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Pediatricians as Primary Mental Health
Professionals5 Essential Drugs
Dr. M.K.C.NairDirector, Child Development CentreMedical College, Tvpm
Dr. Paul RussellProfessor &Head
Child & Adol. Psychiatry Division
Christian Medical College, Vellore
Treatment modality as Treatment modality as recommended recommended
by WHO or based on evidenceby WHO or based on evidenceMedication CBT Family therapy
LDa - - -
ADHDa yes yes -
Ticsa yes yes yes
Depressiona yes yes yes
Psychosesa yes - yes
Schizophreniaa yes - yes
Autismb yes - -
Anxietyb yes yes yes
Conduct disorderb yes yes yes
Substance abuseb yes - yes
Eating Disordersb yes yes yes
Attachment disordersb
- - yes
4
Hierarchy of Diagnosis & Hierarchy of Diagnosis & TreatmentTreatment
Organic brain syndromes
Psychoses/ Pervasive Dev.l Disroders
Mood disorders / ADHD
Anxiety disorders
Tic / Enuresis / Conduct Disorder
Medication: Antipsychotic
Org.Brain Syndromes
Dose
1st-line drug Risperidone (Atypical antipsychotic) 0.25-1mg/day
2nd-line drug Haloperidol (Typical antipsychotic) 0.25-1mg/day
Organic Brain SyndromesOrganic Brain Syndromes
H/O: Temporal correlation with a
demonstrable general medical condition,
CNS pathology, drugs and medication
MSE: attention, orientation, memory
impaired.
PsychosisPsychosis
Psychoses Dose
1st-line drug Risperidone (Atypical antipsychotic) 2-4mg/day
2nd-line drug Haloperidol (Typical antipsychotic) 0.03 – 0.08mg/kg/day
1.Hallucinations
2.Delusions
3.Catatonic
symptoms
4.First Rank
Symptoms
Medication: Antipsychotic
AutismAutism
Symptoms
Hyperactivity, impulsiveness, inattention – Atypical antipsychotic
Rigidity, rituals – Atypical antipsychotic
Aggression, self injury – Atypical antipsychotic
Anxiety, Affective symptoms – Atypical antipsychotic
Review of 19 articles (Barnard et al, J Psychopharmacol 2002)
1. Deviant/ delayed social interaction
2. Deviant/ delayed communication
3. Restricted-repetitive behaviour
Medication: Atypical antipsychotic - Risperidone: Dose: 0.25 – 2mg/day
Mood disorders - Medication of Mood disorders - Medication of choicechoice
Depressive episode1.Mood2. Behaviour3. Cognition4. Biological symptoms
o Worthlessnesso Hopelessnesso Helplessnesso Suicidal ideation
(Antidepressant - Fluoxetine (10-20mg/day)
Bipolar & Hypermania (Mood stabilizer & Antipsychotic)
Pediatrician: Valproate Na (20-30mg/Kg) / Carbamazepine (8-12 mg/L)
Psychiatrist: Lithium ± AP (0.6-1mmol/L)
9
Attention Deficit Hyperactivity Attention Deficit Hyperactivity DisorderDisorder
Medication Line of choice Dose Dosing schedule
CNS stimulants
Methylphenidate 1St line 1mg/kg/day Twice /thrice daily
SNARI (Serotonin NorAdrenergic Reuptake Inhibitor )
Atomoxetine
2nd line/ 1st? 1.2 -1.8mg/kg/day Once/twice daily
6 symptoms of attention deficit
6 symptoms of hyperactivity/impulsivity
2 settings
6 months
<7 years
Medication: CNS stimulants / SNARI
Symptom to Disorder Symptom to Disorder Transition Transition
1. Symptoms out of proportion to cause
2. Definite body symptom (eg. Depression:
Eating, sleeping, libido affected)
3. Impairment of functions
1.Irrational
fear
2.Avoidance
Anxiety DisordersAnxiety Disorders
1.Phobic anxiety disorder
2.Overanxiety disorder of
childhood
3.Seperation anxiety disorder
4.Obssesive compulsive disorder
5.Post-traumatic stress disorder
Medication: Antianxiety
1.Obsessions
2. Compulsions
1.Catastrophic trauma
2.Intrusive recollection
3.Autonomic arousal
4.Avoidance
1. Obsessive compulsive disorder
2. Post-traumatic stress disorder (PTSD)
Disorder 1st-line drug
Dose
OCD
Fluoxetine 10-40mg/day
PTSD
Generalized anxiety disorder (GAD)
Phobia
Medication: Antianxiety drugs
Conduct DisorderConduct Disorder
Dissocial
Defiant
Aggressive
Conduct Disorder Dose
1st-line drug Carbamazepine 8-12 mg/L
2nd-line drug Risperidone 1-2mg/day
Medication: Mood stabiliser
14
Tic DisorderTic Disorder
Tic Disorder
Dose
1st-line drug Risperidone (Atypical antipsychotic)
Haloperidol (Typical antipsychotic)
0.25.-2mg/day
0.2-2mg/day
2nd-line drug Fluoxetine 10-20mg/day
Motor
Vocal
Combined
Medication: Atypical antipsychotic
EnuresisEnuresis
Involuntary voiding
> 4 yrs CA
Enuresis Dose
1st-line drug Imipramine 0.3mg/kg/day
2nd-line drug Desmopressin 20-40g/I.nasal
Medication: TCA
ConclusionConclusionMedicationMedication DisorderDisorder Dose/DayDose/Day Dosing/DayDosing/Day EvidenceEvidence
1 Risperidone Org.Brain Syndromes 0.25-1mg OD-TID Level IIa
Risperidone Psychoses 2 - 4mg OD-TID Level Ib
Risperidone Autism 0.25 – 1 mg OD-BD Level Ia
Risperidone Tic 0.25 - 2mg OD (dinner) Level Ib
Risperidone ± Valproate Na
Mania 2-4mg20mg/kg
OD-TIDOD (dinner)
Level IIa
2 Valproate Na Conduct disorder 20mg/kg OD (dinner) Level Ib
3 Fluoxetine Depression 10-20 mg OD (breakfast) Level Ia
Fluoxetine Anxiety disorder (OCD, PTSD, GAD, Phobia)
10-40 mg OD (breakfast) Level Ib
4 Atomoxetine ADHD 1.2 - 1.8mg/kg OD-BD (break fast, lunch)
Level Ia
5 Imipramine Enuresis 0.3mg/kg/BW OD (dinner) Level Ia