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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 – – – – – – 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) – – – – – 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 • • • • • 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 • • • • 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 • • • • 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 • • • • 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 – – – – constipation dry mouth blurred vision postural hypotension Risperidone • • • • 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