Psychiatric Annals

Psychopharmacology in Childhood and Adolescence

Mina K Dulcan, MD

Abstract

This issue is the second in a two-part series of Psychiatric Annals on child psychiatry. The first was devoted to assessment. This issue addresses the rapidly developing and controversial area of pharmacotherapy with children and adolescents.

Because of space considerations, drug treatment is discussed in relative isolation from other treatment modalities. The reader should not be misled by this. Medication is almost never appropriate as the sole intervention for the entire therapeutic "career" of a child or adolescent. Unfortunately the shortage of child psychiatrists' often leads to piecemeal care, with medication over or under used and poorly integrated with psychosocial and educational interventions. Even for child psychiatrists, psychopharmacology is a difficult area in which to stay current.2 Emphasis in fellowship training is limited due to the rarity of pediatric psychopharmacologists. The authors included in this issue are clinicians who are in touch with the latest in child psychopharmacologic research, either as an investigator or a collaborator. The goals of this issue are twofold: to provide an overview of current research issues and a guide for the practitioner.

All psychopharmacologic agents used in childhood were first used on adults. The science of pediatric psychopharmacology has been hampered by the need to borrow methodology from the study of adults, and the uncertainty about how the child's physiologic and psychologic developmental status alters pharmacokinetics (absorption, metabolism, distribution, and excretion), pharmacodynamics (mechanism of action and interactions with biological receptors), and outcome. In addition, the strong societal feelings attached to medicating children for problems of behavior and emotions color the scientific process.

Stimulant medications are the most studied and most used psychopharmacologic agents for children. Although used since the 1930s, there has been a new appreciation in the last 10 years for the complexity of their actions and of the Attention Deficit Disorders. Dulcan 's article highlights both biological and psychosocial recent advances in research and clinical practice.

As Rancurello points out in his comprehensive review, while stimulants were the fad of the 1960s, antidepressants run the risk of being the panacea of the 1980s. He discusses critically existing studies including both basic pharmacology and clinical issues. Included are the use of tricyclics and related compounds in childhood depression, ADD, enuresis, and separation anxiety disorder, and the controversial use of lithium and the monoamine oxidase inhibitors.

Campbell draws on her extensive clinical and research experience with the most psychiatrically impaired children and adolescents in her overview of neuroleptic medications. These extremely potent compounds offer both promise and hazard in the pediatric population.

Finally, Breuning and Ackles, researchers in the evaluation of pediatric psychopharmacology, present an introduction to single case study methodology which the clinician can use to objectively assess the efficacy of his or her interventions. Selected references offer detailed suggestions for the reader who wishes to pursue this topic.

1. Graduale Medical Education National Advisory Committee: The Report to the Secretary. Department of Health and Human Services. US Department of Health and Human Services. 1980.

2. American Academy of Child Psychiatry: Child Psychiatry: ? Plan for the Coming Decades. American Academy of Child Psychiatry, 1983.…

This issue is the second in a two-part series of Psychiatric Annals on child psychiatry. The first was devoted to assessment. This issue addresses the rapidly developing and controversial area of pharmacotherapy with children and adolescents.

Because of space considerations, drug treatment is discussed in relative isolation from other treatment modalities. The reader should not be misled by this. Medication is almost never appropriate as the sole intervention for the entire therapeutic "career" of a child or adolescent. Unfortunately the shortage of child psychiatrists' often leads to piecemeal care, with medication over or under used and poorly integrated with psychosocial and educational interventions. Even for child psychiatrists, psychopharmacology is a difficult area in which to stay current.2 Emphasis in fellowship training is limited due to the rarity of pediatric psychopharmacologists. The authors included in this issue are clinicians who are in touch with the latest in child psychopharmacologic research, either as an investigator or a collaborator. The goals of this issue are twofold: to provide an overview of current research issues and a guide for the practitioner.

All psychopharmacologic agents used in childhood were first used on adults. The science of pediatric psychopharmacology has been hampered by the need to borrow methodology from the study of adults, and the uncertainty about how the child's physiologic and psychologic developmental status alters pharmacokinetics (absorption, metabolism, distribution, and excretion), pharmacodynamics (mechanism of action and interactions with biological receptors), and outcome. In addition, the strong societal feelings attached to medicating children for problems of behavior and emotions color the scientific process.

Stimulant medications are the most studied and most used psychopharmacologic agents for children. Although used since the 1930s, there has been a new appreciation in the last 10 years for the complexity of their actions and of the Attention Deficit Disorders. Dulcan 's article highlights both biological and psychosocial recent advances in research and clinical practice.

As Rancurello points out in his comprehensive review, while stimulants were the fad of the 1960s, antidepressants run the risk of being the panacea of the 1980s. He discusses critically existing studies including both basic pharmacology and clinical issues. Included are the use of tricyclics and related compounds in childhood depression, ADD, enuresis, and separation anxiety disorder, and the controversial use of lithium and the monoamine oxidase inhibitors.

Campbell draws on her extensive clinical and research experience with the most psychiatrically impaired children and adolescents in her overview of neuroleptic medications. These extremely potent compounds offer both promise and hazard in the pediatric population.

Finally, Breuning and Ackles, researchers in the evaluation of pediatric psychopharmacology, present an introduction to single case study methodology which the clinician can use to objectively assess the efficacy of his or her interventions. Selected references offer detailed suggestions for the reader who wishes to pursue this topic.

REFERENCES

1. Graduale Medical Education National Advisory Committee: The Report to the Secretary. Department of Health and Human Services. US Department of Health and Human Services. 1980.

2. American Academy of Child Psychiatry: Child Psychiatry: ? Plan for the Coming Decades. American Academy of Child Psychiatry, 1983.

10.3928/0048-5713-19850201-05

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