Kaplan + Sadock's Synopsis of Psychiatry, 11e

1301

31.18e Psychiatric Treatment of Adolescents

than 0.12) may necessitate lowering the dosage. FDA guidelines limit dosages to a maximum of 5 mg/kg a day. The drugs can be toxic in an overdose, and in small children, ingestion of 200 to 400 mg can be fatal. When the dosage is lowered too rapidly, withdrawal effects occur, mainly gastrointestinal symptoms— cramping, nausea, and vomiting—and sometimes apathy and weakness. Antipsychotics The SGAs have generally replaced the conventional antipsy- chotics as first-line agents in the treatment of all psychotic dis- orders in children and adolescents. Historically, the best-studied antipsychotics given to pediatric age groups are chlorpromazine (Thorazine) and haloperidol. High-potency and low-potency antipsychotics are thought to differ in their adverse-effect profiles. The phenothiazine derivatives (chlorpromazine and thioridazine) have the most pronounced sedative and atropinic actions, whereas the high-potency antipsychotics are com- monly believed to be associated with extrapyramidal reactions, such as parkinsonian symptoms, akathisia, and acute dysto- nias. The risk of tardive dyskinesia in relation to antipsychotics leads to caution in the use of drugs. Tardive dyskinesia, which is characterized by persistent abnormal involuntary move- ments of the tongue, face, mouth, or jaw and sometimes the extremities, is a known hazard when giving antipsychotics to patients of all age groups. No known treatment is effective. Because transient choreiform movements of the extremities and trunk are common after abrupt discontinuation of antipsy- chotics, clinicians must distinguish these symptoms from per- sistent dyskinesia. R eferences Correll CU, Kratocvil CJ, March J. Developments in pediatric psychopharmacol- ogy: Focus on stimulants, antidepressants and antipsychotics. J Clin Psychiatry. 2011;72:655–670. Findling RL, Adeyi B, Dirks B, Babcock T, Shecner B, Lasser R, DeLeon A, Gins- berg LD. Parent-reported executive function behaviors and clinician ratings of attention-deficit/hyperactivity disorder symptoms in children treated with lis- dexamfetamine. J Child Adolesc Psychopharmacol. 2013;23:28–35. Findling RL, Childress AC, Cutler AJ, Gasior M, Hamdani M, Ferreira-Cornwell MC, Squires L. Efficacy and safety of lisdexamfetamine dimesylate in ado- lescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2011;50;395–405. Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D. Moore P, Choate-Summers M, Garcia A, Edson AL, Foa EB, March JS. Cognitive behav- ior therapy augmentation of pharmacotherapy in pediatric obsessive-compul- sive disorder: The Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA 2011;306:1224–1232. Ginsburg GS, Kendall PC, Sakolsky D, Compton SN, Piacentini J, Albano AM, Walkup JT, Sherrill J, Coffey KA, Rynn MA, Keeton CP, McCracken JT, Berg- man L, Iyengar S, Birmaher B, March J. Remission after acute treatment in children and adolescents with anxiety disorders: findings from The CAMS. J Consult Clin Psychol. 2011;79:806–813. Greenhill, LL, Hechtman, L. Attention-deficit disorders. In: Sadock BJ, Sadock VA, & Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9 th ed. Vol. 2. Philadelphia. Lippincott Williams & Wilkins; 2009;3560. Hammerness PG, Perrin JM, Shelley-Abrahamson R, Wilens TE. Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity disor- der: Update and clinical recommendations. J Am Acad Child Adolesc Psych. 2011;50:978–990. Hughes CW, Emslie GJ, Crimson ML, Posner K, Birmaher B, Ryan N, Jensen P, Curry J, Vitiello B, Lopez M, Shon SP, Piszka SR, Trivedi MH, and The Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. Texas Children’s Medication Algorithm Project: Update from Texas Consensus Conference Panel on medication treatment of childhood major depressive disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:667–686.

Joshi SV. Teamwork: The therapeutic alliance in pediatric pharmacotherapy. Child Adolesc Psychiatr Clin N Am. 2006;12:239. Nilsen TS, Eisemann M, Kvernmo S. Predictors and moderators of outcome in child and adolescent anxiety and depression: A systematic review of psycho- logical treatment studies. Eur Child Adolesc Psychiatry. Feb 2013;22(2):69–87. Pearson GS. Use of polypharmacy with children and adolescents. J Child Adolesc Psychiatr Nurs. May 2013;26(2):158–159. Rynn M, Puliafico A, Heleniak C, Rikhi P, Ghalib K, Vidair H. Advances in phar- macotherapy for pediatric anxiety disorders. Depress Anxiety. 2011;28:76–87. Vitiello B. Research in child and adolescent psychopharmacology: Recent accom- plishments and new challenges. Psychopharmacology. 2007;19:5. Vitiello B. An update on publicly funded multisite trials in pediatric psychophar- macology. Child Adolesc Psychiatr Clin N Am. 2006;15:1. Wagner DK. Pharmacotherapy for major depression in children and adolescents. Prog Neuropsychopharmacol Biol Psychiatry. 2005;29:819. Walkup JT, Albano AM, Piacentini J. Cognitive behavioral therapy, sertraline or a combination in childhood anxiety. N Engl J Med. 2008;359:2753–2766. Zuddas A, Zanni R, Usala T. Second generation antipsychotics (SGAs) for non- psychotic disorders in children and adolescents: A review of the randomized controlled studies. Eur Neuropsychopharmacol. 2011;21:600–620. 31.18e Psychiatric Treatment of Adolescents Adolescence, biologically beginning with puberty, is a period in which social, intellectual, and sexual development take place alongside specific brain processes that enhance teens’ abili- ties for increased abstract reasoning and greater sensitivity to social nuances. However, the developmental brain processes are spread over many years, and maturation is subject to indi- vidual variation. Inherent in development is continuing change; however, most adolescents adapt to changes gradually, and their path toward greater autonomy and independence is not charac- terized by perpetual crises and struggle. Milestones achieved by adolescents during their developmental journey to adulthood are typically reached without overwhelming strife or interven- tion. However, psychiatric treatment is indicated for an adoles- cent who develops a disturbance of thought, affect, or behavior that disrupts normal functioning. In adolescents, disruption of functioning influences eating, sleeping, and school function, as well as relationships with family and peers. A variety of serious psychiatric disorders, including schizophrenia, bipolar disorder, eating disorders, and substance abuse typically have their onset during adolescence. In addition, the risk for completed suicide drastically increases in adolescence. Although some degree of stress is virtually universal in adolescence, most teenagers who do not develop serious mental disorders cope well with environ- mental demands. Teenagers with preexisting mental disorders often experience exacerbations during adolescence and may become frustrated, alienated, and demoralized. Clinicians and parents seeking a window into an adolescent’s viewpoint should be sensitive to their self-perceptions. A range of emotional maturity exists in teens of the same chronologi- cal age. Issues characteristic of adolescence are related to new evolving identities, the development of sexual activity, and developing plans to meet future life goals. Diagnosis Adolescents can be assessed with a focus on general progress in accomplishing the tasks of individuating and developing a sense