Children,
Mental Illness, and Medications
Psychiatry On Call
California Psychiatric Association
In the US, one in five children and adolescents suffer from
mental illness at any given time. Most do not get the help
they need. If left untreated, these children
have increased risks of school failure and drop out, drug
abuse, and many other difficulties, many of which can
be prevented or greatly lessened by timely evaluation and
appropriate treatment. A key is for parents to recognize
the problem and seek appropriate diagnosis and treatment.
As with other illnesses, mental disorders have
specific diagnostic criteria and treatment options.
A complete evaluation by a child psychiatrist is important.
This paper is an overview of the medications most commonly
used to treat childhood mental disorders as part of a comprehensive
treatment plan.
DIAGNOSIS
Medications...should
be used as part of a comprehensive treatment plan. Diagnosis
must precede prescription of medications. It is based
on a collaborative process that should involve psychiatric
and other physicians, the child, the child's family, and school-based
or other appropriate clinicians. Assessment is designed
to reach a comprehensive diagnosis after a thorough evaluation
of psychiatric, social, cognitive, educational, and
medical/neurological factors.
TREATMENT
Following diagnosis, psychiatrists develop a comprehensive
treatment plan that encompasses relevant aspects of a child's
life, taking into account coexisting medical conditions,
the child's needs and family and child preferences. For optimal
outcomes, an informed, multi-modal therapy specifically designed
by a child (pediatric) psychiatrist for a specific child is
the most appropriate. Potential elements include family
and school consultation, medication, and various forms of
therapy, such as cognitive-behavior therapy, psychotherapy,
parental and family therapy, social skills training, &
group therapy.
Medications,
prescribed by a psychiatrist or other well-trained physician,
should not automatically be the first choice in treatment,
but should be used as part of a comprehensive treatment
plan when their benefits outweigh the risk.
Extensive
information regarding the complete range of treatment options
is available from the American Psychiatric Association.
REVIEW
OF MEDICATIONS
Stimulants
Stimulants, including Ritalin, Adderall, & Concerta, are
by far the most widely researched and commonly prescribed
treatments for children with Attention-deficit/ hyperactivity
disorder (ADHD). ADHD is more fully discussed in Vol
1, #1 of Psychiatry on Call. They diminish motor overactivity
and impulsive behaviors seen in ADHD and allow the child to
sustain attention and improve physical coordination.
Stimulants can cause an immediate and often dramatic improvement
in behavior, cognition and judgment, both at school and at
home. In general, stimulants are regarded as an effective
ADHD therapy with high safety. Side effects are usually
mild, short-term, dose-related and subject to individual differences.
There
has been some public concern about whether children taking
stimulants for ADHD are at increased risk for substance abuse.
A 1999 study suggests the opposite, that such medications
may protect children with ADHD from future substance abuse.
Antidepressant
and Antianxiety Medications
Depression tends to run in families. At least one study shows
that more than 25% of depressed children have a close relative
with the disease. Early onset may predict more severe illness
in adult life, unless recognized and treated early in
life. Depression in children is often an underlying factor
in decreased school performance, eating disorders, headaches,
sleep problems and other physical problems. There are many
varieties of antidepressants on the market. The Selective
Serotonin Reuptake Inhibitors (SSRIs) such as Prozac, Zoloft,
Paxil, Celexa, & Luvox; the Serotonin Reuptake Inhibitors
(SRIs) Serzone and Effexor; and the atypical antidepressant
Wellbutrin are the most commonly prescribed. These agents
appear safe and effective for the treatment of severe and
persistent depression. Wellbutrin and Effexor are also
used to treat ADHD.
Children
can also experience anxiety disorders, such as obsessive-compulsive
disorders (OCD) and panic attacks. For example, children
can experience panic disorder and agoraphobia (eg.,
extreme fear of leaving one’s home). Children with
anxiety disorders are most frequently treated with SSRIs and
psychotherapy. Other agents used to treat anxiety disorders
include BuSpar and Inderal.
Medications
for Bipolar Disorder
Bipolar
disorder (also known as “manic-depression”) was
until recently thought to begin only in the late teens or
early adulthood. However, recent studies reveal that
this illness can occur in younger children. Bipolar
disorder is a neurobiological brain disorder characterized
by severe fluctuations in mood and activity level. It can
present with symptoms similar to ADHD. Since the treatments
used for bipolar disorder and ADHD are quite different, a
comprehensive and thorough diagnostic evaluation is needed.
Research suggests that a genetic predisposition to bipolar
disorder can be inherited. Mood stabilizers such as
Depakote, Tegretol, and lithium appear to be helpful,
along with various forms of school accommodations and
psychotherapy for the child, multi-family psycho-education
groups for the child and family, and peer support for parents.
Antipsychotics
Antipsychotic medications have been used to treat childhood
psychotic disorders and to control agitation, aggression,
and self-injurious behaviors in children with developmental
disabilities and pervasive developmental disorders (autism
and autism-like disorders).
The principal
psychotic illnesses that affect children are schizophrenia
and bipolar disorder, both chronic and disabling. Typically,
these emerge in adolescence or early adulthood, although
research studies are revealing that cognitive and social impairments
may be evident earlier in children, and that they can onset
in childhood and be successfully treated. There are a number
of antipsychotic medications available, including Geodon,
Risperdal, Seroquel, and Zyprexa. They generally yield
comparable results. The main differences are in the
potency, the dosage (amount) prescribed to produce beneficial
effects, and the side effects. Older antipsychotics such as
Haldol or Thorazine are used infrequently.
Other
Medications
Clonidine is used to treat ADHD, anxiety disorders,
sleep disturbances, Tourette's syndrome and other tic disorders.
Tenex also appears to have beneficial effects on hyperactive
behaviors, attention abilities, anxiety and tic disorders,
and may be less sedating.
OFF
LABEL USE
Physicians
may legally prescribe medications in ways not specifically
approved by the Food & Drug Administration.
In fact, it is standard practice for physicians to do so,
taking into account new research findings, clinical experience,
and the child's needs. Prescription for "off-label”
purposes of any medication should be made only after a comprehensive
evaluation has been made and other forms of therapy (or combination
of) have been considered, and must be monitored closely.
CONCLUSION
The
American and California Psychiatric Associations share the
desire of the National Institute of Mental Health to
ensure the appropriate treatment of mental illnesses
in children. Medications must be prescribed judiciously as
part of a comprehensive treatment plan and only after a thorough
evaluation by qualified medical personnel. More funding is
needed for mental health services for children, and for further
research to understand the causes of illness and to develop
more effective treatments for children.
Source:
Adapted and updated from a fact sheet from the American Psychiatric
Association (APA) March, 2000. For the complete
fact sheet, with bibliography, consult the APA’s web
site, GOTOBUTTON BM_1_ www.psych.org <http://www.psych.org/>.
Other
useful web sites:
American Academy
of Child and Adolescent Psychiatry
National
Institutes of Mental Health
U.S.
Surgeon General,
American Academy
of Pediatrics
The purpose
of this newsletter is to provide brief information on developments
and quesitons in the medical specialty of psychiatry that
can contribute to high-quality, cost-effective health care.
Published by the California Psychiatric Association
1400 K Street, Suite 302, Sacramento, CA 95814
For reprint permission, call 916-442-5196
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