Pharmacological treatment of psychiatric disorders
of childhood and adolescence
The pharmacological treatment of the psychiatric disorders of childhood
and adolescence is a new and growing field of therapeutic endeavour which
is consistent with the prevalent model of biopsychosocial conceptual model
of these disorders. Whilst the pharmacological treatment may be essential
for certain disorders e.g. early onset schizophrenia, attention deficit-hyperactivity
disorder, Gilles de la Tourette syndrome, it is not sufficient without additional
psychological and social interventions. For other disorders, e.g. conduct
disorder, pharmacotherapy may be helpful at a difficult moment by controlling
symptoms or behaviours that are highly disruptive allowing time for other,
more effective treatments to work.
The psychiatrist who decides to prescribe psychotropic medication for children
and adolescents should first become aware of the effects and possible side-effects
of the drugs by being well informed on new knowledge on them as it becomes
available. The clinician's decision to consider pharmacotherapy should be
based on indications supported by 'double blind placebo controlled' drug
trials that may provide reliable information on efficacy and safety. Since
there are no objective criteria that would lead the clinician to the selection
and the dosage of the drug, he/she will have to exercise clinical judgment
matching drug to disorder. The drug chosen should begin at a low dosage
and under continuous observation for an initial trial period. Appropriate
response and no side-effects will determine whether pharmacotherapy is useful
in that particular case. The prescription of medication regardless of how
effective may be, requires itself counseling addressed to the parents and
the child/adolescent. Furthermore, pharmacotherapy may not be considered
sufficient treatment for most child and adolescent psychiatric disorders.
Other forms of therapeutic interventions administered concurrently e.g.
psychotherapy, behaviour therapy, social skills training, family therapy,
parent management training, special education, are often required.
The following categories of psychotropic drugs have up till now been tested
adequately and have been found useful for children and adolescents:
- Stimulants (methylphenidate, dextroamphetamine, pemoline of magnesium)
- Tricyclic antidepressants (imipramine, amitriptyline, desipramine,
- Selective serotonin reuptake inhibitors (fluoxetin, paroxetine, sertraline,
- Antipsychotic (chlorpromazine, haloperidol, pimozide, risperidone, quetiapine)
- Mood stabilizers ( lithium)
- Antiepileptic for psychiatric use (phenitoin, catbamazepine, valproic)
- Other (clonidine).
The disorders that may be treated with psychotropic drugs include:
Attention deficit-hyperactivity disorder (ADHD): The drugs of choice
are stimulants (methylphenidate, dextroamphetamine) which are short
acting and are given in the morning on school days. At least 70% of
children respond positively to medication. If there are side effects
these are usually benign and are reversed upon discontinuation of the
- Obsessive-compulsive disorder(OCD): Most selective serotonin reuptake
inhibitors (SSRI) and a certain tricyclic antidepressant with similar
effect (clomipramine) are as effective in children as they are in adults
with OCD. The drug effect may become evident over a period of a few weeks.
In the presence of persistent side effects the drug must be discontinued
and another one be tried. More side effects may be expected with clomipramine.
- Gilles de la Tourette syndrome: There are no specific drugs for this
syndrome but in low dosage either risperidone or clonidine may be of help.
- Conduct disorder: This is a highly complex disorder requiring combination
of various forms of therapeutic interventions. In this context drugs may
target specific symptoms/behaviours e.g. explosive and aggressive tempers.
Effective drugs are risperidone and lithium (the latter has been tried
only for brief periods of time).
- Depression: Antidepressants, either tricyclic or SSRIs, are not effective
in depressed children. These drugs become effective in late adolescence
and even then the level of success is not very high.
- Anxiety disorder: There are no drugs specific for the treatment of
anxiety disorders. Benzodiazepines are not recommended for children. Recent
drug trials have shown that the SSRIs fluvoxamine and sertraline may be
suitable for a trial prescription.
- Schizophrenia: Atypical antipsychotics are considered the drugs of
choice for early onset schizophrenia although systematic studies are still
lacking. the sides effects of these drugs may be more pronounced in childern
and adolescents than they are in adults.
- Cyclic psychosis: This is a disorder difficult to diagnose in childern
and young adolescents and there are no studies available on the usefullness
of psychotropic drugs on it.
- Autism: there is no specific drug available as yet to control the core
symptoms of autism. In case of very disruptive behaviour, risperidone
may be of considerable help.
- Anorexia nervosa: no drug is effective. Preliminary studies indicate
that olanzapine may have some effect.
- Enuresis: Imipramine in small dosage or DDVAP (desmopressine) given
at bedtime may be of substantial help.
- Sleep problems: No drug trials are available on childern. A tricyclic
antidepressant (amitriptyline, clomipramine) or an a2-agonist (clonidine)
may be tried for a brief period of time.
- Pharmacotherapy for children under the age of 6 years: the use of psychotropic
drugs has not been studied in this age group with the exception of methyphenidate.
Extreme caution is necessary for any psychotropic drug use in young children.
Key words: Psychiatric disorders of childhood and adolescence, psychopharmacology.