Medication can be an important part of treatment for some psychiatric disorders in children and adolescents. Psychiatric medication should only be used as one part of a comprehensive treatment plan. Ongoing evaluation and monitoring by a physician is essential. Parents and guardians should be provided with complete information when psychiatric medication is recommended as part of their child's treatment plan. Children and adolescents should be included in the discussion about medications, using words they understand.
By asking the following questions, children, adolescents, and their parents will gain a better understanding of psychiatric medications:
1. What is the name of the medication? Is it known by other names?
2. What is known about its helpfulness with other children who have a similar condition to my child?
3. How will the medication help my child? How long before I see improvement? When will it work?
4. What are the side effects, which commonly occur with this medication?
5. Is this medication addictive? Can it be abused?
6. What is the recommended dosage? How often will the medication be taken?
7. Are there any laboratory tests (e.g. heart tests, blood test, etc.), which need to be done before my child begins taking the medication? Will any tests need to be done while my child is taking the medication?
8. Will a child and adolescent psychiatrist be monitoring my child's response to medication and make dosage changes if necessary? How often will progress be checked and by whom?
9. Are there any other medications or foods, which my child should avoid while taking the medication?
10. Are there interactions between this medication and other medications (prescription and/or over-the-counter) my child is taking?
11. Are there any activities that my child should avoid while taking the medication? Are any precautions recommended for other activities?
12. How long will my child need to take this medication? How will the decision be made to stop this medication?
13. What do I do if a problem develops (e.g. if my child becomes ill, doses are missed, or side effects develop)?
14. What is the cost of the medication (generic vs. brand name)?
15. Does my child's school nurse need to be informed about this medication?
Attention Deficit Hyperactivity Disorder—
Attention Deficit Hyperactivity Disorder (ADHD) is a disorder usually first diagnosed in infancy, childhood or adolescence. There are 4 recognized types of ADHD:
Predominantly Inattentive type
Predominantly Hyperactive-Impulsive type
Combined type (inattention and hyperactivity-impulsivity)
ADHD - Not Otherwise Specified.
There is a high level of correlation between children with ADHD and other psychiatric problems (e.g., behavioral, mood, family, anxiety, cognitive, social and school functioning).
Long Acting Stimulants:
The long acting stimulants generally have a duration of 8-12 hours and can be used just once a day. They are especially useful for children who are unable or unwilling to take a dose at school.
Adderall XR The latest medication to get approval to treat ADHD is Adderall XR, and it is approved for use in children over the age of six years, although regular Adderall can be used in younger children from 3-5 years of age. Adderall XR is a sustained release form of Adderall, a popular stimulant, which contains dextroamphetamine and amphetamine. It is available as a 10mg, 20mg and 30mg capsule, and unlike many of the other sustained release products, the capsule can be opened and sprinkled onto applesauce if your child can't swallow a pill. New forms of Adderall XR include a 15mg and 25mg capsule for greater flexibility in dosing for your child.
Concerta Concerta is a sustained release form of methyphenidate (Ritalin). It is available as a 18mg, 36mg and 54mg tablet and is designed to work for 12 hours. Like Adderall XR, it is only approved for children over the age of six years.
Metadate CD This is also a long acting form of methylphenidate (Ritalin).
Ritalin LA This is a new long acting form of methylphenidate (Ritalin). It is available in 10, 20, 30, and 40mg capsules. Unlike the other long acting forms of methylphenidate, like Adderall XR, the Ritalin LA capsules can be opened and sprinkled on something if your child can't swallow them whole.
Short/Intermediate Acting Stimulants:
With all of these new medicines available to treat ADHD, is there still a roll for the older short and intermediate acting stimulants? Should you change your child to a newer medicine?
It is compelling to think about changing to a new long acting medication because of the convenience of once a day dosing and their long lasting effects, but it is important to remember that they shouldn't be any more effective than a short acting medicine.
Short/Intermediate acting stimulants include:
Ritalin (Methylphenidate HCl)
Methylin Chewable Tablet and Oral Solution
Focalin: an short acting stimulant with the active ingredient dexmethylphenidate hydrocholoride, which is also found in methylphenidate (Ritalin). It is available in 2.5mg, 5mg, and 10mg tablets.
Dexedrine (Dextroamphetamine sulfate)
If 2 or 3 stimulants don't work for your child, second line treatments might be tried, including tricyclic antidepressants (Imipramine or Desipramine) or bupropion (Wellbutrin). Clonidine is also sometimes used, especially for children that have ADHD and a coexisting condition.
In general, side effects of stimulants can include a decreased appetite, headaches, stomachaches, trouble getting to sleep, jitteriness, and social withdrawal, and can usually be managed by adjusting the dosage or when the medication is given. Other side effects may occur in children on too high a dosage or those that are overly sensitive to stimulants and might cause them to be 'overfocused on the medication or appear dull or overly restricted.' Some parents are resistant to using a stimulant because they don't want their child to be a 'zombie,' but it is important to remember that these are unwanted side effects and can usually be treated by lowering the dosage of medication or changing to a different medication.
Autism may manifest in early infancy, with the infant shying away from the parent's touch, not responding to a parent who returns after an absence, and inappropriate gaze behavior. The Autistic child may fail to meet early language and other developmental milestones. And there can be as much as a 3-year delay between the report of symptoms and the diagnosis, which is usually made at around age five.
No medication can correct the brain structures or impaired nerve connections that seem to underlie autism. Scientists have found, however, that drugs developed to treat other disorders with similar symptoms are sometimes effective in treating the symptoms and behaviors that make it hard for people with autism to function at home, school, or work.
Medications used to treat anxiety and depression are being explored as a way to relieve certain symptoms of autism. These drugs include fluoxetine (Prozac™), fluvoxamine (Luvox™), sertraline (Zoloft™), and clomipramine (Anafranil™). Some scientists believe that autism and these disorders may share a problem in the functioning of the neurotransmitter serotonin, which these medications apparently help.
One study found that about 60 percent of patients with autism who used fluoxetine became less distraught and aggressive. They became calmer and better able to handle changes in their routine or environment. However, fenfluramine, another medication that affects serotonin levels, has not proven to be helpful.
People with an anxiety disorder called obsessive-compulsive disorder (OCD), like people with autism, are plagued by repetitive actions they can't control. Based on the premise that the two disorders may be related, one NIMH research study found that clomipramine, a medication used to treat OCD, does appear to be effective in reducing obsessive, repetitive behavior in some people with autism. Children with autism who were given the medication also seemed less withdrawn, angry, and anxious. But more research needs to be done to see if the findings of this study can be repeated.
Some children with autism experience hyperactivity, the frenzied activity that is seen in people with attention deficit hyperactivity disorder (ADHD). Since stimulant drugs like Ritalin™ are helpful in treating many people with ADHD, doctors have tried them to reduce the hyperactivity sometimes seen in autism. The drugs seem to be most effective when given to higher-functioning children with autism who do not have seizures or other neurological problems.
Because many children with autism have sensory disturbances and often seem impervious to pain, scientists are also looking for medications that increase or decrease the transmission of physical sensations. Endorphins are natural painkillers produced by the body. But in certain people with autism, the endorphins seem to go too far in suppressing feeling. Scientists are exploring substances that block the effects of endorphins, to see if they can bring the sense of touch to a more normal range. Such drugs may be helpful to children who experience too little sensation. And once they can sense pain, such children could be less likely to bite themselves, bang their heads, or hurt themselves in other ways.
Chlorpromazine, theoridazine, and haloperidol have also been used. Although these powerful drugs are typically used to treat adults with severe psychiatric disorders, they are sometimes given to people with autism to temporarily reduce agitation, aggression, and repetitive behaviors. However, since major tranquilizers are powerful medications that can produce serious and sometimes permanent side effects, they should be prescribed and used with extreme caution.
Vitamin B6, taken with magnesium, is also being explored as a way to stimulate brain activity. Because vitamin B6 plays an important role in creating enzymes needed by the brain, some experts predict that large doses might foster greater brain activity in people with autism. However, clinical studies of the vitamin have been inconclusive and further study is needed.
Like drugs, vitamins change the balance of chemicals in the body and may cause unwanted side effects. For this reason, large doses of vitamins should only be given under the supervision of a doctor. This is true of all vitamins and medications.
Conduct Disorder is essentially a disorder where the person violates the social norms and rights of others. Those with this disorder are habitually in trouble, either with parents, teachers or peers. Despite presenting a tough image to those around them, they have a low self-esteem. Their frustration tolerance, irritability, temper outbursts and recklessness are hallmarks. Conduct Disorder may lead to adult antisocial personality disorder.
Oppositional Defiant Disorder (ODD)
Oppositional Defiant Disorder (ODD) is a disorder in which children ignore or defy adults' requests and rules. They may be passive, finding ways to annoy others, or active, verbally saying "No". They tend to blame others for their mistakes and difficulties. When asked why they are so defiant, they may say that they are only acting against unreasonable rules. They are different from children with conduct disorders in that they do not violate the rights of others. These behaviors are present at home, but not necessarily in other situations, such as school, or with other adults.
We will look at the drugs which are used for violence, oppositionality and aggression regardless of diagnosis. These are drugs have been tested in adults and children who are violent and aggressive for a variety of reasons -- from ADHD to brain damage to Conduct Disorder, and of course ODD.
Atypical Antipsychotics These drugs were first used for schizophrenia, and that is how they got this name. They are now commonly used for many conditions where people are not psychotic. As you can see, these are not benign medications. All of them can have serious side effects. As a result, they are not used for small problems.
Risperidone (Risperidal) This drug was initially developed to be a safer drug for adult schizophrenia. It was then found to be effective in children with schizophrenia and other psychoses. Then it was found to be helpful in some children with Tic disorders. Based on those findings it has been used in Conduct Disorder and ODD. In 2006, a large study of the use of this drug in over 500 children with ODD and/or CD found that it was much better than placebo and that this improvement was still present 6 months later These studies are probably the most exciting news for the medical treatment of CD in 20 years. Risperidone is called Risperidal and comes in a variety of sizes; 25mg, .5 mg, 1mg, 2mg and liquid. It also helps Tourettes and psychosis. Usually this is given twice a day. This drug usually shows an effect within hours of a dose. There are more studies done on this drug than all the other atypical antipsychotics combined.
Olanzapine (Zyprexa) This drug was recently approved for mania in adults. It has been studied less in children. However the early reports are positive. The usual dose is about 5-15 mg a day. It comes in 2.5 mg, 5mg and 10 mg. It is also called Zyprexa. It is more expensive than Risperidone and in adults is associated with more weight gain. This can be given once a day.
Quetiapine (Seroquel) This drug is a little different than the above drugs as it seems to cause very little problems with things like tremor and stiffness. In adolescents it can lower the blood pressure so the dose has to be increased slower. The dosage range is 200-800 mg a day. There are only a few articles on its use in children and adolescents, but these have been quite positive for mood disorders.
Weight Gain -- This is the biggest problem with these drugs in children. Not all kids gain weight, but a fair number can get 10-30lbs or more. In the long term drug trial of Risperidal, the average weight gain was 3.2 kg, and after 4 months, most children did not gain any more weight during the 6 month study. Obviously this is something we watch very carefully. Overall Zyprexa causes the most weight gain, then Seroquel, followed by Risperidal. This is sometimes very hard to manage. It is key to weigh children everytime and start with a diet at the first sign of weight gain. There should also be a weight above which alternative drugs are tried. There is some data to support the use of a drug called Topamax for this. This is covered in the Bipolar handout.
Stiffness, restlessness, and tremor -- These occasionally happen with these drugs, too, but to a much less extent than with the older antipsychotics. This is called drug induced Parkinsons. There can also be a sudden stiffening of the body which is quite terrifying. There is an antidote to this. This is reversible if the dosage is reduced or the drug is stopped. Overall it is most common with Risperidal, then Zyprexa, and least common with Seroquel. In the large study of Risperdal in ODD and CD,1.2% had an episode of dystonia over the 10 months, and about 1/1000 had signs of drug induced Parkinsons.
Elevated Cholesterol and Triglycerides -- It was thought that only those people who were gaining weight got this, but now it is clear that it can happen with children who do not gain a lot of weight. Zyprexa is the most likely to cause this, followed by Seroquel, and least likely is Risperidal.
Diabetes -- This can come out of the blue or be worse on these medications. Zyprexa is the most likely to cause this, followed by Seroquel, and least likely is Risperidal. In the large study of Risperidal, not one child out of over 500 developed Diabetes over the 10 months.
Tardive Dyskinesia -- This is a movement disorder where people can have chewing movements of the mouth, grimacing, head movements, trunk movements and hand movements. The movements are not jerky but smooth and rhythmic. Risperidal is the most likely to cause this, and the other two are very unlikely to cause it. In the large study of Risperidal, not one child out of over 500 developed this problem.