The psychiatric treatment of children with drugs was
essentially taboo until the 1990s, possibly due to the still major influence of
psychodynamic views. This attitude presented a double-sided problem: there was a
disinclination to administer pharmacotherapy to children who needed it and would
benefit from it and, equally concerning, there was a vocal movement for mass
treatment, underscoring a profound cultural shift. The media reported this
widely, for example, in the article “Paxil, Prozac, Ritalin—are these drugs safe
for kids???” [1]. It was thus commonplace to read that parents and schools were
just searching for a quick fix for behaviors that fell outside the “norm.”
Ritalin had been available since 1954, and so perhaps the acceptance of
psychopharmacology as an intervention sped the clock on the acceptability of
pharmacological agents to deal with behaviors outside the new cultural norms.
These treatment options claimed to offer the possibility for any child who fell
outside these behavioral “norms” to be “improved.” Thus, a market force
developed that underpins the efforts of pharmaceutical companies to develop
their products. Although controversial, these concepts have expanded recently to
suggest that early diagnosis of psychiatric disorders such as schizophrenia and
bipolar disorder may warrant the initiation of pharmacotherapy at the earliest
manifestation of “prodromata” of these conditions.
Stimulants may well have been the first entrants into child
pharmacotherapy. Amphetamine was resynthesized in the US in the 1920s and had
been employed as a respiratory stimulant for narcolepsy and as an appetite
suppressant. By 1937 it was shown to be an effective treatment for hyperactivity
in children by Charles Bradley [2]. Later others also reported on the efficacy
of Ritalin in children with hyperactive states. Its effectiveness led to the
acceptance of the concept of minimal brain dysfunction, which in 1980 in DSMIII
was categorized as attention-deficit hyperactivity disorder (ADHD).
Psychopharmacological treatments have been introduced in large
part as the result of serendipitous events. The earliest agents included
lithium, chlorpromazine, and imipramine. They gradually developed a role in the
treatment of adult patients and then were tried in pediatric patients by
deduction of the possible similarity of these behaviors to those established in
adults. There are many assumptions in this last step to the treatment of
children. For example, imipramine and related compounds were indeed quite
effective for major depressive disorder in adults. However, their translation to
children implied an essential assumption that the depression seen in children
was analogous to that seen in adults, and that the underlying substrate would
respond similarly. Whatever the assumptions, the outcome belied these
assumptions, as the careful studies of Ryan et al. [3] clearly demonstrated.
Here we had a cautionary tale and we have not fully explained this outcome and
the assumptions inherent therein. Thus we must move cautiously before we presume
such simple projections from adults to children.
Then there developed a period of major enthusiasm for two new
classes of psychotropic agents: the selective serotonin reuptake inhibitors
(SSRIs) and the atypical second-generation antipsychotics (SGAs). As before,
their usage was explored initially in adults with the SSRIs becoming widely
employed for depressive disorders and pretty much completely displacing the
tricyclics. Both classes of drugs were then extensively prescribed for children
and adolescents. Following the FDA's warnings, with black-box and bold-print
cautions, there has been a significant reduction in their prescriptions.
Associated with this is the hotly debated issue of suicidality associated with
these antidepressants.
Some of the SGAs have also caused serious concern because of the
increased risk of metabolic syndrome with significant weight gain and the
concurrence of type-II diabetes. These adverse effects produce a very special
risk in developing children. These few instances provide adequate warning about
a transfer of psychopharmacological drug prescribing from adults to children.
There is now clearly the need, which has been recognized, for the careful
clinical evaluation of new agents for specific indications in children.
The prevention and treatment of emotional and behavioral problems
affects about one in five children and is the major mental health problem in the
United States. Most major mental health problems begin during adolescence.
Therefore, this is the critical period for their identification, prevention and
often their treatment. Suicide among the young has become an increasing concern
over the past several decades. It is important to consider, within this context,
the high rate of suicide in the young inductees in the armed forces. Another
aspect of this issue has come up over the past 10 years and that has been the
possible effects of administering antidepressant drugs to children and
adolescents and the concerns that were raised about possible increase in
suicidal outcomes. All these questions have increased the importance of the
optimal methods of treatment of depression in these populations.
This third edition of pharmacotherapy for child and adolescent
disorders is being published 10 years after the first edition. Although the
field has advanced considerably, the fact that we are dealing with a
still-developing nervous system presents both special options and serious
cautions. The use of psychotropic agents in adults has become well established
since the 1960s and the picture of their clinical indications and side effect
profile has become much clearer. These issues are still not so well defined in
children, as their diagnostic entities are still being delineated and thus
specific therapies are also under debate. The social and cultural background for
the acceptance of psychotropic interventions has altered over the years.
Initially, they were considered inappropriate, dangerous and treatments of last
resort for children. Society has changed its attitude dramatically and now there
is a serious concern of overmedication of children. Thus, although the field has
progressed significantly, the appropriate administration of psychoactive
medications to children requires training, skill and ongoing interaction with
the patient and family throughout the course of treatment.
This is especially the case as many more drugs have been
introduced and their indications and profile of actions are still in progress.
The basic research studies on their mode and site of action will continue to
provide the field with knowledge, which will help considerably in their more
targeted usage. The question of early usage of therapeutic interventions in some
of these conditions has been raised, offering the possibility of preventive
value. This early and possibly long-term usage raises new and important
questions in regard to short- and long-term possible adverse effects on
developing systems.
Early intervention for all medical or psychiatric disorders is
essentially always considered beneficial. However, with psychiatric disorders in
children, especially in the younger age groups, the prospective identification
of prodromata has been and still is problematic. Various investigators have
presented studies on this problem, such as the proposal of “ultra high risk”
(UHR) criteria [4]. One still unresolved problem is the potential effects of the
various psychotropic drugs on the developing nervous system and other organ
systems, especially if administered long term, as is often necessary in a number
of disorders. Adverse neurocognitive effects of psychotropic medications have
been reported [5,6]. For example, GABAergic agonists have been demonstrated to
interfere with both mood and memory, as well as attention and psychomotor
speed.
Thus, there is a debate about early psychopharmacologic
intervention in children. Specifically, it concerns the issue of whether the
impact and consequences of lack of treatment outweigh the potential for
prematurely labeling children with emotional disturbances. In this population of
children and adolescents, early clinical features can also be difficult to
distinguish from benign conditions and normal experience. These concerns cannot
easily or speedily be resolved. The question of the diagnosis of these
psychiatric disorders is still being evaluated for DSM V. Good data on the
long-term use of psychotropic agents both on body organs and the central nervous
system are still incomplete in young developing systems. Therefore, we believe
we can only raise a cautionary note and await further data on both aspects of
this question. Hopefully we will have a resolution by the time we come to the
fourth edition of this volume.
All of these activities in the field have contributed to the
creation of this third edition. It is hoped that this volume will serve as a
valuable guide to the treatment of patients 18 years of age and under with
psychiatric disorders. This volume is presented as a practical guide to the
clinical psychiatrist. The book also provides valuable material for other health
care professionals in the management of children and adolescents with
psychiatric conditions. The material presented here is in a format readily
available for psychologists, social workers, therapists, nursing staff and
students, as well as medical students, pediatricians and family practitioners.
We felt that a brief historical review of the background of the development of
psychopharmacological interventions in children could provide a frame of
reference for the developments and practices in the field today. It should also
provide a perspective that the field is and should be changing. We have
delineated what is known currently on the basis of a critical review of
controlled trials available. We have also attempted to integrate the basic
neuroscience available to help guide clinical decision making.
References
1. Kalb C:
Drugged-out toddlers. A new study documents an alarming increase in behavior
altering medication for preschoolers. Newsweek 2000;
135: 53.
2. Bradley C: The
behavior of children receiving benzedrine. Am J
Psychiatry 1937; 94: 577–585.
3. Ryan N,
Puig-Antich J, Ambrosini P et al.: The clinical picture of major depression in
children and adolescents. Arch Gen Psychiatry 1987;
44: 854–61.
4. Yung AR, Phillips
LJ, Yuen HP et al.: Risk factors for psychosis in an ultra high risk group.
Psychopathology and Clinical Features. Schiz. Res
2004; 67: 131–42.
5. Henin A, Mick E,
Biederman J, Fried R et al.: Is psychopharmacological treatment associated with
neuropsychological deficits in bipolar youth? J Clin
Psychiatry 2009; 70: 1178–85.
6. Donaldson S,
Goldstein LH, Landau S et al.: The Maudsley Bipolar Disorder Project: the effect
of medication, family history, and duration of illness on IQ and memory in
bipolar I disorder. J Clin Psychiatry 2003; 64:
86–93.
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