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Chapter 31: Child Psychiatry
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
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 and Complications
Antidepressants
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
Table 31.18d-4
Effects of Psychotropic Drugs on Cognitive Tests of Learning Functions
a
Test Function
Drug Class
Continuous
Performance Test
(Attention)
Matching
Familiar Figures
(Impulsivity)
Paired
Associates
(Verbal
Learning)
Porteus Maze
(Planning
Capacity)
Short-Term
Memory
a
WISC
(Intelligence)
Stimulant
↑
↑
↑
↑
↑
↑
Antidepressant
↑
0
0
0
0
0
Antipsychotic
↑↓
0
↓
↓
↓
0
↑
, 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.)
