Practitioner’s Guide to Psychoactive Drugs for Children and Adolescents

457 Pages·1993·12.05 MB·English

by  John S. Werry M.D. (auth.)

Practitioner's Guide
to Psychoactive Drugs
for Children and
Adolescents
Practitioner's Guide
to Psychoactive Drugs
for Children and
Adolescents
Edlted by
s.
John Werry, M.D.
Emeritus Professor of Psychiatry
University ofA uckland
Auckland. New Zealand
and
Michael G. Arnan, Ph.D.
The Nisonger Center for Mental Retardalion and Developmenlal Disabilities
The Ohio State University
Columbus. Ohio
SPRINGER SCIENCE+BUSINESS MEDIA, LLC
Library of Congress Cataloglng-ln-Publlcation Data
Practltloner's gUlde to psychoactlve drugs for chlldren and
adolescents I edited by John S. Werry and Mlchael G. Aman.
p. cm.
Includes blbllographlcal references and Index.
ISBN 978-0-306-44389-3 ISBN 978-1-4615-2884-5 (eBook)
DOI 10.1007/978-1-4615-2884-5
1. Pedlatrlc psychopharmacology--Handbooks. manuals. etc.
1. Werry, John S. II. Aman, Mlchael G.
[DNLM, 1. Psychotroplc Drugs--pharmacology--handbooks.
2. Psychotroplc Drugs--therapeutlc use--handbooks. 3. Mental
Dlsorders--drug therapy--handbooks. 4. Mental Dlsorders--in lnfancy
& Chlldhood--handbooks. 5. Mental D,sorders--,n adolescence-
-handbooks. QV 39 PS95 19931
RJ504.7.P7 1993
61S.92·S91S--dc20
DNLM!DLC
for Llbrary of Congress 93-7044
CIP
109876543
@ 1993 Springer Science+Business Media New York
Originally published by Plenum Press New York in 1993
An rights reserved
No part of this boole may be reproduced. stored in a retrieval system, or transmilled in any fonn or by any
means. electronic, mechanicaI. phoIocopying. microfilming. recording. or otherwise. without wriuen
pcnnission from the PubIisher
Contributors
Michael G. Aman, Ph.D. Director of Research, The Nisonger Center for
Mental Retardation and Developmental Disabilities, The Ohio State University,
Columbus, Ohio 43210; Associate Professor of Psychology and Psychiatry, The
Ohio State University, Columbus, Ohio 43210
Russell A. Ba rkley, Ph. D. Director of Psychology, Departments of Psychiatry
and Neurology, University of Massachusetts Medical Center, Worcester, Massa
chusetts 01655
Kelly Botteron, M.D. Fellow in Child and Adolescent Psychiatry, Department
of Psychiatry, Washington Univer::ity School of Medicine, St. Louis, Missouri
63110
Magda Campbell, M.D. Professor of Psychiatry, Department of Psychiatry,
New York University Medical Center, New York, New York 10016
Richard O. Carpenter, M.D. Department of Psychiatry, Johns Hopkins Uni-
versity School of Medicine, Baltimore, Maryland 21205
C. Keith Conners, Ph.D. Professor of Medical Psychology, Department of
Psychiatry, Division of Medical Psychology, Duke University Medical Center,
Duke University, Durham, North Carolina 27710
Anthony Costello, M.D. Professor of Psychiatry, Department of Psychiatry,
University of Massachusetts Medical Center, Worcester, Massachusetts 01655
Michael Dragunow, Ph.D. Department of Pharmacology and Clinical Pharma-
cology, School of Medicine, University of Auckland, Auckland, New Zealand
Kenneth S. Duckworth, M.D. Child Psychiatry Service, Massachusetts Men-
tal Health Center, Boston, Massachusetts 02114; Instructor in Psychiatry, Har
vard Medical School, Boston, Massachusetts 02115
George J. DuPaul, Ph.D. Assistant Professor of Psychiatry, Department of
Psychiatry, University of Massachusetts Medical Center, Worcester, Massachu
setts 01655; present address: School Psychology Program, Lehigh University,
Bethlehem, Pennsylvania 18015
y
vi Contributors
Monique Ernst, M.D., Ph.D. Research Fellow and Clinical Instructor in
Psychiatry, Division of Child and Adolescent Psychiatry, Department of Psychi
atry, New York University Medical Center, New York, New York 10016; present
address: Brain Imaging Section, Department of Health and Human Services,
National Institutes of Health, Bethesda, Maryland 20892
Kenneth D. Gadow, Ph.D. Research Associate Professor of Psychiatry, De-
partment of Psychiatry and Behavioral Science, State University of New York,
Stony Brook, New York 11794
Barbara Geller, M.D. Professor of Psychiatry and Director of Childhood
Affective Disorders Program, Department of Psychiatry, Washington University
School of Medicine, St. Louis, Missouri 63110
Nilda M. Gonzalez, M.D. Research Fellow and Clinical Instructor in Psychia-
try, Division of Child and Adolescent Psychiatry, Department of Psychiatry,
New York University Medical Center, New York, New York 10016
Jon McClellan, M.D. Assistant Professor, Department of Psychiatry and
Behavioral Sciences, University of Washington, Seattle, Washington 98195
Antony Milch, M.B.B.S., F.R.A.N.Z.C.P. Fellow in Child Psychiatry, Prince
of Wales Children's Hospital, Sydney, Australia
James William Paxton, Ph.D. Senior Lecturer, Department of Pharmacology
and Clinical Pharmacology, School of Medicine, University of Auckland,
Auckland, New Zealand
Ronald Schouten, J.D., M.D. Director, Law and Psychiatry Service, and
Assistant Director, Somatic Therapies Consultation Service, Massachusetts
General Hospital, Boston, Massachusetts 02114; and Department of Psychiatry,
Harvard Medical School, Boston, Massachusetts 02115
Raul R. Silva, M.D. Research Fellow and Clinical Instructor in Psychiatry,
Division of Child and Adolescent Psychiatry, Department of Psychiatry, New
York University Medical Center, New York, New York 10016
Alan S. Unis, M.D. Assistant Professor, Department of Psychiatry and Behav-
ioral Sciences, University of Washington, Seattle, Washington 98195
John O. Viesselman, M.D. Assistant Professor, Department of Psychiatry,
The Ohio State University, Columbus, Ohio 43210; present address: Private
Practitioner, Ventura, California 93003
Eileen P. G. Vining, M.D. Associate Professor, Departments of Neurology and
Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
21287-3141
Contributors vii
Brent Waters, M.D., F.R.C.P', F.R.A.N.Z.C.P. Professor of Psychiatry, School
of Psychiatry, University of New South Wales, Sydney, Australia; Department of
Psychiatry, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
Elizabeth B. Weller, M.D. Professor and Director of Child Psychiatry, Depart-
ment of Psychiatry, The Ohio State University, Columbus, Ohio 43210
Ronald A. Weller, M.D. Professor and Director of Training, Department of
Psychiatry, The Ohio State University, Columbus, Ohio 43210
John S. Werry, M.D. Emeritus Professor of Psychiatry, University of Auck-
land, Auckland, New Zealand; mailing address: 19 Edenvale Crescent, Mount
Eden, Auckland 3, New Zealand.
Emily M. Yamada, B.A. Section on Clinical Brain Imaging, Laboratory of
Cerebral Metabolism, National Institute of Mental Health, Bethesda, Maryland
20892
Shahnour Yaylayan, M.D. Department of Psychiatry, The Ohio State Univer-
sity, Columbus, Ohio 43210
Alan J. Zametkin, M.D. Section on Clinical Brain Imaging, Laboratory of
Cerebral Metabolism, National Institute of Mental Health, Bethesda, Maryland
20892
Pret=ace
Psychoactive drugs are those used to modify emotions and behavior and to treat
psychiatric illnesses. Technical information about these drugs is contained in the
field of psychopharmacology, which began in the 1930s with the introduction of the
modern barbiturates, the psychostimulants, and the antihistamines. However, it was
not until 1950 and the introduction of chlorpromazine (Largactil@, Thorazine®), the
first of the many antipsychotic (neuroleptic or "major tranquilizer") drugs, that it
developed as a major part of the medical specialty of psychiatry. With the introduc
tion of antidepressants, lithium, and the benzodiazepines or "minor tranquilizers"
all before 1965-the use of psychoactive drugs soon spread to embrace the treatment
of less severe illnesses. Interestingly, while psychopharmacological knowledge has
advanced considerably, there have been no major new psychoactive drug groups
discovered since. Together with psychosocial programs, the antipsychotics helped
revolutionize the care of the severely mentally ill and shifted the emphasis from
custodial institutional care to community habilitation. Today, the use of such drugs is
widespread and, as always in the history of medicine, there has been overuse and
abuse of these very valuable treatments that has led to both legitimate and mis
informed public concern.
Though pediatric psychopharmacology actually began in Providence, Rhode
Island, in 1937 with the introduction of psychostimulants, the use of drugs in children
and adolescents has been much slower to get started, partly because the severe
psychiatric illnesses are infrequent until later adolescence, partly because of a
reluctance to resort to such treatment in the immature, and partly because of the
laudable, but false belief that all emotional and behavioral problems in children
should be resolvable by psychological and social means. Nevertheless, there has
been a substantial amount of systematic study of psychoactive drugs in children and
adolescents, though clinical usage has lagged far behind. However, fifty or more years
on from the birth of psychopharmacology, the use of these drugs in children is now
widespread, as witnessed in 1990 by the launching of a scientific journal (Journal of
Child and Adolescent Psychopharmacology) devoted to that topic. As in adults, there
has been intermittent reasonable and prejudicial public concern about the use of these
drugs in _young persons.
There is now a need for a ready reference text that summarizes our knowledge
about psychoactive drugs for children and adolescents for all those who seek
ix
x Preface
information. This book aims to do this for practitioners, professionals in health,
welfare, and education, and interested laypersons, including parents. This is no easy
task, since the levels of technical knowledge vary from that of the special education
teacher seeking information about the drugs that many such pupils will be receiving,
to that of the modern young child and adolescent psychiatrist whose grasp of the
difficult fields of pharmacokinetics (how drugs are absorbed, distributed, and
eliminated) and neurotransmitter physiology (via which most psychoactive drugs
work) is daunting to the editors, who grew up in the bucolic clinical-empirical era.
Inevitably there are sections of the book that will prove too technical for any except
the medically qualified, but considerable effort has been applied to make much of the
text, especially that discussing the clinical uses and side effects of the drugs,
comprehensible to anyone used to getting information by reading. We also take
comfort in the fact that many of the major contributions in pediatric psychophar
macology have been made by nonmedical professionals, notably psychologists,
suggesting that an audience beyond the medically qualified is practicable.
One other problem confronted us-whether to organize the book by psycho
pathological symptoms (e.g., hyperactivity) and disorders (e.g., autism) or by drugs.
Since the limited number of psychoactive drugs available are used across a wide
variety of disorders and symptoms in children and adolescents, and since there are a
number of good texts available operating from the basis of psychiatric disorders, it
was decided that this book should be about the psychoactive drugs, that is, essentially
a pediatric psychopharmacology text, not a textbook of child and adolescent
psychiatry. Further, none of the latter provides the detailed information about
psychoactive drugs that most practitioners now need. However, when the starting
point is a disorder rather than a drug, Chapter 7 ("Disorders, Symptoms, and Their
Pharmacotherapy") will identify what drugs are indicated. Then it will be necessary
to go to the chapter(s) detailing those drugs.
One last point: Chapter 12, on antiepileptic (anticonvulsant) drugs, may seem
out of place in a psychopharmacological text. The reason for its inclusion is not to
teach nonspecialists how to treat the epilepsies; rather, when these disorders are
associated with psychopathological problems, mental health professionals often are
consulted and (along with special educators) need to be knowledgeable about these
drugs, which have important incidental influences on behavior and learning. Many
also have important emerging direct psychoactive uses in addition to those in
epilepsy.
As with most things in life, this book evidences compromises-in this case
eschewing detailed scholarly discussion of the evidence in print, in favor of the
author's statement of critical appraisal of that evidence. We hope that this volume will
serve the practical needs of professionals and consumers who require ready informa
tion about psychoactive drugs, at the same time signposting the important scholarly
work in this area.
John S. Werry
Michael G. Aman
Auckland, New Zealand and Columbus, Ohio
Contents
I. General Principles
1. Introduction: A Guide for Practitioners, Professionals,
and Public
John S. Werry, M.D.
I. Introduction ............................................. 3
A. Preamble ............................................ 3
B. Definitions ........................................... 3
C. The Multidisciplinary Team ............................. 4
D. Child Psychiatry and Behavioral Pediatrics ................ 4
II. Historical Overview ...................................... 5
A. Foundations .......................................... 5
B. Current Trends and Future Directions ..................... 7
III. Classification of Psychoactive Drugs ........................ 8
A. Names of Drugs ...................................... 10
B. Look-Alike Drugs .................................... 10
IV Drug Evaluation ......................................... 11
V Determinants of Prescribing ............................... 12
A. Medical Knowledge ................................... 12
B. Patient and Parent Factors .............................. 13
C. Physician Factors ..................................... 13
D. Social Factors ........................................ 13
E. Economic Factors ..................................... 14
F. The Powerful Placebo ................................. 14
VI. Principles of Drug Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
A. First Do No Harm (Prima Non Nocere) . . . . . . . . . . . . . . . . . . . 15
B. Know the Disorder and Use Drugs When Indicated ......... 15
C. Choose the Best Drug ................................. 16
D. Understand the Drug and Its Properties ................... 16
E. Minimize Drug Use and Dosage ......................... 17
F. Keep Things Simple ................................... 17
xi