Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

only in severe cases, because tolerance to the medications devel- ops. Cessation of these medications can lead to severe rebound worsening of the disorders, and reducing delta sleep in children may have deleterious effects; thus, behavioral approaches are preferred for these disorders. Patients with early-onset panic disorder and panic attacks have benefited from clonazepam (Klonopin) in several open trials. Desmopressin Desmopressin (DDAVP) is effective in about 50 percent of patients with intractable enuresis. Improvements with DDAVP range from diminished wetting with less urine volume, to com- plete cessation of bedwetting. Desmopressin has been used intranasally in dosages of 10 to 40 mg a day. When used over months, nasal discomfort can occur, and water retention is potentially a problem. Patients who respond with full dryness should continue to take the medication for several months to prevent relapses. Desmopressin is now available in oral tablets, and a controlled multicenter study found equal efficacy between intranasal and oral administration of desmopressin in the treat- ment of enuresis. A dose of 400 mg of oral desmopressin was the study condition associated with greater effectiveness than the lower 200 mg used. Adverse effects related to antidepressants have diminished sig- nificantly since SSRI antidepressants have been widely accepted as first-line treatments for depressive disorders in children and adolescents. Tricyclics are rarely recommended because of the significant risks of dangerous adverse effects. The adverse effects of tricyclics for children usually are similar to those for adults and result from the drugs’ anticholinergic properties. These effects include dry mouth, constipation, palpitations, tachycardia, loss of accommodation, and sweating. The most serious adverse effects in children are cardiovascular; diastolic hypertension is more common and postural hypotension occurs more rarely than in adults. ECG changes are most likely seen in children receiving high doses. Slowed cardiac conduction (PR interval greater than 0.20 seconds or QRS interval greater Adverse Effects and Complications Antidepressants

in children and adolescents. Previously, clomipramine proved effective in diminishing obsessions and compulsions in children and adolescents and was generally well tolerated. However, the SSRIs have a more favorable adverse-effect profile and appear to be as effective as clomipramine. Mood-Stabilizing Agents Classic mania in children and adolescents is treated as it is treated in adults. Use of lithium in treating adolescent mania has been supported in many open trials. Divalproex is used frequently to treat bipolar disorder in children and adolescents. A recent double-blind, randomized pilot study comparing que- tiapine (400 to 600 mg a day) or divalproex (serum level 80 to 120 mg/mL) in a trial lasting approximately 1 month, found that quetiapine is at least as effective as divalproex in treat- ing acute manic symptoms. Reduction of symptoms occurred more quickly with quetiapine compared with divalproex. Lithium has been shown in multiple investigations to reduce aggression in conduct disorder, and propranolol (Inderal) has been chosen as an agent to control aggression in open trials, although no evidence supports its use in children and ado- lescents. Carbamazepine (Tegretol) has not been shown to be effective in controlling aggression in child and adolescent conduct disorders. Table 31.18d-4 summarizes the effects of drugs on cognitive tests of learning functions. In children with learning disorders who have attention problems, even in the absence of meeting full criteria for ADHD, methylphenidate facilitates perfor- mance on several standard cognitive, psycholinguistic, memory, and vigilance tests, but does not improve children’s academic achievement ratings or teacher ratings. Cognitive impairment from psychotropic drugs, especially antipsychotics, may be an even greater problem for persons who are mentally retarded than for those with learning disorders. Benzodiazepines Sleep terror disorder and sleepwalking disorder occur in the transition from deep delta-wave sleep (stages 3 and 4) to light sleep. Benzodiazepines may be effective in these disorders. They work by reducing both delta-wave sleep and arousals between sleep stages. The medications should be used temporarily and

Table 31.18d-4 Effects of Psychotropic Drugs on Cognitive Tests of Learning Functions a

Test Function

Paired Associates (Verbal Learning)

Continuous Performance Test (Attention)

Matching Familiar Figures (Impulsivity)

Porteus Maze (Planning Capacity)

Short-Term Memory a

WISC (Intelligence)

Drug Class

↑ ↑

↑ 0 0

↑ 0 ↓

↑ 0 ↓

↑ 0 ↓

↑ 0 0

Stimulant

Antidepressant Antipsychotic

↑↓

↑ , Improved; ↑↓ , inconsistent; ↓ , worse; 0, no effect. a Various tests, digit span, word recall, etc. (Adapted from Amar MG. Drugs, learning and the psychotherapies. In: Werry JS, ed. Pediatric Psychopharmacology: The Use of Behavior Modifying Drugs in Children . New York: Brunner/Mazel; 1978:356, with permission.)