Psychopharmacology in child and adolescent psychiatry: a review of the past five years

Biomarkers for attention-deficit/hyperactivity disorder (ADHD). A consensus report of the WFSBP task force on biological markers and the World Federation of ADHD

OBJECTIVE

Psychiatric "nosology" is largely based on clinical phenomenology using convention-based diagnostic systems not necessarily reflecting neurobiological pathomechanisms. While progress has been made regarding its molecular biology and neuropathology, the phenotypic characterization of ADHD has not improved. Thus, validated biomarkers, more directly linked to the underlying pathology, could constitute an objective measure for the condition.

METHOD

The task force on biological markers of the World Federation of Societies of Biological Psychiatry (WFSBP) and the World Federation of ADHD commissioned this paper to develop a consensus report on potential biomarkers of ADHD. The criteria for biomarker-candidate evaluation were: (1) sensitivity >80%, (2) specificity >80%, (3) the candidate is reliable, reproducible, inexpensive, non-invasive, easy to use, and (4) confirmed by at least two independent studies in peer-reviewed journals conducted by qualified investigators.

RESULTS

No reliable ADHD biomarker has been described to date, but some promising candidates (e.g., olfactory sensitivity, substantial echogenicity) exist. A problem in the development of ADHD markers is sample heterogeneity due to aetiological and phenotypic complexity and age-dependent co-morbidities.

CONCLUSIONS

Most likely, no single ADHD biomarker can be identified. However, the use of a combination of markers may help to reduce heterogeneity and to identify homogeneous subtypes of ADHD.

Clinical drug monitoring in child and adolescent psychiatry: side effects of atypical neuroleptics

OBJECTIVE

The aim of this study was to improve and evaluate the practibility of a method for the assessment of drug-associated side effects, and we implemented a clinical drug monitoring for atypical neuroleptics.

METHODS

Side effects of initially hospitalized patients treated with clozapine (n = 16), olanzapine (n = 16), and risperidone (n = 19) were prospectively monitored on a weekly basis for the first 3 weeks. In the case of stable medication, measurements of all variables were made every 4 weeks or upon discharge. We used the Dosage Record Treatment Emergent Symptom Scale (DOTES) in a supplemented version to measure the presence and severity of side effects.

RESULTS

Drowsiness and decreased motor activity were common, especially in the first 2 weeks. Orthostatic hypotension, increased salivation, constipation, and nasal congestion were seen in more than 30% to 60% of patients treated with clozapine and were less common in adolescents treated with olanzapine and risperidone. Rigidity, tremor, and dystonia were seen in 5% to 15% of patients treated with risperidone and olanzapine. The average weight gain after 6 weeks of treatment with the atypical neuroleptics was significantly higher for the olanzapine group (4.6 +/- 1.9 kg) than for the risperidone (2.8 +/- 1.3 kg) and clozapine (2.5 +/- 2.9 kg) groups.

CONCLUSIONS

The authors' supplemented DOTES version is generally applicable to clinical use in mental health centers. The differences among the side effects of these three agents may affect compliance with medication and medical risks of metabolic syndrome, diabetes, and cardiovascular disease. More research on the short- and long-term safety of psychotropic drugs in children and adolescents, using standardized methods, should be considered.

Changes in urinary monoamine excretion in hyperkinetic children

The pathogenetic mechanisms of hyperkinetic syndrome are not clear and need further investigation. The aim of the study was to find certain features of monoamine metabolism that are characteristic of children with hyperkinetic syndrome (HKS) with special regard to different degrees of severity (i.e. mild HKS and severe HKS ). The levels of L-dopa, dopamine, noradrenaline, adrenaline, homovanillic, vanillylmandelic and 5-hydroxyindoleacetic acids were measured in daily urine of children (7-11 years old) with mild and severe HKS using fluorimetric and chromatographic methods. Severe HKS was characterized by a significant increase of L-dopa (by 186%), dopamine (by 201%) and adrenaline (by 160%) excretion but an unchanged excretion of noradrenaline compared with those with mild HKS. The study revealed principle differences in monoamine metabolism between the mild and severe forms of HKS which may be of importance in deciding different pharmacotherapeutic approaches to use in patients with HKS of differing severity.

Tricyclic drugs for depression in children and adolescents

BACKGROUND

There is a need to identify effective and safe treatments for depression in children and adolescents. While tricyclic drugs are effective in treating depression in adults, individual studies involving children and adolescents have been equivocal.

OBJECTIVES

To assess the effects of oral tricyclic antidepressants compared to placebo in the treatment of child and adolescent depression.

SEARCH STRATEGY

We searched MEDLINE (1966-1997), EMBASE, Excerpta Medica (June 1974-1997), the Cochrane Collaboration Depression, Anxiety and Neurosis Group trials register (most recent search 25/1/2000) and bibliographies of previously published reviews and papers describing original research were cross-checked. Current Contents was screened for recent publications. We contacted authors of relevant abstracts in conference proceedings of the American Academy of Child and Adolescent Psychiatry, and we hand searched the Journal of the American Academy of Child and Adolescent Psychiatry (1978-1999).

SELECTION CRITERIA

Randomised controlled trials comparing the efficacy of orally administered tricyclic medication with placebo in depressed people aged 6-18 years.

DATA COLLECTION AND ANALYSIS

Most studies reported multiple outcome measures including depression scales and clinical global impression scales. For each study the best available depression measure was taken as the index measure of depression outcome. Predetermined criteria were established to assist in the ranking of measures. Where authors reported categorical outcomes we calculated individual and pooled odds ratios for the odds of improvement in treated compared with control subjects. For continuous outcomes pooled effect sizes were calculated as the number of standard deviations by which the change in depression scores for the treatment group exceeded those for the control groups.

MAIN RESULTS

Thirteen trials (involving 506 participants) were included. No overall improvement with treatment compared to placebo was seen for children or adolescents (odds ratio = 0.84, 95% confidence interval 0.56 to 1.25). A statistically significant but small benefit of treatment over placebo was seen in reducing symptoms (effect size (standardised mean difference) = -0.31, 95% confidence interval -0.62 to -0.01). Subgroup analyses suggest a larger benefit among adolescents (effect size = -0.47, 95% confidence interval -0.92 to -0.02), and no benefit among children (effect size = 0.15, 95% confidence interval -0.34 to 0.64). Treatment with a tricyclic antidepressant caused more vertigo (odds ratio = 4.38, 95% confidence interval 2.33 to 8.25), orthostatic hypotension (odds ratio = 6.78, 95% confidence interval 2.06 to 22.26), tremor (odds ratio 6.29, 95% confidence interval 1.78 to 22.17) and dry mouth (odds ratio = 5.17, 95% confidence interval 2.68 to 29.99) than did placebo, but no statistically significant difference was found for other possible adverse effects.

REVIEWER'S CONCLUSIONS

Data suggest tricyclic antidepressants are not useful in treating depression in pre pubertal children. There is marginal evidence to support the use of tricyclic antidepressants in the treatment of depression in adolescents, although the magnitude of effect is likely to be moderate at best.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs. These parameters were previously published in J. Am. Acad. Child Adolesc. Psychiatry, 1994, 33:616-635.

Outcomes of mental health care for children and adolescents: II. Literature review and application of a comprehensive model

OBJECTIVE

Using a comprehensive model of outcomes, the authors review the scientific literature to determine the extent of knowledge concerning the outcomes of mental health care for children and adolescents.

METHOD

Previous research is examined to determine the degree to which it addresses five salient outcome domains: symptoms/diagnoses, functioning, consumer perspectives, environments, and systems (the SFCES model).

RESULTS

Despite numerous studies, only 38 met minimal scientific criteria. They generally fall into two categories, according either to their focus on the efficacy of treatment(s) for specific disorders or the effectiveness of a particular service or service system. Only two studies include outcome assessments across all five domains.

CONCLUSIONS

As health care practices shift, improvements in mental health care will require credible evidence detailing the impact of clinical treatments and services on all salient outcome domains. Embedding efficacious treatments into effective service programs will likely improve care, but treatments will require modification to make them flexible, inclusive, and appropriate to multicultural populations. Furthermore, service delivery systems must be modified to meet the specific clinical needs of children with mental disorders and to embrace new efficacious treatments as they become available.

Brief report: circadian melatonin, thyroid-stimulating hormone, prolactin, and cortisol levels in serum of young adults with autism

An abnormal circadian pattern of melatonin was found in a group of young adults with an extreme autism syndrome. Although not out of phase, the serum melatonin levels differed from normal in amplitude and mesor. Marginal changes in diurnal rhythms of serum TSH and possibly prolactin were also recorded. Subjects with seizures tended to have an abnormal pattern of melatonin correlated with EEG changes. In others, a parallel was evidenced between thyroid function and impairment in verbal communication. There appears to be a tendency for various types of neuroendocrinological abnormalities in autistics, and melatonin, as well as possibly TSH and perhaps prolactin, could serve as biochemical variables of the biological parameters of the disease.

Psychopharmacology in child and adolescent psychiatry: a review of the past seven years. Part II

OBJECTIVE

To present a critical overview of the selected literature published in the past 7 years on the efficacy and safety of psychoactive agents in conduct disorder, schizophrenia, separation anxiety disorder, selective mutism, obsessive-compulsive disorder, panic disorder, major depressive disorder, bipolar disorder, and sleep and eating disorders.

METHOD

Reports of double-blind and placebo-controlled trials and open studies were reviewed and selected studies presented.

RESULTS

Employment of larger samples of diagnostically homogeneous patients and a more sophisticated design and methodology led to progress in the treatment of most of these conditions. Data have been accumulated on dose range and safety of lithium in this age group, and there is supportive evidence that lithium is useful in reducing aggression.

CONCLUSIONS

For a rational treatment approach, further studies are needed, particularly in depression and conduct disorder; psychosocial-environment contributions and possible biological markers should be investigated in order to identify children who require psychopharmacological treatments and those who will respond to psychosocial interventions or the combination of both. Symptoms targeted to require pharmacotherapy and symptoms targeted to respond to psychosocial interventions have to be identified.

Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis

OBJECTIVE

To examine whether tricyclic antidepressants are superior to placebo in the treatment of child and adolescent depression.

DESIGN

Meta-analysis of 12 randomised controlled trials comparing the efficacy of tricyclic antidepressants with placebo in depressed subjects aged 6-18 years.

MAIN OUTCOME MEASURES

Most studies employed several depression rating scales. For each study the "best available" measure was chosen by using objective criteria, and individual and pooled effect sizes were calculated as the number of standard deviations by which the change scores for the treatment groups exceeded those for the control groups. Where authors had reported numbers "responding" to treatment we calculated individual and pooled ratios for the odds of improvement in treated compared with control subjects.

RESULTS

From the six studies presenting data which enabled an estimation of effect size the pooled effect size was 0.35 standard deviations (95% confidence interval of -0.16 to 0.86) indicating no significant benefit of treatment. From the five studies presenting data on the number of "responders" in each group, the ratio of the odds of a response in the treated compared with the control subjects was calculated and the pooled odds ratio was 1.08 (95% confidence interval of 0.53 to 2.17); again indicating no significant benefit of treatment. The pooled sample had more than an 80% chance of detecting a treatment effect of 0.5 standard deviations or greater. There was an inverse relation between study quality and estimated treatment effect.

CONCLUSIONS

Tricyclic antidepressants appear to be no more effective than placebo in the treatment of depression in children and adolescents.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs.

Modification of interpersonal psychotherapy with depressed adolescents (IPT-A): phase I and II studies

OBJECTIVE

To test the acceptability and efficacy of interpersonal psychotherapy for depressed adolescents (IPT-A).

METHOD

In phase I, therapeutic methods were explored and refined in a small sample of depressed adolescents (n = 5). In phase II, 14 depressed adolescents entered a 12-week open clinical trial of IPT-A; after independent evaluation. Subjects were assessed using a semistructured diagnostic interview, self-report, and clinician-administered instruments, at six time points: evaluation week, and weeks 0, 2, 4, 8, and 12.

RESULTS

In phase I, treatment was modified to meet the needs of an adolescent population and was standardized in a treatment manual. The results of phase II indicated a significant decrease in adolescents' depressive symptomatology and symptoms of psychological and physical distress, as well as a significant improvement in functioning over the course of treatment. At termination, none of the subjects met DSM-III-R criteria for any depressive disorder.

CONCLUSIONS

IPT-A appears to be a promising therapy for depressed adolescents. However, because of the limitations of the current study, a larger randomized controlled clinical trial is still needed to test its efficacy.

An open trial of clozapine in 11 adolescents with childhood-onset schizophrenia

OBJECTIVE

To review the response of 11 adolescents with childhood-onset schizophrenia to a 6-week open clozapine trial.

METHOD

Eleven children meeting DSM-III-R criteria for schizophrenia had a 6-week open trial of clozapine (mean sixth week daily dose 370 mg). Behavioral ratings included the Brief Psychiatric Rating Scale and Children's Global Assessment Scale.

RESULTS

More than half showed marked improvement in Brief Psychiatric Rating Scale ratings by 6 weeks of clozapine therapy compared to admission drug rating and compared to a systematic 6-week trial of haloperidol.

CONCLUSIONS

This open trial indicates that clozapine may be a promising treatment for children and adolescents with schizophrenia who do not respond well to typical neuroleptics. A double-blind placebo-controlled study is ongoing.

The role of psychopharmacology on an acute adolescent inpatient unit

This paper is a brief overview of the various pharmacological interventions useful in the acute inpatient treatment of a variety of adolescent disorders of an affective, psychotic, attentional, aggressive and/or post-traumatic nature. Clinical indications, side effects, and management issues are discussed along with numerous vignettes which demonstrate adolescent response to such interventions.

A preliminary trial of ascorbic acid as supplemental therapy for autism

1. This study presents the results of a 30-week double-blind, placebo-controlled trial exploring the effectiveness of ascorbic acid (8g/70kg/day) as a supplemental pharmacological treatment for autistic children in residential treatment. 2. Residential school children (N = 18) were randomly assigned to either ascorbate-ascorbate-placebo treatment order group or ascorbate-placebo-ascorbate treatment order group. Each treatment phase lasted 10 weeks and behaviors were rated weekly using the Ritvo-Freeman scale. 3. Significant group by phase interactions were found for total scores and also sensory motor scores indicating a reduction in symptom severity associated with the ascorbic acid treatment. 4. These results were consistent with a hypothesized dopaminergic mechanism of action of ascorbic acid.

Child and adult psychiatry: comparison and contrast

Since its development from general psychiatry, child psychiatry has been influenced by its close involvements with the child guidance movement and pediatrics and by the age of its patient population. This has led it to evolve in ways quite distinct from adult psychiatry, so much so that at times the understanding and relationship between the two disciplines has been somewhat strained. This paper relates the development of child psychiatry to its history, its tasks and its patient population, highlighting some of the major differences between child and adult psychiatry. It then looks at why research in child psychiatry has lagged behind research in adult psychiatry. It concludes by discussing tensions between the two disciplines, and why it serves the interests of both professions as well as those of our patients, that a better understanding and collaboration between them be established.

Child psychiatry and early intervention: II. The internalizing disorders

This paper uses the concepts introduced in the paper Child Psychiatry and Early Intervention: I. The Aggregate Burden of Suffering to review the internalizing disorders of childhood. This review surveys the internalizing disorders from the point of view of early intervention, for their prevalence, course, risk, early indicators, associated impairment, and responses to intervention. In general, the internalizing disorders have little effect on the community. When coupled with other disorders such as conduct disorder, or when dealing with suicide, the community's concern for these disorders increases and allocation of resources to target populations who are at risk becomes an important public health goal.

Predictors of length of stay of psychiatric adolescent inpatients

This study reviewed 158 consecutive admissions to an inpatient adolescent psychiatric service for factors that determine length of hospitalization. Variables associated with length of stay included diagnostic category and the treatment variables of number and type of psychotropic medications prescribed. Patients with disruptive behavior disorders had the shortest hospitalizations, those with anxiety and affective disorders had stays of intermediate length, and patients with psychotic/organic disorders had the longest hospitalizations. Treatment with lithium, neuroleptics, or tricyclic antidepressants was associated with longer stays. Demographic variables and variables describing the social and family situation or level of dangerousness were not significantly associated with length of hospitalization.

Assessing psychotropic medication side effects among children. A reliability study

The Dosage Record Treatment Emergent Symptom Scale (DOTES) is a rating scale for measuring the presence and intensity of psychotropic medication side effects. Studies to evaluate its reliability have not been published. The purposes of this pilot study are to (1) develop a protocol for training raters to use the DOTES, (2) assess inter-rater agreement, 3) examine the reasons for disagreement among raters to clarify training procedures and symptom definitions, and (4) further refine this instrument for use in clinical and research settings. Five nurses were trained to use the DOTES to rate the absence or presence and intensity of specific medication side effects. After training, Raters 1, 2, and 3 watched a videotape of a nurse interviewing a 13-year-old child and completed the DOTES rating scale. There was agreement on the intensities of 6 (67%) of the 9 symptoms identified as present and agreement on 17 (89%) of the 19 symptoms identified as absent. Process tracings were conducted on the ratings of Nurses 4 and 5 to elicit the criteria they used to determine their ratings. The results of the process tracings were used to identify ambiguities that led to disagreement among raters so that the training protocol and interview could be improved.

Interpersonal psychotherapy for adolescent depression: description of modification and preliminary application

Interpersonal psychotherapy (IPT) is a brief treatment developed and tested specifically for depressed adults. This paper describes a modification for use with depressed adolescents (IPT-A) that will be tested in a controlled clinical trial. A description of IPT, its efficacy in adults, a rationale for developing IPT-A, and preliminary experience with depressed adolescents treated with IPT-A are presented. Data available on the treatment of depressed adolescents using drugs and/or psychotherapy is more than a decade behind that of adults. The specification and testing of psychotherapy will accelerate a rational, scientific basis for their treatment.

A novel biochemical model linking dysfunctions in brain melatonin, proopiomelanocortin peptides, and serotonin in autism

A novel biochemical model for autism is presented, which proposes that a subgroup of autistic individuals may have a hypersecretion of pineal melatonin that produces a cascade of biochemical effects including a corresponding hyposecretion of pituitary proopiomelanocortin (POMC) peptides and a hypersecretion of hypothalamic opioid peptides and serotonin (5-HT). The model is reviewed, and supporting animal and clinical research, is summarized. The first arm of the model suggests that increases in pineal melatonin results in hypersecretion of 5-HT in hypothalamus and blood. The second arm of the model indicates that hypersecretion of melatonin also inhibits the release of hypothalamic corticotrophin-releasing hormone (CRH). Hyposecretion of CRH may result in decreased release of both pituitary B-endorphin (B-E) and adrenocorticotrophin hormone (ACTH); this, in turn, may result in decreased plasma concentrations of B-E, ACTH, and cortisol. In autism, a genetically determined hypersecretion of hypothalamic B-E may further contribute to an inhibition of pituitary B-E because of negative feedback inhibition. Therefore, autism may reflect a dysfunction in the pineal-hypothalamic-pituitary-adrenal axis which, modulates POMC and 5-HT systems of the brain. This model is consistent with numerous clinical investigations implicating hypersecretion of brain 5-HT and opioid peptides in autism. The model may have heuristic importance in guiding future research in the biochemistry of autism.

A review of ECT for children and adolescents

Two cases of electroconvulsive therapy (ECT) in adolescence are presented and the literature on the use of ECT in childhood and adolescence is reviewed. ECT was effective in children and adolescents with bipolar disorder and depression. Inadequate information exists to make a judgment regarding schizophrenia, delirium, and anorexia nervosa. ECT is not effective in autism and chronic organic brain syndromes. Complications cited include organicity and seizures in the period immediately after ECT, anxiety reactions, and disinhibition. Long-term memory deficit or cognitive impairment has not been found, although further research to rule out residual impairment is needed.

Psychopharmacology of the psychiatric disorders of childhood and adolescence

The literature on the psychopharmacology of child and adolescent psychiatric disorders is reviewed. The scanty epidemiological data suggest that psychotherapeutic drugs are utilized more widely than research findings would warrant, especially in preschool-age children. With the exception of hyperactivity, the disorders of childhood and adolescence for which the use of psychopharmacological agents is well-established are rare. This highlights the need for careful prescribing, in which the child's rights, problems with compliance and developmental and behavioural adverse effects are important considerations.

The concurrent use of lithium and methylphenidate in a child

The case of a young boy with symptoms of both attention deficit and affective disorders is presented. The patient was successfully treated with a combination of lithium and methylphenidate. Issues about comorbidity and polypharmacy in children are raised, and the concommitant use of lithium and methylphenidate in a child is discussed.

Psychodynamics and medication

In many training programs and for many practitioners there is conflict between the importance and use of psychotherapy and pharmacotherapy. Some of the historical, political, interpersonal, and intrapersonal roots of the problem are summarized in the hope that understanding and self-scrutiny will help break down the splitting that remains all too common.

Research on a children's psychiatric inpatient service

It is widely recognized that child psychiatry needs to expand its research enterprise. Psychiatric inpatient units that serve children and adolescents should serve important roles in clinical research in child psychiatry. This paper reviews the need for research on the nature and treatment of psychiatric disorders on children's psychiatric inpatient services and discusses the resources necessary for a productive inpatient research program. The intrinsic relationship between clinical care and clinical study is emphasized.