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:

  1. Stimulants (methylphenidate, dextroamphetamine, pemoline of magnesium)
  2. Tricyclic antidepressants (imipramine, amitriptyline, desipramine, clomipramine, nortriptyline)
  3. Selective serotonin reuptake inhibitors (fluoxetin, paroxetine, sertraline, fluvoxamine)
  4. Antipsychotic (chlorpromazine, haloperidol, pimozide, risperidone, quetiapine)
  5. Mood stabilizers ( lithium)
  6. Antiepileptic for psychiatric use (phenitoin, catbamazepine, valproic)
  7. Other (clonidine).

The disorders that may be treated with psychotropic drugs include:

  1. 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 drug.

  2. 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.
  3. 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.
  4. 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).
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. Anorexia nervosa: no drug is effective. Preliminary studies indicate that olanzapine may have some effect.
  11. Enuresis: Imipramine in small dosage or DDVAP (desmopressine) given at bedtime may be of substantial help.
  12. 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.
  13. 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.