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Prenatal
• The first trimester is the period of organ formation and thus IF POSSIBLE avoid medications (as much as possible)
• Most drugs cross the placenta, so fetal medication exposure will continue thruout the pregnancy
Childhood
• Many mental illnesses begin in childhood and can markedly interfere with– Social Development – Interpersonal relationships– Academic development– Identity Development– Emotional Maturity (may look or be PD)– Think back to Life Span
Benefits of medication children
• So development continues with out interference of MI
• Reduce subjective distress• Neuroprotective (protect brain against damage
and/or kindling)– Bipolar– ADHD– Schizophrenia– Some Unipolar– Some PTSD
Issues Associated with prescribing
• No REAL informed consent• Parental fears about meds, drug use, addiction
(most children with MI do not abuse prescriptions and those with ADHD are less likely to abuse A&D than those not treated with stimulants)
• Parental fear of stigma• Parental believe pill will FIX child and ignore
family dynamics, social issues, psychological issues, etc
Informed Consent
• Parents who do not wholeheartedly endorse tx will sabotage. Include risks of not medicating
• Children 7 and older– Should be a part of the discussions about treatment
– Which may help instill more positive attitudes toward mental health
– May promote utilization of services as MI may be lifelong
School
• Best if fully involved
• Need information. Problem getting all teachers in secondary/high schools involved
• Stimulants need only be given on schooldays? (controversy around this issue)
Children with Psychiatric Probelms
• Tend to present with motoric restlessness and inattention, thus diagnosis can be difficult.
• ADHD inattentive type appears to be a totally unrelated neurological disorder that does not often respond to stimulants
Titration
• Children have very effective livers; much of an oral dose is lost on first pass metabolism– So doses may be equal or close to adult dosage– This may be counter intuitive to parents, so explain– 2-4 months around entering puberty, metabolism will
slow and dose adjustment is likely to be required
• Be clear about goals. Don’t be satisfied with just some improvement
• Find a way of measuring improvement, possibly a rating scale
Drugs to know
• methylphenidate/dexamphetamine (stimulants)
• SSRIs
• imipramine
• clonidine
• sedative antihistamines
• benzodiazepines
Drugs to be aware of
• Clomipramine (Anafranil)
• propanolol
• risperidone
• other antipsychotics
• mood stabilisers
Things to remember @ Stimulants
• Stimulants may aggravate anxiety disorders- tx anxiety first
• Start with immediate release formulas then move to extended release
• Stimulants only work short period of time so to help with afternoon/evening drop off, may use antidepressant
Stimulant side effects
• Initial insomnia (give early in day or clonidine or trazadone at bedtime)
• Anorexia (only while drug is active, not the disorder)
• Stomachache (add food)• Mild Dysphoria (change stimulant or add
Welbutrin)• Lethary, poor concentration (lower dose)
Methylphenidate (MPH)
• Stimulates many mental functions by blocking dopamine transporter (i.e.re-uptake blockade at synapse)
• Can do this in normal children (abuse by parents? Desperate Housewives (the TV show))
• Not addictive in ADHD treatment• Sustained release preparations popular (school not
involved - not a good thing?)
Methylphenidate (MPH)
• Onset insomnia– do not give too late in the day
– problems with evening behaviour/homework
– can add evening clonidine (ECG first), melatonin, sedative antihistamine
• Growth problems infrequent with immediate release (Ritalin, Equasym), unknown frequency with sustained release preparations (Concerta XL, Equasym XL)
Methylphenidate (MPH)
• Titration• Can start with am dose, contrast am vs pm• Otherwise aim for 3-3.5 hr intervals
– 5,5,5 (2.5) (8.00, 11.30, 3.00, (5.00)– 10,10,5/10 – 15, 15, 15 (5-10)
• Or Concerta XL 18 then 36 etc. • or Equasym XL?
Dexamphetamine
• very slightly longer duration than MPH
• adverse effects generally trickier to handle
• euphoria and misuse more of a problem
• dose is half that for MPH (5mg=10 mg MPH)
• Adderall (dexamphetamine salts) is essentially the same
Atomoxetine
• non-stimulant (?) ADHD treatment
• blocks norepinephrine transporter, especially in frontal lobes
• no insomnia though some reduced weight gain with growth in first 12 months of use
• likely to be non-controlled
Depression
• 20% comorbid with ADHD• Psychotic symptoms more likely associated with mood disorders (but
weight gain and EPS more common in children)• High risk for Bipolar if
– Atypical symptoms (hypersomnia, severe fatigue, increased appetite/weight)
– Seasonal depressions– Hx of Sep/anx disorder– Hx ADHD– Fam hx– Hx of hypomania– Hard to know if ADHD or manic– 20% onset in late childhood and adolescence
Selective serotonin re-uptake inhibitors (SSRIs)
• May take 8-12 weeks to begin working, desipramine associated with heart and sudden death NE)
• fluoxetine• sertraline• paroxetine• citalopram• escitalopram• fluvoxamine
Selective serotonin re-uptake inhibitors (SSRIs)
• differ from each other mainly in adverse effects
• helpful in depression, anxiety, obsessive compulsive symptoms
• may help self-injurious behaviour in severe learning disability and autism
• a few children become silly and socially disinhibited
Imipramine
• useless antidepressant
• outclassed by desmopressin in enuresis
• not much good with anxiety
• moderately effective in ADHD
Clonidine• moderately useful in ADHD, especially
hyperactivity and hostility, can use in evening
• first line in Tourette’s disorder (but often ineffective)
• post-traumatic stress disorder• self-injurious behaviour in autism• sleep problems (though can produce
insomnia and nightmares in a few)
Clonidine
• start low, go slow
• monitor BP, pulse rate (and ECG?)
• warn parents not to stop abruptly
• drowsiness main problem, wears off after 10 days until ceiling at about 200-300 mcg daily
Sedative antihistamines
• widely used for sleep onset problems (diphenhydramine, promethazine, hydroxyzine,alimemazine/trimeprazine)
• unlikely to help child with anger or anxiety symptoms
Benzodiazepines
• rapid tranquillisation (lorazepam)
• panic attacks (alprazolam)
• may cause paradoxical excitement or dysphoria
• best used for brief periods only
Clomipramine
• tricyclic antidepressant with serotonin re-uptake blocking action
• powerful in OCD• difficulty with adverse effects
– constipation– dry mouth– blurred vision– postural hypotension
Risperidone
• reduces aggressive behaviour and rage
• reduces tics
• looks useful in ADHD symptoms in PDDs
• relatively low risk of extra-pyramidal effects but a few dribble
• weight gain a problem
Other antipsychotics
• haloperidol for tranquillisation and tics
• phenothiazines (chlorpromazine etc) for short-term tranquillisation, otherwise best avoided because of extra-pyramidal complications
• olanzapine increasingly popular but weight gain and sugar/fatty acid problems
Mood stabilisers
• mainly carbamazepine, valproate
• lithium less commonly because of – thyroid and renal problems – blood level monitoring needed
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