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

The role of drugs in the treatment of autism

The prevalence of autism spectrum disorder is increasing. It usually presents in childhood with abnormal behaviour and development The diagnosis can be difficult. There are often comorbidities which can cause confusion Non-drug treatments are first line. Drug treatment is not effective for the core symptoms of autism spectrum disorder. However, drugs may have a role in managing comorbidities and related symptoms, such as irritability and aggression Anxiety is a common comorbidity. Cognitive behaviour therapy can be effective, but in some cases selective serotonin reuptake inhibitors may have a role Most patients have problems sleeping, but drugs are not usually used to treat sleep disorders in children Antipsychotics, such as risperidone, may be considered for irritability and aggression. Clonidine is first line for children with Tourette syndrome. Patients need regular monitoring because of the adverse effects of these drugs

Étude descriptive de l’utilisation de psychotropes chez les personnes autistes de 20 à 35 ans en institution du Languedoc-Roussillon

The Pervasive Developmental Disorders complications can lead to an important life long handicap. There is an important literature about autism, but in most cases, specifically concerning children and adolescents problems. We wished to focus our attention on adults, in order to describe, on one hand their socio-adaptive profile, and on the other hand, the necessity to resort to a psycho-active treatment. The geographic zone chosen in order to carry out this, was Languedoc-Roussillon, and the applied method was a descriptive study of psychotropic use in the 20-35 age adults with autism. The instruments used were standardized and validated. The diagnosis was confirmed using ICD 10 criteria checklist and individual characteristics including adaptive profile estimated on the Vineland scale, were collected. Moreover the prescriber's global impressions were collected on the CGI scale. Out of 165 case files collected, the sex-ratio was 3 men for 2 women, 45% showed associated somatic disorders (of which 24% epileptic), 66% -benefited from a psycho-active treatment; 85% had been admitted in institutions during childhood or adolescence. The admittance framework being respectfully, MAS 21.8%, community homes 35.2%, CAT 17.6% and psychiatric services 20.6%. Mean equivalent age, in the three Vineland adaptive domains, were from 21 months in Communication to 43 months in Autonomy in daily life Skills and 17 months in Socialization. The development quotient showed adaptive retardation in 100% of cases. The 110 persons benefiting from a medicinal treatment, were treated for aggressiveness in 62.7% of cases, agitation in 43.6% of cases and anxiety in 48.2% of cases. The therapeutic categories used were, in majority, antipsychotics in 85% of cases, anxiolitics in 40.2% of cases; hypnotics as well as anti-depressants or mood-regulators, each representing 10% of prescriptions. Associations of several molecules representing 83% of cases. The therapeutic effect was considered interesting in more than two-thirds of cases. Undesirable side-effects were reported in 50% of the patients under treatment; 50% of the persons treated had been administered the same treatment for more than 5 years. The adaptive-profile significantly varied, depending on the accommodation structures and also the presence or absence of a psycho-active treatment. The results of this study portrayed the level of social adaptation and the types of psychoactive treatment in adults with autism, who are severely limited in their adaptive functioning due to their handicaps.

Autism and pervasive developmental disorders

The quantity and quality of research into autism and related conditions have increased dramatically in recent years. Consequently we selectively review key accomplishments and highlight directions for future research. More consistent approaches to diagnosis and more rigorous assessment methods have significantly advanced research, although the boundaries of the 'broader phenotype' remain to be defined and the validity of Asperger's disorder as a discrete syndrome remains controversial. Recent epidemiological studies have shown that Autism Spectrum Disorders are common, but there continues to be debate about the causes of the increase in the frequency with which autism is diagnosed. Psychological research has helped to develop new developmental models for the disorder and there have also been significant advances in the molecular genetics of autism and understanding of the underlying neurobiological processes. Areas important for future research include the study of autism as it first develops, i.e., in infants and very young children, and of specific processes (psychological and neurobiological) which underlie the disorder. Significant challenges lie ahead in evaluating the growing number of treatments for autism and in integrating the results of research into treatment and educational settings.

Psychopharmacology in the Treatment of Conduct Disorder Children and Adolescents: Rationale, Prospects, and Ethics

The rationale for psychopharmacological treatments of conduct disorder (CD) in children and adolescent is discussed with reference to the presumed neurophysiological basis of the disorder. Specific psychopharmacological treatments for children with CD are identified and briefly evaluated in terms of their empirical foundations. The lack of a secure knowledge base on the biochemical basis of CD and the efficacy of psychopharmacological treatments with children and adolescents suggests the need for caution in the wide use of pharmacotherapy with these populations. Psychopharmacological treatments with children and adolescents with CD are particularly indicated for reactive aggression, and CD with comordid conditions. Conceptual and methodological improvements in use of psychotropic medications with children and adolescents are discussed as well as the associated ethical considerations.

Risperidone in the treatment of childhood autistic disorder: an open pilot study

OBJECTIVE

To evaluate the tolerability and efficacy of risperidone in childhood autistic disorder.

METHODS

A multicenter, open-label, dose-titration study involving seven autistic children (mean age 7.6 years) receiving risperidone for 4 weeks.

RESULTS

Mean dose was 0.01 mg/kg/day on day 1, 0.019 mg/kg/day on day 7 (range 0.01-0.041 mg/kg/day) and 0.035 mg/kg/day on day 28 (range 0.014-0.064 mg/kg/day). Over the 4-week period, the Ritvo-Freeman Real Life Rating Scale total score measuring autistic behavior was significantly decreased (P = 0.019), as was the affectual reactions subscale (P = 0.029). Aberrant Behavior Checklist total score was significantly improved (P < 0.001), as were all subscales except inappropriate speech. Visual Analog Scale for individual target symptoms was significantly decreased (P = 0.001), and Clinical Global Impression severity of illness score was significantly improved (P = 0.006). The incidence of adverse effects was low, and no extrapyramidal symptoms were observed. No significant changes or clinically relevant abnormalities occurred in laboratory tests, vital signs or electrocardiograms. Plasma concentrations of the drug were similar to those in adult patients.

CONCLUSIONS

These favorable results suggest that larger controlled trials of risperidone should be performed in autistic or mentally retarded patients with behavioral disturbances.

Pervasive developmental disorders: a 10-year review

OBJECTIVE

To summarize recent advances about the nature, diagnosis, and treatment of pervasive developmental disorders.

METHOD

Review of Medline databases, books, and book chapters published between July 1989 and November 1999.

RESULTS

Clinical and genetic studies support expansion of the concept of autism to include a broader spectrum of social communication handicaps. The prevalence of autism is approximately 1 per 2,000; the prevalence of autism and Asperger's disorder together is 1 per 1,000. The Checklist for Autism in Toddlers is a useful screening instrument for 18-month-old children; the Autism Diagnostic Interview-Revised and the Autism Diagnostic Observation Schedule are instruments of choice for research. Although twin and family studies clearly support genetic factors as important in autism, linkage analysis studies indicate that many genes may be involved. There is no one treatment of choice. Social-pragmatic approaches, augmented by individualized strategies and social coaching, may be best for teaching social communication skills. Pharmacological interventions have a limited role in improving social communication, but selective serotonin reuptake inhibitors and atypical neuroleptic medications may help ameliorate aggression, hyperactivity, and other secondary problems.

CONCLUSIONS

Private and government agencies must continue to support basic and applied research.

The treatment of attention-deficit hyperactivity disorder: an annotated bibliography and critical appraisal of published systematic reviews and metaanalyses

CONTEXT

The Agency for Health Care Policy and Research charged the McMaster Evidence-based Practice Center with conducting a comprehensive systematic review of the literature on the treatment of attention-deficit hyperactivity disorder (ADHD), with input from various groups of stakeholders. One strategy used to avoid duplication of work included a critical appraisal of existing systematic reviews and metaanalyses.

OBJECTIVE

To identify and appraise published metaanalyses and systematic reviews on the treatment of ADHD and to produce an annotated bibliography.

DATA SOURCES

Medline, Cumulative Index in Nursing and Allied Health (CINAHL), Healthstar, Psycinfo, and Embase were searched to September 1998; the Cochrane Database (1998 issue 3), selected Internet sites, and the files of investigators were also reviewed.

STUDY SELECTION

Review articles described as systematic reviews or metaanalyses or including a Methods section were identified independently by 3 reviewers.

DATA EXTRACTION

Two reviewers extracted, by consensus, relevant information on the name, methodological quality, ADHD-related aspects (comorbid disorders, family characteristics) of those reviews; data on the population, study setting, interventions, and outcomes evaluated by the reviews were also retrieved.

RESULTS

Thirteen reviews, published from 1982 to 1998, were included. Eight included metaanalysis and 5 a qualitative review. Nonpharmacological treatments were mentioned in 6 reviews and combination therapies in 3. One review focused on the treatment of adults. Forty-seven drugs and 20 adverse effects were mentioned. Most reviews had major methodological flaws.

CONCLUSIONS

Most published systematic reviews and metaanalyses on the treatment of ADHD have limited value for guiding clinical, policy, and research decisions. A rigorous, systematic review following established methodological criteria is warranted.

Psychotherapy outcome research in child psychiatric disorders

OBJECTIVE

To compile, review, and comment upon the application of psychotherapy to the treatment of psychiatric disorders first appearing in childhood and adolescence.

METHOD

Representative research papers published over the past 4 decades on the subject of psychotherapy of children and adolescents were compiled. Selection for inclusion in this review was based upon salience to the subject of treatment of child psychiatric disorders. Special consideration was given to large-scale and metaanalytic studies, as well as to studies comparing psychotherapy with other forms of treatment.

RESULTS

There is mixed evidence for the efficacy of psychotherapy for child psychiatric disorders. There are few direct comparisons between treatment modalities in the child psychiatric literature. Methodological problems include a history of theoretical development of therapies without reference to current conceptions of mental illness, a paucity of direct comparisons among psychotherapies and between psychotherapy and other psychiatric treatments, inconsistent definition of psychotherapy from study to study, and inconsistency in stated outcome measures. In general, cognitive-behavioural therapies performed better in application to child psychiatric disorders than did insight-oriented therapies.

CONCLUSIONS

Outcome research in child-oriented psychotherapy is still in its infancy. There are simply too few studies of many therapies and many conditions to draw firm conclusions about efficacy. More work is needed in matching discrete, consistently applied therapies to selected psychiatric pathologies. Questions regarding psychotherapy's potential application to prevention of mental illness and to management of distress surrounding mental illness (as distinct from treatment of the illness itself) remain to be answered.

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.