineffectiveness is noncompliance.
Medication is not given, given at the wrong times, or skipped at times.
If patient/parents dislike a medication or its effects they need to let
the physician know. If they have questions or concerns, they should ask.
Physicians encourage families to read appropriate medication materials.
Booklets regarding diagnosis and treatment are available from pharmaceutical
companies and physicians. Informative books are available at the public
library. Other materials are available through specialty organizations
(such as CHADD). Excellent assistance can also be provided by local bookstores,
which may be the only carriers of certain books.
|
