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  3. Practical Child and Adolescent Psychopharmacology
  • Cited by 17
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    • Publisher:
      Cambridge University Press
      Publication date:
      31 August 2009
      18 April 2002
      ISBN:
      9780511543920
      9780521655422
      DOI:
      https://doi.org/10.1017/CBO9780511543920
      Dimensions:
      Weight & Pages:
      Dimensions:
      (247 x 174 mm)
      Weight & Pages:
      0.977kg, 484 Pages
      • Series:
      Cambridge Child and Adolescent Psychiatry
      Subjects:
      Psychiatry and Clinical Psychology, Developmental Psychology, Medicine, Pediatrics and Child Health, Psychiatry
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    Series:
    Cambridge Child and Adolescent Psychiatry
    Subjects:
    Psychiatry and Clinical Psychology, Developmental Psychology, Medicine, Pediatrics and Child Health, Psychiatry
    Information

    Book description

    The field of child and adolescent psychopharmacology is rapidly growing, but psychopharmacological treatments for children cannot be straightforwardly extrapolated from adult studies, which presents clinicians with assessment and prescribing challenges. This important book synthesises research findings about drug treatment of a broad range of psychiatric disorders in children, including attention-deficit hyperactivity disorder, obsessive-compulsive disorder, major depression, schizophrenia, bipolar mania, aggression in pervasive developmental disorder, Tourette's syndrome and substance abuse. They examine the issues of tolerability and efficacy, and appropriate use, within a social and developmental context. For each disorder, pharmacotherapy is discussed in the wider context of neurobiology, etiology, diagnosis and treatment. This will be essential reading for all mental health professionals to inform practice and improve patient outcomes.

    Reviews

    ‘… a very welcome addition to the still relatively small number of reference texts in child and adolescent psychopharmacology … the overall quality of the text is excellent … this book makes an important contribution to a field where clinical practice tends to run ahead of the clinical evidence-base and remain relatively uninformed by basic neuroscience. This book should be essential reading for all child psychiatry trainees …’

    Source: Journal of Child Psychology

    ‘… a very well written and clearly set out book … excellent book for anyone who wants a current insight into how medication is used in child and adolescent psychiatry, how different it may be to treatment in adults.’

    Source: Journal of Pharmacy Practice and Research

    ‘The chapters offer timely and expert overviews of a complex and evolving field.’

    Marc Sandrolini Source: Divine.com

    '… should serve as a good reference guide for the clinicians. I particularly liked the chapters on Obsessive Compulsive Disorders, Anxiety and Attention Deficit Hyperactivity Disorder.'

    Source: Pediatric Rehabilitation

    'This is an interesting and worthwhile book.'

    Source: Psychological Medicine

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    Contents

    Contents
    • 1 - Child and adolescent psychopharmacology at the turn of the millennium
      pp 1-37
    • View abstract

      Summary

      Child and adolescent psychopharmacology is a leading edge of pediatric psychiatry and is rapidly developing. Attention-deficit/hyperactivity disorder (ADHD) has become the psychiatric model or prototype disorder for the medication treatment of children. Psychostimulants remain the treatment of choice for ADHD, partially because of their solid effectiveness in treating the behavioral symptoms and especially because of their unmatched effectiveness in ameliorating the cognitive symptoms. In the 1990s, child and adolescent psychopharmacologic treatment entered everyday psychiatric practice. Its speedy expansion led drug treatment, alongside and integrated with psychosocial interventions, to become the prevailing approach in child psychiatry by mid 1990s. The preoccupation of child psychiatry with psychoanalysis has given way to a more eclectic and empirical clinical methodology. Therapeutic empiricism has become the watchword by which clinicians decide when to treat and when to delay the use of medication and psychosocial treatments.
    • 2 - Developmental psychopharmacology
      pp 38-69
    • View abstract

      Summary

      This chapter reviews the normal development of central nervous system (CNS), developmental aspects of neurotransmitters and receptors, developmental neuroimaging, and experimental studies involving psychotropic compounds in young animals. The complementary concepts of brain plasticity and sensitive periods are two important frameworks which inform many aspects of brain development. It is known that neurotransmitters and receptors are expressed at their highest levels in the immature brain and in anatomic regions different than in the mature brain, even in the absence of fully functional synapses. Investigators have hypothesized that stressful experiences during development may have a long-term effect on hippocampus by directly altering its structure and functioning. Two areas of research that are of immediate application in the child and adolescent age group are the theory of genetic anticipation and the identification of candidate genes in ADHD.
    • 3 - Clinical aspects of child and adolescent psychopharmacology
      pp 70-90
    • View abstract

      Summary

      Pathology is operationally defined by a set of rating scales which addresses the dimension at issue. In psychiatry, many dimensions are measured with rating scales e.g. anxiety, depression, hyperactivity, impulsivity, inattention, aggressiveness, extroversion, introversion, and emotional liability. The diagnostician's job is first to connect the symptoms/problems with which the patient presents with possible disorders that might be responsible for the symptoms/problems. For parents who consider medication treatment as the court of last resort, it may be sensible to recommend a trial of psychologic treatment with a time period built in such that continuation of problems after x number of weeks warrants reconsideration of medication. It is important to target psychosocial functioning separately from change in psychopathology. Other issues that complicate treatment include the presence of multiple disorders, which is the rule rather than the exception for children requiring medication treatment.
    • 4 - Depression
      pp 91-105
      • By Neal D. Ryan, Western Psychiatric Institute, Pittsburgh, Pennsylvania, USA
    • View abstract

      Summary

      Depression in childhood and adolescence is a chronic, recurring, and highly morbid disorder associated with poor psychosocial functioning, suffering, and attempted and completed suicide. This chapter throws light on how to diagnose depression in children and adolescents. It explores how the clinical picture of depression changes between childhood and adulthood, and focuses on ways people can adapt interviewing techniques for children. The information that the parent conveys helps to structure the interview with the child and helps efficiently and completely to elicit symptoms from the child. Reliability on the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS) and other instruments suggests that the diagnosis of depression in children and adolescents could be made as reliably as these diagnoses are made in adults. Discussing psychopharmacologic treatment, the chapter highlights that for medication, a selective serotonin reuptake inhibitor (SSRI) is most likely the first choice.
    • 5 - Bipolar mood disorders: diagnosis, etiology, and treatment
      pp 106-133
    • View abstract

      Summary

      Bipolar disorder in adolescents and children has recently become the focus of increasing study. During adolescence, normal developmental mood shifts may complicate the diagnosis of mood disorders. The commonality of symptoms associated with a variety of childhood disorders (especially ADHD) confuses the diagnostic process. Confusion regarding comorbidity can also occur if cross-sectional rather than longitudinal analyses are conducted. Genetic imprinting is the differential gene expression depending on whether the illness is transmitted maternally or paternally. Psychosocial functioning in bipolar youth has been described premorbidly and postillness onset (4.6 years) in a cohort of BMD I teenagers. Many young people who are initially diagnosed as having unipolar depression or dysthymia later meet criteria for a bipolar disorder. Electro-convulsive therapy (ECT) in adults with bipolar illness is one of the most effective treatments in both the depressive and manic phases of bipolar illness.
    • 6 - Schizophrenia and related psychoses
      pp 134-158
      • By Keith Marriage, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
    • View abstract

      Summary

      Optimal management of schizophrenic illness in children and adolescents requires the successful differentiation of schizophrenia from a number of other psychotic and nonpsychotic disorders with similar presentations. Given the challenges posed by differential diagnoses, and the changing course of the various psychotic illnesses, structured interviews may be fruitfully employed to produce a semiquantitative profile of symptoms at presentation, and to follow these symptoms as the illness evolves. The causal factors of this group of syndromes are unknown, but a number of different models have been proposed. Current thinking favors various biologic hypotheses, with some synthesis between biochemical, genetic, neuropathologic, and developmental factors. In the past 10 years, a group of atypical neuroleptics have emerged, the prototype of which has been clozapine. This medication has proved to have efficacy in controlling positive symptoms in one-third to one-half of the sufferers who had been previously refractory to typical antipsychotic therapy.
    • 7 - Obsessive–compulsive disorder
      pp 159-186
    • View abstract

      Summary

      This chapter reviews the current state of knowledge regarding the phenomenology, diagnosis, etiology, and treatment of obsessive-compulsive disorder (OCD) specifically as related to children and adolescents. The most common compulsions seen include excessive washing or cleaning, repeating, checking, touching, counting, ordering/arranging, and hoarding. Behaviors which may indicate the presence of OCD include lengthy bedtime rituals or exaggerated requests for reassurance, particularly if centered on a fear of harm coming to self or others. Additional evidence supporting a neurobiologic etiology of OCD includes a plethora of neuroanatomic, neurophysiologic, and neuroimmunologic findings. Psychodynamic psychotherapy may be an effective approach to the treatment of comorbid conditions such as depression or personality disorders (American Academy of Child and Adolescent Psychiatry, 1998). In conclusion, CBT and pharmacotherapy appear to work well together, and many children with OCD require or would benefit from both CBT and pharmacotherapy.
    • 8 - Anxiety disorders
      pp 187-229
      • By E. Jane Garland, Outpatient Psychiatry, Vancouver, British Columbia, Canada
    • View abstract

      Summary

      Anxiety disorders of childhood are recognized as chronic, disabling conditions requiring early and effective interventions. The remaining specific anxiety disorder of childhood is SAD, although this may be an early manifestation of panic disorder. Post-traumatic stress disorder (PTSD) describes disabling anxiety responses to an extreme traumatic stressor involving actual or threatened personal injury, or threats to one's integrity. This chapter discusses temperament research focused on behavioral patterns which are presumed to reflect neurobiologic makeup. Combined pharmacotherapy may be used to target acute anxiety while modulating underlying anxiety levels, as in benzodiazepine coverage during initiation of serotonergic medications. Pharmacotherapy for GAD in adults has received increased attention due to advent of efficacious nonbenzodiazepine medication. SSRIs have gained favor in children due to lack of serious, especially cardiac, side effects and relative safety in overdose. Medication may reduce physical anxiety, reset panic alarm, and reduce the cognitive worry associated with anxiety sensitivity.
    • 9 - Attention-deficit/hyperactivity disorder
      pp 230-264
    • View abstract

      Summary

      This chapter discusses attention-deficit/hyperactivity disorder (ADHD) is one of the major clinical and public health problems because of its associated morbidity and disability in children, adolescents, and adults. Conduct disorder (CD) is the most well-established comorbid condition of childhood ADHD, and has been widely reported in epidemiologic. Stimulants have been demonstrated to improve cognitive function as measured by tests of vigilance, impulsivity, reaction time, short-term memory, and learning of verbal and nonverbal material in children with ADHD. The chapter preludes the preliminary studies to suggest that MAOIs are effective in juvenile and adult ADHD. Major limitation to the use of MAOIs is the potential for hypertensive crisis (treatable with phentolamine) associated with dietetic transgressions (tyramine-containing foods, i.e., most cheeses) and drug interactions (pressoamines, most cold medicines, amphetamines).
    • 10 - Pervasive development disorder
      pp 265-304
      • By Sandra N. Fisman, Children's Hospital of Western Ontario, London, Ontario, Canada
    • View abstract

      Summary

      The pervasive developmental disorders (PDDs) are characterized by impairments in socialization, communication, and imagination, and the presence of repetitive and ritualistic behaviors (American Psychiatric Association, DSM-IV, 1994). The PDDs do share some of the positive and negative symptoms of schizophrenia. Autistic disorder is the paradigmatic PDD. Disturbance in social relatedness remains a major defining feature of the disorder. A number of neuroanatomic loci, as well as abnormalities in cerebral lateralization, have been described in the PDD. The most consistent neurotransmitter abnormalities in the PDDs have been found in the serotonin. Since the PDDs are early-onset developmental disorders more readily identifiable in childhood, there is a paucity of information available on the psychopharmacologic treatment of adults with PDD. Currently, the best guide for pharmacologic management of these disorders is empirical treatment of target symptoms. Pharmacologic treatment must be seen in the context of an overall treatment plan.
    • 11 - Aggressive behavior
      pp 305-327
      • By Deborah Lynn, UCLA Neuropsychiatric Institute, Los Angeles, California, USA, Bryan H. King, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
    • View abstract

      Summary

      The psychopharmacology of aggression in humans typically focuses on physical, active, and direct aggressive acts. This chapter focuses aggression directed outside of one's self. J. M. Halperin's study implies that there is perhaps a developmental lesion that begins as aggression in children and may change as maturation resulting in variation in adult aggressive behavior. The medications most widely employed in the treatment of aggression, regardless of etiology, include major tranquilizers, antidepressants, and mood stabilizers. PRN medicines, or pro re nata, according to circumstances, constitute a common method for treating the acute aggression. The risk/benefit ratio of these medications must be considered as well as monitoring for side effects. Psychologic treatment modalities, including individual therapy, family treatment, and group therapy, either in the context of an outpatient or inpatient setting, should compliment pharmacotherapy. Behavioral therapy can be especially useful for the aggressive patient.
    • 12 - Adolescent substance use disorder
      pp 328-381
    • View abstract

      Summary

      This chapter begins with an overview of substance use disorder (SUD) in adolescents followed by a review of the neurobiologic mechanisms of SUD and ends with some practical guidelines for the management of young people with SUD and comorbid psychiatric disorders. SUDs are characterized by the constellation of symptoms and maladaptive behavioral changes associated with the regular use of psychoactive substances. The chapter discusses addiction referring to a chronic, compulsive pattern of substance use leading to tolerance, withdrawal symptoms, and/or other physiologic changes. Treatment of withdrawal states can typically be achieved by replacing the abused drug with a drug of similar pharmacologic actions. Maintenance treatment with agonists is designed to support many patients with chronic relapsing opioid dependence. The goals of pharmacologic treatments include reduction in craving/subjective effects of abused substances, prevention of relapse, and treatment of comorbid psychiatric disorders.
    • 13 - Tic disorders and Tourette's syndrome
      pp 382-409
    • View abstract

      Summary

      Tourette's syndrome (TS) is characterized as a disorder of the mind, and tic symptoms the result of psychologic mechanisms. TS begins in childhood and for most patients symptom severity peaks in latency and early adolescence and decreases in adulthood. The diagnosis of TS and other tic disorders is dependent on the presence of motor and vocal tics. Problems with mood and impulse control, obsessive-compulsive behaviors, anxiety, disruptive behavior, attention, and learning are common in clinically ascertained populations of TS subjects. Patient and parent education is perhaps the most important component of treatment. Patients treated with medications for comorbid conditions that co-occur with TS may experience increased tic severity temporally associated with medication use. For many TS patients, the treatment of OCD, ADHD, or other psychiatric disorders may be the most important first step, as these disorders are often more impairing than tics.
    • 14 - Eating disorders and related disturbances
      pp 410-430
      • By Lisa A. Kotler, Columbia University/New York State Psychiatric Institute, New York, USA, Michael J. Devlin, Columbia University/New York State Psychiatric Institute, New York, USA, B. Timothy Walsh, Columbia University/New York State Psychiatric Institute, New York, USA
    • View abstract

      Summary

      This chapter reviews the role of medication in the treatment of eating disorders, with particular emphasis on trials conducted in children and adolescents. More than 90% of all cases of anorexia nervosa occur in females. Hypothesized biologic mechanisms for anorexia nervosa have included disturbances in the monoamine neurotransmitters serotonin, dopamine, and noradrenaline, as well as in neuropeptides and peripheral hormones. Pharmacotherapy is often used as an adjunct to a multidisciplinary approach including nutritional counseling, and family and cognitive-behavioral psychotherapies. Bulimia nervosa is more prevalent than anorexia nervosa, with estimates ranging from 1 to 5% of adolescent and young adult females. The pharmacotherapy of bulimia nervosa is based on the use of antidepressant medications. DSM-IV suggested diagnostic criteria for a new eating disorder, binge eating disorder. The precise role of psychopharmacologic agents in the treatment of eating disorders in children and adolescents is a fertile area for future research.
    • 15 - Medical psychiatric conditions
      pp 431-454
    • View abstract

      Summary

      The chapter first reviews evidence regarding the association between the psychiatric and medical disorders in children. It familiarizes clinicians with the range of medical or neurobiologic processes that might potentially contribute to the development of childhood psychopathology. The chapter hopefully sensitizes the clinician to the potential impact of underlying biologic processes on clinical psychiatric presentation. It provides a few guidelines for the clinician in the evaluation of children and adolescents presenting with psychopathology. Finally, the chapter summarizes a set of practical issues related to the evaluation and treatment of children with potentially co-occurring medical and psychiatric syndromes. Children with focal brain lesions face an elevated risk for psychiatric disorders, particularly behavior disorders. Based on this well-recognized association, an assessment of perinatal history and a neurologic examination have become an integral component of the comprehensive psychiatric evaluation in children and adolescents.

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