Pediatric Psychopharmacology


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Pediatric Psychopharmacology

  1. 1. Pediatric Psychopharmacology The Facts and Why it Can Save Our Kids Armeta Dastyar Priya Mathews
  2. 2. Introduction • Pediatric Psychopharmacology refers to the study of interaction of drugs with the body and its behavioral effects in children [1] • First reports of psychotropic drug use in adolescents in the 1930’s by Charles Bradley [2]
  3. 3. History of Pediatric Psychopharmacology • 1997- FDA Moderation Act gave incentives for pediatric research on already adult-approved medications [3] • 2002- Best Pharmaceuticals for Children Act- an extensive process for studying medications in pediatric populations [3] • 2003- Pediatric Research Equity Act authorized FDA to require drug manufacturers to conduct pediatric studies [3] • With these regulations  consumers and medical providers have a fairly large database for using these psychotropic medications in children
  4. 4. What’s the Controversy About? • Supporters claim that the use of psychotropic drugs can help manage pediatric disorders where behavioral or psychosocial interventions alone cannot. Also, it is important to prevent these children from harming themselves or others. • Opponents claim that many of these drugs have not been extensively tested for children and that long term effects are still unknown. They believe that we are overmedicating our children.
  5. 5. Evaluations Required • Are kids simply being put on numerous drugs without a second thought? [4] • Extensive physical and psychiatric evaluations in a variety of settings are required: – Physical examination – Structured interview – Behavioral rating scales – Direct observations of behavior – Standardized measures of performance
  6. 6. Different Classes of Drugs • Doctors strive to find the safest and most effective medication for every individual child. • Each class of drugs has a different way of functioning in the body [4]: • Stimulants • Anti-depressants • Anti-psychotics • Mood Stabilizers/Anti-Convulsants • Anxiolytics and Sedatives
  7. 7. Stimulants • Centrally and peripherally enhance both dopaminergic and noradrenergic transmission to improve cognitive and behavioral functioning [2] • Methylphenidate (Ritalin), Dextroamphetamine (Focalin), Pemoline (Cylert), Amphetamine- dextroamphetamine (Adderall) • Are the most prescribed psychotropic agents • Most commonly used with ADHD [5] • Over 200 controlled studies have shown that stimulant medications are safe and effective [2]
  8. 8. Anti-Depressants • Act on central pre- and post-synaptic receptors  affect neurotransmitter release and uptake (i.e. serotonin, norepinephrine, dopamine) [2] • 4 main sub-classes: monoamine oxidase inhibitors (MAOIs), tricyclic (TCAs), selective serotonin uptake inhibitors (SSRIs), atypical anti-depressants • Of these, SSRIs are the most frequently prescribed (i.e. Prozac, Zoloft, Paxil) • Mostly used for major depressive disorder, but also for: OCD, insomnia, ADHD, anxiety disorders [4]
  9. 9. Anti-Psychotics • Effectively treat psychosis, including hallucinations, delusions, bizarre behavior, severe agitation [4] – Thought to be related to dopamine antagonist properties • 2 main classes: traditional and atypical • Common anti-psychotics: Olanzapine (Zyprexa), Clozapine (Clorzaril), Chlorpromazine (Thorazine) • Mostly used for schizophrenia, but also for psychotic depression, mania, autism spectrum disorders, severe aggressive behaviors [15]
  10. 10. Mood Stabilizers/Anti-Convulsants • Act through a variety of mechanisms affecting intracellular processes- still being researched • 3 most commonly used: lithium, valproate, and carbamazepine [2] • Lithium is only FDA approved drug for pediatric bipolar disorder [4] – Also used to improve aggressive behavior and conduct disorder • Valproate effectively treats mania in adults and possibly children
  11. 11. Anxiolytics and Sedatives • Relatively less evidence compared to the other categories of medication, but still used with pediatric medications [2] • Benzodiazepines have been used for anxiety (GAD) and panic disorders [15] • Buspirone, TCA’s, SSRIs, Beta Blockers, and α-2a agonists [4] • Need for more research with children, so not as frequently used
  12. 12. Miscellaneous • Atomoxetine (Strattera)- nonstimulant drug that was approved for ADHD treatment [9] – Thought to inhibit norepinephrine receptors • Clonidine- α-adrenergic agonist used especially for tics and sometimes ADHD and anxiety disorders [13] – Reduces sympathetic outflow directly at the brain stem  therapeutic effects
  13. 13. Disorders that All Show Support for Pediatric Psychopharmacology • ADHD • Pediatric Bipolar • Depression • OCD • Schizophrenia • Anxiety • Autism • Anorexia • Bulimia nervosa • Obesity
  14. 14. ADHD • ADHD is the most commonly diagnosed psychiatric disorder of childhood [2] • 4.5 million children between 5-17 years of age have been diagnosed with ADHD as of the end of 2006. [6] CDC, 2007 • Children with ADHD can experience peer rejection, impulsivity, disruptive behaviors, low self-esteem  which can affect their daily life [7] • If not treated, symptoms can persist into adulthood [2] Medication has proven to be extremely effective for treating ADHD
  15. 15. ADHD • Over 200 controlled studies have shown that stimulant medication is safe and effective [2] • Methylphenidate and atomoxetine have repeatedly been found to decrease inattention and hyperactivity [9] • Stimulants for ADHD do not result in substance abuse disorders and may actually have a protective effect against development of substance abuse in adolescence [8] – Also protective factor for legal difficulties and poor impulse control • Concerns that stimulant medication may be responsible for smaller brain structures  not well supported [5]
  16. 16. ADHD • Semrud-Clikeman et al. 2008 [7] – Compared ADHD kids that have at least some history of medication (current or past) to ADHD kids that were never exposed to treatment – ADHD children with some history of medication performed significantly better in writing, attention, executive functioning, verbal working memory, and academics. They also had less mood problems and aggressive behaviors. – ADHD children that have been medicated show better functioning even when medicine has been discontinued.
  17. 17. ADHD • Pappadopulos et al. 2004 [11] – When reviewing a decade of studies- stimulant medication has been tested on over 6000 ADHD children  substantial evidence showing stimulants are effective at treating ADHD symptoms • Pelham et al. 2002 [12] – Methylphenidate shown to reduce ADHD treatments in children with normal and low IQ
  18. 18. ADHD • ADHD Attitudes [5] – Parent • Over 90% of parents challenged and were skeptical of the doctor’s recommendation of starting medication • After 2 years- about 80% of parents considered methylphenidate a safe and effective drug • A few parents stopped the medication in between- but all of them restarted treatment because of belief that child performed better on medication – Child: • After 2 years on stimulant drugs- 86% of kids considered methylphenidate safe and effective
  19. 19. ADHD • In the school settings- teachers and school psychologists are working with medical doctors to provide a multinodal treatment for ADHD children [10] – Medication combined with psychosocial interventions show greatest decrease in symptoms – 75% of parents believe that the best treatment for ADHD = methylphenidate + psychological support – Behavioral interventions alone did not exert improvement in academic performance, emotional status, and overall functioning [13] • American Academy of Pediatrics announced that stimulant medication should be recommended to improve outcomes in ADHD children [5]
  20. 20. ADHD Effectiveness of stimulants in children 6 years and older with ADHD [14]
  21. 21. ADHD Video Clip
  22. 22. Pediatric Bipolar Disorder • PBD children experience moods that alternate between depression and mania episodes • Early onset PBD often starts with depression episode that switches to BD [2] – Therefore hard to estimate PBD prevalence • Children with PBD can be extremely harmful to themselves, family, and society Medication is critical with almost all PBD cases
  23. 23. Pediatric Bipolar Disorder • Lithium- only FDA approved drug for treatment of PBD [15] – Clinical Global Assessment Scale score of more than 65 was achieved by 47% of kids receiving lithium versus 8% of kids on the placebo [11] • Findling et al. 2003 [17] – Lithium + divalproex sodium (mood- stabilizer) treatment produced significant improvements in various areas  47% subjects met criteria for full remission after medication for 20 weeks
  24. 24. Pediatric Bipolar Disorder • Kafantaris et al. 2001 [18] – Lithium + Anti-psychotic treatment (Haloperidol) showed improvement of symptoms for adolescents with PBD – Majority of patients showed reoccurrence of symptoms once medication was discontinued • Biederman et al. 2005 [21] – When given Risperidone (anti-psychotic)- PBD patients showed 70% response for manic symptoms and 35% for ADHD symptoms.
  25. 25. Pediatric Bipolar Disorder • Pavuluri et al. 2009 [16] – Lamotrigine is an anti-convulsant commonly used for adult BD • Controls glutamate release activates serotonin levels – This study showed that kids on lamotrigine medication showed significantly reduced depressive symptoms and controlled aggression and irritability compared to the placebo group – Previous adverse effect of benign rash only seen in 6% of patients and was quickly treated with no long-term effects
  26. 26. Pediatric Bipolar Disorder • PBD can be extremely severe if left untreated • Certain researchers today consider it unethical to have a placebo group for children with PBD  because withholding treatment can have drastic long term effects – Without medication- high risk for substance abuse, conduct disorder, suicide, and other co-morbidities [21] – Show symptoms of hallucinations, verbal and physical intrusion, lack of self-control, delusional thinking, possibly assaultive, and more [2]
  27. 27. Pediatric Bipolar Disorder Video Clip
  28. 28. Depression • Increased rates of depression among kids: especially in families dealing with divorce, abuse, neglect, bereavement [3] – Harvard Medical School study in 2006 found that childhood depression is increasing by 23% a year • Depression rates and suicide are strongly correlated  suicide is 6th leading cause of death among children ages 5-14 [22]
  29. 29. Depression • Fluoxetine (SSRI) has been shown to be superior to placebo in many controlled studies. Emslie et al. 2002 [24] Tao et al. 2009 [26] – Fluoxetine medication showed significantly improved results compared to cognitive behavioral therapy alone [25] – Only FDA approved drug for pediatric depression • Tricyclic antidepressant (Anafranil) and paroxetine (Paxil) have shown some promising results in the treatment of pediatric depression – More controlled studies is needed before these drugs can be frequently distributed for treatment
  30. 30. Obsessive Compulsive Disorder • OCD in children obsessions, compulsions, persistent thoughts, impulses, or images that are intrusive/inappropriate [14] – Causes anxiety & stress – Repetitive behaviors are in response to obsession • 1/3-1/4 of OCD patients had symptoms before the age of 15 [27] • Symptoms can manifest similar to adult OCD but often differently (i.e. temper tantrums, food restrictions, decreased academic performance) [2]
  31. 31. Obsessive Compulsive Disorder • Of all childhood disorders- OCD has most evidence supporting pharmacologic treatment & largest number of FDA approved drugs [2] • SSRIs fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft) and clomipramine (Anafranil) are FDA approved for treating childhood OCD (age 6 and up) [2] • Geller et al. 2003 [28] – Meta analysis of children with OCD showed significant difference between children on medication and placebo – Clomipramine was shown to be the most superior of the SSRIs [2]
  32. 32. Obsessive Compulsive Disorder • Wagner et al. 2003 [29] – Sertaraline has been shown effective in long term trials because of significant remission rates and improved functional status in majority of patients • Gellar et al. 2003 [28] – Continued paroxetine treatment significantly reduces pediatric OCD relapse rates compared to the placebo • Is often comorbid with other disorders such as ADHD, tics, anxiety disorders, and PBD [14]
  33. 33. Obsessive Compulsive Disorder • Case 1 [27] : – 4 year old with symptoms: severe anxiety, lack of appetite, frequent crying, dysphoric mood and obsession with sexual contact  diagnosed with OCD – Began medication (Sertaline) because of severity of symptoms and had to double the dose due to lack of response – Risperidone added to control side effects of Sertaline (i.e. hyperactivity, impulsivity) – Symptoms completely resolved after 9 months of treatment • Case 2 [27] : – 5 year old with symptoms: swearing to God, excessive handwashing and rituals  diagnosed with OCD – Prescribed Sertraline and after 2 months – patient was symptom free and has been ever since
  34. 34. Schizophrenia • Pediatric schizophrenia is serious disorder that affects cognition and ability to relate socially with others  gross impairment of reality [2] • Symptoms include delusions, hallucinations, distortion, disordered speech and communication, catatonic behavior, intensity of emotions and exaggeration of behavioral control [14] • These children are significantly delayed in their school functioning, relationships, and self care. Again, without medication- can be extremely dangerous to themselves and society.
  35. 35. Schizophrenia • Sikich et al. 2004 [30] – Schizophrenic children and adolescents between 8-19 years of age show significant improvement when taking either risperidone, olazapine, and haloperiodol medication • Sikich et al. 2008 [20] – First and second generation atypical antipsychotics (molindone, olanzapine and risperidone) have been shown to significantly decrease pediatric schizophrenia symptoms • Kranzler et al. 2005 [31] – Schizophrenic children can often be extremely aggressive – Clozapine treatment showed significant clinical improvement for severely aggressive children
  36. 36. Schizophrenia • Psychotherapy alone has not been proven to be effective for treating pediatric schizophrenia – Adjunctive psychosocial treatments (psychoeducation, behaviorally based therapy, cognitive-behavioral therapy) improves symptoms and reduces relapse rates [32] • If the disorder is at an advanced stage- constant hallucinations and bizarre ideation can take over the child’s life without medication
  37. 37. Anxiety Disorders • One of the most commonly diagnosed psychiatric disorders affecting populations in U.S. and Europe [14] – Includes separation anxiety, panic disorder, social phobia, specific phobias, and generalized anxiety • Not only distress to thought of threat, but also cognitive feelings of losing control, unwelcome or intrusive thoughts, inattention, insomnia, and perceptual disturbances. – Affects youth more than adults because anxiety affects normal physical and mental development
  38. 38. Anxiety Disorders • Due to a lack of current research, there are no FDA approved drugs for the treatment of pediatric anxiety disorders [2] • But numerous medications have shown promising results: – SSRIs: such as Fluoxentine have shown notable symptom reduction with minimal side effects [10] – Benzodiazepines: such as Clonazepam is useful in short-term treatment (i.e. used to ensure child attends school) [2] – α-2a Agonists: help with symptoms of hyperautonomic arousal (i.e. palpitations) – Tricyclic antidepressants [14]
  39. 39. Anxiety Disorders Case study [2] : – 8 year old who had symptoms of: poor academic performance, followed mother everywhere, cried in school everyday because hated parting with mother, would become physically sick in school until mother came, and symptoms lessened on weekends – Diagnosed with SAD  prescribed sertraline and intensive behavioral therapy – After just one month- the child had already improved his symptoms (began attending schools without any argument, reduced physical sickness in school) – Eventually tapered off medication after remission
  40. 40. Other Disorders • There are several studies show evidence of psychotropic medication decreasing symptoms in other disorders: – Autism [2] • SSRIs, anti-psychotic (haloperidol, thioridazine), α-2a agonists, anticonvulsants, stimulants – Anorexia nervosa [33] • Atypical antipsychotics (olanzapine), appetite enhancers, mood stabilizers – Bulimia nervosa [33] • Anti-depressants, Tri-cyclic anti-depressants, SSRIs (fluoxentine) – Obesity [33] • Anti-depressants, appetite suppressants
  41. 41. Opposition to Pediatric Psychopharmacology Reasons Against Pediatric Meds But…. No significant evidence showing this is true  certain medications Drug addiction act as protective factors against later substance abuse and criminal problems If properly monitored and regulated by family and doctors  Drug overdose should not be an issue Suicide Yes this is a possible risk- but how many suicides are we preventing with medication? Also if suicide is a high risk- then clozapine and lithium have been shown to be effective treatments [15] Weight gain & other side effects Possibility- but drug dosage can be adjusted to minimize risks. Also, what medications don’t come with possible side-effects? Not enough research Pediatric psychopharmacology is a rapidly growing field that is repeatedly testing medications. Also FDA works extensively before approving any medication, and will continue to come out with approvals for more drugs to help save children Over-prescribed If done properly- before prescribing medication there should be an overall extensive evaluation of the child in a variety of settings. The problem of over-prescribing is due to lack of monitoring and standardized system , rather than the drug itself. Parents aren’t given a choice As mentioned before- majority of parents consult other medical and non-medical advisors before giving their children medication.
  42. 42. Conclusions • Clearly there is a substantial amount of evidence that supports the use of pediatric psychopharmacology • Of course, adjunctive therapy can definitely help…but the unique effect of medication cannot be ignored • These children can be extremely sick, and medication is the only way for them and their family to have a chance of a normal life
  43. 43. References 1) Orkin, B. G. (2002). The use of atypical antipsychotic agents for nonpsychotic disorders in children and adolescents. Doctoral dissertation, ProQuest Information and Learning Company, Ann Arbor, MI. 2) Cheng, K., & Myers, K. M. (2005). Child and adolescent psychiatry: The essentials. Baltimore: Lippincott Williams & Wilkens. 3) Emslie, G. J. (2009). Understanding Placebo Response in Pediatric Depression Trials. American Journal of Psychiatry, 166(1), 1-3. 4) Brown, R. T., & Sammons, M. T. (2002). Pediatric psychopharmacology: A review of new developments and recent research. Professional psychology, research and practice, 33(2), 135-147. 5) Berger, I., Dor, T., Nevo, Y., & Goldzweig, G. (2008). Attitudes Toward Attention-Deficit Hyperactivity Disorder (ADHD) Treatment: Parents' and Children's Perspectives. Journal of Child Neurology, 23(9), 1036-1042. 6) (2009). Retrieved April 14, 2009, 7) Semrud-Clikeman, M., Pliszka, S., & Liotti, M. (2008). Executive Functioning in Children With Attention-Deficit/Hyperactivity Disorder: Combined Type With and Without a Stimulant Medication History. Neuropsychology, 22(3), 329-340. 8) Wilens, T. E., Faraone, S. V., Biederman, J., & Gunawardene, S. (2003). Does Stimulant Therapy of Attention-Deficit/Hyperactivity Disorder Beget Later Substance Abuse. Pediatrics, 111(1), 179-185. 9) Spencer, T., Heilgenstein, J. H., Biederman, J., Faries, D. E., Kratochvil, C. J., Conners, K., et al. (2002). Results from 2 proof-of-concept, placebo-controlled studies of Atomoxetine in children with attention-deficit/hyperactivity disorder. The Journal of Clinical Psychiatry, 63(12), 1140-1147. 10) Abrams, L., Flood, J., & Phelps, L. (2006). Psychopharmacology in the schools. Psychopharmacology in the schools, 43(4), 493-501. 11) Pappadopulos, E. A., Guelzow, T. B., Wong, C., Ortega, M., & Jensen, P. S. (2004). A review of the growing evidence base for pediatric psychopharmacology . Child and Adolescent Psychiatric Clinics of North America, 13(4), 817-855. 12) Pelham, W. E., Hoza, B., Pillow, D. R., Gnagy, E. M., Kipp, H. L., Greiner, A. R., et al. (2002). Effects of methylphenidate and expectancy on children with ADHD: behavior, academic performance, and attributions in a summer treatment program and regular classroom settings. Journal of Consulting and Clinical Psychology, 70(2), 320-325. 13) Abikoff, H., Hechtman, L., Klein, R., Gallagher, R., Fleiss, K., Ectovitch, J., et al. (2004). Social Functioning in Children With ADHD Treated With Long-Term Methylphenidate and Multimodal Psychosocial Treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 43(7), 820-829. 14) Vitiello, B., Masi, G., & Marazziti, D. (2006). Handbook of child and adolescent psychopharmacology (). New York: Informa HealthCare. 15) Ryan, N. D. (2003). Medication treatment for depression in children and adolescents. CNS Spectrums, 8(4), 283-287. 16) Pavuluri, M. N., Henry, D. B., Moss, M., Mohammed, T., Carbay, J. A., & Sweeney, J. (2009). Effectiveness of Lamotrigine in Maintaining Symptom Control in Pediatric Bipolar Disorder. Journal of Child and Adolescent Psychopharmacology, 19(1), 75-82.
  44. 44. References 17) Findling, R. L., McNamara, N. K., Stansbrey, R., Gracious, B. L., Whipkey, R. E., Demeter, C., et al. (2006). Combination lithium and divalproex sodium in pediatric bipolarity. Journal of the American Academy of Child and Adolescent Psychiatry, 45(2), 142-146. 18) Kafantaris, V., Dicker, R., Coletti, D. J., & Kane, J. M. (2001). Adjunctive Antipsychotic Treatment Is Necessary for Adolescents with Psychotic Mania. Journal of Child and Adolescent Psychopharmacology, 11(4), 409-413. 19) Biederman, J. (2005). Attention-deficit/hyperactivity disorder: a selective overview. Biological Psychiatry, 57(11), 1215-1220. 20) Sikich, L., Frazier, J., McClellan, J., Findling, R., Vitiello, B., Ritz, L., et al. (2008). Double-Blind Comparison of First- and Second- Generation Antipsychotics in Early-Onset Schizophrenia and Schizo-affective Disorder: Findings From the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) Study. American Journal of Psychiatry, 165, 1369-1372. 21) Wilens, T., Biederman, J., Kwon, A., Ditterline, J., Forkner, P., Moore, H., et al. (2004). Risk of Substance Use Disorders in Adolescents With Bipolar Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 43(11), 1380-1386. 22) (2009). Retrieved 14 Apr. 2009, 23) (2008). Retrieved 14 Apr. 2009, 24) Emslie, G. J., Heiligenstein, J., Wagner, K. D., Hoog, S., & Ernest, S. E. (2002). Fluoxetine for Acute Treatment of Depression in Children and Adolescents: A Placebo-Controlled, Randomized Clinical Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 41(10), 1205-1215. 25) TADS Team (2004) The Treatment for Adolescents with Depression Study (TADS): short-term effectiveness and safety outcomes. JAMA 292:807–820 26) Tao, R., Emslie, G., Mayes, T., Nakonezny, P., Kennard, B., & Hughes, C. (2009). Early prediction of acute antidepressant treatment response and remission in pediatric major depressive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 48(1), 71-78. 27) Oner, O., & Oner, P. (2008). Psychopharmacology of pediatric obsessive compulsive disorder: three case reports. Journal of Psychopharmacology, 22(7), 809-811. 28) Geller, D. A., Biederman, J., Stewart, E., Mullin, B., Martin, B., & Spencer, T. (2003). Which SSRI? A Meta-Analysis of Pharmacotherapy Trials in Pediatric Obsessive-Compulsive Disorder . American Journal of Psychiatry, 160, 1919-1928. 29) Wagner, K., Ambrosini, P., Rynn, M., Wohlberg, C., Yang, R., Greenbaum, M., et al. (2003). Efficacy of Sertraline in the Treatment of Children and Adolescents With Major Depressive Disorder . The Journal of the American Medical Association, 290(8), 1033-1041. 30) Sikich, L., Hamer, R. M., Bashford, R. A., Sheitman, B. B., & Lieberman, J. A. (2004). A pilot study of risperidone, olanzapine, and haloperidol in psychotic youth: A double-blind, randomized, 8-week trial. Neuropsychopharmacology, 29(1), 133-145 31) Kranzler, H., Roofeh, D., Gerbino-Rosen, G., Dombrowski, C., McMeniman, C., Dethomas, C., et al. (2005). Clozapine: Its impact on aggressive behavior among children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 44(1), 55-63. 32) Rector, N. A., & Beck, A. T. (2001). Cognitive Behavioral Therapy for Schizophrenia: An Empirical Review. The Journal of Nervous and Mental Disease, 189(5), 278-287. 33) Powers, P. S., & Bruty, H. (2009). Pharmacotherapy for Eating Disorders and Obesity. Clinics , 18(1), 175-187.