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Treatment of Children with Mental Disorders
From The National Institute of Mental Health
A booklet with answers to frequently asked questions
about the treatment of mental disorders in children — includes a medications
chart. (2004)
A Note to Parents
There has been public concern over reports that very
young children are being prescribed psychotropic medications. The studies to
date are incomplete, and much more needs to be learned about young children who
are treated with medications for all kinds of illnesses. In the field of mental
health, new studies are needed to tell us what the best treatments are for
children with emotional and behavioral disturbances.
Children are in a state of rapid change and growth during
their developmental years. Diagnosis and treatment of mental disorders must be
viewed with these changes in mind. While some problems are short-lived and
don’t need treatment, others are persistent and very serious, and parents
should seek professional help for their children.
Not long ago, it was thought that many brain disorders
such as anxiety disorders, depression, and bipolar disorder began only after
childhood. We now know they can begin in early childhood. An estimated 1 in 10
children and adolescents in the United States suffers from mental illness
severe enough to cause some level of impairment. Fewer than one in five of
these ill children receives treatment. Perhaps the most studied, diagnosed, and
treated childhood-onset mental disorder is attention deficit hyperactivity
disorder (ADHD), but even with this disorder there is a need for further
research in very young children.
This booklet contains answers to frequently asked
questions regarding the treatment of children with mental disorders.
Questions and Answers
Q: What should I do if I am concerned about mental, behavioral, or
emotional symptoms in my young child?
A: Talk to your child’s doctor. Ask questions and find
out everything you can about the behavior or symptoms that worry you. Every
child is different and even normal development varies from child to child.
Sensory processing, language, and motor skills are developing during early
childhood, as well as the ability to relate to parents and to socialize with
caregivers and other children. If your child is in daycare or preschool, ask
the caretaker or teacher if your child has been showing any worrisome changes
in behavior, and discuss this with your child’s doctor.
Q: How do I know if my child’s problems are serious?
A: Many everyday stresses cause changes in behavior. The
birth of a sibling may cause a child to temporarily act much younger. It is
important to recognize such behavior changes, but also to differentiate them
from signs of more serious problems. Problems deserve attention when they are
severe, persistent, and impact on daily activities. Seek help for your child if
you observe problems such as changes in appetite or sleep, social withdrawal,
or fearfulness; behavior that seems to slip back to an earlier phase such as
bed-wetting; signs of distress such as sadness or tearfulness; self-destructive
behavior such as head banging; or a tendency to have frequent injuries. In
addition, it is essential to review the development of your child, any
important medical problem he/she might have had, family history of mental
disorders, as well as physical and psychological traumas or situations that may
cause stress.
Q: Whom should I consult to help my child?
A: First, consult your child’s doctor. Ask for a complete
health examination of your child. Describe the behaviors that worry you. Ask
whether your child needs further evaluation by a specialist in child behavioral
problems. Such specialists may include psychiatrists, psychologists, social
workers, and behavioral therapists. Educators may also be needed to help your
child.
Q: How are mental disorders diagnosed in young children?
A: Similar to adults, disorders are diagnosed by
observing signs and symptoms. A skilled professional will consider these signs
and symptoms in the context of the child’s developmental level, social and
physical environment, and reports from parents and other caretakers or
teachers, and an assessment will be made according to criteria established by
experts. Very young children often cannot express their thoughts and feelings,
which makes diagnosis a challenging task. The signs of a mental disorder in a
young child may be quite different from those of an older child or an adult.
Q: Won’t my child get better with time?
A: Sometimes yes, but in other cases children need
professional help. Problems that are severe, persistent, and impact on daily
activities should be brought to the attention of the child’s doctor. Great care
should be taken to help a child who is suffering, because mental, behavioral,
or emotional disorders can affect the way the child grows up.
Q: Which mental disorders are seen in children?
A: Mental disorders with possible onset in childhood
include: anxiety disorders; attention deficit and disruptive behavior
disorders; autism and other pervasive developmental disorders; eating disorders
(e.g., anorexia nervosa); mood disorders (e.g., major depression, bipolar
disorder); schizophrenia; and tic disorders. Under some circumstances,
bed-wetting and soiling may be symptoms of a mental disorder.
Q: Are there situations in which it is advisable to use psychotropic
medications in young children?
A: Psychotropic medications may be prescribed for young
children with mental, behavioral, or emotional symptoms when the potential
benefits of treatment outweigh the risks. Some problems are so severe and
persistent that they would have serious negative consequences for the child if
untreated, and psychosocial interventions may not always be effective by
themselves. The safety and efficacy of most psychotropic medications have not
yet been studied in young children. As a parent, you will want to ask many
questions and evaluate with your doctor the risks of starting and continuing
your child on these medications. Learn everything you can about the medications
prescribed for your child, including potential side effects. Learn which side
effects are tolerable and which ones are threatening. In addition, learn and
keep in mind the goals of a particular treatment (e.g., change in specific
behaviors). Combining multiple psychotropic medications should be avoided in
very young children unless absolutely necessary.
Q: Does medication affect young children differently from older children or
adults?
A: Yes. Young children’s bodies handle medications
differently than older individuals and this has implications for dosage. The brains
of young children are in a state of very rapid development, and animal studies
have shown that the developing neurotransmitter systems can be very sensitive
to medications. A great deal of research is still needed to determine the
effects and benefits of medications in children of all ages. Yet it is
important to remember that serious untreated mental disorders themselves
negatively impact brain development.
Q: If my preschool child receives a diagnosis of a mental disorder, does
this mean that medications have to be used?
A: No. Psychotropic medications are not generally the
first option for a preschool child with a mental disorder. The first goal is to
understand the factors that may be contributing to the condition. The child’s
own physical and emotional state is key, but many other factors such as
parental stress or a changing family environment may influence the child’s
symptoms. Certain psychosocial treatments may be as effective as medication.
Q: How should medication be included in an overall treatment plan?
A: When medication is used, it should not be the only
strategy. There are other services that you may want to investigate for your
child. Family support services, educational classes, behavior management
techniques, as well as family therapy and other approaches should be
considered. If medication is prescribed, it should be monitored and evaluated
regularly.
Q: What medications are used for which kinds of childhood mental disorders?
A: There are several major categories of psychotropic
medications: stimulants, antidepressants, antianxiety agents, antipsychotics,
and mood stabilizers. For medications approved by the FDA for use in children,
dosages depend on body weight and age. The Medications Chart in this booklet shows the most
commonly prescribed medications for children with mood or anxiety disorders
(including OCD).
Stimulant
Medications
There are four stimulant medications that are approved
for use in the treatment of attention deficit hyperactivity disorder (ADHD),
the most common behavioral disorder of childhood. These medications have all
been extensively studied and are specifically labeled for pediatric use.
Children with ADHD exhibit such symptoms as short attention span, excessive
activity, and impulsivity that cause substantial impairment in functioning.
Stimulant medication should be prescribed only after a careful evaluation to
establish the diagnosis of ADHD and to rule out other disorders or conditions.
Medication treatment should be administered and monitored in the context of the
overall needs of the child and family, and consideration should be given to
combining it with behavioral therapy. If the child is of school age,
collaboration with teachers is essential.
Antidepressant
and Antianxiety Medications
These medications follow the stimulant medications in
prevalence among children and adolescents. They are used for depression, a
disorder recognized only in the last 20 years as a problem for children, and
for anxiety disorders, including obsessive-compulsive disorder (OCD). The
medications most widely prescribed for these disorders are the selective
serotonin reuptake inhibitors (the SSRIs).
In the human brain, there are many “neurotransmitters”
that affect the way we think, feel, and act. Three of these neurotransmitters
that antidepressants influence are serotonin, dopamine, and norepinephrine.
SSRIs affect mainly serotonin and have been found to be effective in treating
depression and anxiety without as many side effects as some older
antidepressants.
Antipsychotic
Medications
These medications are used to treat children with
schizophrenia, bipolar disorder, autism, Tourette’s syndrome, and severe
conduct disorders. Some of the older antipsychotic medications have specific
indications and dose guidelines for children. Some of the newer “atypical”
antipsychotics, which have fewer side effects, are also being used for
children. Such use requires close monitoring for side effects.
Mood Stabilizing
Medications
These medications are used to treat bipolar disorder
(manic-depressive illness). However, because there is very limited data on the
safety and efficacy of most mood stabilizers in youth, treatment of children
and adolescents is based mainly on experience with adults. The most typically
used mood stabilizers are lithium and valproate (Depakote®), which are often
very effective for controlling mania and preventing recurrences of manic and depressive
episodes in adults. Research on the effectiveness of these and other
medications in children and adolescents with bipolar disorder is ongoing. In
addition, studies are investigating various forms of psychotherapy, including
cognitive-behavioral therapy, to complement medication treatment for this
illness in young people.
Effective treatment depends on appropriate diagnosis of
bipolar disorder in children and adolescents. There is some evidence that using
antidepressant medication to treat depression in a person who has bipolar
disorder may induce manic symptoms if it is taken without a mood stabilizer. In
addition, using stimulant medications to treat co-occurring ADHD or ADHD-like
symptoms in a child with bipolar disorder may worsen manic symptoms. While it
can be hard to determine which young patients will become manic, there is a
greater likelihood among children and adolescents who have a family history of
bipolar disorder. If manic symptoms develop or markedly worsen during
antidepressant or stimulant use, a physician should be consulted immediately,
and diagnosis and treatment for bipolar disorder should be considered.
Q: What difference does it make if a medication is specifically approved
for use in children or not?
A: Approval of a medication by the FDA means that
adequate data have been provided to the FDA by the drug manufacturer to show
safety and efficacy for a particular therapy in a particular population. Based
on the data, a label indication for the drug is established that includes proper
dosage, potential side effects, and approved age. Doctors prescribe medications
as they feel appropriate even if those uses are not included in the labeling.
Although in some cases there is extensive clinical experience in using
medications for children or adolescents, in many cases there is not. Everyone
agrees that more studies in children are needed if we are to know the
appropriate dosages, how a drug works in children, and what effects there are
on learning and development.
Q: What does “off-label” use of a medication mean?
A: Many medications that are on the market have not been
officially approved by the FDA for use in children. Treatment of children with
these medications is called “off-label” use. For some medications, the
off-label use is supported by data from well-conducted studies in children. For
instance, some antidepressant medications have been shown to be effective in
children and adolescents with depression. For other medications, there are no
controlled studies in children, but only isolated clinical reports. In
particular, the use of psychotropic medications in preschoolers has not been
adequately studied and must be considered very carefully by balancing severity
of symptoms, degree of impairment, and potential benefits and risks of
treatment.
Q: Why haven’t many medications been tested in children?
A: In the past, medications were not studied in children
because of ethical concerns about involving children in clinical trials.
However, this created a new problem: lack of knowledge about the best
treatments for children. In clinical settings where children are suffering from
mental or behavioral disorders, medications are being prescribed at
increasingly early ages. The FDA has been urging that products be appropriately
studied in children and has offered incentives to drug manufacturers to carry
out such testing. The NIH and the FDA are examining the issue of medication
research in children and are developing new research approaches.
Q: Does the FDA approve medications for different age groups among
children?
A: Yes. However, this is based on the data provided to
the FDA by the drug manufacturer and the policies in effect at the time of
approval. For example, Ritalin® is approved for children age 6 and older,
whereas Dexedrine® is approved for children as young as 3. When Ritalin® was
tested for efficacy by its manufacturer, only children age 6 and above were
involved; therefore, age 6 was approved as the lower age limit for Ritalin®.
Q: Can events such as a death in the family, illness in a parent, onset of
poverty, or divorce cause symptoms?
A: Yes. When a tragedy occurs or some extreme stress
hits, every member of a family is affected, even the youngest ones. This should
also be considered when evaluating mental, emotional, or behavioral symptoms in
a child.
Medications Chart
|
Type of Medication |
Brand Name |
Generic Name |
Approved Age |
|
Stimulant Medications |
Adderall |
amphetamines |
3 and older |
|
Concerta |
methylphenidate |
6 and older |
|
|
Cylert* |
pemoline |
6 and older |
|
|
Dexedrine |
dextroamphetamine |
3 and older |
|
|
Dextrostat |
dextroamphetamine |
3 and older |
|
|
Ritalin |
methylphenidate |
6 and older |
|
|
Antidepressant and Antianxiety Medications |
Anafranil |
clomipramine |
10 and older (for OCD) |
|
BuSpar |
buspirone |
18 and older |
|
|
Effexor |
venlafaxine |
18 and older |
|
|
Luvox (SSRI) |
fluvoxamine |
8 and older (for OCD) |
|
|
Paxil (SSRI) |
paroxetine |
18 and older |
|
|
Prozac (SSRI) |
fluoxetine |
18 and older |
|
|
Serzone (SSRI) |
nefazodone |
18 and older |
|
|
Sinequan |
doxepin |
12 and older |
|
|
Tofranil |
imipramine |
6 and older (for bed-wetting) |
|
|
Wellbutrin |
bupropion |
18 and older |
|
|
Zoloft (SSRI) |
sertraline |
6 and older (for OCD) |
|
|
Antipsychotic Medications |
Clozaril(atypical) |
clozapine |
18 and older |
|
Haldol |
haloperidol |
3 and older |
|
|
Risperdal (atypical) |
risperidone |
5 to 16 years (for irritability associated
with autistic disorder); 18 and older (for schizophrenia and bipolar mania) |
|
|
Seroquel (atypical) |
quetiapine |
18 and older |
|
|
(Generic Only) |
thioridazine |
2 and older |
|
|
Zyprexa (atypical) |
olanzapine |
18 and older |
|
|
Orap |
pimozide |
12 and older (for Tourette’s syndrome). |
|
|
Mood Stabilizing Medications |
Cibalith-S |
lithium citrate |
12 and older |
|
Depakote |
divalproex sodium |
2 and older (for seizures) |
|
|
Eskalith |
lithium carbonate |
12 and older |
|
|
Lithobid |
lithium carbonate |
12 and older |
|
|
Tegretol |
carbamazepine |
any age (for seizures) |
*Because of its potential for serious side effects
affecting the liver, Cylert should not ordinarily be considered as first line
drug therapy for ADHD.
References
1. Burns BJ, Costello EJ, Angold A, Tweed D, Stangl D,
Farmer EM, Erkanli A. Data Watch: children’s mental health service use across
service sectors. Health Affairs, 1995; 14(3): 147-59.
2. Coyle JT. Psychotropic drug use in very young children
[editorial]. Journal of the American Medical Association, 2000;
283(8): 1059-60.
3. Physician’s Desk Reference (PDR).
Montvale, NJ: Medical Economics Company, 1999.
4. Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini
J, Schwab-Stone ME, Lahey BB, Bourdon K, Jensen PS, Bird HR, Canino G, Regier
DA. The NIMH diagnostic interview schedule for children version 2.3 (DISC 2.3):
description, acceptability, prevalence, rates, and performance in the MECA
study. Journal of the Academy of Child and Adolescent Psychiatry,
1996; 35(7): 865-77.
5. Zito JM, Safer DJ, dosReis S, Gardner JF, Botes M,
Lynch F. Trends in the prescribing of psychotropic medications to preschoolers.
Journal of the American Medical Association, 2000; 283(8):
1025-30.
John
Kaighn is a Registered Investment Advisor with Jersey Benefits Advisors and
writes articles on various business and investment information, ideas and
opportunities. For more information
about this and other topics you can visit http://www.johnkaighn.com/and http://www.jerseybenefits.com/
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