Children, Mental Illness and Medications

Psychiatry On Call
California Psychiatric Association

In the US, one in five children and adolescents suffer from mental illness at any given time. Most do not get the help they need. If left untreated, these children have increased risks of school failure and drop out, drug abuse, and many other difficulties, many of which can be prevented or greatly lessened by timely evaluation and appropriate treatment. A key is for parents to recognize the problem and seek appropriate diagnosis and treatment. As with other  illnesses, mental disorders have specific diagnostic criteria and treatment options. A complete evaluation by a child psychiatrist is important. Below, please find an overview of the medications most commonly used to treat childhood mental disorders as part of a comprehensive treatment plan.

Diagnosis

Medications...should be used as part of a comprehensive treatment plan. Diagnosis must precede prescription of medications.  It is based on a collaborative process that should involve psychiatric and other physicians, the child, the child's family, and school-based or other appropriate clinicians. Assessment is designed to reach a comprehensive diagnosis after a thorough evaluation of psychiatric, social, cognitive, educational, and  medical/neurological factors.

Treatment

Following diagnosis, psychiatrists develop a comprehensive treatment plan that encompasses relevant aspects of a child's life, taking into account coexisting medical conditions, the child's needs, and family and child preferences. For optimal outcomes, an informed, multi-modal therapy specifically designed by a child (pediatric) psychiatrist for a specific child is the most appropriate. Potential elements include family and school consultation, medication, and various forms of therapy, such as cognitive-behavior therapy, psychotherapy, parental and family therapy, social skills training, & group therapy.

Medications, prescribed by a psychiatrist or other well-trained physician, should not automatically be the first choice in treatment, but should be used as part of a comprehensive treatment plan when their benefits outweigh the risk.

Extensive information regarding the complete range of treatment options is available from the American Psychiatric Association.

Review of Medications

Stimulants

Stimulants, including Ritalin, Adderall, & Concerta, are by far the most widely researched and commonly prescribed treatments for children with Attention-deficit/ hyperactivity disorder (ADHD). They diminish motor overactivity and impulsive behaviors seen in ADHD and allow the child to sustain attention and improve physical coordination. Stimulants can cause an immediate and often dramatic improvement in behavior, cognition and judgment, both at school and at home. In general, stimulants are regarded as an effective ADHD therapy with high safety. Side effects are usually mild, short-term, dose-related and subject to individual differences.

There has been some public concern about whether children taking stimulants for ADHD are at increased risk for substance abuse. A 1999 study suggests the opposite, that such medications may protect children with ADHD from future substance abuse.

Antidepressant and Antianxiety Medications

Depression tends to run in families. At least one study shows that more than 25% of depressed children have a close relative with the disease. Early onset may predict more severe illness in adult life, unless recognized and treated early in life. Depression in children is often an underlying factor in decreased school performance, eating disorders, headaches, sleep problems and other physical problems. There are many varieties of antidepressants on the market.  The Serotonin Reuptake Inhibitors (SSRIs) such as Prozac, Zoloft, Paxil, Celexa, & Luvox; the Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) such as Effexor, Cymbalta, & Fetzima; and other antidepressants such as Wellbutrin are the most commonly prescribed. These agents appear safe and effective for the treatment of severe and persistent depression. Wellbutrin is also used to treat ADHD.

Children can also experience anxiety disorders, such as obsessive-compulsive disorders (OCD) and panic attacks. For example, children can experience panic disorder and agoraphobia (eg., extreme  fear of leaving one’s home). Children with anxiety disorders are most frequently treated with SSRIs and psychotherapy. Other agents used to treat anxiety disorders include BuSpar and propranolol.

Medications for Bipolar Disorder

Bipolar disorder (also known as “manic-depression”) was until recently thought to begin only in the late teens or early adulthood.  However, recent studies reveal that this illness can occur in younger children. Bipolar disorder is a neurobiological brain disorder characterized by severe fluctuations in mood and activity level. It can present with symptoms similar to ADHD. Since the treatments used for bipolar disorder and ADHD are quite different, a comprehensive and thorough diagnostic evaluation is needed. Research suggests that a genetic predisposition to bipolar disorder can be inherited. Mood stabilizers such as Depakote, Tegretol,  lithium, and numerous newer agents appear to be helpful, along with various forms of school accommodations and psychotherapy for  the child, multi-family psycho-education groups for the child and family, and peer support for parents.

Antipsychotics

Antipsychotic medications have been used to treat childhood psychotic disorders and to control agitation, aggression, and self-injurious behaviors in children with developmental disabilities and pervasive developmental disorders (autism and autism-like disorders).

The principal psychotic illness that affects children is schizophrenia, which may be chronic and disabling. Typically, schizophrenia emerges in adolescence or early adulthood, although  research studies are revealing that cognitive and social impairments may be evident earlier in children, and although it may appear in childhood, it can be successfully treated. There are a number of antipsychotic medications available, including Abilify, Geodon, Risperdal, Seroquel, and Zyprexa. They generally yield comparable results. The main differences are in the potency, the dosage (amount) prescribed to produce beneficial effects, and the side effects. Older antipsychotics such as Haldol or Thorazine are used infrequently.

Other Medications

Clonidine is used to treat ADHD, anxiety disorders, sleep disturbances, Tourette's syndrome and other tic disorders. Tenex also appears to have beneficial effects on hyperactive behaviors, attention abilities, anxiety and tic disorders, and may be less sedating. Strattera is used to treat ADHD.

Off Label Use

Physicians may legally prescribe medications in ways not specifically approved by the Food & Drug Administration. In fact, it is standard practice for physicians to do so, taking into account new research findings, clinical experience, and the child's needs. Prescription for "off-label” purposes of any medication should be made only after a comprehensive evaluation has been made and other forms of therapy (or combination of) have been considered, and must be monitored closely.

Conclusion

The American and California Psychiatric Associations share the desire of the National Institute of Mental Health to ensure the appropriate treatment of mental illnesses in children. Medications must be prescribed judiciously as part of a comprehensive treatment plan and only after a thorough evaluation by qualified medical personnel. More funding is needed for mental health services for children, and for further research to understand the causes of illness and to develop more effective treatments for children.

Source: Adapted and updated May 26, 2015, from a fact sheet from the American Psychiatric Association (APA) March, 2000. For the complete fact sheet, with bibliography, consult the APA’s web site, www.psych.org <https://www.psych.org/>.

Other useful web sites:

• American Academy of Child and Adolescent Psychiatry
• National Institutes of Mental Health
• U.S. Surgeon General
• American Academy of Pediatrics

The purpose of this newsletter is to provide brief information on developments and questions in the medical specialty of psychiatry that can contribute to high-quality, cost-effective health care.

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