Supporting pediatric psychopharmacology

1. Pediatric Psychopharmacology
The Facts and
Why it Can Save Our Kids
Armeta Dastyar
Priya Mathews

2. Introduction
• Pediatric Psychopharmacology
refers to the study of
interaction of drugs with the
body and its behavioral effects
in children [1]
• First reports of psychotropic
drug use in adolescents in the
1930’s by Charles Bradley [2]

3. History of Pediatric Psychopharmacology
• 1997- FDA Moderation Act gave incentives for pediatric
research on already adult-approved medications [3]
• 2002- Best Pharmaceuticals for Children Act- an
extensive process for studying medications in pediatric
populations [3]
• 2003- Pediatric Research Equity Act authorized FDA to
require drug manufacturers to conduct pediatric
studies [3]
• With these regulations  consumers and medical
providers have a fairly large database for using these
psychotropic medications in children

4. What’s the Controversy About?
• Supporters claim that the use of
psychotropic drugs can help manage
pediatric disorders where behavioral
or psychosocial interventions alone
cannot. Also, it is important to
prevent these children from harming
themselves or others.
• Opponents claim that many of these
drugs have not been extensively
tested for children and that long term
effects are still unknown. They
believe that we are overmedicating
our children.

5. Evaluations Required
• Are kids simply being put on
numerous drugs without a
second thought? [4]
• Extensive physical and
psychiatric evaluations in a
variety of settings are required:
– Physical examination
– Structured interview
– Behavioral rating scales
– Direct observations of behavior
– Standardized measures of
performance

6. Different Classes of Drugs
• Doctors strive to find the safest and most
effective medication for every individual child.
• Each class of drugs has a different way of
functioning in the body [4]:
• Stimulants
• Anti-depressants
• Anti-psychotics
• Mood Stabilizers/Anti-Convulsants
• Anxiolytics and Sedatives

7. Stimulants
• Centrally and peripherally enhance both
dopaminergic and noradrenergic transmission to
improve cognitive and behavioral functioning [2]
• Methylphenidate (Ritalin), Dextroamphetamine
(Focalin), Pemoline (Cylert), Amphetamine-
dextroamphetamine (Adderall)
• Are the most prescribed psychotropic agents
• Most commonly used with ADHD [5]
• Over 200 controlled studies have shown that
stimulant medications are safe and effective [2]

8. Anti-Depressants
• Act on central pre- and post-synaptic receptors 
affect neurotransmitter release and uptake (i.e.
serotonin, norepinephrine, dopamine) [2]
• 4 main sub-classes: monoamine oxidase inhibitors
(MAOIs), tricyclic (TCAs), selective serotonin uptake
inhibitors (SSRIs), atypical anti-depressants
• Of these, SSRIs are the most frequently prescribed (i.e.
Prozac, Zoloft, Paxil)
• Mostly used for major depressive disorder, but also for:
OCD, insomnia, ADHD, anxiety disorders [4]

9. Anti-Psychotics
• Effectively treat psychosis, including
hallucinations, delusions, bizarre behavior, severe
agitation [4]
– Thought to be related to dopamine antagonist
properties
• 2 main classes: traditional and atypical
• Common anti-psychotics: Olanzapine (Zyprexa),
Clozapine (Clorzaril), Chlorpromazine (Thorazine)
• Mostly used for schizophrenia, but also for
psychotic depression, mania, autism spectrum
disorders, severe aggressive behaviors [15]

10. Mood Stabilizers/Anti-Convulsants
• Act through a variety of mechanisms affecting
intracellular processes- still being researched
• 3 most commonly used: lithium, valproate, and
carbamazepine [2]
• Lithium is only FDA approved drug for pediatric
bipolar disorder [4]
– Also used to improve aggressive
behavior and conduct disorder
• Valproate effectively treats mania
in adults and possibly children

11. Anxiolytics and Sedatives
• Relatively less evidence compared to the other
categories of medication, but still used with pediatric
medications [2]
• Benzodiazepines have been used for anxiety (GAD) and
panic disorders [15]
• Buspirone, TCA’s, SSRIs, Beta
Blockers, and α-2a agonists [4]
• Need for more research with
children, so not as frequently
used

12. Miscellaneous
• Atomoxetine (Strattera)- nonstimulant drug that
was approved for ADHD treatment [9]
– Thought to inhibit norepinephrine receptors
• Clonidine- α-adrenergic agonist used especially
for tics and sometimes ADHD and anxiety
disorders [13]
– Reduces sympathetic
outflow directly at the
brain stem  therapeutic
effects

13. Disorders that All Show Support for
Pediatric Psychopharmacology
• ADHD
• Pediatric Bipolar
• Depression
• OCD
• Schizophrenia
• Anxiety
• Autism
• Anorexia
• Bulimia nervosa
• Obesity

14. ADHD
• ADHD is the most commonly
diagnosed psychiatric
disorder of childhood [2]
• 4.5 million children between
5-17 years of age have been
diagnosed with ADHD as of
the end of 2006. [6]
CDC, 2007
• Children with ADHD can experience peer rejection,
impulsivity, disruptive behaviors, low self-esteem  which
can affect their daily life [7]
• If not treated, symptoms can persist into adulthood [2]
Medication has proven to be extremely
effective for treating ADHD

15. ADHD
• Over 200 controlled studies have shown that stimulant
medication is safe and effective [2]
• Methylphenidate and atomoxetine have repeatedly been
found to decrease inattention and hyperactivity [9]
• Stimulants for ADHD do not result in substance abuse
disorders and may actually have a protective effect against
development of substance abuse in adolescence [8]
– Also protective factor for legal difficulties and poor impulse
control
• Concerns that stimulant medication may be responsible
for smaller brain structures  not well supported [5]

16. ADHD
• Semrud-Clikeman et al. 2008 [7]
– Compared ADHD kids that have at least some history
of medication (current or past) to ADHD kids that
were never exposed to treatment
– ADHD children with some history of medication
performed significantly better in writing, attention,
executive functioning, verbal working memory, and
academics. They also had less mood problems and
aggressive behaviors.
– ADHD children that have been
medicated show better functioning
even when medicine has been
discontinued.

17. ADHD
• Pappadopulos et al. 2004 [11]
– When reviewing a decade of studies- stimulant
medication has been tested on over 6000 ADHD
children  substantial evidence showing
stimulants are effective at treating ADHD
symptoms
• Pelham et al. 2002 [12]
– Methylphenidate shown to reduce
ADHD treatments in children with
normal and low IQ

18. ADHD
• ADHD Attitudes [5]
– Parent
• Over 90% of parents challenged and were
skeptical of the doctor’s recommendation of
starting medication
• After 2 years- about 80% of parents
considered methylphenidate a safe and
effective drug
• A few parents stopped the medication in between- but all of them
restarted treatment because of belief that child performed better
on medication
– Child:
• After 2 years on stimulant drugs- 86% of kids considered
methylphenidate safe and effective

19. ADHD
• In the school settings- teachers and school psychologists are
working with medical doctors to provide a multinodal
treatment for ADHD children [10]
– Medication combined with psychosocial interventions show
greatest decrease in symptoms
– 75% of parents believe that the best treatment for ADHD =
methylphenidate + psychological support
– Behavioral interventions alone did not exert improvement in
academic performance, emotional status, and overall functioning
[13]
• American Academy of Pediatrics announced that stimulant
medication should be recommended to improve outcomes in
ADHD children [5]

20. ADHD
Effectiveness of
stimulants in
children 6 years
and older with
ADHD [14]

21. ADHD
Video Clip

22. Pediatric Bipolar Disorder
• PBD children experience moods
that alternate between depression
and mania episodes
• Early onset PBD often starts with
depression episode that switches to
BD [2]
– Therefore hard to estimate PBD
prevalence
• Children with PBD can be extremely
harmful to themselves, family, and
society
Medication is critical with
almost all PBD cases

23. Pediatric Bipolar Disorder
• Lithium- only FDA approved drug for
treatment of PBD [15]
– Clinical Global Assessment Scale score
of more than 65 was achieved by 47%
of kids receiving lithium versus 8% of
kids on the placebo [11]
• Findling et al. 2003 [17]
– Lithium + divalproex sodium (mood-
stabilizer) treatment produced
significant improvements in various
areas  47% subjects met criteria for
full remission after medication for 20
weeks

24. Pediatric Bipolar Disorder
• Kafantaris et al. 2001 [18]
– Lithium + Anti-psychotic
treatment (Haloperidol) showed
improvement of symptoms for
adolescents with PBD
– Majority of patients showed
reoccurrence of symptoms once
medication was discontinued
• Biederman et al. 2005 [21]
– When given Risperidone (anti-psychotic)- PBD patients
showed 70% response for manic symptoms and 35% for
ADHD symptoms.

25. Pediatric Bipolar Disorder
• Pavuluri et al. 2009 [16]
– Lamotrigine is an anti-convulsant commonly used for
adult BD
• Controls glutamate release activates serotonin levels
– This study showed that kids on lamotrigine medication
showed significantly reduced depressive symptoms
and controlled aggression and irritability compared to
the placebo group
– Previous adverse effect of benign rash only seen in 6%
of patients and was quickly treated with no long-term
effects

26. Pediatric Bipolar Disorder
• PBD can be extremely severe if left untreated
• Certain researchers today consider it unethical to
have a placebo group for children with PBD 
because withholding treatment can have drastic
long term effects
– Without medication- high risk for substance abuse,
conduct disorder, suicide, and other co-morbidities
[21]
– Show symptoms of hallucinations, verbal and physical
intrusion, lack of self-control, delusional thinking,
possibly assaultive, and more [2]

27. Pediatric Bipolar Disorder
Video Clip

28. Depression
• Increased rates of depression among kids:
especially in families dealing with divorce, abuse,
neglect, bereavement [3]
– Harvard Medical School study in 2006 found that
childhood depression is increasing by 23% a year
• Depression rates and
suicide are strongly
correlated  suicide is
6th leading cause of death
among children ages
5-14 [22]

29. Depression
• Fluoxetine (SSRI) has been shown to be superior to
placebo in many controlled studies. Emslie et al. 2002 [24]
Tao et al. 2009 [26]
– Fluoxetine medication showed significantly improved results
compared to cognitive behavioral therapy alone [25]
– Only FDA approved drug for pediatric depression
• Tricyclic antidepressant (Anafranil) and paroxetine (Paxil)
have shown some promising results in the treatment of
pediatric depression
– More controlled studies is needed before these drugs can be
frequently distributed for treatment

30. Obsessive Compulsive Disorder
• OCD in children obsessions, compulsions,
persistent thoughts, impulses, or images that are
intrusive/inappropriate [14]
– Causes anxiety & stress
– Repetitive behaviors are in response to obsession
• 1/3-1/4 of OCD patients had
symptoms before the age of 15 [27]
• Symptoms can manifest similar to
adult OCD but often differently (i.e.
temper tantrums, food restrictions,
decreased academic performance) [2]

31. Obsessive Compulsive Disorder
• Of all childhood disorders- OCD has most evidence
supporting pharmacologic treatment & largest number
of FDA approved drugs [2]
• SSRIs fluoxetine (Prozac), fluvoxamine (Luvox), sertraline
(Zoloft) and clomipramine (Anafranil) are FDA approved
for treating childhood OCD (age 6 and up) [2]
• Geller et al. 2003 [28]
– Meta analysis of children with OCD showed significant
difference between children on medication and placebo
– Clomipramine was shown to be the most superior of the
SSRIs [2]

32. Obsessive Compulsive Disorder
• Wagner et al. 2003 [29]
– Sertaraline has been shown effective
in long term trials because of
significant remission rates and
improved functional status in
majority of patients
• Gellar et al. 2003 [28]
– Continued paroxetine treatment
significantly reduces pediatric OCD
relapse rates compared to the
placebo
• Is often comorbid with other
disorders such as ADHD, tics,
anxiety disorders, and PBD [14]

33. Obsessive Compulsive Disorder
• Case 1 [27] :
– 4 year old with symptoms: severe anxiety, lack of appetite,
frequent crying, dysphoric mood and obsession with sexual
contact  diagnosed with OCD
– Began medication (Sertaline) because of severity of symptoms
and had to double the dose due to lack of response
– Risperidone added to control side effects of Sertaline (i.e.
hyperactivity, impulsivity)
– Symptoms completely resolved after 9 months of treatment
• Case 2 [27] :
– 5 year old with symptoms: swearing to God, excessive
handwashing and rituals  diagnosed with OCD
– Prescribed Sertraline and after 2 months – patient was
symptom free and has been ever since

34. Schizophrenia
• Pediatric schizophrenia is serious disorder that affects
cognition and ability to relate socially with others 
gross impairment of reality [2]
• Symptoms include delusions, hallucinations, distortion,
disordered speech and communication, catatonic
behavior, intensity of emotions and exaggeration of
behavioral control [14]
• These children are significantly delayed in their school
functioning, relationships, and self care. Again,
without medication- can be extremely dangerous to
themselves and society.

35. Schizophrenia
• Sikich et al. 2004 [30]
– Schizophrenic children and adolescents between 8-19 years
of age show significant improvement when taking either
risperidone, olazapine, and haloperiodol medication
• Sikich et al. 2008 [20]
– First and second generation atypical antipsychotics
(molindone, olanzapine and risperidone) have been shown
to significantly decrease pediatric schizophrenia symptoms
• Kranzler et al. 2005 [31]
– Schizophrenic children can often be extremely aggressive
– Clozapine treatment showed significant clinical improvement
for severely aggressive children

36. Schizophrenia
• Psychotherapy alone has not
been proven to be effective for
treating pediatric schizophrenia
– Adjunctive psychosocial
treatments (psychoeducation,
behaviorally based therapy,
cognitive-behavioral therapy)
improves symptoms and reduces
relapse rates [32]
• If the disorder is at an advanced stage- constant
hallucinations and bizarre ideation can take over the
child’s life without medication

37. Anxiety Disorders
• One of the most commonly diagnosed psychiatric
disorders affecting populations in U.S. and Europe [14]
– Includes separation anxiety, panic disorder, social phobia,
specific phobias, and generalized anxiety
• Not only distress to thought of threat, but also
cognitive feelings of losing control, unwelcome or
intrusive thoughts, inattention, insomnia, and
perceptual disturbances.
– Affects youth more than adults
because anxiety affects normal
physical and mental development

38. Anxiety Disorders
• Due to a lack of current research, there are no FDA
approved drugs for the treatment of pediatric anxiety
disorders [2]
• But numerous medications have shown promising
results:
– SSRIs: such as Fluoxentine have shown notable symptom
reduction with minimal side effects [10]
– Benzodiazepines: such as Clonazepam is useful in short-term
treatment (i.e. used to ensure child attends school) [2]
– α-2a Agonists: help with symptoms
of hyperautonomic arousal (i.e. palpitations)
– Tricyclic antidepressants [14]

39. Anxiety Disorders
Case study [2] :
– 8 year old who had symptoms of: poor academic
performance, followed mother everywhere, cried in school
everyday because hated parting with mother, would become
physically sick in school until mother came, and symptoms
lessened on weekends
– Diagnosed with SAD  prescribed sertraline and intensive
behavioral therapy
– After just one month- the child had already
improved his symptoms (began attending
schools without any argument, reduced
physical sickness in school)
– Eventually tapered off medication after
remission

40. Other Disorders
• There are several studies show evidence of psychotropic
medication decreasing symptoms in other disorders:
– Autism [2]
• SSRIs, anti-psychotic (haloperidol, thioridazine), α-2a agonists,
anticonvulsants, stimulants
– Anorexia nervosa [33]
• Atypical antipsychotics (olanzapine), appetite enhancers, mood
stabilizers
– Bulimia nervosa [33]
• Anti-depressants, Tri-cyclic anti-depressants, SSRIs (fluoxentine)
– Obesity [33]
• Anti-depressants, appetite suppressants

41. Opposition to Pediatric Psychopharmacology
Reasons Against Pediatric Meds But….
No significant evidence showing this is true  certain medications
Drug addiction
act as protective factors against later substance abuse and criminal
problems
If properly monitored and regulated by family and doctors 
Drug overdose
should not be an issue
Suicide Yes this is a possible risk- but how many suicides are we preventing
with medication? Also if suicide is a high risk- then clozapine and
lithium have been shown to be effective treatments [15]
Weight gain & other side effects Possibility- but drug dosage can be adjusted to minimize risks.
Also, what medications don’t come with possible side-effects?
Not enough research Pediatric psychopharmacology is a rapidly growing field that is
repeatedly testing medications. Also FDA works extensively before
approving any medication, and will continue to come out with
approvals for more drugs to help save children
Over-prescribed If done properly- before prescribing medication there should be an
overall extensive evaluation of the child in a variety of settings. The
problem of over-prescribing is due to lack of monitoring and
standardized system , rather than the drug itself.
Parents aren’t given a choice As mentioned before- majority of parents consult other medical
and non-medical advisors before giving their children medication.

42. Conclusions
• Clearly there is a substantial amount of evidence that
supports the use of pediatric psychopharmacology
• Of course, adjunctive therapy can definitely help…but the
unique effect of medication cannot be ignored
• These children can be
extremely sick, and medication
is the only way for them and
their family to have a chance of
a normal life

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