Pediatric psychopharmacology: A review of new developments and recent research.

Advances in psychopharmacology have revolutionalized the management of emotional and behavioral disorders in children and adolescents. Recent developments in pediatric psychopharmacology and the prevalence of pharmacotherapy for various psychological disorders in children are examined, and clinical updates for classes of psychotropics are provided. Issues including monitoring and assessing drug effects, acceptability and satisfaction, and the social, political, and cultural issues surrounding the use of psychotropics in children are discussed. The authors conclude that the current clinical use of psychotropics in children exceeds extant efficacy and safety data. The involvement of practicing psychologists in pediatric psychopharmacology and the need for a firm empirical foundation for pediatric psychopharmacology are also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation and treatment of neurodevelopmental deficits in sexually aggressive children and adolescents.

Recent advances in developmental psychopathology demonstrate that comorbidities routinely appear in clinical samples of children and adolescents, particularly in those youngsters with disruptive behavior disorders and problems with aggressive behavior. This article discusses (a) the prevalence of comorbid neurodevelopmental deficits, particularly attention-deficit/hyperactivity disorder, in a clinical sample of 72 children and adolescents, ages 6-17, who displayed sexually aggressive behavior; (b) the theoretical implications of these findings; and (c) the relevance of this comorbidity for the clinical evaluation and treatment of sexually aggressive youth. Because adult models of psychopathology are limited, the need for a developmentally appropriate model for understanding sexual aggression in children is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Risperidone treatment of children and adolescents with pervasive developmental disorders: a prospective open-label study

OBJECTIVE: To investigate the short-term safety and efficacy of risperidone in the treatment of children and adolescents with pervasive developmental disorders. METHOD: This was a 12-week, prospective, systematic, open-label trial that included 18 subjects (15 boys and 3 girls) with a mean age of 10.2 +/- 3.7 years. The sample included 11 subjects with autistic disorder, 3 with Asperger's disorder, 1 with childhood disintegrative disorder, and 3 with pervasive developmental disorder not otherwise specified. Fourteen subjects had comorbid mental retardation. Behavioral ratings were obtained during two baseline visits and again after 12 weeks of risperidone treatment. RESULTS: The optimal dose of risperidone for the 18 subjects was 1.8 +/- 1.0 mg/day. On the basis of the global improvement item of the Clinical Global Impression Scale, 12 of 18 subjects were considered responders. Significant improvement was seen in measures of interfering repetitive behavior, aggression and impulsivity, and some elements of impaired social relatedness. The most common side effect was weight gain (range 10 to 35 lb). CONCLUSIONS: These preliminary results suggest that risperidone may be effective for improving interfering behavioral symptoms in some children and adolescents with pervasive developmental disorders. Double-blind, placebo-controlled studies are needed before definitive statements of safety and efficacy can be made.     

Recent developments in the pharmacotherapy of attention-deficit/hyperactivity disorder (ADHD).

In comparison to other mental health disorders in pediatric populations, there seems to be compelling evidence-based support for both the efficacy of stimulant medication for children and adolescents with attention deficit/hyperactivity disorder (ADHD) and associated symptoms. Tricyclic antidepressants provide an alternative when stimulants are found to be ineffective or associated with too many adverse effects, particularly for children who have comorbid conditions including anxiety and depression. Finally, the alpha-adrenergic agents, although not approved for the management of ADHD, have been widely employed clinically, particularly for the treatment of impulsivity, overactivity, and aggression. Behavior therapy has been demonstrated to be effective for many of the functional impairments associated with ADHD. Research efforts are needed to examine these therapies either alone or in combination on the long-term outcome of children with ADHD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences in psychiatric comorbidity among adolescents with substance use disorders.

The authors examined gender differences in rates of comorbid psychiatric disorders among adolescents with 1 or more psychoactive substance use disorders. Baseline diagnostic data were obtained from 135 adolescents, ages 12 to 19, and their parents-guardians, who participated in a study to develop and efficacy test Integrated Family and Cognitive-Behavioral Therapy. Rates of attention-deficit/hyperactivity disorder and conduct disorder were higher among drug-abusing male adolescents compared with drug-abusing female adolescents. However, high rates of disruptive behavior disorders also characterized drug-abusing female adolescents. Similarly, drug-abusing female adolescents exhibited a higher rate of major depression compared with drug-abusing male adolescents. However, rates of dysthymia, double depression (i.e., major depression and dysthymia), and bipolar disorder were equivalent between genders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric Comorbidity and Substance Use Treatment Outcomes of Adolescents.

Treatment outcomes of 126 adolescents (13-18 years old) with comorbid substance use disorders (SUDs) and Axis I psychiatric disorders (mood, anxiety, conduct, and attention-deficit/hyperactivity disorders) were compared to 81 SUD adolescents with no additional Axis I disorder. Participants completed structured interviews and symptom measures while participating in an adolescent treatment program and at 6 months following treatment. Results indicated that comorbid youth received more treatment during the outcome period; despite this, more comorbid SUD-Axis I disordered adolescents used substances following treatment than SUD-only youth, even after controlling for socioeconomic status and ethnicity. Among comorbid youth, internalizing disordered adolescents were less likely to use substances during the follow-up period, and externalizing disordered youth returned to substance use most rapidly after discharge from treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Recent Advances in Pharmacotherapies for the Externalizing Disorders.

This article provides a review of various psychotropic agents employed for children and adolescents with externalizing disorders. With the exception of the stimulants, clinical use of psychotropic medications for children with externalizing disorders far exceeds the available empirical literature. Further, there are insufficient data pertaining to the safety and efficacy of most psychotropics. Studies that examine the combination of psychotherapy and pharmacotherapy are also reviewed, with particular attention to the National Institutes of Health Multimodal Treatment Study for Children with Attention-Deficit/Hyperactivity Disorder. Recommendations are made for future multimodal studies all externalizing disorders and with all psychotropics in addition to the stimulants. Future goals for research over the next decade include studies that examine treatment acceptability, adherence and satisfaction, adherence with various psychotropic agents, and ecologically valid investigations of pharmacotherapies for both symptom reduction and enhancement of functional behaviors among children and adolescents with externalizing behavioral problems. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Pharmacotherapy in Autism and Related Disorders.

Autistic disorder is characterized by qualitative impairment in the areas of social interaction and communication, as well as stereotypic, repetitive patterns of behavior. In addition to the core features of autism, many individuals display a range of behavioral concerns including anxiety, aggression, agitation, overactivity, self-injury, and stereotypic behavior. Recent prevalence estimates indicate that over 45% of individuals with autism are prescribed psychotropic medications for management of associated behavioral disorders. Yet, there remain considerable gaps in our knowledge of medication efficacy and safety in this population. This article provides an overview of the research in this area, including efficacy and potential side effects of the most commonly prescribed psychotropic medications for children and adolescents with autism. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Use of atypical neuroleptics in child and adolescent psychiatry

BACKGROUND: This article reviews the published clinical experience with atypical neuroleptics in children and adolescents. METHOD: A computerized literature search was conducted (MEDLINE, 1974-1998) to retrieve all reports on the use of atypical neuroleptics in children and adolescents. A hand search was performed as well. All relevant clinical data were collated by type of drug. RESULTS: We found 5 blind placebo-controlled clinical trials (105 patients), 24 open-label clinical trials (387 patients), and 33 case series (115 patients) describing the use of the atypical neuroleptics clozapine, risperidone, olanzapine, sulpiride, tiapride, amisulpride, remoxipride, and clothiapine in children and adolescents. Some of these agents, especially clozapine, risperidone, and olanzapine, were found to be efficacious in the treatment of schizophrenia, bipolar disorders, and pervasive developmental disorders. The role of atypical neuroleptics as augmenters of serotonin reuptake inhibitors in obsessive-compulsive disorder is unclear. Risperidone appears to possess anti-tic properties in patients with Tourette's disorder. CONCLUSION: The most convincing evidence of the efficacy of atypical neuroleptics in children and adolescents concerns clozapine in the treatment of schizophrenia. Data on other atypical neuroleptics in other disorders are still sparse, and further research is needed. Some of the atypical neuroleptics may become the first-line treatment for childhood schizophrenia and pervasive developmental disorders.     

Marital and severe parent-to-adolescent physical aggression in clinic-referred families: Mother and adolescent reports on co-occurence and links to child behavior problems.

This study examined the interplay of marital and severe parental physical aggression, and their links to child behavior problems, in 232 families of clinic-referred adolescents. Combined reports from mothers and adolescents indicated that two thirds of adolescents exposed to marital aggression in the past year had also experienced parental aggression. Mothers and fathers who used and/or were victims of marital aggression were both more likely to direct aggression toward their adolescent. Mother and youth reports of marital aggression were tied to each party's report of greater externalizing problems and to youth reports of greater internalizing problems. Severe parental aggression uniquely predicted maternal reports of both behavior problems, after controlling for marital aggression; the reverse was not true. Also, adolescents exposed to both types of family aggression did not display greater maladjustment than those subjected to only one type of family aggression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle

OBJECTIVE: To evaluate the scope of the available therapeutic armamentarium in attention-deficit hyperactivity disorder (ADHD). METHOD: The literature of medication trials in ADHD was systematically reviewed, with attention to issues of psychiatric comorbidity, age, gender, and ethnic background. RESULTS: One hundred fifty-five controlled studies of 5,768 children, adolescents, and adults have documented the efficacy of stimulants in an estimated 70% of subjects. The literature clearly documents that stimulants not only improve abnormal behaviors of ADHD, but also self-esteem, cognition, and social and family function. However, response varied in different age groups and with certain comorbid conditions. In addition, there is an impressive body of literature documenting the efficacy of tricyclic antidepressants on ADHD in more than 1,000 subjects. Studies of alternative antidepressants, antipsychotics, antihypertensives, and other compounds were also reviewed. CONCLUSIONS: The available literature indicates the important role of psychopharmacological agents in the reduction of the core symptoms of ADHD and associated impairments. More research is needed on alternative pharmacological treatments and to further evaluate established therapeutics beyond school-age Caucasian boys. In addition, more research is needed on the efficacy of treatment for comorbid ADHD, use of combined medications, and the combination of medication and psychosocial treatment.     

Typical and atypical antipsychotics in adolescent schizophrenia: efficacy, tolerability, and differential sensitivity to extrapyramidal symptoms

OBJECTIVE: To review the existing literature on the efficacy and tolerability of antipsychotics for adolescent psychosis. The review focuses in particular on literature regarding adverse effects that are thought to have an increased incidence in young patients and on the possible neurobiological bases for such differential sensitivity. METHOD: Pertinent studies were sought using Medline searches, supplemented by selected bibliographies, and reviewed. RESULTS: There is a relative paucity of research in this area; in particular, well-controlled trails are lacking. The existing literature suggests fairly good efficacy of both typical and atypical antipsychotics in the treatment of psychotic disorders in children and adolescents. However, the incidence of certain side effects, particularly extrapyramidal symptoms (EPS). is found to be higher in younger patients compared with adults. Positron emission tomography (PET) receptor studies in adults have demonstrated that the incidence of EPS is related to dose-dependent dopamine type-2 (D2) receptor occupancy and that there is a significant relationship between the number of these receptors and age. CONCLUSIONS: Improved tolerability is leading to the increasing us of atypical antipsychotics for adolescent patients, though these new drugs to have specific adverse effects of their own. There is a need for more controlled studies of atypical antipsychotics in children and adolescents. In particular, dose-finding studies are needed to determine the optimal dose range to produce the greatest improvement with the least side effects for each of these drugs.     

Child sleep disorders: Associations with parental sleep duration and daytime sleepiness.

This study examined the associations between childhood sleep disorders and mothers' and fathers' sleep duration and daytime sleepiness. One hundred seven families of children (ages 2-12 years) presenting to a pediatric sleep disorders clinic completed questionnaires assessing the sleep symptoms of the mother, father, and child. Parents of children with more than 1 type of sleep disorder experienced more daytime sleepiness than parents of children with a single sleep disorder. The pattern of results suggested more associations between maternal and child sleep than between paternal and child sleep. Within families, mothers reported significantly more daytime sleepiness than fathers, although there were no parental differences in sleep duration. Results provide preliminary evidence for an association between child sleep problems and parental daytime sleepiness, which may, in turn, extend previous research linking young children's sleep problems and parental functioning. Implications for treatment of both children and adults with sleep problems are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How treatments for pathological gambling can be informed by treatments for substance use disorders.

Substance use disorders and pathological gambling share similarities in terms of diagnostic criteria, epidemiology, and clinical course. However, relatively few studies have evaluated the efficacy of treatments for gambling disorders. As interest in pathological gambling grows, adaptation of effective treatments from the field of substance abuse may advance the study of treatment for pathological gambling. This article reviews the similarities and differences between pathological gambling and substance use disorders. It describes psychotherapeutic and pharmacological treatments for substance use disorders and their translation to pathological gambling. Future research should consider investigating the onset and course of pathological gambling within the context of other psychiatric disorders, biological abnormalities associated with gambling, and combined effects of psychotherapy and pharmacotherapy in the treatment of this disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Overt and Relational Aggression and Perceived Popularity: Developmental Differences in Concurrent and Prospective Relations.

Relations of overt and relational aggression with perceived popularity among children and early adolescents were examined in 2 studies (Ns = 607 and 1,049). Among older youths, positive concurrent relations found between overt aggression and perceived popularity became nonsignificant when relational aggression was controlled, whereas positive associations found between relational aggression and perceived popularity held when overt aggression was controlled. Aggression and perceived popularity were not positively related for the younger participants. The 2nd study also examined the temporal ordering of these relations over 6 months. For older girls, positive relations between relational aggression and perceived popularity were bidirectional. For older boys, relational aggression did not predict increased perceived popularity, but perceived popularity predicted increased relational aggression. Implications for intervention are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric disorders and sexual risk among adolescents in mental health treatment.

Objective: To examine the relationship between psychiatric disorders and sexual behaviors among adolescents receiving mental health treatment. Adolescents in mental health treatment have been found to have higher rates of HIV risk behavior than their peers, but data concerning the relationship between psychopathology and risk are inconsistent and limited. Method: Eight hundred and forty adolescents (56% female, 58% African American, mean age = 14.9 years) and their parents completed computerized assessments of psychiatric symptoms via the Computerized Diagnostic Interview Schedule for Children (Shaffer, 2000a, 2000b). Adolescents also reported on sexual risk behaviors (vaginal/anal sex, condom use at last sex) and completed urine screens for a sexually transmitted infection (STI). Results: Adolescents meeting criteria for mania, externalizing disorders (oppositional defiant, conduct, and attention-deficit/hyperactivity disorders), or comorbid for externalizing and internalizing disorders (major depressive, generalized anxiety, and posttraumatic stress disorders) were significantly more likely to report a lifetime history of vaginal or anal sex than those who did not meet criteria for any psychiatric disorder (odds ratio [OR] = 2.0, 2.3, and 1.9, respectively). Adolescents meeting criteria for mania were significantly more likely to have 2 or more partners in the past 90 days (OR = 3.2) and to test positive for a STI (OR = 4.3) relative to adolescents who did not meet criteria for a psychiatric disorder. Conclusions: The presence of internalizing and externalizing disorders, especially mania, suggests the need for careful screening and targeting of adolescent sexual behavior during psychiatric treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pathways from proactive and reactive aggression to substance use.

Childhood aggression is a known risk factor for adolescent substance use; however, aggression is a complex construct, and developmental researchers have identified a variety of subdimensions that may be germane to substance use. Very little research has examined risk pathways from subdimensions of aggression. The current study examined a developmental model and tested whether childhood proactive aggression, reactive aggression, or both were related to the development of substance use in adolescence in a sample of 126 children (mean age at initial assessment = 10.4 years, SD = 0.51). Peer rejection and peer delinquency were examined as potential mediators of these relations. The findings suggest that proactive aggression was indirectly associated with substance use through peer delinquency. Reactive aggression was also indirectly associated with substance use through a complex mediational chain, such that high levels of reactive aggression were associated with high levels of peer rejection, which in turn were associated with peer delinquency (p = .06), which subsequently predicted substance use. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sertraline treatment of children and adolescents with obsessive-compulsive disorder or depression: pharmacokinetics, tolerability, and efficacy

OBJECTIVE: To evaluate the pharmacokinetics, safety, and efficacy of sertraline in children (6 to 12 years old) and adolescents (13 to 17 years old). METHOD: Children (n = 29) and adolescents (n = 32) with major depression, obsessive-compulsive disorder (OCD), or both received a single dose of 50 mg of sertraline followed, 1 week later, by 35 days of sertraline treatment as follows: (1) either a starting dose of 25 mg/day titrated to 200 mg/day in 25-mg increments or (2) a starting dose of 50 mg/day titrated to 200 mg/day in 50-mg increments. Sertraline and desmethylsertraline pharmacokinetics were determined approximately weekly, and efficacy measures were assessed before drug administration and at the end of treatment. RESULTS: Mean area under the plasma concentration-time curve (AUC), peak plasma concentration (Cmax), and elimination half-life (t1/2) for sertraline and desmethylsertraline were similar to previously reported adult values. No titration-dependent pharmacokinetic or safety differences were seen. While Cmax and AUC0-24 were greater for children versus adolescents, these differences disappeared after parameters were normalized for body weight. Sertraline was well tolerated in both children and adolescents, with adverse experiences similar to those previously reported by adult patients. Efficacy measurements indicated improvement (p < .001) in depression and OCD symptomatology. CONCLUSIONS: Sertraline can be safely administered to pediatric patients using the currently recommended adult titration schedule.