Young Children and Mental Health
Although the FDA is approving more medications for kids, 80% of the Rx’s are not approved for use in children. Fewer evidence-based studies in children than in adult psychiatry and most were retrospective. There’s also a huge stigma with kids being medicated instead of just letting them grow and develop normally. However, mental illnesses and brain injuries don’t age discriminate and can cause a lower quality of life that can lead to greater consequences without treatment going into adulthood.
Abnormal behaviors or behavior changes that indicate a young person needs help: sudden drop in grades, changes in friends or personality, constant thoughts and fears about their personal safety or safety of family members, do not want to go to school, new or frequent complaints of headache, stomach aches, and other sicknesses, trouble sleeping or nightmares, prolonged feelings of sadness and loneliness, doesn’t care about favorite activities or is “too tired to play”, feels angry, getting into fights, trouble sitting still or concentrating, running away, noticeable weight loss or gain, talks about death/suicide.
When using medications with kids, clinicians most often have to use their best judgment based on adult literature and experiences. However, proceeding with caution, staying within guidelines, and possibly with consultation, medication can provide great results. Pharmacotherapy is just part of the toolkit, counseling (for the child and family) tends to show the best efficacy than using medications alone. Here are some considerations with children:
Pharmacokinetics in Pediatrics
Lipophilic Medications
- Most psychotropic medications are highly lipophilic.
- The percentage of total body fat increases during the first year of life and then decreases gradually until puberty.
- Children have different volumes of fat for drug storage at different ages and dosing may need to be lower as fat storages usually decrease with height.
CYP/Metabolizing Enzymes
- Both CYP450 and phase II drug-metabolizing enzymes generally are absent in infancy, though rapidly develop over the first few years of life.
- Toddlers and older children may have levels of these drug-metabolizing enzymes which exceed adult levels!
- These decline until puberty, where they generally remain the same until adulthood.
Liver Mass Effects
- Relative to body weight, the liver mass of a toddler is 40-50% greater than an adult. A 6-year-old is 30% greater than an adult.
- Children tend to clear drugs more rapidly than adults.
- Children may require higher mg/kg concentrations to achieve the same plasma levels.
Renal Filtration
- By age 1, GFR and renal tubular mechanisms for secretion have reached adult levels.
- However, fluid intake may be greater in children relative to adults.
- Therefore, medications have more rapid renal clearance in children compared to adults.
Post-Puberty
- Drug metabolism resembles a young adult
- Approximately 5% of adolescent (12-19 years old) takes an antidepressant however agents may be approved for other indications. ALL antidepressants have a black box warning r/t suicide risks.
Symptoms and Diagnosis: In mental health, many diagnoses can have similar symptoms-
- Irritability: depression, bipolar disorder, substance abuse, autism
- Aggression: bipolar disorder, ADHD, conduct disorder, disruptive behavior disorder, schizophrenia
- Depression: major depression, bipolar disorder, schizophrenia
R/O Other Causes of Anxiety
- Medical: hyperthyroidism, vitamin B12 deficiency, hypoxia, neurological disorders, anemia, pheochromocytoma, hypoglycemia
- Medication/Substance-Induced: caffeine, theophylline, amphetamines, etoh/sedative withdrawals, mercury/lead toxicity, penicillin, sulfonamides
Differential Diagnosis of ADHD: misc. anxiety disorders, bipolar, depression (may see irritability with children), dysthymia, PTSD, or trauma events, sleep disorders, brain injuries, also check vision and hearing. Also, consider using the Vanderbilt screening tool.
ADHD Medications
- Can help greatly with the quality of life by affecting the ability to focus, decreasing physical hyperactivity
- A combination of medications and behavioral interventions have been shown as a superior treatment to either alone
- The goal of medication is symptom reduction, which requires careful assessment and ongoing monitoring of mental status/psychosocial functioning
- Stimulants
- Most widely used
- 65-75% efficacy in treating ADHD symptoms vs 4-30% placebo response
- Only 55% of patients with ADHD get medication treatment
- Non-stimulants
- May have fewer (or different) side effects
- Typically considered second-line treatment
Key Points of ADHD- Stimulants
- Most effective in treating ADHD – both in children and adults
- Side-effects are not trivial: monitor of BP and heart rate as well as baseline weight and follow-up EKGs due to strong cardiovascular risks
Non-Stimulant Treatment of ADHD
Other Non-stimulant Meds for ADHD
- Bupropion:
- NE reuptake and DA reuptake inhibitor
- Dosing is somewhat unclear in children; adults = mean 393mg/day of Wellbutrin XR
- a2 Adrenergic Agonists:
- May strengthen working memory by improving functional connectivity in the prefrontal cortex
- Clonidine: less effective than stimulants, used as an adjunct to manage tics, sleep problems, and aggression
- Adverse Effects include bradycardia and sedation (take at night/pm)
- Guanfacine: more selective for a2a receptor
- less sedation/dizziness than clonidine
- 2-4 mg with effect between 2-4 weeks
Anti-Depressants used to Treat Certain Conditions
| Class | Medication | Age | Diagnosis |
|---|---|---|---|
| SSRI | Fluoxetine (Prozac) | 7y+ | Major Depression OCD |
| Escitalopram (Lexapro) | 12y+ | Major Depression | |
| Sertaline (Zoloft) | 6y+ | OCD, Major Depression | |
| Olanzapine + fluoxetine, rx combination (Symbax) | 10y+ | Bipolar Depression | |
| SNRI | Duloxetine (Cymbalta) | 7y+ | Generalized Anxiety Disorder |
| TCA | Clomipramine (Anafranil) | 10y+ | OCD |
| Imipramine | Bed Wetting |
F.D.A. Approved Antipsychotics in Pediatric Populations
| Pediatric Bipolar | Pediatric Schizophrenia | Irritability in Autism | Adjunct in MDD | |
|---|---|---|---|---|
| Abilify | 10-17y | 13-17y | 6-17y | X |
| Saphris | 10-17y | |||
| Zyprexa | 13-17y | 13-17y | ||
| Invega | 12-17y | |||
| Seroquel | 10-17y | 13-17y | ||
| Seroquel XR | X | |||
| Risperdal | 10-17y | 13-17y | 5-16y | |
| Risperdal Consta | ||||
| Latuda | approved for bipolar depression |
In Conclusion
- Make sure the child is only taking the prescribed dose; educate/discourage about NOT cutting an adult dose in half, related to complications and adverse effects. Provide thorough patient education.
- Pediatric dosing sometimes requires adult dosages due to the child’s increased ability to quickly metabolize the medications but remain conservative or cautious with med changes.
- Children may also exhibit unusual side effects compared to adults and should be monitored/assess very frequently to rule out other causes/track improvements.
- Stay within the practice guidelines/recommendations or consider what previously worked in the child’s past. Also, consider seeking pharmacy and peer consultation.
Additional Resources
- About Complications
- Early Adverse Childhood Events
- New Medical Device for ADHD
- Websites for ADHD/ADD
- Other Mental Conditions
- Don’t forget about informed consents by AAP & Rochester
- Society of Pediatric Nurses (SPN): a broad-based pediatric nursing organization founded for all nurses involved in the care of children and families.
