Children, Mental Illness and Medicines

It is unfortunate that childhood offers no protection against mental illness. In the US, one in five children and adolescents suffer from mental health problems at any given time. The key to ideally handling these childhood disorders is for parents to recognize the problem and seek appropriate treatment. The causes of mental illness in children are complex and never due to a single factor. As with other types of illnesses, mental disorders have specific diagnostic criteria and treatments, and a complete evaluation by a child psychiatrist is imperative to determine whether a child needs help.

DIAGNOSIS

Diagnosis is based on a collaborative process that should involve psychiatric and other physicians, the child, and the child's family, and school-based or other health care clinicians as appropriate. They are involved in an assessment designed to reach a comprehensive diagnosis and the creation of a treatment plan. When deciding what treatment will best benefit the child, it is essential to apply a careful diagnostic assessment after a thorough evaluation of psychiatric, social, cognitive, educational, and medical/neurological factors.

TREATMENT

Psychiatrists develop a comprehensive treatment plan that encompasses all aspects of a child's life. After a comprehensive diagnostic evaluation, an individual treatment approach based on any coexisting mental and physical conditions should be selected according to the child's needs and family and child preferences. Psychotherapy, family and school consultation, and medication are all potential elements of comprehensive treatment.

Medications should not be used alone due to the need to deal with ongoing developmental processes. The benefits of psychotropic medications along with various forms of therapy (e.g. cognitive-behavior therapy, psychotherapy, parental and family therapy, social skills training, group therapy) should be carefully examined and accounted for when determining the next steps. Medications should not automatically be considered to be the first choice in treatment, and should be used as part of a comprehensive treatment plan only when their benefits outweigh the risk.

REVIEW OF MEDICATIONS

Stimulants

Attention deficit and hyperactivity disorder (ADHD) affects 3-5% of children, and some adults. It is characterized by distractibility, impulsiveness and disorganization. Stimulants, including methylphenidate, amphetamine and pemoline, are by far the most widely researched and commonly prescribed treatments for children with ADHD. They diminish motor overactivity and impulsive behaviors seen in ADHD and allow the child to sustain attention and improve physical coordination (e.g. handwriting, sports).

Methylphenidate helps a child focus by preventing the reuptake of dopamine and norepinephrine--two chemicals involved in normal brain function. It should be prescribed carefully and only by a medical expert. D-amphetamine (Dexadrine) and adderall may also be prescribed for ADHD. All stimulants can have mild side effects including insomnia, weight loss, decreased appetite, abdominal pain and headaches. Most side effects of stimulants are short-term, dose-related and subject to individual differences.

Use of stimulants can result in an immediate and often dramatic improvement in behavior both at school and at home. The benefits and the risks associated with stimulant treatment must be weighed carefully, and evaluated and monitored continually for every child. In general, stimulants are regarded as an effective ADHD therapy with high safety and relatively few side effects.

There has been some public concern about whether exposure to stimulant medication in children with ADHD increases the risk for substance abuse in later life. A recent study by Biederman et. al. (1999) suggests that rather than inducing substance use in youth with ADHD, such medications may protect children with ADHD from future substance abuse.

Antidepressants

Depression tends to run in families. While a predisposition does not automatically mean that a child will get the disease at least one study shows that more than one in four depressed children have a close relative with the disease. Evidence shows that early onset may predict more severe illness in adult life, unless otherwise recognized and treated early in life. Depression in children often comes hand in hand with school performance and other problems. It is an often underlying factor in eating disorders, headaches, sleep problems and other physical problems affecting children and teens.

Many clinical research studies have reported beneficial effects of antidepressant medications as part of a comprehensive treatment plan in children and adolescents. It must be remembered that medications are only part of a comprehensive treatment plan and a psychiatrist or other well-trained physician must prescribe them. There are three major classes of antidepressants:

Selective serotonin reuptake inhibitors (SSRIs) - fluoxetine, sertraline, paroxetine, fluvoxamine and citalopram - are the second most prescribed psychotropic medications, after stimulants, for children. They appear safe and effective for the treatment of severe and persistent depression and anxiety disorders, such as obsessive-compulsive disorders (OCD) and panic attacks, in children and adolescents.

Heterocyclic antidepressants - imipramine, desipramine, amitriptyline, nortripltyline, clomipramine. This type of antidepressant also may be prescribed to treat depression in children. However, despite the fact that HCAs are the third most frequently prescribed psychotropic medications for children, available studies do not support the efficacy of HCAs for depression in this age group.

Imipramine is also used to treat enuresis (bed-wetting) in children after the age at which urinary control should have been achieved. Clomipramine is used to treat obsessive-compulsive disorder (OCD). Nortriptyline and imipramine are also prescribed for ADHD, particularly if a child is prone to tics.

Monoamine oxidase inhibitors (MAOIs) - MAOIs are known to be helpful in the treatment of depressive disorders with prominent anxiety features but are not recommended for use in children. The major limitations associated with the use of MAOIs are significant dietary restrictions, including most cheeses, tomato sauces, and other foods popular with children, and interactions with over-the-counter medications such as cold treatments and diet pills.

Antianxiety Medications

Anxiety is the most common mental health problem that occurs in children and adolescents. Studies report that children can also experience panic disorder and agoraphobia (Biederman, 1987). Children with anxiety disorders are often treated with a group of antianxiety medications called benzodiazepines: clonazepam, diazepam and alprazolam, and beta blockers. These medications work quickly to even out a child's anxiety.

Antipsychotics

Antipsychotic medications have been used to treat childhood psychotic disorders but also to control symptoms of agitation, aggression, and self-injurious behaviors in children with severe developmental disorders (including mental retardation) and pervasive developmental disorder (autistic and autistic-like disorders).

The principal categories of psychotic illness that affect children are schizophrenia and bi-polar disorder, both chronic and disabling disorders. Typically, the illness emerges in mid to late adolescence or early adulthood. However, research studies are revealing that cognitive and social impairments may be evident earlier in children who later develop schizophrenia.

There are a number of antipsychotic medications available. They generally yield comparable results: the main differences are in the potency, the dosage (amount) prescribed to produce beneficial effects, and the side effects.

Other Medications

Clonidine, a medication used primarily in the treatment of adult hypertension, has become more prominent in pediatric psychopharmacology because of its wide range of indications. In addition to being used to treat ADHD and sleep disturbances, clonidine is now considered the first line of treatment in Tourette's syndrome and other tic disorders (Leckman et al 1991). It is the fourth widely used psychotropic medication in children and has been increasingly accepted because of its relative safety.

Guanfancine, as with clonidine, appears to have beneficial effects on hyperactive behaviors, attention abilities, and tic disorders (Chappell et al. 1995). Compared to clonidine, guanfancine appears to be less sedating.

OFF LABEL USE

Physicians are allowed by law to prescribe medications in ways not specifically approved by the Food & Drug Administration, such as prescribing psychotropic medications for children younger than five years old. New research findings, clinical experience, and the child's and parent's personal preferences are factors considered by physicians when deciding the appropriate medications to prescribe. Prescription for "off-label" purposes of any medication should be made only after a comprehensive evaluation has been made, other forms of therapy (or combination of) have been considered, and must be monitored closely.

SUMMARY

In a study published by the Journal of the American Medical Association (February 2000), researchers reported the use of certain psychotropic medications in two-to-four-year-olds rose up to three-fold between 1991 and 1995. One of the reasons for this increase may be attributed to a growing acceptance of psychotropic medications. The mounting pressure for children to conform to social standards of good behavior may also contribute to this increase. School administrators play a critical role in determining which kids may need help as they are often the first to notice the symptoms of behavioral disorders. However, it is not their responsibility, nor do they have the training, to recommend or mandate the use of medications as a solution to behavior problems.

Another reason for this increase may be that more physicians are diagnosing behavior disorders at an early age. However, in a consensus conference by the NIH on ADHD in 1999, it was found that family doctors, the ones with the least expertise in ADHD, diagnose more quickly and prescribe medications more frequently. Experts worry that some doctors are making diagnoses based on symptom checklists rather than on thorough evaluation of a child's life both in and out of the home. The current managed care approach to reimbursement has compounded this problem because it makes it extremely difficult for multidisciplinary clinics -- that in the past brought together pediatric, psychiatric, behavioral and family dynamic expertise -- to obtain adequate reimbursement for their services. As a result, children with mental illnesses now are increasingly subjected to quick and inexpensive pharmacological fixes. For optimal outcomes, an informed, multi-modal therapy specifically designed by a pediatric psychiatrist for a specific child's condition is highly necessary.

According to David Fassler, M.D., chairman of the American Psychiatric Association's Council on Children, Adolescents and their Families, "The real tragedy is that most children and adolescents with psychiatric disorders still do not get the help they need. It is easy to overlook the seriousness of childhood mental disorders. If left untreated, the physical, emotional, social and intellectual development of children with mental disorders will be severely stunted, if not crippled. These children are at a heightened risk for school failure and dropout, drug abuse, and many other difficulties - all of which can be prevented by timely evaluation and appropriate treatment."

For parents who have recognized symptoms of childhood mental disorders in their children, sought medical help, and have embarked upon a treatment plan that includes medications, child and adolescent psychiatrists recommend:

• Medications should be closely monitored for efficacy, adverse effects and ongoing needs. Careful observation will ensure that the child is getting the appropriate dosage. Talk to your psychiatrist about all medications your child is taking, including non-prescription medicines, to learn of possible contraindications.

• Talk regularly with your child's teachers, caregivers and physician(s) about how your child is doing, especially when medication is first started, re-started or when the dose is changed.

• Applaud your child for improvements in behavior (better grades, developed social skills, more friends, etc.). The therapy and medications are not responsible for these improvements - they simply make it possible for your child's own assets and natural skills to shine through.

• Find a school or classroom setting that can provide structure and organization beneficial to your child. A child with mental health problems does not need unnecessary pressure and inappropriate expectations.

• Help children feel comfortable with their therapy and medication. They need to know the value of their treatment program and that being a part of it does not make them different from the rest of their peers.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.