 by MARK P. FABER, M.D.
Child and Adolescent Psychiatrist
Director of the Division of Pediatric Psychiatry, Saint Barnabas Medical Center
Children’s mental health is a very important subject, not only for kids, but also for their families and schools. Between 10 and 20 percent of children meet criteria for a mental illness depending upon which source of data is reviewed. For example, the American Academy of Pediatrics has indicated almost 10 percent of children may meet criteria for Attention Deficit Hyperactivity
Disorder (ADHD). Many others experience depression, anxiety, other mood or developmental disorders.
A recent controversy has arisen regarding psychiatric medication use in children, particularly given the increase in pediatric prescriptions. In short, if a medication is considered it should be for a well-documented condition, and given at a dose that is effective with few or no side-effects.
 CAUSES OF MENTAL ILLNESS:
Four primary causes of mental illness include:
• A genetic predisposition to a condition, that is “it runs in families”
• Biological factors such as a decrease in certain chemical neurotransmitters in the brain
• Current stressors
• Prior stressors which may impact here and now
PSYCHOTHERAPY:
For most conditions, there is value to psychotherapy, which may include individual, group or family therapy. Strategies used include cognitive, behavioral, play and interpersonal therapy. They are designed to give the child tools for helping to address mood and anxiety and behavioral symptoms.
In many cases, however, psychotherapy in combination with medication does provide the best response. This is particularly true in mood and anxiety disorders and ADHD.
MEDICATION TREATMENT FOR ADHD:
ADHD begins before age seven, includes distractibility, impulsivity and/or hyperactivity and occurs in multiple settings (home, school, socially). It persists in 50 to 80 percent of children into adolescence and adulthood.
Treatments include stimulant and nonstimulant medications, which increase norepinephrine and dopamine in the brain. A recent National Institutes of Health study showed medication is a primary treatment for ADHD.
Long-acting stimulants, such as Concerta® and Adderall XR®, prevent the need for in-school dosing. Common side-effects include decreased appetite, stomach upset and difficulty with sleep. These medications have a 70 to 90 percent rate of success.
Strattera® is a new FDA-approved treatment for ADHD (age six and above). It requires three to four weeks to take effect once it is at a therapeutic dose
(1-1.4 mg/kg/day). Common side-effects include fatigue, gastrointestinal symptoms and headache. These side-effects can be minimized by starting
Strattera® at dinnertime. Unlike stimulants, Strattera® may be effective during the day and evening.
Clonidine® and Tenex® may decrease impulsivity, hyperactivity, tics and outbursts, but will not increase attention. These medications may decrease blood pressure and pulse and cause sleepiness. In adults they are used to decrease blood pressure.
MEDICATION TREATMENT FOR ANXIETY:
Anxiety disorders include separation anxiety, obsessive-compulsive (OCD), panic, posttraumatic stress disorder (PTSD), generalized anxiety and social anxiety. Zoloft® is FDA approved age six and above for OCD. It has also been used to treat other anxiety disorders and depression. This and other "serotonin selective reuptake inhibitors” (SSRI’s) include Luvox®, Prozac®, and at times, Celexa®. Paxil® and Effexor® are not currently recommended for children, although their use on an individual basis may be evaluated with a psychiatrist.
The best treatment approach is often a combination of a serotonin medication
and cognitive behavioral therapy.
 MEDICATION TREATMENT FOR DEPRESSION:
Major depression lasts for at least two weeks and includes decreased energy, interest and concentration as well as an increase or decrease in appetite and sleep. It may also include hopelessness, helplessness and suicidal thoughts. Dysthymia lasts for one year and is a feeling of “the blahs,” not as severe as major depression and with brief periods of stable mood.
These may also be treated with SSRI’s. Prozac® has the longest “ half-life” in the body and has drug interaction with certain medications. If side-effects develop, they may continue up to one week after the medicine is stopped. Paxil® has the shortest half-life in the body, but, due to recent concerns, it is not currently recommended for children. Zoloft® and Celexa® have minimal drug interaction and an intermediate half life. Lexapro® is a more potent version of Celexa®. Wellbutrin® has sometimes been used and it increases norepinephrine and dopamine. Wellbutrin® should not be given in those with an eating or seizure disorder and may also cause a rash.
Common SSRI side-effects include headache, stomach upset, and decreased sleep. Unusual side effects include restlessness and agitation, which may be seen with impulsivity. Close monitoring is essential.
MEDICATION TREATMENT FOR BIPOLAR DISORDER:
Bipolar disorder is found in one percent of our population and has been a topic of much discussion when evaluating children. Some have stated that up to 20 percent of children with ADHD have bipolar disorder, but this has been called into question by the NIMH.
Children with bipolar disorder typically demonstrate euphoria, a decreased need for sleep and cyclicity of mood. A family history, major outbursts, racing
thoughts, rapid speech, grandiose and sexual thoughts may also be seen. Sometimes an antidepressant medication may trigger mania. Treatment includes “mood stabilizing” medication. Lithium is effective, but may decrease thyroid functioning, increase urination and thirst, increase tremors and increase fluid retention. It does require a blood level and lab work.
Depakote® is also used, but in overweight girls with significant hair growth on their arms and legs it may contribute to polycystic ovaries. It requires a blood
level and lab follow-up including liver enzymes. Trileptal® has shown promise and requires a check of serum sodium during early treatment (it may decrease sodium). Lamictal® is being used for bipolar depression, but has a high rate of rash, which, though rare, may be serious.
MEDICATION TREATMENT FOR AUTISM SPECTRUM:
Autism spectrum, once thought to occur in 4 in 10,000 children, now appears to be seen in 1:250 children. Reasons for this increase may include broader
diagnosis, improved detection and unknown factors. It does not appear to be linked to immunizations.
Medications may target and treat associated ADHD-like, OCD-like and physical acting out behaviors. Stimulant and nonstimulant medications may decrease restlessness, impulsivity and distractibility. Often, however, distractibility is linked to internal preoccupation with cartoons, TV shows or video games. Along with rigidity in routine, repeating words or phrases and various rituals, the SSRI’s may be effective. Outbursts may be related to being redirected from a ritual/routine or even due to subclinical seizure activity. Up to 1 in 3 children with autism spectrum go on to develop abnormal EEG’s or seizure activity. Treatment may include an antiepileptic medication or low dose Risperdal®.
However, Risperdal® may result in weight gain, increased lipids and increased blood sugar.
CONCLUSION:
Given the large numbers of children with mental illness, careful evaluation and treatment decisions are necessary. If certain behaviors or symptoms persist and interfere with functioning, then medication may be considered. It is important to weigh the benefits against any possible risks. Effort should be
made to use the fewest medications at the most effective dose. These medications should be monitored closely.
For an appointment with the Division of Pediatric Psychiatry, please call The Saint Barnabas Pediatric Specialty Center at (973) 322-7600. The Division of Pediatric Psychiatry treats young patients in a range of areas, including depression, anxiety, ADHD and autism.
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