Psychiatric Annals

from the guest editor 

Child and Adolescent Psychopharmacology

Richard Balon, MD

Abstract

Treatment of mental disorders has undergone profound change during the past 50 years. Since the introduction of chlorpromazine, imipramine, and inhibitors of monoamine oxidase during the 1950s we have witnessed a tremendous expansion of pharmacotherapy of mental disorders and a relative decline in the use of some psychotherapies, at least by psychiatrists. The developments of clinical psychopharmacology fundamentally changed the practice of psychiatry and the lives of our patients. However, most of the development and research in psychopharmacology had been happening in the area of adult mental disorders. For years, the use of stimulants, mostly methylphenidate, for attentiondeficit/hyperactivity disorder (ADHD) constituted almost the entire field of child and adolescent psychopharmacology. Only during the past two decades have we seen gradual developments, such as the use of various antidepressants for childhood and adolescent depression (though the efficacy of antidepressants in this indication remains questionable for many), or the use of selective serotonin reuptake inhibitors (SSRIs) in pediatric anxiety disorders. The use of antidepressants among youth in the United States increased between 2.9 and 4.6 times (Midwestern Medicaid and mid-Atlantic Medicaid) between 1988 and 1994.1 Surprisingly, this increase was mainly generated by primary care physicians.1 Clinical practice has clearly outpaced the research. However, clinical practice may not always be well supported by research data. According to this study, primary care physicians prescribed antidepressants primarily for ADHD and psychiatrists usually prescribed these drugs for depression.' In another survey study,2 95% of responding child psychiatrists used pharmacotherapy to treat childhood posttraumatic stress disorder (PTSD); the most preferred medications to treat childhood PTSD were SSRIs and alphaadrenergic agonists. Interestingly, no controlled studies with these medications in PTSD have been published to date.

One might ask for the reason for the "developmental lag" of child and adolescent psychopharmacology compared to adult psychopharmacology. Actually, this lag of development has probably had several reasons. First, as Rosenberg, Holttum and Gershon pointed out in the introduction to their textbook,3 until fairly recently specific psychiatric diagnoses were not well defined and characterized in the pediatric population. Second, psychotropic medications are not totally harmless and have various potential side effects. Their administration to children and adolescents requires skills, training, and ongoing interaction with the patient and his/her family.3 We have also lacked solid research data on the efficacy and safety of these agents in the pediatric population. Finally, there have been social, ethical, and legal reasons for a careful approach to using psychotropic agents in this population.3 The ongoing controversy about the use of methylphenidate in the ADHD fueled by the Church of Scientology is an illustrious example of one of these reasons.

One might also wonder about the reasons for the seemingly sudden and extensive change in the use of psychotropic medications in children and adolescents. As with the developmental lag, there are probably several reasons for the expansion of child and adolescent psychopharmacology. First, the newer drugs are far better tolerated and thus their use in children and adolescents, right or wrong, may seem to be easier to justify. Second, again right or wrong, there have been various societal pressures on child and adolescent psychiatrists and pediatricians to handle various child and adolescent behavioral problems. Some of these problems are symptoms of mental disorders and some of them respond to medication. The societal pressures have been going also in the opposite direction, as demonstrated by various legislative attempts to limit the use of stimulants or by the mentioned pressure by the Church of Scientology. Third, our diagnostic system has become a bit more refined and specific. Last, but not least, there has been a huge increase in clinical research…

Treatment of mental disorders has undergone profound change during the past 50 years. Since the introduction of chlorpromazine, imipramine, and inhibitors of monoamine oxidase during the 1950s we have witnessed a tremendous expansion of pharmacotherapy of mental disorders and a relative decline in the use of some psychotherapies, at least by psychiatrists. The developments of clinical psychopharmacology fundamentally changed the practice of psychiatry and the lives of our patients. However, most of the development and research in psychopharmacology had been happening in the area of adult mental disorders. For years, the use of stimulants, mostly methylphenidate, for attentiondeficit/hyperactivity disorder (ADHD) constituted almost the entire field of child and adolescent psychopharmacology. Only during the past two decades have we seen gradual developments, such as the use of various antidepressants for childhood and adolescent depression (though the efficacy of antidepressants in this indication remains questionable for many), or the use of selective serotonin reuptake inhibitors (SSRIs) in pediatric anxiety disorders. The use of antidepressants among youth in the United States increased between 2.9 and 4.6 times (Midwestern Medicaid and mid-Atlantic Medicaid) between 1988 and 1994.1 Surprisingly, this increase was mainly generated by primary care physicians.1 Clinical practice has clearly outpaced the research. However, clinical practice may not always be well supported by research data. According to this study, primary care physicians prescribed antidepressants primarily for ADHD and psychiatrists usually prescribed these drugs for depression.' In another survey study,2 95% of responding child psychiatrists used pharmacotherapy to treat childhood posttraumatic stress disorder (PTSD); the most preferred medications to treat childhood PTSD were SSRIs and alphaadrenergic agonists. Interestingly, no controlled studies with these medications in PTSD have been published to date.

One might ask for the reason for the "developmental lag" of child and adolescent psychopharmacology compared to adult psychopharmacology. Actually, this lag of development has probably had several reasons. First, as Rosenberg, Holttum and Gershon pointed out in the introduction to their textbook,3 until fairly recently specific psychiatric diagnoses were not well defined and characterized in the pediatric population. Second, psychotropic medications are not totally harmless and have various potential side effects. Their administration to children and adolescents requires skills, training, and ongoing interaction with the patient and his/her family.3 We have also lacked solid research data on the efficacy and safety of these agents in the pediatric population. Finally, there have been social, ethical, and legal reasons for a careful approach to using psychotropic agents in this population.3 The ongoing controversy about the use of methylphenidate in the ADHD fueled by the Church of Scientology is an illustrious example of one of these reasons.

One might also wonder about the reasons for the seemingly sudden and extensive change in the use of psychotropic medications in children and adolescents. As with the developmental lag, there are probably several reasons for the expansion of child and adolescent psychopharmacology. First, the newer drugs are far better tolerated and thus their use in children and adolescents, right or wrong, may seem to be easier to justify. Second, again right or wrong, there have been various societal pressures on child and adolescent psychiatrists and pediatricians to handle various child and adolescent behavioral problems. Some of these problems are symptoms of mental disorders and some of them respond to medication. The societal pressures have been going also in the opposite direction, as demonstrated by various legislative attempts to limit the use of stimulants or by the mentioned pressure by the Church of Scientology. Third, our diagnostic system has become a bit more refined and specific. Last, but not least, there has been a huge increase in clinical research in child and adolescent psychopharmacology. In addition to the Journal of Clinical Psychopharmacology, the Journal of Child and Adolescent Psychopharmacology was started more than a decade ago. Besides stimulants, SSRIs have probably been the most frequently studied medications. They have been used in disorders previously either hardly diagnosed in children and adolescents or usually treated with psychotherapy, such as dysthymia.4,5 Most of the published studies have not been placebo controlled so far. However, the number of controlled studies, mostly in the areas of ADHD6,7 and depression8 but even in less prevalent conditions such as behavioral problems in autism,9 has been growing.

In spite of all the controversies and not yet clarified issues, child and adolescent psychopharmacology, following the lead of adult psychopharmacology, has developed and expanded tremendously. The four articles in this issue of Psychiatric Annals present a testimony to this development.

The first article by Robert Althoff, David Rettew, and James Hudziak reviews the psychopharmacology of ADHD, oppositional defiant disorder, and conduct disorder. The authors emphasize that these disorders are very common and that they frequently occur as comorbid conditions. They suggest that the comorbid conditions should be carefully considered when choosing a medication for these disorders. The authors provide guidance to the treatment of ADHD not only with stimulants, but also with other psychotropic agents, such as antidepressants and a-adrenergic agonists.

In the second article, Boris Birmaher skillfully summarizes the recent knowledge in a difficult area - treatment of psychosis in children and adolescents. Psychosis in children or adolescents can be devastating and have life-long negative consequences in all aspects of life. Early recognition and treatment, particularly of the first psychotic episode, may be essential as studies suggest that early treatment of psychosis has been associated with better prognosis. Dr. Birmaher discusses the data on the use of typical and atypical antipsychotics in the treatment of acute psychotic episode and also in continuation and maintenance therapy. In addition, he emphasizes the importance of psychoeducation and supportive therapy of both the children and their families.

The third article, by Karen Dineen Wagner, discusses the recent developments in the treatment of major depression in children and adolescents. Dr. Wagner suggests that SSRIs are the firstline medication treatment for children and adolescents suffering from depression, as they have been found efficacious and well tolerated. She also finds it reasonable to try another SSRI if the child fails to respond to the first one, since failure to one drug does not necessarily predict failure to respond to another one. Importantly, Dr. Wagner recommends that antidepressants should be continued for at least 9 months after symptom resolution.

Finally, in the last article, David Rosenberg, S. Preeya Banerjee, Jennifer Ivey, and Elisa Lorch present the recent knowledge on psychopharmacology of child and adolescent anxiety disorders. The authors state that SSRIs are the drugs of choice for anxiety disorders in youth. However, they also suggest that these disorders should not be treated with medication only and that psychotherapy, particularly cognitive-behavioral therapy, is a viable treatment choice (alone or in combination with medications) for pediatric anxiety disorders.

Though these four articles do not cover the entire field of child and adolescent psychopharmacology, they address the treatment issues of the four most extensively studied areas of child and adolescent psychopharmacology. It is hoped that practicing physicians will find all four articles helpful in navigating through the difficult and not fully explored area of child and adolescent psychopharmacology. It is also our hope that these articles will help to de-stigmatize the use of psychotropic medications in children and adolescents.

REFERENCES

1. Zito JM. Safer DJ. DosReis S. et al. Rising prevalence of antidepressants among US youth. Pediatrics. 2002;109:721-727.

2. Cohen JA. Mannarino AP, Rogai S. Treatment practices for childhood posttraumatic stress disorder. Child Abuse Neg. 2001;25:1234-1235.

3. Rosenberg DR. Holttum J, Gershon S. Textbook of Pharmacotherapy for Child and Adolescent Psychiatric Disorders. New York, NY: Brunner/Mazel; 1994.

4. Rabe-Jablonska J. Therapeutic effects and tolerability of fluvoxamine treatment in adolescents with dysthymia. J Child Adolesc Psychopharmacol. 2000;10:9-18.

5. Nobile M, Belletti B, Marino C, Molteni M. Battaglia M. An open trial of paroxetine in the treatment of children and adolescents diagnosed with dysthymia. J Child Adolesc Psychopharmacol. 2000;10:103-109.

6. Prince JB. Wilens TE. Biederman J. et al. A controlled study of nortriptyline in children and adolescents with attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol. 2000;10:193-204.

7. Bostic JQ. Biederman J. Spencer TJ, et al. Pemoline treatment of adolescents with attention deficit hyperactivity disorder: a short-term controlled trial. J Child Adolesc Psychopharmacol. 2000;10:205-216.

8. Emslie GJ, Rush JA, Weinberg WA. et al. A double-blind, randomized, placebocontrolled trial of fluoxetine in children and adolescent with depression. Arch Gen Psychiatry. 1997;54: 1031-1037.

9. McCracken JT. McGough J. Shah B, et al. Risperidone in children with autism and serious behavioral problems. N Engl J Med. 2002;347:314-321.

10.3928/0048-5713-20030401-04

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