I. Description of the Problem. The use of psychopharmacologic agents in children most commonly occurs in the treatment of attention-deficit/hyperactivity disorder (ADHD)/impulse control problems, mood and anxiety symptoms, and psychosis. Although many studies demonstrate highly effective and safe treatment of pediatric ADHD, data for efficacy with most other symptom complexes is less compelling. Because of the paucity of research on children, most use of medications for non-ADHD symptoms remains “off label.” In the United States, 20% of children and adolescents have a diagnosable mental health disorder that requires intervention or monitoring and interferes with daily functioning. Primary care providers currently assume all mental healthcare for the majority of affected children. With the increased recognition of childhood psychiatric disorders, ease of obtaining information on the Internet, and ongoing marketing of psychotropic medications, the need for primary care providers to stay current with treatment options remains clinically imperative.
II. Epidemiology.
Mental health disorders affect up to 20% of U.S. children and adolescents.
ADHD affects 3%-9% of U.S. children.
Depression affects up to 3% of children and 8% of adolescents.
Anxiety disorders affect up to 15% of those younger than 18 years.
By some estimates, bipolar disorder affects close to 1 million children and adolescents in the United States at any given time. Several studies have reported that more than 80% of children who have early-onset bipolar disorder will meet full criteria for ADHD.
III. Deciding to treat with medication. Determining that a child’s presentation indicates the need for psychopharmacology requires
Identification of target symptoms.
Review of appropriate home and school supports and interventions.
Degree to which symptoms causes functional impairment.
Informed consent.
These decisions can be complicated by difficulties in clearly diagnosing the pediatric population, as well as concerns about potential long-term effects of psychotropics on brain development. Children with depression, anxiety, severe aggression, or psychotic thinking should work with a therapist, who can help identify contributing stressors, and teach the child strategies to cope better with tension, worries, fears, and negative thoughts. For many, however, individual psychotherapy will be augmented by psychopharmacological intervention. When medication is deemed necessary, it is helpful to use validated rating scales to monitor progress. Examples of such scales are the Clinical Global Impression Scale, Aberrant Behavior Checklist, Self-Report for Childhood Anxiety Related Emotional Disorder (SCARED), and Multidimensional Anxiety Scale for Children (MASC). See bibliography for information regarding these tools.
IV. Medical and philosophical controversies. In the past several decades, clinicians have had to extrapolate the findings from adult psychopharmacology to children, and only recently have research studies become available to document the efficacy and safety of these medications in children. Many of the medications used have potentially serious side effects, which must be weighed against the adverse effects of not treating difficult or dangerous behaviors with medication. With the increasing prevalence of mental health disorders recognized in children, there is more and more of a need to understand and provide effective and safe treatment. Debate remains over which clinicians are best suited to oversee both behavioral and medication management and, in some areas, a paucity of clinicians limits options.
V. History: key clinical questions.
“What are your greatest concerns at this time? How impairing are these behaviors or feelings?” Medication may be helpful to the child whose depression, anxiety, or aggression prevents adequate learning, participation in the classroom, or social success. Setting realistic expectations to improve sleep, brighten affect, or improve school behavior comes from clear discussion of what the problems are and how the medication will help.
Table 20-1. Selective serotonin reuptake inhibitors (SSRIs)
Brand name (generic name)
Age and approved indications
Off-label clinical indications
Metabolism
Preparation
Start dose per day (mg)
Target dose per day (mg)
Celexa® (citalopram)
No pediatric approval
Depression, anxiety, OCD
Weak IID6, IIIA4, IIC19
10, 20, 40 mg 10 mg/5 mL
5-10
10-60
Lexapro® (escitalopram)
≥12 yr: depression
Anxiety
Weak IID6, IIIA4, IIC19
5, 10, 20 mg 5 mg/5 mL
1.25-5
2.5-20
Luvox® (fluvoxamine)
≥8 yr: OCD
Depression, anxiety
IA2, IIIA3-4, IIC19
25, 50, 100 mg; 100, 150 mg ER
12.5-25
25-300
Paxil® (paroxetine)
No pediatric approval; not recommended for depression under 18 yr
Anxiety, OCD
IID6, IIIA4
10, 20, 30, 40 mg; 12.5, 25, 37.5 mg
CR
10 mg/5 mL
5-10
10-60
Prozac® (fluoxetine)
≥8 yr: depression
≥7 yr: OCD
Anxiety
IID6, IIIA3-4, IIC19
10, 20, 40 mg
20 mg/5 mL
2.5-10
5-20 MDD
20-60 OCD
Zoloft® (sertraline)
≥6 yr: OCD
Depression, anxiety
Weak IID6, IIC19
25, 50, 100 mg
20 mg/mL
12.5-50
25-200
MDD, major depressive disorder; OCD, obsessive compulsive disorder; ER, extended release; CR, controlled release.
Table 20-2. Atypical and tricyclic antidepressants
Brand name (generic name)
Age and approved pediatric indications
Off-label clinical indications
Metabolism
Preparation
Start dose per day
Target dose per day
Atypical antidepressants
Buspar® (buspirone)
No pediatric approval
Anxiety, depression
IIIa4
5, 10, 15, 30 mg
2.5 mg
20-60 mg divided tid
Desyrel® (trazodone)
No pediatric approval
Sedation, anxiety
IIIa4/5
50, 100, 150, 300 mg
25 mg
25-150 mg qhs
Effexor® (venlafaxine)
Over 18 yr; not recommended for depression under 18 yr
Depression, anxiety, ADHD
IId6, IIIa4
25, 37.5, 50, 75, 100 mg; 37.5, 75, 150 mg ER
37.5 mg XR
37.5-225 mg XR
Remeron® (mirtazapine)
No pediatric approval
Insomnia, depression, anxiety, weight loss
IId6, IA2, IIIa4
15, 30, 45 mg
15 mg qhs
15-45 mg
Wellbutrin® (bupropion)
No pediatric approval
Depression, ADHD
IIb6, IIIa4
75, 100 mg; 100, 150, 200, 300 mg ER
50 mg SR
50-200 SR bid, 150-450 XL qd
Tricyclic antidepressants
Anafranil® (clomipramine)
Over 10 yr for OCD
ADHD
IId6, Ia2, IIa4/5
25, 50, 75 mg
25 mg
Up to 200 mg (2-5 mg/kg)
Norpramin® (desipramine)
No pediatric approval
ADHD, chronic pain
IId6
10, 25, 50, 75, 100, 150 mg
10-25 mg
100-200 mg (2-5 mg/kg)
Pamelor® (nortriptyline)
No pediatric approval
ADHD
IId6
10, 25, 50, 75 mg 10 mg/5 mL
10-25 mg
0.5-4 mg/kg, plasma level 50-175 ng/mL
Tofranil® (imipramine)
Childhood enuresis in children older than 5 yr
ADHD, depression
IId6, IIc9, 11c18/19, IIa4/5
10, 25, 50, 75, 100, 125, 150 mg
10-25 mg
75 mg
OCD, obsessive compulsive disorder; ADHD, attention deficit/hyperactivity disorder; ER, extended release.
Table 20-3. Atypical and tricyclic antidepressant side effects
Medication
Notable side effects
Management considerations
Buspar® (buspirone)
Dizziness, drowsiness, headache, nausea, vomiting
Use with caution in patients with renal of hepatic disease
Desyrel® (trazodone)
Sedation, priapism
Use for insomnia
Effexor® (venlafaxine)
Sustained hypertension
Avoid in patients with high BP
Remeron® (mirtazapine)
Sedation, increased appetite, rare agranulocytosis
Use for insomnia and poor appetite, consider monitoring CBC count
Wellbutrin® (bupropion)
Weight loss, tics, activation, lower seizure threshold
Avoid in patients with bulimia or anorexia, uncontrolled seizures, risk for seizures
All tricyclics
Increases PR, QRS, QTc; tremor, sedation, dry mouth, constipation, blurry vision, dizzy
Monitor vital signs, plasma levels and EKG; do not provide more than 1 week supply to patients at risk for overdose
QTc, corrected QT; CBC, complete blood cell; BP, blood pressure; EKG, electrocardiograph.
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Psychopharmacology
Psychopharmacology
Elizabeth Harstad
Alison Schonwald
