Chi20889 961.973

Practice Parameter on the Use of Psychotropic The purpose of this practice parameter is to promote the appropriate and safe use of psychotropic medications in children and adolescents with psychiatric disorders by emphasizing the best practice principles that underlie medication pre- scribing. The evidence base supporting the use of psychotropic medication for children and adolescents with psychiatric disorders has increased for the past 15 to 20 years, as has their use. It is hoped that clinicians who implement the principles outlined in this parameter will be more likely to use medications with the potential for pharmacological benefit in children safely and to reduce the use of ineffective and inappropriate medications or medication combinations. The best practice principles covered in this parameter include completing a psychiatric and medical evaluation, developing a treatment and monitoring plan, educating the patient and family regarding the child’s disorder and the treatment and monitoring plan, completing and documenting assent of the child and consent of the parent, conducting an adequate medication treatment trial, managing the patient who does not respond as expected, establishing procedures to implement before using medication combinations, and following principles for the discontinuation of medication. J. Am. Acad. Child Adolesc.
Psychiatry, 2009;48(9):961Y973. Key Words: practice parameter, psychopharmacology, multiple medications, treatment.
During the past 15 to 20 years, there has been a marked pharmacological and psychosocial treatments. Children are increase in our understanding of childhood psychiatric commonly affected by psychiatric disorders, and without disorders and a developing evidence base for both psycho- treatment, they can experience short- and long-term distress The primary intended audience for the AACAP practice parameters is child This parameter was developed by John Walkup, M.D., principal author, and the and adolescent psychiatrists; however, the information contained therein may also Work Group on Quality Issues: William Bernet, M.D., Oscar Bukstein, M.D., be useful for other mental health clinicians.
M.P.H., and Heather Walter, M.D., M.P.H., Co-Chairs, and Valerie Arnold, The author acknowledges the following experts for their contributions to this M.D., R. Scott Benson, M.D., Joseph Beitchman, M.D., Allan Chrisman, M.D., parameter: Daniel S. Pine, M.D., Laurence L. Greenhill, M.D., Christopher Tiffany R. Farchione, M.D., John Hamilton, M.D., Helene Keable, M.D., Kratochvil, M.D., Aradhana Bela Sood, M.D., Mark Riddle, M.D., Timothy Joan Kinlan, M.D., Jon McClellan, M.D., Ulrich Schoettle, M.D., Jon Shaw, Wilens, M.D., and Charles H. Zeanah, Jr., M.D.
M.D., Matthew Siegel, M.D., and Saundra Stock, M.D. American Academy of This parameter was reviewed at the Member Forum at the AACAP Annual Child and Adolescent Psychiatry (AACAP) Staff: Kristin Kroeger Ptakowski and From September 2006 to December 2007, this parameter was reviewed by AACAP practice parameters are developed by the AACAP Work Group on a Consensus Group convened by the WGQI. Consensus Group members and Quality Issues (WGQI) in accordance with American Medical Association policy.
their constituent groups were as follows: WGQI (Oscar Bukstein, M.D., Chair, Parameter development is an iterative process between the primary author(s), the Allan Chrisman, M.D., and Saundra Stock, M.D., Members); Topic Experts WGQI, topic experts, and representatives from multiple constituent groups, (Daniel S. Pine, M.D., and Timothy Wilens, M.D.); AACAP Assembly of including the AACAP membership, relevant AACAP components, the AACAP Regional Organizations (Susan Daily, M.D.); and AACAP Council (Aradhana Assembly of Regional Organizations, and the AACAP Council. Details of the Bela Sood, M.D., and Charles Zeanah, Jr., M.D.).
parameter development process can be accessed on the AACAP Web site.
Disclosures of potential conflicts of interest for authors and WGQI chairs are Responsibility for parameter content and review rests with the author(s), the provided at the end of the parameter. Disclosures of potential conflicts of interest WGQI, the WGQI Consensus Group, and the AACAP Council.
for all other individuals named above are provided on the AACAP Web site on the The AACAP develops both patient-oriented and clinician-oriented practice parameters. Patient-oriented parameters provide recommendations to guide clini- This practice parameter was approved by the AACAP Council on March 18, cians toward best treatment practices. Recommendations are based on empirical evidence (when available) and clinical consensus (when not) and are graded This practice parameter is available on the Internet (www.aacap.org).
according to the strength of the empirical and clinical support. Clinician-oriented Reprint requests to the AACAP Communications Department, 3615 parameters provide clinicians with the information (stated as principles) needed to Wisconsin Avenue, NW, Washington, DC 20016.
develop practice-based skills. Although empirical evidence may be available to 0890-8567/09/4809-0961Ó2009 by the American Academy of Child and support certain principles, principles are primarily based on expert opinion derived from clinical experience. This parameter is a clinician-oriented parameter.
J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTE MBER 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
and impairment. The current evidence base to address the This parameter is divided into five sections: assessment, treatment needs of these children comes from high-quality development of the treatment and monitoring plan, randomized controlled trials for most psychotropic medica- psychoeducation and assent/consent, implementation of tion classes (e.g., stimulants, antidepressants, antipsychotics) the treatment and monitoring plan, and management of and for a number of manual-based psychotherapeutic complex pharmacological interventions including medication Despite the advances of the past 2 decades, the vast Prescriber refers to any clinician who has the capacity to majority of children with mental health problems still do not evaluate children for and treat children with psychotropic receive appropriate evaluative and treatment services.2 medications (e.g., child and adolescent psychiatrists, general Reports of the increased use of psychotropic medications in psychiatrists, pediatricians, family doctors, nurse practitioners).
children3,4 suggest that prescribers, parents, and patients view Parents refer to biological parents or legal guardians. Disorder pharmacological treatment as an important intervention to refers to the target of treatment, whether it is a disorder reduce the symptoms of childhood psychiatric disorders.
or symptom cluster. Psychoeducation refers to the process of However, reports of increased psychotropic medication use imparting information about a disorder and its treatment, has also led to concerns that some children and adolescents both the generic information and information of specific are being overdiagnosed with psychiatric disorders and are relevance to an individual child and family.
being treated with medication/s that are not appropriate forthem. Strategies to address the overuse or inappropriate useof medications (e.g., the Food and Drug Administration advisory ‘‘black box’’ warning for antidepressants) may ac- A literature review of relevant articles pertaining to tually create barriers to care (e.g., decreased antidepressant psychopharmacology in children and adults was completed prescription rates5) and may result in unintended negative using the PubMed database. In addition, textbooks on consequences (e.g., increased teen suicide rate6). Rather than pediatric psychopharmacology were reviewed as were their advocating for restricting access to medication treatment, this reference lists. In addition, a PubMed search on quality parameter advocates for high-quality assessment and pre- medical care and the overuse of medical testing (e.g., routine scribing practices to enhance outcomes for children and to laboratory or radiological testing), other medical procedures address societal concerns about how children with psychiatric considered to be used excessively (e.g., cesarean section), and other medical conditions that have historically been over- There is a great range of appropriate psychopharmacolog- diagnosed or misdiagnosed and treated inappropriately (e.g., ical practice, reflecting the range of medical specialties, levels patients with viral infections treated with antibiotics) of expertise, and clinical settings of today’s prescribers. The provided background for this parameter.
principles highlighted in this parameter are not intended tocreate a uniform approach for all prescribers. A single ap-proach for all prescribers would not be applicable or practical and could inadvertently restrict children in need from accessto effective treatments. By focusing on the decision-making The increased use of psychotropic medications3,4 and principles that underlie optimal psychopharmacological prac- psychotropic medication combinations14,15 to treat child- tice, it is hoped that more children will have the opportunity hood psychiatric disorders reflects a deservedly larger role for to receive appropriate treatment with medication and reduce medication treatment of childhood psychiatric disorders. A the exposure of children to medication interventions that may number of factors have likely influenced this increased use not be appropriate. Given the focus in this parameter on the including increased support for the biological basis of some best practice principles for using psychotropic medications in childhood psychiatric disorders, a developing evidence base children and adolescents, there is limited discussion of the demonstrating the efficacy of psychotropic medications in details of the psychiatric evaluation and details about med- children and adolescents, advocacy efforts to identify and treat ication and psychosocial treatments for specific disorders.
the large number of children with psychiatric disorders, The American Academy of Child and Adolescent Psychiatry reductions in funding and changing patterns of reimburse- (AACAP) practice parameter for psychiatric assessment7 ad- ment for mental health care, and the marketing efforts of dresses specific guidelines for the evaluation of children and pharmaceutical companies to prescribers and consumers.
adolescents, and the AACAP practice parameters for the as- Advances in neuroscience suggest that childhood psychi- sessment and treatment of specific disorders8Y13 address the atric disorders can be associated with abnormalities in neuro- evidence base for psychopharmacological and psychosocial transmitters and/or structural or functional abnormalities of treatments in children and adolescents.
specific brain regions and/or the circuitry that interconnect J. AM. A CAD. C HIL D AD OLES C. PS YCHIATRY, 48: 9, SE PTEMBE R 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
affected brain regions. These abnormalities may be caused by mation as well as the larger medical literature. The product environmental factors, genetic factors, or their combination.
information for a specific medication, developed coopera- Neurobiological explanations of childhood psychiatric dis- tively by the pharmaceutical manufacturer and the Food orders are often used to support the use of psychotropic and Drug Administration, generally reflects the evidence medications for childhood psychiatric disorders (see Martin from studies sponsored by the pharmaceutical manufacturer, is geared toward marketing for a specific indication, and The current evidence base in child psychopharmacology does not always reflect the evolving evidence base that may includes basic and clinical research, which supports the safe include investigator-initiated and federally funded postmar- and effective use of psychotropic medications (e.g., random- keting studies. Consequently, prescribers may have to rely on ized controlled trials, studies of what the body does to the the reports of randomized controlled trials in the medical medication [pharmacokinetics], and what the medication does literature, consensus guidelines, and practice parameters, as to the body [pharmacodynamics]). Efficacy and safety data are well as the product information to effectively practice available for single pharmacological agents in the short-term evidence-based psychopharmacology. For some psychiatric treatment of a number of childhood psychiatric disorders, disorders, prescribers may use psychotropic medications ‘‘off- including attention-deficit/hyperactivity disorder (ADHD)16; label’’ (e.g., selective serotonin reuptake inhibitors [SSRIs] major depressive disorder17Y20; obsessive-compulsive disorder for non-OCD anxiety disorders26Y28,32) or inconsistent with (OCD)21Y25; other anxiety disorders including separation the product labeling (e.g., stimulants for children with anxiety disorder, social phobia, and generalized anxiety ADHD and tic disorders42) to best address the treatment disorders26Y32; and mania and tic disorders.33 There is also needs of children and adolescents and to be consistent with evidence supporting the use of medications for aggression and serious problems with impulse control in children with Advocacy efforts by the federal government such as Sur- disruptive behavior disorders34,35 and autism.36 For disorders geon General Satcher’s National Action Report,2 practitioner that present similarly in childhood, adolescence, and adult- organizations (e.g., AACAP, American Academy of Pediatrics, hood (e.g., schizophrenia), data from adult studies12 and from American Psychiatric Association), and family and patient extensive clinical practice8 can guide medication choices for support groups (e.g., National Alliance on Mental Illness, children and adolescents. The evidence for short-term safety Children and Adults with Attention-Deficit/Hyperactivity and efficacy is complemented by increasing information Disorder) have educated the public regarding the need for about the longer term safety and usefulness of some medica- evaluation and treatment services for childhood psychiatric disorders. Advocacy has likely resulted in decreased stigma In contrast to what is known about treatment with a and increasing interest in and use of mental heath care, single psychotropic medication, there is a smaller evidence base supporting the efficacy of medication combinations.40 For the past 10 to 15 years, significant changes in mental Psychotropic medication combinations are commonly used health services, including a shortage of child and adolescent to address complex comorbid presentations,41Y43 to enhance psychiatrists, limitations in insurance coverage for inpatient outcome for treatment-refractory or partially responsive pa- and partial hospital programs, and fewer outpatient psycho- tients,43,44 to manage side effects of an effective agent (e.g., therapy services by psychiatrists, may have also contributed to anticholinergic medication for extrapyramidal symptoms), increase in psychotropic medication use.48,49 or to address symptoms hypothesized to be associated with Finally, the increased use of psychotropic medications has multiple underlying neurotransmitter abnormalities (e.g., been attributed to the direct financial role of the pharmaceu- dopamine agonists for hyperactivity and serotonin agonists tical industry in funding clinical trials,50 financial support to for anxiety45). Although the design of studies of a single investigators,51 for resident training and continuing medical medication is relatively straightforward (e.g., randomized education,52 and direct-to-consumer advertising.53 Although controlled trials), studies of medication combinations, com- it has been repeatedly asserted that financial support for bining medication and psychotherapy,18,32,46 and studies to research and medical education at all levels has increased the address the sequence of treatment for complex presentations use of psychotropic medications, it is difficult to quantify and require more complex study designs47 and are more costly to to prove conclusively.54 Direct-to-consumer advertising on implement (e.g., Sequenced Treatment Alternative to Relieve television, which increased dramatically in the mid-1990s, has Depression). The cost and complexity of these studies may been posited as eliciting inappropriate demand that leads to partially explain the lack of such studies in children and inappropriate prescribing, yet direct-to-consumer advertising has also been demonstrated to be a helpful educational tool to The evidence base on which prescribers depend to make increase awareness of treatment options for disorders that are treatment decisions includes a medication’s product infor- undertreated or stigmatized, such as depression.55 J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTE MBER 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
The purpose of this practice parameter is to promote the public’s perception of prescribers of psychotropic medications safe and appropriate use of psychotropic medications in chil- and lead to a loss of public support for psychiatric treatment dren and adolescents with psychiatric disorders by empha- sizing the best practice principles that underlie medicationprescribing. There are multiple steps involved in the use ofpsychotropic medication in children and adolescents. First, the prescriber is responsible for completing an evaluation ofthe patient and family. The evaluation leads to a diagnostic formulation and the development of a psychosocial and Principle 1. Before Initiating Pharmacotherapy, a Psychiatric psychopharmacological treatment plan based on the best Evaluation Is Completed. The psychiatric evaluation7 is com- available evidence. The pharmacological treatment plan prehensive enough to identify symptoms best addressed includes not only an adequate medication trial but also pharmacologically and best addressed with psychosocial treat- strategies for preparing the patient and family and monitoring ments and to identify psychosocial factors that may impede an outcome and side effects. Before initiating the medication adequate and safe medication trial or confound the assess- treatment plan, the patient and family need to be educated ment of outcome. A comprehensive evaluation increases the about the child’s problem, treatment options, and the treat- likelihood that medication interventions will be well concep- ment and monitoring plan. The education of the patient and tualized and hopefully reduces the likelihood of treatment parent sets the stage for obtaining assent for treatment from failure and poor adherence. Attention to psychosocial factors the child and consent from the parents. Treatment is initiated in the evaluation helps to ensure that psychosocial approaches according to the treatment plan with strategies to monitor for both benefits and side effects. Once the patient is stabilized on The psychiatric evaluation includes interviews with both medication, monitoring visits occur regularly and predictably the child and parents. During the assessment, the confidenti- enough to enhance the patient’s and family’s confidence in ality needs of both the child and parents are balanced against the treatment and prescriber and to ensure effective manage- the need for all involved to have a common information ment of longer term treatment and safety issues. Finally, if base on which to make treatment decisions. A review of clinically indicated, the clinician, patient, and family identify previous records to assess past successful and unsuccessful a time for a medication discontinuation trial and have a plan treatments can enhance the likelihood that proposed inter- for follow-up that will allow children to discontinue medica- vention will be the next logical treatment step and reduce tion with minimal risk for an unmonitored relapse/recurrence the chance that previously ineffective treatments will be The prescriber establishes procedures to implement these tasks and uses them routinely to provide high-quality care Principle 2. Before Initiating Pharmacotherapy, a Medical that integrates the psychopharmacological evidence base, History Is Obtained, and a Medical Evaluation Is Considered state-of-the-art clinical skills, and the patient’s and family’s When Appropriate. Because a medication intervention in a needs and values. The clinician who establishes a high-quality child is a significant medical event, it is prudent to complete a approach to assessment and treatment will hopefully practice medical evaluation to ensure that the child has no medical more consistently and have patients and families who under- problem accounting for the psychiatric presentation and is stand, adhere to, and actively participate in the interven- healthy enough to participate in a medication trial with min- tion and assessment of outcome. A proactive and positive imal risk. For example, the medical history helps to determine approach may also decrease the stigma that some children and whether the child has any current or past medical problems; their parents experience from participating in psychiatric care.
is taking any medications including prescribed medications, For clinicians who do not use a rigorous consistent approach over-the-counter medications, complementary/alternative to assessment and treatment, it is possible that they will treatments, or illicit substances; has medication allergies; or introduce unacceptable variability into the pharmacological has a personal or family history of medical problems asso- treatment of children, underuse psychosocial and pharmaco- ciated with increased risk for side effects (e.g., a personal logical treatment approaches, and succumb to the use of history of a structural cardiac abnormality before starting ineffective treatment approaches or inappropriate medica- stimulants or family history of malignant arrhythmias or tions or medication combinations. Children and families who sudden cardiac death before starting atypical antipsychotics).
do not receive high-quality mental health care may become Targeted medical testing may be appropriate to establish a demoralized by their care experience and may drop out of medical baseline before initiating medications with known risks treatment or not seek treatment in the future. It is also (e.g., height and weight for stimulants13; height, weight, and possible that poor quality of psychiatric care may affect the lipid testing for antipsychotics56). Although a routine history, J. AM. A CAD. C HIL D AD OLES C. PS YCHIATRY, 48: 9, SE PTEMBE R 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
physical, and laboratory testing completed by a pediatric nance phase, during which responders to treatment consoli- specialist is not necessary before starting most psychotropic date their gains and remission or recovery occurs; and a medications, completing such an evaluation just before starting discontinuation phase during which, if clinically indicated, medication may be useful to document that a child is healthy medication is successfully tapered with minimal risk for and establishes a normal baseline. Such a medical screening relapse/recurrence.57 The initial discussion of the treatment evaluation may also put the patient, family, and prescriber at plan with the patient and family includes a discussion of the ease and thereby facilitate the initiation of the medication trial.
goals and approaches used in all phases of treatment.
Specific recommendations regarding medical screening are At the beginning of the acute phase of treatment, psycho- included in specific AACAP practice parameters for disorders social interventions to address patient and family factors that for which medication treatments have proven benefit (e.g., may impede the medication trial (e.g., inadequate supervision ADHD, anxiety disorders, mood disorders).
of medication adherence) or the assessment of outcome (e.g.,parental lack of an understanding of target symptoms or Principle 3. The Prescriber Is Advised to Communicate With common side effects) are initiated. Most clinicians will ad- Other Professionals Involved With the Child to Obtain dress this as part of the psychoeducation of the patient and Collateral History and Set the Stage for Monitoring Outcome and Side Effects During the Medication Trial. Good commu- The plan for the medication trial is specific: starting dose, nication and coordination among medical, mental health, timing of dose changes, estimated maximum dose or blood and education professionals involved in the child’s life is level, strategies for monitoring and managing medication important for the safe and effective use of psychotropic side effects, duration of the trial, assessment strategies (e.g., medications. Communicating with these professionals during self-reports, parent reports, teacher reports), and alternative the evaluation process ensures that the evaluation is complete treatment strategies if the child is partially responsive or and sets the stage for subsequent interactions during treat- the trial is not successful. The AACAP practice parameters ment. Early communication also elicits the support of key for specific disorders referenced above describe the detailed professionals for the treatment plan (e.g., pediatricians who strategies for choosing a medication, starting doses and provide ongoing medical care, school nurses who may dis- adjustment schedules, trial duration, and monitoring out- pense medication, teachers who may be involved in evaluating the outcome) and may reduce the chance of misunder- Traditionally, psychosocial treatment is recommended standings during treatment. Follow-up among professionals before pharmacological treatment. However, data are in- during treatment enables all professionals involved to be up creasingly available from comparative treatment trials to guide to date with the treatment plan and that treatment is well the selection of first-line treatment. To date, randomized controlled trials suggest that medication management forADHD is the first-line treatment16 and that medicationcombined with behavioral treatment may be required for optimal outcome in children with more complex problems.58 Principle 4. The Prescriber Develops a Psychosocial and For OCD, beginning with cognitive-behavioral therapy, Psychopharmacological Treatment Plan Based on the Best Avail- especially if delivered by expert psychotherapists, or com- able Evidence. After completing the evaluation, the prescriber bined treatment is the best first option.46 In contrast, the organizes the case material into a diagnostic formulation that Treatment of Adolescent Depression Study demonstrated ef- considers biological, psychological, and social etiologies for ficacy for combination therapy and medication management the patient’s problems. The treatment plan will include strat- but not for cognitive-behavioral therapy alone at 12 weeks, egies to ready the patient and family for treatment, the suggesting that beginning with psychotherapy only in mode- specific pharmacological and psychosocial treatments neces- rate to severe depression may not be the best first step.18 sary to address the various targets of treatment, the timing Prescribers are guided by the evidence base in developing and sequencing of psychosocial and psychopharmacological their treatment plan. However, the evidence base for pediatric interventions, and the strategies for monitoring outcome and psychopharmacology is far from complete40 and may not be side effects. Pharmacological treatments can be initiated specifically applicable or adequate to maximizing outcome before, concurrent with, or after psychosocial treatments, for the child. For example, when the severity of the child’s depending on the evidence base and needs of the patient.
problem is such that the disorder precludes active participa- Treatment with medication can be considered to have tion in targeted psychosocial treatment (e.g., OCD with psy- three phases: an acute phase, which includes the initiation chotic symptoms), beginning with medication and supportive of medication treatment and subsequent dose adjustments to psychological treatment may be a reasonable approach. Also, maximize response and minimize side effects; the mainte- although empirically supported psychosocial treatments may J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTE MBER 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
be first line as in OCD, many communities lack skillful for dose titration, by the timing of onset of side effects, and providers of such treatments. In these communities, starting to maintain the doctorYpatientYfamily relationship. For ex- treatment with medication may be the only evidenced-based ample, medications that require multiple upward adjustments in dose may require more frequent visits initially than medi- At some point in the transition from the acute phase to the cations with fewer dosing adjustments. Monitoring medica- maintenance phase of treatment, the prescriber reviews the tions with significant early-onset side effects (e.g., appetite progress to date and discusses the plan for maintenance suppression and insomnia on stimulants) would lead to more treatment. The discussion of maintenance treatment goals is frequent early visits; monitoring for late-onset side effects often easier for patients and parents than the discussion of (e.g., change in growth trajectory on stimulants) require at initiating treatment, as moving into the maintenance phase minimum the frequency of visits to ensure that side effects are suggests that the patient has experienced some benefit and detected. Follow-up visits are also an opportunity to provide satisfactorily has passed through the period for acute side psychosocial support, to address stressors and problems with effects. The frequency of visits during the maintenance phase adherence. Using rating scales in follow-up visits can be reflects the goals of maintaining response and adherence, helpful to follow symptom severity; similarly, systematically reducing functional impairment, and monitoring for late- documenting information on drug-specific side effects (e.g., onset side effects (e.g., tardive dyskinesia) or side effects of weight gain, height, blood pressure) may be useful. The accumulating significance (e.g., weight gain, slowed growth) AACAP practice parameters for specific disorders (referenced and the development of co-occurring conditions.
above) offer guidelines on appropriate monitoring strategies.
If the patient has evidenced a sustained period of remission The clinician, patient, and family should develop an indi- or recovery and the prescriber believes that the medication vidualized monitoring plan appropriate to the needs of the may no longer be necessary, a discontinuation trial may be patient and family and consistent with the prescriber’s role clinically indicated. Before initiating a discontinuation trial, the plan for discontinuation is reviewed with the patient and During the maintenance phase, visits may not need to family focusing on the risks of discontinuation (e.g., the risks occur frequently. For example, children and adolescents with for withdrawal symptoms and the risk for relapse or stable high-quality response and good adherence can be seen recurrence of symptoms) and the treatment plan if symptoms as infrequently as two to four times per year. Children and return. This is especially important if the patient was signifi- families under psychosocial stress or who have problems with cantly impaired or suicidal before medication treatment. A adherence may need more frequent visits to maintain a high- specific plan for tapering and discontinuing medication and appropriate frequency of monitoring visits prevents with- During the discontinuation phase, patients may actually drawal effects of medication and allows the clinician to need to be seen more frequently than during the maintenance identify early relapse/recurrence of symptoms. Monitoring phase. Close monitoring as the dose of medication is being children for a period of time after they are off medication lowered and, for a period of time thereafter, ensures that allows for early identification of relapse/recurrence before withdrawal symptoms and early signs of relapse/recurrence The AACAP practice parameters, consensus guidelines, and There are few data to help determine how long to monitor treatment algorithms (e.g., Texas Medication Algorithm Proj- a child after the discontinuation of medication; however, the ect, http://www.dshs.state.tx.us/mhprograms/TMAPover.shtm) duration of follow-up reflects the risk for relapse in the short provide detailed information about treatment approaches term and risk for recurrence of illness over the longer term.
to patients with various disorders at the various phases of For example, in children with anxiety disorders, a monitoring period off medication of up to 6 months may be reasonable,given the time and financial burden of such follow-up and the Principle 5. The Prescriber Develops a Plan to Monitor the low risk for relapse/recurrence for children who remain Patient, Short and Long Term. Many factors are involved in asymptomatic 6 to 12 months after treatment has been determining a monitoring strategy for children on psycho- discontinued.59 After discontinuation, visits may occur more tropic medications including the type of medication, the risk frequently in the first few months and less frequently for and timing of onset of side effects, the patient’s need for thereafter. It may be useful to schedule such follow-up visits ongoing psychological support, the patient’s and family’s risk before high-stress periods (e.g., the start of school for children for nonadherence, and the phase of treatment. Discussion of with separation anxiety) or periods of known risk for recur- the monitoring plan with the patient and family includes the rence (e.g., winter for seasonal affective disorder). For major frequency of visits and methods used to assess outcome and depressive disorder and other disorders with a high risk side effects. The frequency of visits is determined by the need for recurrence, it may be prudent to monitor children who J. AM. A CAD. C HIL D AD OLES C. PS YCHIATRY, 48: 9, SE PTEMBE R 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
have discontinued medication at low frequency into Pharmacopoeia handouts) can be a useful adjunct to in- To put the specific child’s treatment plan into context, the Principle 6. Prescribers Should Be Cautious When Imple- prescriber discusses how his or her plan for the patient and menting a Treatment Plan That Cannot Be Appropriately family reflects the evidence base and relates to the usual care Monitored. Implementing a pharmacological intervention re- in the local community (i.e., the plan is more or less intensive quires extra caution in clinical situations in which there are than usual care or consists of medication management only or barriers to monitoring the patient for outcomes and side psychotherapy only). This information provides the patient effects. For example, a pharmacological trial is more challeng- and family an opportunity to evaluate the prescriber’s plan ing to implement when there is inadequate adult supervision, vis-a`-vis the evidence base and the practice pattern of other limited patient and family investment in treatment, or a high prescribers. Although the spectrum of clinical practice is risk for nonadherence. Barriers to monitoring outcome and broad, the prescriber should be familiar with the standard of adherence increase the risk that the medication trial may be care within his or her community and be able to commu- deemed unsuccessful or incomplete and increase the risk for nicate how he or she practices pharmacotherapy. As phar- inappropriate dosing, frequent medication switches, or the macological treatment of childhood psychiatric disorders is use of medication combinations. For example, if a prescriber increasingly a topic in the media, the prescriber’s under- is unaware that medications are not provided as planned, the standing of recent controversies (e.g., SSRIs and suicidality) prescriber may unknowingly increase the dose or add a second and how they have an impact on treatment planning is critical to prescribing psychotropic medications to children.
Extended psychoeducation to address specific attitudinal or psychological issues regarding medication and/or specific psychosocial interventions to stabilize the home environment Principle 7. The Prescriber Provides Feedback About the may be necessary to ready some patients and families to Diagnosis and Educates the Patient and Family Regarding the effectively implement or monitor a pharmacological treat- Child’s Disorder and the Treatment and Monitoring Plan. After ment trial.62 For example, some teenagers may see taking completing the evaluation and developing the treatment and medication as making them only ‘‘different’’ but not ‘‘better.’’ monitoring plan, the prescriber educates the patient and the Similarly, some families may not understand their child’s family about the child’s problems, treatment options, and difficulties from a psychopharmacological point of view (e.g., the treatment/monitoring plan. Such psychoeducation of the ‘‘He doesn’t need medication, he just won’t listen.’’), have patient and family prepares them to assent and consent for difficulty understanding how medication may be useful (e.g., treatment. The psychoeducation of the patient and family ‘‘Aren’t all teenagers moody?’’), have too high (or too low) addresses the target of treatment, including the disorder’s expectations for medication treatment, or worry excessively signs and symptoms; the course, including common compli- cations (e.g., risk for oppositional behavior in children with For the effective implementation of the trial, prescribers ADHD) or potential for evolution of symptoms over time need to clarify who is responsible for the various elements of (e.g., recurrent depression may ultimately evolve into bipolar the treatment plan. The responsibility for some elements may disorder); and the long-term prognosis (e.g., tic severity fall to the family and some to other professionals involved generally improves in late adolescence).60 Specific risk factors with the child (e.g., teacher ratings during stimulant treat- (e.g., poor parenting skills) and protective factors (e.g., aca- ment). Parents are ultimately responsible for storing medica- demic ability) that may affect the outcome of treatment also tion safely and monitoring medication adherence, benefits, can be discussed. Negative attitudes about medication and and side effects. Empowering the child to identify and com- the risk for adverse psychological reactions to taking medica- municate benefits and problems with the medication trial is tions in some children and their families are to be addressed also important. Although there can be variability in how directly.61 The specifics of the medication treatment plan are children and families choose to implement pharmacological provided: generic and trade name of the medication, starting treatment (e.g., older teens taking more responsibility for dose, timing of dose changes, estimated peak dose or blood taking their medication), being clear with the patient and level, strategies for monitoring and managing medication side family regarding their specific roles and responsibilities in effects, duration of the trial, assessment strategies (e.g., self- treatment and strategies for managing his or her medication report, parent report, teacher report), alternative treatment may improve adherence and enhance outcome. The pre- strategies, and the plan if the child does not respond as scriber also needs to be clear with the family about his or expected. Providing high-quality printed information from her role in treatment. Some prescribers restrict their role to reliable sources about the proposed medication (e.g., U.S.
pharmacotherapy only, others will prescribe medication only J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTE MBER 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
if they are also responsible for the psychotherapy, and some The duration of the assent/consent procedure will vary, who can prescribe may restrict their practice to assessment/ depending in part on how well the prescriber has prepared the consultation or psychotherapy only. Patients and their fam- patient and family. Many of the issues to be addressed during ilies may not always understand that prescribers can delimit assent/consent are part of the prescriber’s psychoeducation of their role in these ways and may expect the prescriber to the patient and family. The assent and consent discussion for function more comprehensively. Clinicians who limit the most patients and families can be completed in a single session.
range of interventions provided may unwittingly implement atreatment plan that does not address the complexity of the Principle 9. The Assent and Consent Discussion Focuses on the patient’s problems. For example, it is possible that patients Risks and Benefits of the Proposed and Alternative Treatments.
who receive medication management only may not have their The content of assent/consent discussion should meet the psychosocial needs assessed or treated and run the risk for current ethical and medical-legal standards. As consent stan- being given medications to address problems that might be dards evolve over time, and are tailored to meet the needs of better addressed through psychosocial interventions. Simi- the patient and family, it is critical for prescribers to be aware larly, clinicians who only practice psychotherapy may not use of the standard of care in their specialty, their community, medications when clinically appropriate.
and more specifically what patients and families need to knowto actively participate in the treatment. A variety of resources Principle 8. Complete and Document the Assent of the Child are available to clinicians about the standards for consent; and Consent of the Parents Before Initiating Medication however, most published information concerns informed Treatment and at Important Points During Treatment. Assent consent for research. For more specific information about the and consent is considered an ongoing process of relationship consent standard for prescribers in clinical practice, a discus- building with both the patient and the family that begins with sion with the prescriber’s malpractice carrier may be helpful.
the evaluation and continues after treatment has been initi- Basic information provided during assent/consent would ated. A specific assent/consent discussion before initiating a include the target of treatment, that is, signs and symptoms new medication treatment provides an opportunity for the present in a particular child; the potential for benefit and side prescriber to summarize the findings from the assessment, for effects; the risks of not treating with medication; the timing the prescriber to present the treatment/monitoring plan, and and method of assessing outcome and side effects; the time for the child and parent to have their questions and concerns commitment for treatment and monitoring; a description of addressed. The assent/consent procedure also provides the the usual care in the community, including treatment alterna- clinician an additional opportunity to assess what the patient tives (e.g., both medication and psychosocial alternatives) and and family understands of the child’s problems and their their respective benefits and risks; a clear expectation that the readiness and commitment to participate in treatment. After family and patient will participate actively in the trial; and treatment has begun, the prescriber continues to assess what to do if problems develop in treatment or the child does whether the family and patient truly understand the process in which they are involved and determines whether the family The prescriber has the responsibility to place the benefits is providing ongoing assent/consent for the care they receive.
and risks of the medication trial into perspective for the As assent/consent is an ongoing process; it is recommended patient and family. For example, it can be helpful for parents that before initiation of any additional psychotropic medica- to understand that the goal of the acute phase of treatment is tions, at the transition to the maintenance phase, and before to know how well their child responds to a medication and a discontinuation trial, the prescriber, patient, and family that the vast majority of side effects encountered during the review the rationale for treatment; the past treatment expe- acute phase (e.g., stomachaches, sedation, insomnia) respond rience; and the benefits, risks, and alternative treatments for to dose reduction or discontinuation and have little lasting each additional medication or the next phase of treatment.
significance. If the child responds, then the parents have to Prescribers should document in the patient’s medical decide whether to transition to the maintenance phase of record the initial assent/consent procedure as well as ongoing treatment. Thus, at the end of a successful short-term trial, assent/consent during treatment. The documentation does patients and parents are weighing the observed benefit of not have to be extensive, but it does need to reflect adequately medication against the acute side effects and potential for any what occurred in the discussion with the patient and family. It longer term risks of the medication. Reassuring patients and is also useful for the prescriber to document that the patient parents that the prescriber will discontinue medications that and family had an opportunity to ask questions and have are not useful or have unacceptable side effects may increase them answered and that the family understood the nature of patients’ and parents’ comfort with starting medication.
the target of treatment and the specific risks and benefits of Although it is not possible to provide a full and complete description of all the potential benefits and risks of the J. AM. A CAD. C HIL D AD OLES C. PS YCHIATRY, 48: 9, SE PTEMBE R 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
proposed treatment and alternative treatment options, patient and parents should understand that some children respond Principle 10. Implement Medication Trials Using an well to medication treatment, and some do not respond at all.
Adequate Dose and for an Adequate Duration of Treatment.
Common and expectable risks of the medication as well as For most medications, there is a dose level of the medication patient- and family-specific risks (e.g., the potential for added (measured by milligrams per day, milligrams per kilogram per risk for antipsychotic-induced weight gain in a child with day, or blood level) and duration of the treatment trial (based obesity and a family history of type II diabetes) are discussed.
on pace of upward adjustment and time frame for observing Adverse events that may have prognostic significance (e.g., a response) that will qualify a medication trial as adequate.
switching to mania on antidepressants) are rare, but clinically For example, stimulants can be dosed empirically or on important adverse events (e.g., development of suicidal idea- milligrams per kilogram per dose or milligrams per kilogram tion during the medication treatment of depression) are also per day basis. An older child may require larger doses and discussed. It may also be useful to discuss with patients and more upward dose adjustments than a younger and smaller families that unexpected, unique, and perhaps even life- child; therefore, the trial may take longer for older and threatening events may occur during the course of treatment larger children. Antidepressants do not work as quickly as that may or may not be related to medication (e.g., sudden stimulants and may require upward of 8 weeks of treatment unexpected cardiac death). Although general information on an optimal dose to identify a response (Child Medication about the medication plan are shared, issues of specific Algorithm ProjectVMDD Tactics, http://www.dshs.state.tx.us/ relevance to the patient and family are also discussed (e.g., mhprograms/mddpage.shtm). Completing a trial of adequate alcohol use and unprotected sex during medication treatment dose and duration gives the child the best chance to be able to for at-risk teenagers) and addressed (e.g., problems with pill benefit from a single medication. The outcomes of medication swallowing in younger children and teenagers’ concerns about trials that are not adequate in either dose or duration are taking medication at school or on overnight activities). As difficult to interpret. Inadequate medication trials may increase many families may learn about medication benefits and risks the risk that children will not have the opportunity to benefit in the popular media, specifically addressing the controversies or put children at risk for multiple medication switches or regarding the use of medication for childhood psychiatric medication combinations. For example, a child given too low a disorders may be useful (e.g., suicidality associated with dose because of unrealistic concerns about side effects may fail antidepressant use and the cardiac risks of stimulants). Much to respond. Yet because the child was exposed to medication, of the information discussed during assent/consent may not the patient, family, and prescriber may consider the child a be retained by the patient and family, and periodic review ‘‘nonresponder’’ and then treat the child with second-line of the goals of treatment, as well as risks and benefits of medications or multiple medications.
Clinicians should confidently provide information regard- Principle 11. The Prescriber Reassesses the Patient if the Child ing risks and benefits and then put the treatment recom- Does Not Respond to the Initial Medication Trial as Expected. A mendation into context: How important is it to consider variety of factors can be involved in an unexpected lack of medication? What is a reasonable time frame for patients and response to a medication trial: the original assessment was not parents to deliberate? For example, in a child with excellent accurate (e.g., comorbid disorders or psychosocial factors were coping and mild to moderate depression, it may be advisable unaccounted for or not addressed adequately), the family was to attempt a trial of psychotherapy first63 or to allow the not ready to implement and participate in the trial, the trial family and patient more time to consider pharmacological did not include an adequate dose or duration of medication treatment. On the other hand, it may not be appropriate for treatment, or there was poor adherence. If the acute phase parents to delay pharmacological treatment of a depressed and trial was adequate in dose, duration, and adherence, then a suicidal teenager because of concerns regarding the risk for reassessment of the patient is appropriate. The reassessment readily managed side effects. Emphasizing the benefits and can include a review of the original assessment and treatment minimizing the risks of pharmacological treatment to enhance plan, an actual psychiatric reassessment of the patient, or the chance that the family and patient will agree to a medi- cation trial is not consistent with good clinical care. The Prescribers need to be particularly alert to mistaking be- prescriberYpatient relationship may be harmed, if the discus- havioral and emotional reactions to psychosocial stressors sion of side effects is not detailed enough and significant as symptoms of an underlying biological illness. Such mis- attribution can occur not only during the initial evaluation Prescribers are encouraged to have a similar discussion but also during treatment. For example, children recovering before adding additional medications and before the transi- from a major depressive disorder may have persistent aca- tion to maintenance and discontinuation phases.
demic and social disability and may become irritable when J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTE MBER 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
facing academic or social challenges. If the irritability is part the use of two antidepressants to cover two neurotransmitter of the mood disorder, then medication treatments may be systems (i.e., using a serotonergic and a noradrenergic anti- appropriate. If, however, the irritability is related to the chal- depressant for a certain profile of depressive symptoms). Basing lenge of getting back to the previous level of functioning after treatment decisions on theories about central nervous sys- a significant depressive episode, then psychosocial interven- tem functioning or clinical correlates of hypothesized neuro- tions may be more useful. The problem of using medications transmitter abnormalities (e.g., specific symptom profiles, to address ‘‘all’’ of a patient’s symptoms is not isolated to EEG, single-photon emission computed tomography testing) prescribers. Other stakeholders in the child’s life (e.g., may put patients at risk for unnecessary medication com- parents, teachers) may also believe that fluctuations in binations ‘‘to cover the neurotransmitter bases’’ or ‘‘to treat ‘‘symptoms’’ need to be addressed by medication changes the EEG or single-photon emission computed tomography or additions. The prescriber who does not appreciate the need for combined psychosocial and psychopharmacologicaltreatment for children with concomitant psychosocial prob- Principle 13. Discontinuing Medication in Children Requires lems (e.g., ADHD with oppositional defiant disorder58) a Specific Plan. More is known about starting children on may unnecessarily expose the child to increasingly complex medication than about how long to treat and how best to pharmacological treatment strategies.
discontinue one or more medications in children. Discon-tinuing medications can occur for a variety of reasons: the Principle 12. The Prescriber Needs a Clear Rationale for patient seems to have recovered and may no longer need med- Using Medication Combinations. Before the use of medication ication, the patient has developed side effects to the medication combinations, the prescriber needs to develop a treatment that make it untenable for the patient to continue to take the and monitoring plan, educate the patient and family, obtain medication (e.g., weight gain, concerns about growth or the assent/consent, and then implement the treatment trial as development of involuntary movements), or the patient may be described under the principles above.
taking a medication that the current prescriber does not feel is Commonly used psychotropic medication combinations warranted or is considered to be no longer effective. A thought- include the following: medication combinations used to treat ful and safe plan for medication discontinuation is as impor- multiple disorders in the same patient (e.g., a stimulant and tant as a thoughtful and safe plan for starting medications.
an SSRI for ADHD and anxiety41 or an antipsychotic and an Before discontinuing any medication, prescribers are SSRI for tics and OCD43), medication combinations that encouraged to obtain the history of previous psychiatric offer unique treatment advantages for a single disorder (e.g., symptoms and response to medication. The history gathering the addition of lithium to ongoing antidepressant treat- can start with the patient and family; however, a review of ment44), and medication combinations to address side effects medical records and discussion with the previous prescribers of an effective agent (e.g., benztropine for extrapyramidal may also be useful. Although many patients can describe the symptoms secondary to an antipsychotic).
symptoms of the disorder for which medication was given, Although it is possible that combining medications from not all patients and families are able to do so, and collateral the same class may have empirical support in the future, there history may be critical to making a decision to implement is limited support for such approaches at this time. For a discontinuation trial. Reviewing the history is especially example, there is limited evidence in children and adolescents important for the prescriber who believes that the current for the use of two antidepressants or two antipsychotics as medication is not warranted or is no longer effective.
an initial treatment approach or as a specific endpoint for Reviewing the history ensures that the patient will not be treatment. However, it is not uncommon for patients to be exposed to medication discontinuation that may result in a taking two antidepressants or two antipsychotics at the same needless and unexpected return of symptoms.
time when transitioning from one medication to another. For Developing a monitoring plan for a discontinuation trial bipolar disorder in adults, data do support the use of two is also critical. Although it may take only hours to days to mood stabilizers,64 and there is preliminary support for the identify a return of hyperactivity symptoms in a child with use of similar strategies in children with bipolar disorder.65 ADHD off stimulants, a more extended period of monitoring In addition, two stimulant formulations (i.e., short and may be required to determine whether patients with the in- long acting) may be used to ‘‘sculpt’’ dosing for coverage of attentive subtype of ADHD are having a return of symptoms.
Similarly, patients with mood and anxiety disorders may be Evidence supporting medication combinations based on a able to have their medication tapered only to have a return of matching medication mechanism of action with a hypothe- symptoms weeks to months after their last dose. Medication sized underlying central nervous system abnormality is rudi- discontinuation in inpatient or partial hospital settings mentary at best. For example, there is limited data to support with short lengths of stay may be particularly problematic.
J. AM. A CAD. C HIL D AD OLES C. PS YCHIATRY, 48: 9, SE PTEMBE R 2009 Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
Discontinuation of effective medications in such settings may became depressed, it might be more appropriate to discon- result in an unexpected and unmonitored return of symptoms In all of the above cases, the role of the underlying and Although some medications may not actually require most severe condition and the sequence and rationale for gradual tapering, prescribers are generally encouraged to taper which medications were combined contribute to the plan for medication slowly to avoid withdrawal symptoms (e.g., discontinuation of multiple medications in children.
benzodiazepines or SSRIs) or rebound worsening of symp-toms (e.g., antipsychotics for tics or lithium for mania).
Gradual tapering may also be prudent if it is unclear whetherthe current medication is having a beneficial effect.
The AACAP practice parameters are developed to assist At this time, there are little or no data to suggest which clinicians in psychiatric decision making. These parameters medication to remove first in children who are taking are not intended to define the standard of care, nor should multiple medications. Given the lack of data, the examples they be deemed inclusive of all proper methods of care or follow general clinical reasoning. If a child is taking two exclusive of other methods of care directed at obtaining the medications that target the same disorder, the first medication desired results. The ultimate judgment regarding the care of a to be removed would likely be the medication that was used particular patient must be made by the clinician in light of all adjunctively or as an augmenter. For example, in children of the circumstances presented by the patient and his or her with OCD treated first with clomipramine and later with a family, the diagnostic and treatment options available, and benzodiazepine or antipsychotic to further reduce anxiety, it would be reasonable to reduce and eliminate the benzo-diazepine or antipsychotic first. Similarly, in a child with Disclosure: Dr. Walkup receives or has received research support from depression who had a partial response to antidepressants and Eli Lilly & Company, Pfizer, and Abbott Laboratories; acted as a then achieved remission with lithium augmentation, remov- consultant and/or served on an advisory board for Eli Lilly & Company, ing the lithium may be the most appropriate first step. A GlaxoSmithKline, and Cliffs Communities; and receives or has received corollary to this approach is to keep the medication with the honoraria from CME. Dr. Walkup’s spouse serves as a consultant to most prophylactic efficacy or the one with the least long-term Abbott Laboratories. Dr. Bukstein receives or has received researchsupport, acted as a consultant, and/or served on the speakers’ bureaus of side effect potential. For example, a teenager with bipolar McNeil Pediatrics and Novartis Pharmaceuticals. Drs. Bernet and disorder may have derived equivalent benefit from an anti- Walter have no financial relationships to disclose.
psychotic and lithium. Given the relative long-term safetyprofile and prophylactic effects of these medications, the antipsychotic might be tapered first.
If a child is on two medications, one for the underlying disorder and the second to manage side effects of the first, it is References with an asterisk (*) are particularly recommended.
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