Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.18d Pharmacotherapy

specialize in special educational and structured environmen- tal needs of mentally retarded children. Others offer special therapeutic efforts required to treat children with autism and schizophrenia. Still other programs provide the total spectrum of treatment usually found in full residential treatment, of which they may be a part. Children may move from one part of the program to another and may be in residential treatment or day treatment according to their needs. The school program always is a major component of day treatment, and psychiatric treat- ment varies according to a child’s needs and diagnosis. Results Recently, attempts have been made to analyze the treatment outcome of day treatment and partial hospitalization. Many dif- ferent dimensions exist to analyzing overall benefits of such pro- grams. Assessment of level of improvement in clinical status, academic progress, peer relationships, community interactions (legal difficulties), and family relationships are some pertinent areas to measure. In a recent follow-up 1 year after discharge from a partial hospital program, comparison of patients at admission and 1-year post-discharge showed statistically sig- nificant improvement in clinical symptoms on each subscale of the Child Behavior Checklist, except for sex problems. These improvements were in mood symptoms, somatic complaints, attention problems, thought problems, delinquent behavior, and aggressive behavior. The assessment of long-term effectiveness of day treatment is fraught with difficulties, from the point of view of a child’s maintenance of gains, a therapist’s view of psy- chological gains, or cost-to-benefit ratios. At the same time, the advantage of day treatment has encour- aged further development of programs. Moreover, the lessons learned from day treatment programs have moved mental health disciplines toward having services follow children, rather than perpetuating discontinuities of care. The experiences of day treatment for psychiatric conditions of children and adolescents have also encouraged pediatric hospitals and departments to adopt a model that promotes continuity of care for the medical treatment of children with chronic physical illnesses. R eferences Aarons GA, James S, Monn AR, Raghavan R, Wells RS, Leslie LK. Behavioral problems and placement change in a national child welfare sample: A prospec- tive study. J Am Acad Child Adolesc Psychiatry. 2010;49:70–80. Baeza I, Correll CU, Saito E, Aranbekova D, Kapoor S, Chekuri R, De Hert M, Carbon M. Frequency, characteristics and management of adolescent inpatient aggression. J Child Adolesc Psychopharmacol. 2013;23:271–281. Damnjanovic M, Lakic A, Stevanovic ED, Jovanovic A. Effects of mental health on quality of life in children and adolescents living in residential and foster care: a cross-sectional study. Epidemiol Psychiatr Sci. 2011;20:257–262. Epstein RA Jr. Inpatient and residential treatment effects for children and adoles- cents: A review and critique. Child Adolesc Psychiatr Clin N Am. 2004;13:411. Geller JL, Biebel K. The premature demise of public child and adolescent inpa- tient beds: Part I: Overview and current conditions. Psychiatric Q. 2006;77:251. Geller JL, Biebel K. The premature demise of public child and adolescent inpatient beds: Part II: Challenges and implications. Psychiatr Q. 2006;77(4):273–291. Kober D, Martin A. Inpatient psychiatric, partial hospital and residential treat- ment for children and adolescents. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9 th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:3766. Miller L, Riddle MA, Pruitt D, Zachik A, DosReis S. Antipsychotic treatment patterns and aggressive behavior among adolescents in residential facilities. J Behav Health Serv Res. 2013;40:97–110. Noftle JW, Cook S, Leschied A, St Pierre J, Stewart SL, Johnson AM. The trajec- tory of change for children and youth in residential treatment. Child Psychiatry Hum Dev. 2011;42:65–77.

31.18d Pharmacotherapy Over the last decade, increasing evidence has emerged regard- ing the efficacy and safety of psychopharmacological agents to treat child and adolescent psychiatric disorders. Random- ized placebo-controlled trials have confirmed the short-term efficacy of selective serotonin reuptake inhibitors (SSRIs), for depressive disorders, anxiety, and OCD; second-gener- ation antipsychotics (SGAs) for psychosis and aggression; and multiple central nervous system stimulants for ADHD. Published data support the short-term efficacy and safety of fluoxetine, sertraline, fluvoxamine, and escitalopram in the treatment of youth depression, anxiety disorders and OCD. First-line evidence-based treatment for ADHD, has preferen- tially shifted toward long-acting stimulant medications, includ- ing methylphenidate preparations (Concerta) and amphetamine and amphetamine salt preparations (Adderall XR). Significant progress in the field has been made through multi-site, National Institute of Mental Health (NIMH)– funded research comparing types of treatment with treat- ment combinations of pharmacological interventions and psychosocial treatments, for disorders including OCD and major depressive disorders, and anxiety disorders. Studies repeatedly found that cognitive-behavioral psychotherapy in combination with an SSRI has advantages over either alone. Another area of progress has been evidence-based treatment of ADHD in younger age groups. The NIMH Preschooler with ADHD Treatment Study (PATS) was the first multisite study of ADHD preschool children, treated first with a parent training component and followed, if necessary, by administra- tion of methylphenidate. This regimen was found to be effec- tive and safe. Double-blind, placebo-controlled studies have provided evi- dence for the efficacy of fluoxetine, sertraline, and escitalopram treatment for depressive disorders in youth, and the Food and Drug Administration (FDA) has approved both fluoxetine and escitalopram in the treatment of adolescent depression. Fluox- etine, sertraline, and fluvoxamine have been shown to have positive results based on randomized controlled trials (RCTs) in the treatment of OCD in youth. Although the FDA has not yet approved SSRIs in the treatment of child and adolescent anxi- ety, positive random-controlled trials (RCTs) exist for fluox- etine, sertraline, paroxetine, and fluvoxamine in the treatment of youth anxiety. In 2004, the FDA released a statement on the recom- mendation of the Psychopharmacologic Drugs and Pediatric Advisory Committees of a “black-box” warning relating to an increased risk for suicidality in pediatric patients for all antidepressant medications. The advisory committees came to the conclusion that an increased risk of suicidal behaviors existed, although there were no suicides completed among the data reviewed. All of the antidepressant medications must include the black box warning for pediatric patients regardless of whether they have been studied in pediatric populations. Currently, the SGAs, also known as serotonin- dopamine antagonists (SDAs), have generally replaced the conventional antipsychotics (dopamine receptor antagonists) in the treatment of psychotic disorders and for aggressive behavior management.