Child and Adolescent Clinical Psychopharmacology Made

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 Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold
with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional
services. If expert assistance or counseling is needed, the services of a competent professional should be sought.
Chapter 9 of this text, “Over-the-Counter Medications and Dietary Supplements,” is adapted from CLINICAL
PSYCHOPHARMACOLOGY MADE RIDICULOUSLY SIMPLE (8th ed.), by John D. Preston and James Johnson. Copyright ©
2014 John D. Preston and James Johnson. Used by permission of MedMaster, Inc.
Distributed in Canada by Raincoast Books
Copyright © 2015 by John Preston, John H. O’Neal, & Mary C. Talaga
New Harbinger Publications, Inc.
5674 Shattuck Avenue
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www.newharbinger.com
All Rights Reserved
Acquired by Melissa Kirk and Catharine Meyers; Cover design by Amy Shoup;
Edited by Kayla Sussell; Text design by Tracy Marie Carlson
Library of Congress Cataloging-in-Publication Data on file
To my grandsons, Atticus and Ender: identical and so unique!
—JP
In memory of Patrick Everette Cummings. …
Your spirit lives on.
—MT
To my patients, for they have been my best teachers.
—JO
 Contents
ACKNOWLEDGMENTS
INTRODUCTION: SHARING OUR CONCERNS: FOR HEALTH
CARE PROVIDERS, PARENTS, AND PATIENTS
1 ISSUES IN PSYCHOPHARMACOLOGICAL TREATMENT OF
CHILDREN AND ADOLESCENTS
2 DEPRESSION
3 BIPOLAR DISORDER
4 ANXIETY DISORDERS
5 PSYCHOTIC DISORDERS
6 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
7 AUTISM SPECTRUM DISORDERS
8 MISCELLANEOUS DISORDERS
9 OVER-THE-COUNTER MEDICATIONS AND DIETARY
SUPPLEMENTS
APPENDIX: PATIENT AND CAREGIVER INFORMATION SHEETS
ON PSYCHIATRIC MEDICATIONS
REFERENCES
 Acknowledgments
Many thanks to our publisher, Dr. Matthew McKay, freelance copy editor
Gretel Hakanson, and our most excellent editors, Melissa Kirk, Catharine
Meyers, Karen O’Donnell Stein, and Kayla Sussell.
Thanks to our families, with deep appreciation for their patience and
encouragement.
Finally, a heartfelt thanks to our patients.
May this book help our fellow mental health clinicians in our shared
and ongoing struggle to reduce emotional suffering in young people.
 Introduction

Sharing Our Concerns: For Health Care

Providers, Parents, and Patients
Facts without values, fragmentary specialties with no integrating
philosophy of life as a whole, data with no ethical standards for their
use, techniques … with no convictions about life’s ultimate meaning
… here a panacea has turned out to be a problem.
—Harry Emerson Fosdick The Living of These Days(1956)

Many young people experience considerable emotional suffering.

Oftentimes this psychological pain is associated with poverty, poor prenatal
care, racial or other forms of discrimination, serious family dysfunction,
traumatic life events, or any of a host of neuropsychiatric disorders. Only
certain types of emotional distress are appropriate for treatment with
psychiatric medications.
Psychiatric medication treatment of children and teenagers began in the
1960s. Yet only recently have large-scale medication trials been conducted.
The research in child psychiatry is still considered to be limited. Clearly
advances have been made, both in the safety of medications and in the
development of treatment guidelines. In this book we summarize basic
information regarding classes of psychological disorders for which
medications are often prescribed, and we present current guidelines for the
use of medications. However, we first want to state three important and
overarching concerns.
The first concern is that in the current era of managed care, it is
common for insufficient time or attention to be given to conducting a
comprehensive history and diagnostic evaluation. Such an evaluation is
essential before any recommendation can be made regarding treatment.
Second, it is clear that when psychiatric medications are used to treat
particular disorders, close follow-up is warranted and essential for
addressing problems of treatment adherence, managing side effects, and
monitoring response to treatment. Third, most children and teenagers
suffering from psychological problems do not require medication treatment;
instead, they may need psychosocial interventions, often involving the
family as well as the individual. Even in those conditions that are judged to
be largely neurobiological in nature and responsive to medication
treatments, psychotherapy is alwaysindicated.
In voicing these three issues, it may seem as if we are just stating the
obvious; however, our concern is that with the quick-fix and get-on-with-
your-life mentality in our social culture and the health care industry’s focus
on cost containment, the knee-jerk reaction of too many providers may be
to reach for the prescription pad whenever they see psychological
symptoms. While the appropriate use of psychiatric medications has helped
many young people, we feel it’s important for us to strongly endorse a
comprehensive approach to treatment. This approach should be based on
careful evaluations, close monitoring, and the use of psychotherapy, with
medications prescribed only if warranted.
It is also important for clinicians, consumers, and parents alike to be
aware of the risks and benefits of all treatments. Because of the enormous
complexity of human psychological functioning, most problems are
multidimensional and require interventions on a number of levels. And it is
equally important to be humble regarding our approaches to treatment.
Psychiatric drugs, as we shall see in this volume, can reduce rates of
suicide, may decrease the risk of substance abuse, and in some instances
may prevent certain kinds of brain damage. But medical treatments also
have clear limits; there are no panaceas. No drug can mend a broken heart,
fill an empty life, or teach parents how to love their children.
 CHAPTER 1

Issues in Psychopharmacological Treatment

of Children and Adolescents
In this first chapter we address a number of general issues that are
important to consider prior to discussing diagnosis and treatment, the
specifics of which we’ll cover in the chapters that follow.

Diagnosing and Treating Children and Adolescents

Until just recently, in child psychiatry there appeared to be an assumption
that children with psychiatric disorders were quite similar, if not identical,
to adults with respect to both diagnostic and pharmacological treatment
issues. The recommended approach was to diagnose and treat as you would
with adults, although generally starting treatment with lower doses of
medications. Even though there is some degree of symptomatic overlap
between adult-onset and childhood-onset disorders, there are also
significant features that distinguish psychiatric syndromes as well as
pharmacological treatments in children and adults. Also keep in mind that
the target of psychiatric drugs (the central nervous system) is continuously
undergoing maturational changes throughout childhood and adolescence.
Certain neurotransmitter systems are not fully online in children, and some
brain structures have not reached full development. In a sense, using
psychotropic drugs with younger clients is like shooting at a moving target.
Likewise, there are significant differences between adults and younger
people in the way the drugs are metabolized. Kids are not just smaller
versions of adults.
It is likely that the majority of emotional suffering experienced by
youngsters is related to situational stress and responds best to nonmedical,
psychological treatments (e.g., family therapy). However, it is also
becoming increasingly clear that many major mental illnesses begin in
childhood (for example, 25 percent of obsessive-compulsive disorder cases
and up to 15 percent of bipolar disorder cases have childhood or early-
adolescent onset). Not only do these disorders cause considerable suffering
in young children, but they can also markedly interfere with normal social
and academic developmental experiences. For example, more than one-half
of children experiencing major depression continue to be symptomatic for
more than 2 years. During depressive episodes, many experience significant
social withdrawal and academic failure, often due to an impaired ability to
concentrate. Even if they recover, many of these children find it hard to ever
catch up academically or socially.
Increasing evidence also shows that some psychiatric disorders, if they
go untreated, leave patients subject to progressive neurobiological
impairment (the kindling model of disease progression). Toxic levels of
neurotransmitters, such as glutamate, or stress hormones, such as cortisol,
may damage neural tissue or interfere with normal patterns of
neuromaturation (see figure 1-A). Pharmacological treatment of these
disorders may be not only successful in improving symptoms but also
neuroprotective (in other words, medication treatment may either protect
against brain damage or promote normal neuromaturation; in some
instances, medications may promote the regeneration of some nerve cells, a
process called neurogenesis).

Informed Consent and Addressing Parental Concerns

In addition to clinical considerations, other unique challenges arise in the
prescribing of psychotropic medications for children. Children cannot give
true informed consent since parents are the ones who usually decide
whether or not to allow medication treatment. This presents at least four
concerns: (1) fears about drug use (or possible addiction) may lead parents
to withhold treatment from some children who need it; (2) some parents
may see psychiatric disorders simply as chemical imbalances, believe that
pills will fix the problem, and ignore psychological factors (such as
dysfunctional family dynamics) as a focus for treatment; (3) parents may
use medications primarily for behavioral control despite detrimental side
effects (for example, using excessive doses of stimulants to markedly
reduce hyperactive behavior in children with attention-deficit/hyperactivity
disorder, even though it may cause lethargy and sedation and, if doses
become too high, decreased cognitive functioning); and (4) the young
person is left out of the loop, perhaps not consulted about how he or she
feels about medication treatment.
Most pediatric clinicians agree that children should be included in
discussions about psychiatric medication treatment (especially children ages
seven and older whose cognitive development has proceeded enough that
they can understand some information regarding medication treatment).
Providing information is important in order to encourage the child to voice
concerns about treatment, since many children conclude that if they need
medicine, they must be very ill or “crazy.” Also, these early experiences
with psychiatric treatment, if perceived to be beneficial by the child, may
go a long way toward instilling positive attitudes about mental health
treatment (this is a critical point, since many of the more severe disorders
that warrant medical treatment during childhood are the first manifestations
of what may be lifelong mental illnesses). Including the child in discussions
regarding medication treatment can often make him or her feel respected
and thereby foster a positive relationship with the therapist or physician.
Because parents who do not wholeheartedly endorse treatment will
often sabotage it, professionals need to devote a good deal of time to
addressing all of their concerns about drug treatment. Informed consent
should also include the risks of not treating certain disorders.

Parental Fears Regarding Drug Addiction

 Many parents are understandably concerned about the use of habit-
forming drugs to treat their children. It is important that clinicians talk
openly with parents about these concerns (even if parents do not initiate the
conversation). Among psychiatric medications, only two classes encompass
potential drugs of abuse: stimulants (such as Ritalin and Adderall) and
benzodiazepines (antianxiety drugs such as Xanax). However, the vast
majority of children with psychiatric disorders do not abuse these
medications. Although stimulants can be abused by those genetically
predisposed toward substance abuse, such drugs generally do not produce
euphoria in ADHD children. In fact, many children with ADHD experience
mild dysphoric effects from stimulants. Additionally, current data indicates
that among those with ADHD, the use of stimulants may decrease the risk
of substance abuse in comparison to drug abuse rates among nontreated
ADHD subjects.
Substance abuse by children and adolescents is a common and serious
concern in our society. It must also be kept in mind that untreated mental
illnesses result in significant emotional suffering and contribute to a much
higher likelihood of drug abuse down the line. Low self-esteem, depression,
anxiety, and a sense of alienation often prompt the use of illicit drugs as a
form of self-medication. Thus any risk-benefit assessment of medication
treatment and drug abuse must certainly take into consideration the risks of
failure to treat the psychiatric disorder.

Medications and the Media

Research studies and clinical experience certainly influence prescribing
practices. However, in recent years the media have had a profound effect on
public opinion and ultimately on clinical practice. Public opinion is often
influenced by both drug companies’ marketing efforts (and thus their profit
motives) and news headlines—an example of this is the recent concern over
antidepressant use in children and its possible relationship with increased
suicidality, an issue discussed in more detail in chapter 2.
In the late 1980s negative attention was focused on the drug Ritalin
(methylphenidate), a widely prescribed stimulant used to treat ADHD.
Andrew Brotman (1992), summarizing the work of Safer and Krager
(1992), states, “The media attack was led by major national television talk
show hosts and in the opinion of the authors, allowed anecdotal and
unsubstantiated allegations concerning Ritalin to be aired. There were also
over twenty lawsuits initiated throughout the country, most by a lawyer
linked to the Church of Scientology.”
In a study conducted in Baltimore, Maryland, examining the effects of
this negative media and litigation blitz, Safer and Krager found that during
the 2-year period just following the negative media attention, prescriptions
for Ritalin had dropped by 40 percent. What were the consequences? Of
those children who discontinued use of Ritalin, 36 percent experienced
major academic maladjustment (such as failing grades or suspension) and
another 47 percent had mild to moderate academic problems. During this
time there was a 400 percent increase in the prescription of tricyclic
antidepressants (TCAs), which were then being used in place of Ritalin
(studies had demonstrated that tricyclics were somewhat effective in
treating ADHD symptoms but clearly much less effective than stimulants).
Further, tricyclics are considerably more toxic, have much higher rates of
side effects, and have been associated with sudden cardiac-related deaths in
six children. Clearly, parents had heard the negative reports about Ritalin in
the media and approached their pediatricians with concerns about the drug.
As a result, many children were taken off the stimulant and put on a class of
drugs that was less effective and considerably more dangerous.
Media attention is important in that it can alert consumers and
professionals (including the Food and Drug Administration, or FDA) to
possible problems with certain medications. When this leads to more
thorough investigations, sometimes drugs are found to be problematic or
unsafe. However, it can also lead to unwarranted fears and ultimately to
clinical decisions that may not be in the best interest of our clients. The
point is that media-driven concerns raised by our clients and their parents
can be significant, and we as clinicians must be aware of and sensitive to
such concerns.

Drug Research and Outcome Studies

As important as efficacy studies are, there is a relative paucity of good
studies in child psychopharmacology (with the notable exception of the
numerous well-controlled studies of the treatment of ADHD with
stimulants). In the past, pharmaceutical companies did not conduct tests of
psychiatric drugs on children. However, in 1998 the Food and Drug
Administration mandated that safety studies be carried out for new
psychiatric drugs with child subjects, and has it recently begun offering
financial incentives (in the form of extensions of patents) for conducting
efficacy studies with children. Thus, in very recent times, better-controlled
studies have been initiated, although many of these are not yet published
and some suffer from significant methodological flaws. It is hoped that in
the next few years the number of well-done studies will increase
significantly.
Another concern is that many studies do not include severely ill children
(the reason being that it is not considered ethical to expose severely
disturbed children to placebos over a period of months). Thus, in some child
psychiatry studies involving random assignment and the use of placebos,
groups of subjects often include only mild to moderately severe cases.
Information about treatment outcomes for severely ill kids is often limited
to that which comes from clinical experience and case studies. It is
important to keep these research limitations in mind when evaluating the
outcomes of medication studies.
A third area of concern, both for clinicians and for parents, is the effect
of very long-term use of psychiatric medications in children. Short-term
side effects are well documented and will be discussed in detail in
subsequent chapters. However, there is relatively little hard data that
indicates the risks associated with long-term treatments. Yet, for many of
the disorders discussed in this book, including bipolar disorder, ADHD, and
psychotic disorders, long-term medication treatment is strongly
recommended. It is our belief that when this topic arises in discussions with
patients and their parents, the clinician’s only appropriate response is to be
completely candid about the lack of knowledge regarding long-term drug
exposure, but to also be clear about the risks of not treating certain
disorders. Deciding whether to use medication is always a matter of
evaluating risk versus benefit, and parents need to be offered as much
information as possible so they can make informed choices.

Medication Metabolism in Young Clients

The normal rate of hepatic (liver) metabolism is high in children until the
time of puberty. The result is that most medications are aggressively
metabolized in the liver and rapidly excreted. Because what ultimately
matters is how much of the drug enters the bloodstream, treatment of
prepubertal children may require doses that approach or equal those for
adults. (The use of seemingly high doses for young children may seem
counterintuitive to many parents, and thus it will be helpful for clinicians to
explain the role of increased rates of drug metabolism.)
During the 2 to 4 months surrounding the entry into puberty, the rate of
hepatic metabolism significantly slows. For this reason, youngsters who
have been on a maintenance dose of psychiatric medication and tolerating it
well may begin to show increasing side effects when this change in
metabolic rate occurs and more of the drug begins to escape the liver and
enter circulation. Dosage adjustments may then be required, to minimize
side effects.

Approved Drugs and Off-Label Use

Currently very few psychiatric drugs are approved by the FDA for use in
treating children and young adolescents. Yet these few drugs are also in
widespread use in child psychiatry. It is very common practice in the field,
and in general medicine, to prescribe drugs off label, meaning other than as
approved by the FDA. For example, the antipsychotic medication Haldol
(haloperidol) is FDA approved for the treatment of schizophrenia but not
bipolar disorder. However, Haldol has been used for a number of years to
treat cases of mania. Since clinical and scientific research supports the use
of this drug in treating mania, its use is considered to be in keeping with
medical standards of practice, and thus neither illegal nor unethical.
Likewise, many drugs approved for use in adults (but not in children) are
used to treat child psychiatric patients. For example, only one
antidepressant (fluoxetine, or Prozac) has been approved by the FDA for the
treatment of major depression in children, yet many other antidepressants
are used to treat childhood-onset depression.
Some drug classes, most notably antidepressants, have been found
effective in treating a host of disorders other than depression, such as panic
disorder, OCD, and social anxiety. We will discuss the use of
antidepressants in more detail in chapter 2, and in later chapters we will
address how such drugs play a role in the treatment of other disorders.
 Attitudes and Realities Regarding
Psychopharmacology with Children and Adolescents
Despite the fact that some of the disorders discussed in the following
chapters are deemed to be due largely to a primary neurobiological cause
and require drug treatment, we categorically state, as we did in the
introduction, that no child should ever be treated with psychiatric
medications without concurrent psychotherapy. It is common for
pediatricians to diagnose psychiatric disorders and prescribe psychotropic
medications, and in very rare cases pediatricians have both appropriate
training for diagnosing and treating psychiatric disorders and enough time
to conduct a comprehensive evaluation. Yet the reality is that most primary
care doctors are overwhelmed with patients and have grossly inadequate
amounts of time to devote to taking careful histories, conducting thorough
diagnostic evaluations, and providing timely, appropriate follow-up. We
strongly believe that children with serious mental illnesses should be
evaluated and treated by mental health specialists.

The Use of DSM-5 Diagnostic Criteria

We have incorporated criteria from DSM-5 (Diagnostic and Statistical
Manual of Mental Disorders, fifth edition, 2013); however, in many
instances we have described diagnostic criteria more briefly than can be
found in DSM-5. This book is written both for professionals and for a lay
audience (parents), and thus, we have listed criteria using language that is
familiar to both types of readers. DSM-5 contains a much more detailed
description of diagnostic signs and symptoms.

Where We Go from Here

In the chapters that follow we will discuss specific classes of psychiatric
disorders. The initial focus of each chapter will be on important issues
regarding diagnosis, highlighting new developments in the diagnosis of
childhood disorders. This will be followed by an overview of medications
that are commonly used to treat particular disorders, and then specific
treatment guidelines. Please note that the appendix of this book includes
general information sheets regarding six common classes of psychotropic
drugs that may be given to patients or used by caregivers. We believe that it
is very important for consumers to become knowledgeable about treatment
options and the risks and benefits of medications. Please feel free to make
copies of these sheets and use them as handouts in your practice. You can
also find downloadable versions of the handouts online at
http://www.newharbinger.com/31915. (See the very back of this book for
more information.)
 CHAPTER 2

Depression
Accurate prevalence rates for adjustment disorders with depressed mood in
children are not available, although the rates are likely to be high. However,
epidemiologic studies have established that yearly prevalence rates of major
depression are significant (2 percent for children and 10 percent for
teenagers). Of great concern is the fact that serious depressive episodes in
children and young adolescents are also likely to herald the onset of either
severe and highly recurrent unipolar depression (35 percent of cases) or
bipolar disorder (48 percent), based on ten-year follow-up after an index
episode of depression (Geller et al., 2002; Geller & DelBello, 2003).
Central to the treatment of severe depression is not only reducing the
suffering and disability experienced in the current episode but also
anticipating these extraordinarily high rates of recurrence and addressing
relapse prevention.

Diagnostic Issues
Although there are similarities between childhood-onset and adult-onset
major depression, there are also notable differences. Use of the Diagnostic
and Statistical Manual of Mental Disorders (fourth edition, DSM-IV;
American Psychiatric Association, 2000) standard criteria for diagnosing
major depression failed to accurately diagnose 76 percent of young children
judged to be suffering from major depression (Luby et al., 2002). Little has
changed in diagnostic criteria in DSM-5 (American Psychiatric Association,
2013). For more diagnostic precision, Luby et al. recommend the modified
diagnostic criteria listed in figure 2-A.