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33 Principles of Child and Adolescent Psychopharmacology4. Galanter M, Gleaton T, Marcus CE, McMillen J : Self-help groups for parents of young drug and alcoholabusers. Am J Psychiatry 141:889-891, 1984.5 . Henggler SW, Borduin CM: Family Therapy and Beyond: A Multisystemic Approach to Treating theBehavior Problems of Children and Adolescents. Pacific Grove, CA, Brooks/Cole, 1990.6 . Kaminer Y: Adolescent Substance Abuse: A Comprehensive Guide to Theory and Practice. New York,
Plenum, 1994.7. Kandel DB, Chen K, Warner LA, Kessler RC, Grant B: Prevalence and demographic correlates of symptomsof last year dependence on alcohol, nicotine, marijuana and cocaine in the US population. Drug AlcoholDepend 44:ll-29, 1997.
8. Kandel DB, Johnson JG, Bird HR, et al: Psychiatric disorders associated with substance use among childrenand adolescents: findings from the Methods for the Epidemiology of Child and Adolescent MentalDisorders (MECA) Study. J Abnonn Child Psycho1 25:121-132, 1997.9. Riggs DD: Depression in substance-dependent delinquents. J Am Acad Child Adolesc Psychiatry 34:764-771, 1995.10. Weissman MM, Warner V, Wickramaratne PJ, Kandel DB: Mental smoking during pregnancy and psy-chopathologyin offspring followed to adulthood.J Am Acad Child Adolesc Psychiatry 38392-899, 1999.1 1. Zoccolillo M, Vitaro F Tremblay RE: Problem drug and alcohol use in a community sample of adolescents.
J Am Acad Child Adolesc Psychiatry 38:900-907, 1999.
6 1 PRINCIPLES O F CHILD AND A DOLESCENTPSYCHOPHARMACOLOGYFrederick B. HeGert, M . D .
1. Why are physicians concerned about child and adolescent medications?Practitioners sometimes avoid giving medications to children and adolescents because they are
concerned about unusual responses or dosage requirements. However, except for the lack of a eu-phoric response to stimulants in children, there are few qualitative differences between children andadults in their response to medication. Childrens younger organs frequently clear medications morequickly, whereas adolescents generally need adult doses.2. What are major issues for the family practitioner?
Families sometimes focus all difficulties on unlikely medical causes or past injuries and expectthat medications either will not work at all or will work miracles. Medications may allow a seriouslyill child to be treated as an outpatient; this is an important point, but hardly a miracle. Medicationsare part of a total treatment plan. Parents and practitioners need to be supportive, never using med-ications as a punishment. Children and adolescents need to remember that medications do not excusethem from the need to work o n their problems. Below are specific principles for treatment of atten-tion deficit-hyperactivity disorder, depression, psychosis, conduct disorders, and anxiety disorders.
ATTENTION DEFICIT-HYPERACTIVITY DISORDER3. Why is so much attention paid to attention deficit-hyperactivity disorder(ADHD)?ADHD is a common and well-researched childhood disorder. The central notion of a short at-
tention span and hyperactivity has been around since a German poet wrote about Fidgety Phil ahundred years ago. In the ensuing years, over 10,000articles have been published in the scientificliterature. Although stimulant medications have been used for over 50 years, from time to time splin-ter groups have raised questions about their use. From the standpoint of the scientific community,stimulants remain one of the safest and most effective of all psychotropic medications. The increasein use of stimulants is probably the result of an increased recognition that 15 of patients with
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Principles of Child and Adolescent Psychopharmacology 333ADH D continue to show signs and symptoms in adolescence. Girls suffer from AD HD only on e-fourth as often as boys. In the d ifferential diagnosis, mood disorders are most difficult to rule o ut. Apositive family history of mood d isorder and lack of learning disability are more likely in bipolar pa-tients. Thirty to 50 of the men tal health referrals for children are for AD HD .4. Are stimulant medications still the mainstay of the medication treatment for ADHD?Absolutely. Stimulants remain the best medications for ADHD. Recent concern over the short dura-tion of action of methy lphenidate (Ritalin) and the small dose size of dexedrine tablets has led to the de-velopm ent of mixed salts of a single-entity amphetamine product, marketed as Adderal. Adderal showedgreater efficacy than methylphenidate at mid-day and days end across several behavioral measures.Side effects were similar to other stimulants: anorexia, insomnia, stomach pain, headache, irritability,and weight loss. Adderal often is titrated up to 0.75 m gkg , or 75 of the dose of methy lphenidate.In additio n, bupropion, m arketed as an antidep ressan t, has been shown to be equ al tomethylphenidate in at least one study of ADHD when it was given at doses of about 3 m a g bodyweight. The larger tablet sizes available in Add era l(1 0, 20, 30 m g, scored) and Wellbutrin (75, 100,100 SR, 150 mg SR, unscored) permit dosing in heavier adolescents and young adults but may posea problem in children. Risk of seizure with bupropion also is a consideration (especially with a his-tory of head injury or seizure disorder).5. What can we tell parents about ADHD?The physician m ust take a careful history and have parents and teachers fill out checklists, be-cause only 20 of children show signs of AD HD in the office. Historical factors in AD HD know n tobe associated w ith the mothers pregnancy include heavy metal exposure, chronic drug abuse, m od-erate alcohol use, or smoking m ore than 4 cigare ttedda y. Once the diagnosis is made and beforemedication is started, an explanation to the parents is helpful. Com pare the brain to a mac hine, andtell parents that the medication lubricates the system and makes it run more smoothly; it does notoffer a cure. Physician an d parents can tell the child that the medication is like a baseball glove; ifthe child takes the med ication, it will help him or her, but the child must still try to play the game.6. What is the role of clonidine in the treatment of child and adolescent behavior disorders?Clonidine is useful in treating patients with ADHD and oppositional defiant disorders who havenot responded to more conservative treatment with stimulants and behavioral therapy. It is a cen-trally acting drug that inhibits release of norepinephrine and acts centrally to reduce brain arou sal;its effects on attention are indirect. Its antihypertensive effects are not clinically evident in childrenand adolescents, despite a 10 decrease in measured blood pressure. Clonidine reduces arousal and
irritability, improving frustration tolerance. Parents have noted improvement in doing chores, andteachers have seen a reduction in classroom aggression.Clonidine is rapidly absorb ed, peaking in 60-90 minu tes. If inactive, such as sitting on a schoolbus, patients m ay fall asleep for up to 30 m inutes afterwards. When active, patients are alert and notsedated. The clinical effects last only 3 -4 hours because of rapid metabolism by both liver and kid-neys. The dose ranges from 4-6 pg/kg/day. A typical starting dose is one-half of a 0. I-m g tablet atbedtime for 3 days. Another half tablet is added in the afternoon or m orning, increasing gradually toa dose of 2-4 tablets given 2-3 timedday.Clonidine has been used as a test for growth hormone release, but it is not clear whether it actu-ally increases growth. It increases appe tite, however, and this effect is helpful in reducing weight losswhen clonidine is com bined with methy lphenidate hydrochloride (R italin). Clonidine also reducesenergy and stam ina, and these effects, along with lowered blood p ressure, should be monitored.Clonidine is available in the form of a skin patch (Catapres TTS) in doses of 1 2 and 3 mg; thepatch lasts for about 5 days. Young patients adapt easily and wear the patch on their back. The patchtolerates brief exposure to water (as in the shower), but if submerged or pulled at, it loosens. Anoverlay patch, which com es with each medication patch, may be used. A new area of the back shouldbe chosen each week. About 25-50 of patients react w ith local irritation, itching, and erythema.The reaction is more com monly to the gum in the patch than to the medication itself. Older children
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334 Principles of Child and Adolescent Psychopharmacologyand adolescents frequently want to demonstrate their own control by improving or removing thepatch. Some adolescents explain its presence as a way of staying off nicotine, although clonidinewas not effective for this indication in adult trials.
7. Can clonidine be combined with methylphenidate hydrochloride?For patients with both oppositional or conduct disorders and ADHD , clonidine may be combinedwith methylphenidate hydrochloride. S uch children often are highly distractible an d explosively ag-gressive; combined med ication helps to avoid institutional placemen t. Often p atients take high >mg/kg) doses of m ethylphenidate hydrochloride in the morning and at noon and are difficult to con-trol in the afternoon and evening. The add ition of clonidine allows an afternoon nap for younger chil-dren and more controlled bedtime behavior. In the evening, clonidine should be given at bedtime;otherwise, some patients awaken later in the evening and cannot return to sleep. Frequently, the doseof m ethylphenidate hydrochloride can be reduced by one-third o r more. S ide effects such as anorexiaand insomnia are relieved whether clonidine is given concurrently or separately later in the day.Clonidine also has been comb ined clinically with tricyclic antide press ants (TC As) and neu-roleptics. In on e case report a patien t with only a 1-day wash-out from propranolol had a seriousdrop in heart rate when clonidine was started. Heart rate rebounded when clonidine was discontin-ued. Propranolol and clonidine should no t be given simultaneously.8. Can Tourettes disorder TD) in children be treated with clonidine?
It is important to establish the correct diagnosis. Many children have m otor tics, but the diagno-sis of T D requires additional vocalizations (grunts, yelps, explosive sounds, or w ords). TD in adultsmost often is treated with haloperidol, but child psychiatrists often start with clonidine. Clonidinehas a slower on set of action and lower response rate than haloperidol or pimozide, but a lower inci-dence of side effects and no risk fo r tardive dyskinesia.
DEPRESSION9. Do children become depressed like adults?Depression is now recognized in children, although it may no t be the same disorder as in adults.Because larger numbers of children respond to placebo, it is difficult to tell whether medications areeffective. Sym ptoms of depression in children includ e self-deprecation, inhibition, sleep distur-bance, mo rning tiredness, decreased activity, difficulty in co ncen trating, and poo r school perfor-mance. But they also may exhibit aggr ession , enu resis, and hypochondriasis-symptoms not
predicted from the adult model. TCA doses have ranged from 1-5 mg/kg, usually of imipramine,after an initial EKG. Blood levels and serial EK Gs are performed weekly w hen patients take doses >4 m g k g to monitor the quinidine-like effect of imipramine. Responders had higher plasma levels(about 150 nglml) than nonresponders, with optimal response at blood levels of about 200 ng/ml ofimipramine and its metabolites. Higher levels were asso ciated with decreased efficacy and deliriumon som e occasions.10. Is monitoringof blood levels necessary in every child?It is imp ortant to measu re TC A blood levels routinely in children, because clinical response isrelated to blood level, not dosage, and a 40-fold difference may exist in the plasma concentration ofdifferent patients receiving the same do se. Because children differ from adults in body fat, percent oftotal body water, and protein-binding characteristics, and have more active enzyme systems, theymay create and accu mu late more metabolites than adults. Available studies indicate that both benefi-cial and serious side effects of TCAs are related to plasma concentration and that the therapeuticrange is relatively n arrow; thus monitoring of plasma levels is necessary in the treatment of child-hood depression. A I-we ek baseline period should be obtained in all children before treatment, asabout 20 will no longer be depressed after this interval. There is no benefit in monitoring bloodlevels of other antidepressants, as blood levels are not well correlated with clinical response.
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336 Principles of Child and Adolescent Psychopharmacologydoses up to 400 mg/day. Bec ause trazodone is initially quite sedating a nd may cause light-headed-ness, it was originally given in divided doses after meals. Now it is most often used as an adjunctto fluoxetine to help the patient sleep. It is given at bedtime after a snack. Anticholinergic and car-diac effects are unlikely, but priapism shortly after initiating treatment has been repo rted; this sideeffect is a relative con traindication for adolescent boy s. Li ke all currently kn own antidep ressants,trazodone is excreted in breast milk and should not be given to nursing mothers; it is considered acategory C drug because of increased fetal absorption in rats. Overall, these medications are muchsafer than older tricyclics, a re at least as effective, and often are better tolerated.16. Do all classes of depression in adolescents look like depression in adults?Although major depressions respond to regular antidepressants, many depressed adolescentsdo not meet criteria for major depression, Atypical depressions present with dysphoric mood, butpatients maintain m ood reactivity while depressed ; that is, they respond to comm ents by the inter-viewer with a change of mood. In addition, patients may have a history of sensitivity to rejection.Instead of weight loss and inab ility to sleep, they may show increased appetite or weight gain andsleep over 10 hou rdd ay. Any sleep disturbance in adolescents needs to be distinguished from thecommon habit of staying up late and sleeping in with overall adequ ate sleep time. Pa tients also maycomplain of severe fatigue, som etimes m anifested by com plaints of leaden weights in arm s or legs.17. What medications are useful in atypical depression?Earlier studies demonstrated that for atypical depression in young adults, monoam ine oxidaseinhibitors (MAOIs) were better than TCAs. Of adolescents unresponsive to TCAs, 75 respondedto phenelzine in one study. Side effects were numerous, but dietary compliance was a problem fo rless than one-third. M ost patients had no significant side effects, even with dietary indiscretion.Later studies concluded that atypical depression may reflect primarily the age of the patient. A morerecent study found that adolescents w ho fail to respond to treatment w ith TC As often improve whenlithium carbonate is added. At therapeutic doses of lithium, adolescents took up to 2 weeks to re-spond , but improvement persisted. Atypical depressions m ay also represent depression in individu-als with bipolar disorder; hence treatment m ay need to be m odified. Atypical depressions may alsorespond to SSRIs and venlafaxine.18. Can newer medication be used for atypical depression?Concern over lethal overdose led to a search for treatments of adolescent depression of all typeswith agents that are less likely to be harm ful. Fluoxetine has gained w ide use in adults, but few stud iesare available in adolescents. Bupropion, w hich is unrelated to both TCA s and SSRIs, has been effectivein atypical depression in adu lts. It has show n stimulant effects and w as withheld from introduction be-cause of seizures in bulimic patients who too k the drug. Overall risk is low if the dose is below 400 mgper day and any single dose is less than 150 mg. The usual adult dose is 150 mg SR, two timedday; atypical dose in ado lescents is 250 mg/day or less. Menstrual irregularities were seen infrequently withbupropion. Both medications are safer in overdose than TC As, MA OIs, or lithium carbonate.
PSYCHOSIS19. What kinds of psychoses are seen in children and adolescents?Psychosis in children and adolescents may be reflective of primary psychiatric illness or sec-ondary to medical problems (e.g., toxicity). Delirium is usually the result of drug ingestion, eitheraccidental in children o r recreational in adolescents. In either case, treatment is directed to the un-derlying cause, but delirium -induced agitation may need separate treatment.20. How is delirium treated in children and adolescents?Treatment usually takes the form of a structured and locked setting, including the use of a seclu-sion room or restraints if necessary. Delirium-induced agitation also m ay require judicious medica-tion. A child w ho is thrashing a bou t may need to be sedated for brain s can, EEG, or radiograph.
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Principles of Child an d Adolescent Psychopharmacology 337Adolescents w ho have taken hallucinogens usually can be talked dow n. Patients wh o have takenphencyclidine (PCP) may become agitated if a therapeutic enco unte r is attempted. Su ch patientsmay seriously harm themselves and others because the anesthetic properties of PCP keep them f romknowing that they have painful injuries.
Agitated an d de lirio us patients can be sedated with haloperidol, 0.1-0.3 mglkg , over 1 hour;dystonia is the only likely acute sid e effect. Th is side effect frequently is m ore frightening to the pa-tient and family than the original delirium. Any child o r adolescent given haloperidol should be o b-served closely for 24 hours so that dystonic reactions can be treated. Benadryl (diphe nhydram ine),25-50 mg orally or intramuscularly, and reassurance once the dystonia subsides usually are the onlytreatments needed for dystonias.21. What about chronic psychotic disorders that accompany autism and head injuries?M ore recently, medications have been used to treat the obsessive-repetitive behaviors in autisticchildren. Clomipramine and fluoxetine have reduced stereotypic behaviors. Patients with chronicpsy chos es due to head injury, autism, or pervasive developmental d isorders m ay respond to lowdoses of h aloperidol, w hich reduce stereotyped and agg ressive behavior.22. Can short-term use of antipsychotic medications cause serious side effects?A major concern is the potential for movement disorders, especially tardive dyskinesia (TD).Acute use of antipsychotic m edications is unlikely to cause TD . However, children and adolescentsmay develop a time-limited form of TD after taking antipsychotics only 6 months. Symptoms appearin the extremities as choreiform m ovements o r as ataxia and usually d isapp ear 2 weeks after themedication is discontinued, but movem ents may persist from 3-12 mon ths. Ma ny chronically illchildren and adolescents m ay need to be on neuroleptics fo r years and, like adu lts, are at risk fo rlong-term oral-buccal tardive dyskinesia. One of the newer atypical neuroleptics, resperidone, hasalso caused dyskinesias. Olanzapine has led to large weight gain and akathisia. Quetiapine has beenassociated with cataracts in dogs.23. What primary psychiatric illnesses can present as psychosis?Mania, schizophrenia, and depression can all present as psychosis. Psychotically depressed chil-dren and adolescents have m ore auditory hallucinations than adults; these can be treated by addingneuroleptics to the antidepressants. Hallucinations usually remit in less than 1 month, and the neu-roleptics can be discontinued. Adolescents and children with psychotic depressions are at risk forbipolar disorder. Although mania is quite uncomm on in children, 20 of all bipolar disorders havetheir onset before the age of 20, most often presenting initially as major depression.24. How is mania treated?Mania in children and adolescents presents m ore commonly with irritability than eupho ria andalso has a high incid ence of hallucinations, making differentiation from schizo phr enia difficult.Clinicians should err in favor of the least disabling diagnosis; thus the diagnosis frequently is mania,even if not all hallucinations are related to mood. Agitation and hallucinations respond to neurolep-tics, but the grandiosity usually requires lithium carbonate. Baseline kidney and thyroid functionstudies are done to confirm the patients ability to clear lithium and euthyroid status. Lithium car -bonate is begun at up to 30 mglkg in divided do ses. Lithium carbonate, 300 mg in sustained-releaseform, avoids the gastric upset an d dizziness associated with regular lithium. Within 5 day s the pa-tient should be in range of 0.8-1.2 mEq /L. C hildren and many ado lescents need to reach levels of1.5 m E q L for a goo d serum level. Doses which m aintain a serum range of 0.8-1.2 m E q L are alsoappropriate for maintenance. T he seru m level is followed at gradually greate r intervals. Thyroidstudies should be repeated at 6-month intervals, because a few patients become hypothyroid. If agood respon se ensues, with tolerable side effects, chronic m aintenance is recommen ded as bipolarillness tends to get worse over repeated episodes. Preventing recurrence is extremely important tothe long-term prognosis.
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338 Principles o Child and Ado lescent Psychopharmacology25. What are the alternative med ications for m ania?Carbamazepine and valproic acid have been used as alternatives because 3 0 4 0 of adult manicpatients d o not respond to or canno t tolerate lithium carbo nate. Th e use of carbam azep ine is lesscomm on in children than in adults. S odiu m divalproex is used fo r dysphoric mania, rapid cycling,and patients whose presentation includes psychotic symp toms or sub stance abuse in addition tomania. Many adolescents present with psychotic sym ptom s, and sodium divalproex often is added tolithium carbonate, but also may be used alone.After baseline liver and platelet studie s, sodium divalproex is given in divided d oses of 20mg k g It is rapidly ab sorbed w ith a peak action at 4-6 hours. Th e dose is gradually increased untillevels of SO-120 mg/ml are reached. Patients frequently respond in 5-10 days. The most commonside effects are GI upset, m ild tremor, and initial lethargy. A decrea se in platelets an d an increase inliver enzym es may occur. An increase of liver function values to 300 of baseline is acceptable, andthrombocytopenia usually is not seen until blood levels exceed 100 mg /ml of valproate. Hair thin-ning is transient and dose-related but may be particularly disturbing to adolescents. Sodium dival-proex also is available in pull-apart capsules as a sprinkle that can b e used i n soft foods with youngerchildren or patients wh o cannot take capsu les by mou th. Unlike lithium, sodium divalproex is80-95 protein-bound and thus competes with other protein-bound medications, such as carba-mazepine or fluoxetine. As a result of the interaction, the less tightly bound drug is displaced and itsside effects are increased. Although sodium divalproex and carbam azepine have been u sed in com bi-nation in adults, their interaction is complex. Little experience is available in adolescents; it is saferto use o ne or the other by itself. Sodium divalproex is a recent addition to the child psychiatry arma-mentarium an d, if polypharm acy is avoided in youn ger children, a safe alternative to li thium.However, use of valproate in g irls poses a risk of polycystic ovary; hence it should be used onlywhen o ther options have failed o r are contraindicated.26. How is sch izophrenia treated?Schizophrenia frequently begins in adolescence. A g radual decline in functioning with the onsetof suspiciousness and auditory hallucinations that comm ent on ones behavior are ominou s signs. Abaseline C T scan is done to check ventricular size. Atroph y is associated with poor prognosis. Th isalso screens for lesions that could cau se psychosis. Treatm ent with neuroleptics requires a minimaldose of 300 mg of chlorpromazine or 5 mg of haloperidol. Chlorpromazine and thioridazine causeproblem s with sexual side effects (retrograde ejaculation or galactorrhea) and gen eral inhibition ofmovement (akinesia). The potent neuroleptics tend to induce dystonia, particularly if large doses aregiven early in treatment. The newer, atypical antipsychotic medications are rapidly becoming thefirst-line treatments because of more tolerable side effects and greater efficacy.
Akathesia, which may appear later with any neuroleptic, requires a reduction in dose or the ad-dition of propranolol, 40-120 mg/day. If the patients agitation or perplexity persists, the dose ofneuroleptic is gradually increased, and the patient is observed for approx imately a week before in-creasing the dose again. Over a perio d of approximately 6 weeks the patients hallucinations andpsychosis gradually come under control. A significant portion of psychoses in adolescents seems toresult from severe external stresses and remit without further recurrence. Mania and schizoph renia,on the other hand, are considered life-time illnesses.
BEHAVIOR OR CONDU CT DISORDERS27. Is there a practical way of classifying behavior disorders?Behavior disorders can be divided into good ki d and bad kid styles. The good kid hasdiscrete episodes of anger, usually with little or no precipitant. Good kid adolescents trash theirrooms, throw things, or hit whoever happens to be close. Once over this episode, they are contriteand apologetic. An EEG m ay be helpful, because some patients have an epileptic focus, usually inthe temporal lobe. How ever, up to 40 of EEGs are false negatives, and nasal ph aryngeal leads arenot well tolerated.
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Principles of Child and Adolescent Psychopharmacology 339Sometimes diagnosed as having explosive disorders, such patients do better on carbamazepine. Abaseline CBC with reticulocyte count is necessary, because carbam azepine usually reduces the WBCinitially. If carbamazep ine is started at a low dose of 200 m g/day and increased by 200 m g each w eekwith weekly blood counts for the first month, there are few problems. If the dose is increased too
quickly, the patient often complains of upset stomach. In almost all cases, the reticulocyte count de-creases, with a later decrease in overall white cell count. A petechial rash rarely appears. Therap euticcarbamazepine levels of 0.8-1.2 pg/ml are associated with a reduction in ou tbursts after 1 month withadequa te drug serum levels. If the white cell count dro ps below 4000, the clinician may con sider thetrial a failure. Patients who respond need regular white coun ts with gradually decreasing frequency. Asin adults, blood levels may d rop over time because of enzyme induction. Clinically, some ado lescentsshow increased imtab ility on carbam azepine, particularly those with an associated affect disorder.28. Are the bad kids more commonly diagnosed?order, requiring a t least three fo r the diagnosis:The bad kids are classified as conduct disorders. DSM -IV lists 15 symptoms of conduct dis-
Often bullies, threatens, or intimidates othersOften initiates physical fightsUsed a weapon that can cause serious physical harm to othersHas been phy sically cruel to peopleHas been physically cruel to animalsHas stolen, with confrontation of the victimForced sexual activity on som eoneDeliberately engaged in fire setting with intention of serious damageDeliberately destroyed others propertyHas broken into someone elses propertyOften lies, to obtain favors or avoid obligations (con s)Has stolen without confrontation of victim m ore than on ceStays out at night, with onset before age 13Has run away from hom e overnight at least twiceOften truant from school, with onset before age 1 3The diagnosis of con duct disorder is much m ore commo n than explosive disorder (good kid ,because only three symptom s from the list above are required.
29. What other diagnoses should be considered?Even when th e patient meets the criteria for diagnosis of conduct d isorder, a careful review ofthe possibility of ADHD and affective disorders should be performed. AD HD is comm only associ-ated with conduct disorder and worsens the overall prognosis. It is worthwhile to consider a trial ofclonidine if the aggression is mostly verbal and ADHD is prominent; clonidine seems to reduce i r r -tability in patients with AD HD . Of delinquent populations, 23-30 meet the criteria for major de-pression and des erve treatment. In one study of depressed conduct-disordered male adolescents,behavior improved as the depression lifted after treatment with imipramine.
Bipolar disorderalso shou ld be ruled out, with particular attention to family history. Clinicianshave increasing awareness of bipolar disorder in adolescents with the understanding that the off-spring of bipolar parents also are at risk for mania. Mania in adolescents frequently presents as im -tability, and underlying irritability frequently accompanies conduct disorder behavior; thus, lithiumwas tried in the treatment of cond uct disorder. On e study comparing lithium with haloperidol foundboth to be equally effective, but lithium caused fewer side effects, including no detrimental effect onlearning. Although responsiveness to lithium does not prove a bipolar diagnosis, it is reasonab le togive a conduct-disordered adolescent a trial of lithium if other treatable disorders are unlikely. Onlyone controlled study has show n that youth with affective symptoms are more responsive to lithium.30. What are the general principles of treating conduct disorder with medication?Treatment for co nduct disorder with li thium follows the regimen f or bipolar disorder withkidney and thyroid studies and with g radu al increa se in the lithium level to the rang e of 1 O-1.5
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340 Principles of Child and Adolescent PsychopharmacologymEq/L. An EEG should be ob tained before lithium is started, because lithium in the system createsEEG artifacts. Hand tremor and gastric distress are comm on but m ild. Sustained-release lithium maybe used to reduce gastric distress, and beta blockers m ay redu ce tremors. Medications frequently arenecessaryfor conduct disorder, hut never sufficient. Structure and con trol during inpatient care andfollow-up are always necessary. Many, if not all, patients w ith condu ct disorders need rem edial edu-cation for reading and learning disabilities.
GENERAL ANXIETY AN D OBSESSIVE-COMPULSIVE DISORDER31. Why were childhood anxiety disorders not treated in the past?Child psychiatrists traditionally have not treated anxiety disorders with medications because ofa belief that anxiety w as part of the developmental process an d a concern that medication m ay inter-fere with the process. Until recently, medications used to treat anxiety also carried some potential foraddiction or at least psycholo gical dependenc e amo ng adults. The introduction of buspirone allowsthe treatment of anxiety disorders with a m edication that has n o addiction liability and do es not pro-duce sedation. There are few reports of its use in children o r adolescents. Case reports have found ituseful in treating anxiety in ado lescents. Additional repo rts have sho wn it to be a useful adjunct inreducing aggression in autistic adolescents. Currently the indications are clinical; its efticacy has notbeen established for general use.32. Does increasing evidence suggest that obsessive-compulsive disorder OCD) is an organicmedical problem?On e specific typ e of anxiety associated with obsessions and com pulsions has responded toagents that increase serotonin in the CNS. Such agents markedly reduce behaviors associated withthis particular anxiety. Althoug h the cause is un know n, recent biologic, clinical, radiologic, andphysiologic evidence strongly implicates problems in the caudate or connections from caudate to theprefrontal a rea of the brain. Patients with Sydenhams cho rea and postencephalitic patients haveOC D more often than the general population, and bo th disorders have obvious organic causes. OCDis much more comm on than previously thought. A s much as 2-3 of the U.S. population is esti-mated to be affected-more than 4 million people. Clues in children include erased school papers(sometimes so repeatedly that holes ar e worn throug h the paper) and/or retraced letters. Clues inadolescents include bleeding gum s from overbrushing and extrem e religiosity.33. What treatments have been used for OCD?Many treatments have been tried. Psychotherapy is ineffective. Behavior therapies have beenvariably effective. Stimulus exposure with response prevention is effective, but 25 of patients dropout, and many d o not follow through o n exposu re-resp onse prevention. Antianxiety a gen ts, neu-roleptics, and antidepressants have been tried without much success. Infrequently, children respondto imipramine and , rarely, clonidine. Clom ipramine is a strong serotonin reuptake blocker often usedfor OC D in children. Clom ipramine has a typical tricyclic side-effect profile of dry m outh, constipa-tion, tremor, dizziness, somnolence, headache, and fatigue, but such effects are seen less often inchildren. As much as 200 mg/day or as little as 3 mg/kg may b e used for children or adolescents.Fluvoxam ine is now also indicated in the pediatric age group (8-17) for the treatment of OCD .Doses start with 25 mg at bedtime, titrated up to 200 mg per day in divided do ses, with the largestdose g iven at bedtime. Behavior therapy with parental assistance helps.
BIBLIOGRAPHY1 Campbell M, et al: Lithium in hospitalized children with conduct disorder: A double-blind and placebo-con-2. Conners CK: Rating scales in attention-deficit disorder: Use in assessment and treatment monitoring. J Clin3. Cowart VS: The Ritalin controversy: Whats made this drugs opponents hyperactive? JAMA 259:2521-
trolled study. J Am Acad Child Adolesc Psychiatry 34:445-453, 1995.Psychiatry 59:24-30, 1998.2523. 1988.
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