1. Psychopharmacology for Children

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. Drugs to know methylphenidate/dexamphetamine (stimulants) SSRIs imipramine clonidine sedative antihistamines benzodiazepines

11. Drugs to be aware of Clomipramine (Anafranil) propanolol risperidone other antipsychotics mood stabilisers

12. 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

13. 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)

14. 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?)

15. 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)

16. 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?

17. 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

18. 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

19. 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

20. 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

21. 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

22. Imipramine useless antidepressant outclassed by desmopressin in enuresis not much good with anxiety moderately effective in ADHD

23. 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)

24. 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

25. Sedative antihistamines widely used for sleep onset problems (diphenhydramine, promethazine, hydroxyzine,alimemazine/trimeprazine) unlikely to help child with anger or anxiety symptoms

26. Benzodiazepines rapid tranquillisation (lorazepam) panic attacks (alprazolam) may cause paradoxical excitement or dysphoria best used for brief periods only

27. Clomipramine tricyclic antidepressant with serotonin re- uptake blocking action powerful in OCD difficulty with adverse effects –constipation –dry mouth –blurred vision –postural hypotension

28. 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

29. 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

30. Mood stabilisers mainly carbamazepine, valproate lithium less commonly because of –thyroid and renal problems –blood level monitoring needed

31. 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