Information ⬇
Editors
Psychopharmacotherapy in Children and Adolescents
Essentials
- Psychopharmacotherapy is not often used in children and adolescents. However, drug therapy has established itself as a part of overall care, particularly when treating severe psychological problems.
- If medication is used appropriately and combined with psychotherapeutic and other treatments, it can relieve the child's mental suffering and speed up recovery.
- Use of psychoactive drugs in children and adolescents often deviates from the official indications (so called off-label use) and requires careful needs assessment and justification for starting the pharmacotherapy, as well as thorough follow-up.
- Psychiatric medication in children usually needs specialist management.
- Primary care professionals may be responsible for some of the monitoring of drug treatment.
- It is important that primary care professionals are aware of the child's psychiatric medication (interactions with other medicinal products, adverse effects etc.).
- All health care professionals should adopt a positive attitude towards psychopharmaceuticals in order to motivate the child and his/her family to comply with the treatment.
Before prescribing medication
- Before the medication is prescribed a careful diagnosis must be made and the possibilities of different treatment approaches explored.
- The possible risks of starting the medication should be weighed against the risks of not starting the medication. The benefits gained from the medication are also weighed against the possible risks.
- In children and adolescents the central nervous system is in the developing stage and drug effects may deviate from those in adults.
- The reasons why psychiatric medication is recommended should be discussed with the child and his/her parents, as should the medication's mode of action and possible adverse effects. It is often also worth exploring the most common fears and beliefs associated with psychiatric medication.
- It is very important to achieve good treatment compliance.
- Before the treatment is started it is recommended to identify the target symptoms to be monitored and the possible adverse effects of the medication. It should also be agreed on who is to carry out the monitoring (in outpatient care usually the parents, teacher etc. and in inpatient care nursing staff, hospital play therapist/teacher, parents etc.).
- Monitoring should ideally start before the drug treatment and continue, depending on the effects of the drug, for a sufficient length of time.
- Monitoring may consist of filling in standard symptom charts, or individual child-specific charts may be created.
- The justification for the treatment and the follow-up plan are carefully recorded in the patient files.
Investigations before and during treatment
- A clinical examination should be carried out before the medication is started, establishing the patient's physical and neurological state. The physical and neurological examinations should be repeated during the medication as indicated.
- Any drug-specific laboratory and other investigation should be carried out before the treatment is started. It is important to carry out necessary laboratory monitoring etc. during the treatment.
- The effectiveness of the medication and the need for continuing it should be assessed at regular intervals.
- The effect of some drugs on target symptoms may appear only weeks after the medication is started.
Starting and stopping treatment
- Starting psychiatric drug treatment in children and adolescents usually involves gradually increasing the dose. Likewise, the treatment is often withdrawn by gradually decreasing the dose.
- The dosage and dose frequency may differ from adult recommendations due to special metabolic and other characteristics in children.
- Ineffective medication and medication that has become unnecessary is discontinued. Also adverse effects may warrant stopping the medication.
- Antipsychotic drugsAntipsychotic Medication for Childhood-Onset Schizophrenia are used both to control and prevent the recurrence of psychotic symptoms. Some antipsychotic agents may also be useful in the treatment of other symptoms (tic disorder, Tourette syndrome, aggressiveness associated with a mental disorder etc.).
- Antidepressants:serotonin re-uptake inhibitors (SSRIs) are used, in addition to the treatment of depression, in the treatment of panic disorder, obsessive-compulsive disorder and certain other anxiety disorders in children and adolescents.
- The drug treatment of attention deficit hyperactivity disorder (ADHD ADHD) consists of methylphenidate, lisdexamfetamine and dexamfetamine and the norepinephrine reuptake inhibitor atomoxetine, which have all been demonstrated to be effective in the treatment of children and adolescents with ADHD.
- The effect of clonidine has been studied in hyperkinetic children with attention deficit disorder as well as in tic disorders and Tourette syndrome. The doses used have been smaller than those used in hypertonia. Clonidine as well as of other drugs primarily indicated for the treatment of other disorders than ADHD (such as modafinil and guanfacine) are very little used in ADHD.
- As mood stabilizers in the treatment of bipolar disorder in children and adolescents, second-generation antipsychotics, antiepileptic drugs and lithium are used.
- Many second-generation antipsychotics are used in the treatment of mania and as mood stabilizers.
- Sodium valproate may be used for maintenance therapy in bipolar disorder. It also has some effectiveness in the treatment of severe aggressiveness and impulsiveness in association with conduct disorders and neuropsychiatric disorders.
- Carbamazepine is not recommended as the first-line mood stabilizer in children and adolescents.
- Lithium is used for the prevention and treatment of manic and depressive phases of bipolar disorder in over 12 year olds. It also has some effectiveness in the treatment of severe aggressiveness and impulsiveness in association with conduct disorders and neuropsychiatric disorders. Monitoring during lithium therapy: see Bipolar Disorder.
- Tranquillizing drugs (benzodiazepines, hydroxyzine hydrochloride etc.) may be used after careful consideration as short-term therapy where other treatment is not sufficient to control high anxiety states, where medication is needed to restore normal sleep pattern or to treat other sleep disturbances.
- Benzodiazepines may in children and adolescents cause responses that differ from the ordinary drug effects (e.g. restlessness, aggressiveness, agitation, nightmares, hallucinations).
- Behaviour therapies are primary methods in the treatment of sleep disorders. Melatonin may be temporarily used in combination with other measures to support falling asleep.
Evidence Summaries ⬆