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Psychopharmacologic Medication:
What Teachers Need to Know

Steven R. Forness, Dwight P. Sweeney, Kathy Toy

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Note - A reformatted version of this article appeared in Beyond Behavior, 7(2), 4-11, Winter 1996.

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Abstract
Introduction
Psychostimulants
Antidepressants

Tricyclic Antidepressants
Novel Antidepressants
Monoamine Oxidase Inhibitors

Antipsychotic Agents
Lithium
Anticonvulsants
Summary and Recommendations
References
About the Authors
Tables

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Abstract

There are four major medications used in psychoparmacology for children with learning or behavioral disorders, and research estimates suggest that between 2 and 3 percent of all school children may be on one or another of these medications at any point in time. In special education, it has been estimated that between 15 and 20 percent of children may be receiving one or more of these drugs.

Stimulant medications, such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine) or magnesium pemoline (Cylert), are among the most well studied in children. Only about 70 to 80 percent of children with attention deficit hyperactivity disorder may respond to stimulants. Lower doses of stimulants such as Ritalin may improve classroom performance, while higher doses that control behavior may be detrimental to learning. A few studies suggest that behavior modification and stimulants used in combination may have better results than either used alone. Therapeutic effects of Ritalin may peak within an hour or two after administration and may begin to disappear by 3 or 4 hours.

It should be noted however, that irritability, agitation, or inattention may sometimes represent symptoms of other disorders such as depression or schizophrenia. For the former, antidepressants such as the tricyclic, imipramine (Tofranil), the selective serotonin reuptake inhibitor, fluoxetine (Prozac), or the mood stabilizer, lithium (Eskalith) may be used. Antidepressants may take 3 to 4 weeks to achieve maximum therapeutic effect and lithium 7 to 10 days. Neuroleptics such as thioridazine (Mellaril), haloperidol (Haldol), Clozapine (Clozaril) or Pimozide (Orap) may be used for various schizophrenic or psychotic disorders. Therapeutic effects usually appear within hours for symptoms such as agitation, but hallucinations may not disappear until later in the first week, and improvements in socialization and thought disorder may not be evident until 1 or 2 months later. Side effects of antidepressants may include jitteriness, stomach upset, dry mouth, or blurred vision; neuroleptics may produce irritability, drowsiness, dizziness, and even dyskinetic movements with prolonged use. Complications may also arise for children on anticonvulsants, e.g., phenytoin (Dilantin), ethosuximide (Zarontin) or carbamazepine (Tegretol).

This article discusses the potential uses and abuses of psychopharmarcologic therapy with children or adolescents displaying learning, emotional, or behavioral disorders. It will explore the indications and contraindications of such therapy and enumerate the known side effects of the most frequently prescribed medications.

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The use of psychopharmacology in treating children and adolescents with a variety of presenting problems and psychiatric diagnoses has increased dramatically over the past seven years (Campbell & Cueva, 1995). The four major categories of medications used with children and adolescents are psychostimulants, antidepressants, neuroleptics, and anticonvulsants. Research has estimated that between 2 and 3 percent of all school children may be on one or more of these medications at any given point in time. Within special education classes it is estimated that between 15 and 20 percent of all students may be receiving one or more of these drugs (Barkley, 1979: Barkley, 1990; Forness & Kavale, 1988; Forness, Swenson, Cantwell, Guthrie, & Sena, 1992).

Among some professionals there is a growing concern that this increased reliance on psychopharmacology represents a trend in which quality programming for children and adolescents with emotional or behavioral disorders is being replaced by attempts to find a quick cure to behavior problems through the use of medication. Gadow (1992) has noted that advances in pharmacology have provided better information about dosing levels, concentration of the drug at the effector site (pharmacokinetics), the end response (pharmacodynamics), and the balancing of these variables have enabled many drugs to be used selectively to treat psychiatric symptoms or behaviors not previously thought to respond to these medications. For example, antidepressants and neuroleptics are beginning to be used to treat behavior disorders (Rosenberg, Holttum, & Gershon, 1994).

Virtually every article reviewed for this study indicated concern over the lack of controlled, double-blind studies to determine the efficacy of these new drugs and their relative safety when used with children younger than 16 years of age. Referring to childhood anxiety disorders, Allen, Leonard, & Swedo (1994) warned "...that until additional research is done, clinicians must carefully consider the relative risk-to-benefit ratio when prescribing these medications." (p.976).

The primary issues of concern when using any medication with children are drug concentration, dosing level and interval, distribution through the system, site of absorption into the system, and elimination through metabolism and excretion. Other concerns are the long term effects of the medication and the changing metabolism and absorption rates in children during the developmental period (Rosenberg, Holttum, & Gershon, 1994). Also of concern are the possible interactions of a prescribed medication with other prescribed or illicit drugs.

All of these concerns suggest the need to carefully monitor any child placed on any medication to ensure that the medication is having the desired effect and is not contributing to any negative side effects that are impacting either the child's behavior or learning. Thus, this article will now examine the four classes of drugs most commonly prescribed to the school age population. Each section will explore the indications, counterindications, and possible side effects associated with each class of medication in an effort to provide classroom teachers with information to assist in evaluating changes in behavior and learning patterns when children in your classroom are placed on medication.

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Psychostimulants

The psychostimulants methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and magnesium pemoline (Cylert) are among the most commonly prescribed and most controversial medications in all of child psychiatry. Barkley (1990) has estimated that nearly 2% of the school-age population receive stimulant medication for ADHD symptoms despite concerns for abuse and addiction. Forness & Kavale (1988) and (Forness, Swanson, Cantwell, Guthrie, & Sena (1992) have also noted a decrease in classroom performance among children treated with psychostimulants for ADHD and disruptive classroom behavior. They have questioned whether the resultant decrease in behavior or relative gains in attention are worth the greater loss of learning performance in some children.

The only FDA approved uses for these drugs in children and adolescents are for ADHD and narcolepsy. However, current prescription studies indicate that psychostimulants are also being prescribed to treat ADHD like symptoms co-existing with intellectually subaverage children and adolescents, preschool children, Fragile X syndrome, PPD or autism, organic brain disease, or Tourette's syndrome. All such treatments should be considered experimental and be closely monitored by the prescribing physician relying on behavioral observations from parents and teachers.

Table 1 indicates that all three stimulants have different time of onset ranging from 30 minutes up to four hours. Table 1 also indicates that the relative plasma half-life of each drug varies between 1 and 12 hours. Since many schools are reluctant to disperse prescription medication at school, many children are placed on sustained release versions of these medications. Unfortunately, the sustained release versions have proven less effective at maintaining a therapeutic dose of the medication throughout the school day and result in some children experiencing peaks and valleys throughout the day (Pelham, Swanson, Furman, & Schwindt, 1995).

It is also important to note that given different points of absorption and different receptor sites, the three drugs are not equal and should not be freely substituted without medical consultation. Compliance with psychostimulant treatment has also been a frequent problem reported in the literature. Stine (1994) has suggested that in addition to the dosing issues already noted, there are a wide variety of psychosocial and psychodynamic issues that contribute to the widespread noncompliance with psychostimulant treatment.

Table 2 list the indications, contraindications, and known side effects of the psychostimulants. It is significant that the potential relative contraindications of this class of drug correspond very closely with some of the possible indications. It is important to note that since Cylert is absorbed through the liver, it should not be given to students with known liver abnormalities. Teachers should also be aware of the sudden onset of jaundice or other symptoms of liver dysfunction in students on Cylert.

As shown in Table 2, the most common side effects of the stimulants are insomnia, decreased appetite, GI problems, irritability, clinically significant increase in heart rate, and in some cases a worsening of the symptoms for which the medication was prescribed. In addition, while noted to be uncommon, the other side effects noted in Table 2 should also be monitored wherever possible by classroom teachers.

Other recent research (Carlson, Rapport, Kelly, & Pataki, 1995), found clinically modest positive effects when treating comorbid behavior and mood disorders with a combination of Ritalin and Desipramine. Shah, Seese, Abikoff and Klein (1994), found that Cylert was effective in reducing the negative behaviors in a group of adolescents diagnosed with conduct disorder. In contrast to the study cited above, this study further noted that Cylert used in combination with Ritalin also proved effective in reducing negative behavior among some of the study group. Finally, Barrickman et. al. (1995), have found that the antidepressant Bupropion was equally as effective as Ritalin in the treatment of ADHD when rated by teachers and parents in controlled, double-blind, crossover studies.

These findings are significant in that physicians are now becoming aware that drugs other than stimulants may be effective in the treatment of ADHD. It is also significant to note that many classes of drugs are now being studied in multiple dosing combinations in efforts to decrease targeted symptoms while at the same time reducing the undesirable side effects often associated with using stimulant medication in isolation.

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Antidepressants

Next to psychostimulants, antidepressants are quickly becoming to second most often prescribed drug for the treatment of ADHD, depression, obsessive-compulsive disorder and school phobia (Werkman, 1993). Three different types of antidepressants will be considered here: Tricyclic Antidepressants (TCAs); Novel (Atypical) Antidepressants; and, Monoamine Oxidase Inhibitors (MAOIs).

1. Tricyclic Antidepressants

TCAs have been found effective in adults in treating major depressive disorders, anxiety disorders, panic disorders, and generalized disorders. They are relatively safe, effective and easy to administer. Within children and adolescents, however, they have not proven quite as effective (Rosenberg, Holttum, & Gershon, 1994). TCAs are metabolized by the liver and loosely bind to protein. As in all substances with primary hepatic metabolism, TCAs are metabolized more rapidly in children and adolescents than in adults. For example, children and adolescents treated with similar doses of TCAs controlled for body mass can have blood levels of the drug that can differ by 30-fold within the active life of the medication (Rosenberg, Holttum, & Gershon).

The exact mechanism that make TCAs effective in the treatment of adult depression has not been clearly established. TCAs block the reuptake of norepinephrine and serotonin thereby increasing their concentration in the brain compensating for a presumed deficiency that could be the etiology of some depressions.

Table 3 indicates that the only FDA approved indications for the use of TCAs with children and adolescents is for the treatment of enuresis. Current research and practice suggests that TCAs may also be indicated for the treatment of school phobia, OCD, and generalized depression in children and adolescents. Absolute contraindications for the use of TCAs are pregnancy, prior hypersensitivity reaction or current use of MAOIs. Relative contraindications include epilepsy, psychosis, known cardiac or thyroid problems and diabetes. TCA side effects include cardiac irregularities, psychosis, mania, seizures, hypertension, confusion, tics, anxiety and the other symptoms noted in Table 3.

Table 4 lists the most commonly prescribed TCAs along with their available forms. Rosenberg, Holttum and Gershon (1994) have noted that despite their proven efficacy in relieving major depressive disorders in children and adolescents, their use in many clinical settings has become routine. Allen, Leonard and Swedo (1994), have also suggested that when treating childhood anxiety disorders with any form of antidepressant, the risk-to-benefit ratio must be considered on an individual basis before prescribing any form of antidepressant.

Bird, Gould, & Staghezza (1993) have noted that depressive disorders among this population tend to be comorbid, chronic, and disabling. Recognizing the relative lack of efficacy of using a single medication in the treatment of psychiatric disorders in children and adolescents may be due in part to the existing comorbidity of several disorders, Wilens, Spencer, Biederman, & Connor (1994) have explored the effects of combined pharmacotherapy in treating a variety of psychiatric disorders in children and adolescents. Thus, current practice may dictate prescribing TCAs in combination with psychostimulants, other forms of antidepressants, lithium, antipsychotics, or in some case anticonvulsants (Bastianens, & Bastianens, 1993).

Finally, the administration of TCAs alone or in combination needs to be closely monitored and supervised. There are no set guidelines for dosing patterns or duration of treatment in children and adolescents. Long term consequences of their use in this population are still in need of systematic longitudinal research.

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2. Novel Antidepressants

The Novel or Atypical Antidepressants include Fluoxetine (Prozac), Sertraline (Zoloft), and Paroxetine (Paxil). The Novel drugs are Selective Serotonin Reuptake Inhibitors (SSUIs). Also included in this category are Bupropion (Welbutrin) and Trazadone (Desyrel). Bupropion and Trazadone are not chemically related to TCAs or SSUIs but have proven effective in the treatment of depression in adults (Rosenberg, Holttum, & Gershon, 1994).

Of these, Prozac has become the drug of choice in treating adults because of its relative lack of side effects and withdrawal symptoms. All of the SSUIs have fewer side effects than the TCAs and are more selective in their chemical action. The onset of action and time of half-life for the SSUIs are found in Table 5. All three of the SSUIs approved for use in the United States begin to work within two to three weeks with Prozac having the longest half-life.

Table 6 indicates that while there are no currently established indications for the use of SSUIs in the treatment of children and adolescents, possible indications include MDD, ADHD, OCD, poor impulse control, self-injurious behavior, post-traumatic stress disorder, and eating disorders. Absolute contraindications include recent use of MAOIs or other SSUIs, pregnancy, or a history of liver disease. Relative contraindications include epilepsy, psychosis, thyroid disorders and diabetes.

Common side effects from use of SSUIs include GI problems, loss of appetite, nervousness, sedation, and motor restlessness. Indications, contraindications, and known side effects for the SSUIs are found in Table 6.

While their have been limited studies in the use of SSUIs in treating childhood depression, Wilens et al, (1994) found that when used in combination with TCAs, SSUIs appeared effective with few side effects in the treatment of childhood anxiety disorders. Tierney, Joshi, Llinas, Rosenberg, & Riddle (1995) report that while some children with major depressive disorders (MDD) responded well to Sertraline, adverse behavioral effects were common.

Among the other atypical antidepressants approved for use in the United States, Trazadone is not recommended for routine use with children and adolescents. Bupropion has been used to treat ADHD and is being used experimentally in the treatment of MDD in children and adolescents either alone or in combination with other medications (Barrickman et al., 1995; Campbell & Cueva, 1995; and Jensen, 1993). Bupropion is not approved for use with patients under the age of 18. Table 7 lists the indications, contraindications and side effects of Trazadone and Bupropion. As noted in Table 7, ADHD and MDD are thus far the only possible indications for Bupropion. Given the extensive list of absolute and relative contraindications for Bupropion it is suggested that it only be used in controlled settings with children and adolescents. Side effects of Bupropion include seizures, agitation, weight loss, headache, nausea, and URI symptoms.

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3. Monoamine Oxidase Inhibitors

Monoamine oxidase inhibitors (MAOIs) are a class of antidepressant that inhibit the enzyme monoamine oxidase (MAO). As one of the first type of antidepressants developed MAOIs have been researched over the past fifty years. They have fallen into disuse as newer antidepressants have been developed and side effects such as hepatic failure and hypertensive crisis were associated with their use. Several MAOIs such as Iproniazid have been withdrawn from the market due to the lack of demonstrated efficacy and concern over the extreme side effects mentioned above.

However, many newer MAOIs have been developed that are undergoing experimental use in the treatment of depressive psychiatric disorders. Table 8 shows the indications, contraindications, and side effects for the MAOIs. It is important to note that currently no MAOI is approved for psychiatric use in children less than 16 years of age. Due to a tendency to bring on hepatic failure, all patients treated with MAOIs should undergo regular liver function tests to assure early detection of any signs of liver failure. Best practice would suggest that the MAOIs only be considered when depressive symptoms fail to respond to other less dangerous forms of antidepressants such as TCAs or Novel antidepressants.

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Antipsychotic Agents

The antipsychotic agents, also called neuroleptics or major tranquilizers, are a primary mode of treatment in adults. However, because of concerns over possible severe neurological and developmental sequelae with long term use and the possibility of short-term side effects that may hamper socialization and learning, only seven agents have FDA approval for use with children less than 12 years of age (Baldessarini & Teicher, 1995; Forness et al., 1992; and McClellan & Werry, 1994).

Table 9 lists the characteristics of the most commonly prescribed neuroleptics. Because of being indicated for a variety of emotional or behavioral problems including severe behavior disorders, psychosis, mania, and Tourette's neuroleptics are being used increasingly to replace more costly positive behavioral interventions as a way of controlling a wide range of conduct disorders and self-injurious behavior in school settings (Campbell & Cueva, 1995; Wilens et al., 1995). In addition to the established indications, neuroleptics are also used experimentally in the treatment of PDD and some autistic behavior. Trials with such populations have yielded mixed results with the efficacy of treatment of these disorders not clearly established.

Focusing specifically on childhood-onset schizophrenia, several new atypical neuroleptics such as Clozapine and Risperidone have shown promising results with relatively few side effects when treating children and adolescents (Frazier, Gordon, McKenna, Lenane, Jih, & Rapoport, 1994, and Quintana & Keshavan, 1995). However, these researchers note that their preliminary studies have been conducted on small samples in controlled settings and that treatment with these two drugs still need to be considered experimental in children and adolescents.

The contraindications for antipsychotics include concurrent use of CNS depressants and pregnancy. However, teachers should be most concerned by the long list of side effects associated with the use of neuroleptics as almost all of the known side effects can have a negative effect on attention and learning in the classroom (Campbell, & Cueva, 1995; Forness & Kavale, 1988; and Gadow, 1992). Baldessarini & Teicher (1995) have also warned that neuroleptic dosing guidelines, especially for the newer atypical neuroleptics, are not well established and in need of close monitoring when used with children and adolescents. In any case, best practice suggests that the duration of treatment with neuroleptics be as short as possible.

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Lithium

Lithium is also being used to treat some psychiatric disorders of children and adolescents. Lithium's only established indication is for the treatment of bipolar disorders in patients greater than 12 years of age. Table 10 lists some of the possible indications for use of Lithium. Campbell et al. (1995) have found Lithium to be effective in the treatment of severely aggressive children with conduct disorders. Alessi, Naylor, Ghaziuddin, & Zubieta (1994) have indicated that Lithium has also proven effective in the treatment of childhood aggression and behavior disorders associated with mental retardation and other developmental disorders such as autism. However, reported results vary when using Lithium alone or in combination with other psychoactive agents.

It is important to note that while GI problems are the most common side effects of Lithium treatment, ocular irritation, cardiovascular problems, diabetes, hair loss, and growth and development delays have also been reported. Like the other classes of medication reviewed here, dosing levels and intervals for Lithium have not been established when used to treat children and adolescents. Thus, best practice again suggests that treatment with Lithium needs to be closely supervised with blood levels monitored regularly to determine the most effective dosage.

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Anticonvulsants

The final class of medication to be considered here are the anticonvulsants. The primary use of anticonvulsants is in the treatment of epileptic disorders. However, recent research has indicated that the anticonvulsants are also useful in the treatment of some behavioral disorders (Rosenberg, Holttum & Gershon, 1994). Table 11 lists the characteristics of the three anticonvulsants most frequently prescribed today in treating non-epileptic psychiatric disorders in children and adolescents. Table 11 indicates that while the indications are the same for Tegretol, Depakene, and Dilantin each has different contraindications and side effects. The fact that all three of these drugs have the potential for fairly severe long term side effects indicates that the duration of treatment for non-epileptic disorders should be brief.

Anticonvulsants are currently being used experimentally in the treatment of bipolar disorders, major depression, ADHD, conduct disorders and sleep terror disorders in children and adolescents. The efficacy of treating these problems in this population has not yet been established. The use of anticonvulsants alone or in combination with other psychoactive drugs for the treatment of non-epileptic disorders is still in the research stage and suggests that such experimental treatments will need to be closely controlled and monitored.

Summary and Recommendations

There appears to be a growing trend to use medication to control certain behaviors among children and adolescents with emotional or behavioral disorders. There is little doubt that some medications have proven efficacy in treating certain symptoms. However, there remains concern that some medications are still in the experimental stage and should only be prescribed when they can be closely monitored by the prescribing physician. With the limits placed on mental health treatment by HMOs and other managed care companies, there is a danger that medication may be prescribed to some students without adequate supervision and follow-up.

It also seems clear that gains in behavior control may come at the expense of either learner performance or long term health risk. We should be aware that some educators, parents and medical professional may come to rely on medication as a quick fix to classroom or home behavior problems. Given the recent decrease in funding to special education programs, it seems likely that we may be more pressed to look for quick fixes in the future. This is contrary to known best practice which suggests that medications may best be used as adjuncts to positive behavioral programming, social skills training, and other mental health intervention programs with established efficacy.

Given these concerns over cost cutting and the growing legal requirements in some states such as California that someone familiar with psychopharmacology be present at IEP meetings, it is imperative that teachers become more aware of the effects and side effects of the various classes of medication. In the absence of controlled clinical studies, teachers can play a vital role as trained observers to provide feedback to prescribing physicians on any improvements or regressions noted in a given student once they have begun a drug regimen.

This article has attempted to provide a summary of what teachers need to know about the most commonly prescribed medications. It is important to recognize that all of the drugs cited in this report are currently being used at least experimentally to treat disorders other than those they were originally developed and approved for. Given the need to carefully monitor dosing, economic inequity in the form of limited mental health insurance may limit some students access to current best practice.

Aman & Wolford (1995) have noted that there is a low degree of consumer satisfaction in their involvement in drug research. This suggests that in addition to teachers, parents will need to become better informed about the potential risks and benefits of placing children and adolescents on any form of psychoactive medication. To assist in this awareness effort, Konopasek (1995), has prepared a series of medication "fact sheets" for non-medical professionals. Teacher and related service educators may also need to consider adding basic courses in psychopharmacology to preservice and inservice training programs. At the very least, teachers will need to become aware of the various medication side effects so that they are not mistakenly identified as new symptoms leading to additional referral, evaluation and treatment.

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References

Alessi, N., Naylor, M. W., Ghaziuddin, M., & Zubieta, J, K. (1994). Update on lithium carbonate therapy in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33 (3), 291-304.

Allen, A. J., Leonard, H., & Swedo, S. E. (1995). Current knowledge of medications for the treatment of childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (8), 976-986.

Aman, M. G., & Wolford, P. L. (1995). Consumer satisfaction with involvement in drug research: A social validity study. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (7), 940-945.

Baldessarini, R. J., & Teicher, M. H. (1995). Dosing of antipsychotic agents in pediatric populations. Journal of Child and Adolescent Psychopharmacology, 5 (1), 1-4.

Barkley, R. A. (1990). Hyperactive children: A handbook for diagnosis and treatment. New York: Guilford Press.

Barrickman, L. L., Perry, P. J., Allen, A. J., Kuperman, S., Arndt, S. V., Herrmann, K. J., & Schumacher, E. (1995). Bupropion versus methylphenidate in the treatment of attention-deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (5), 649-657.

Bastianens, L., & Bastianens, D. K. (1993). A manual of psychiatric medications for teenagers. Journal of Child and Adolescent Psychopharmacology, 3 , 175, M1-M59.

Bird, H. R., Gould, M. S., & Staghezza, B. M. (1993). Patterns of comorbidity in a community sample of children aged 9 through 16 years. Journal of the American Academy of Child and Adolescent Psychiatry, 32 (3), 361-368.

Campbell, M., & Cueva, J. E. (1995). Psychopharmacology in child and adolescent psychiatry: A review of the past seven years. Part II. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (10), 1262-1271.

Campbell, M., Adams, P. B., Small, A. M., Kafantaris, V., Silva, R. R., Shell, J., Perry, R., & Overall, J. E. (1995). Lithium in hospitalized agressive children with conduct disorder: A double-blind and placebo-controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (54), 445-453.

Carlson, G. A., Rapport, M. D., Kelly, K. L., & Pataki, C. S. (1995). Methylphenidate and desipramine in hospitalized children with comorbid behavior and mood disorders: Separate and combined effects on behavior and mood. Journal of Child and Adolescent Psychopharmacology, 5 (3), 191-204.

Forness, S. R., & Kavale, K. A. (1988). Psychopharmacologic treatment: A note on classroom effects. Journal of Learning Disabilities, 21, (3), 144-147.

Forness, S. R., Swanson, J. M., Cantwell, D. P., Guthrie, D., & Sena, R. (1992). Response to stimulant medication across six measures of school-related performance in children with adhd and disruptive behavior. Behavioral Disorders, 18, 42-53.

Frazier, J. A., Gordon, C. T., McKenna, K., Lenane, M. C., Jih, D., & Rapoport, J. L. (1994). An open trial of clozapine in 11 adolescents with childhood-onset schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 33 (5), 658-663.

Gadow, K. D. (1992). Pediatric psychopharmacology: A review of recent research. Journal of Child Psychology and Psychiatry, 33, 153-195.

Jensen, P. S. (1993). Development and implementation of multimodal and combined treatment studies in children and adolescents: NIMH perspectives. Psychopharmacology Bulletin, 29, 19-26.

Konopasek, D. E. (1995). Medication "Fact Sheets": A medication reference guide for the non-medical professional. Anchorage, Alaska: Artic Tern Publishing Co.

McClellan, J., & Werry, J. (1994). Practice parameters for assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 33 (5), 616-635.

Pelham, W. E., Swanson, J. m., Furman, M. b., & Schwindt, H. (1995). Pemoline effects on children with ADHD: A time-response by dose-response analysis on classroom measures. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (11), 1504-1513.

Quintana, H., & Keshavan, M. (1995). Case study: Risperidone in children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (10), 1292-1296.

Rosenberg, D. R., Holttum, J., & Gershon, S. (1994). Textbook of pharmacotherapy for child and adolescent psychiatric disorders. New York: Brunner/Mazel Publishers.

Shah, M. R., Seese, L. M., Abikoff, H., & Klein, R. G. (1994). Pemoline for children and adolescents with conduct disorder: A pilot investigation. Journal of Child and Adolescent Psychopharmacology, 4 (4), 255-261.

Stine, J. J. (1994). Psychosocial and psychodynamic issues affecting noncompliance with psychostimulant treatment. Journal of Child and Adolescent Psychopharmacology, 4 (2), 75-86.

Tierney, E., Joshi, P., Llinas, J. F., Rosenberg, L. A., & Riddle, M. A. (1995). Sertraline for major depression in children and adolescents: Preliminary clinical experience. Journal of Child and Adolescent Psychopharmacology, 5 (1), 13-27.

Werkman, S. (1993). The role of medication in treatment of childhood depression. Journal of Emotional and Behavioral Problems, 2, (2), 42-44.

Wilens, T. E. , Spencer, T., Biederman, J., Wozniak, J., & Connor, D. (1995). Combined pharmacotherapy: An emerging trend in pediatric psychopharmacology. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (1), 110-112.

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About the authors:

Steven R. Forness, Ed.D., is Professor of Psychiatry and Biobehavioral Science and Principal of the Inpatient School, UCLA Neuropsychiatric Institute and Hospital.

Dwight P. Sweeney, Ph.D., is Associate Professor and Coordinator of the School Counseling and School Psychology Programs, California State University, San Bernardino.

Kathy Toy, M.S., is a school counselor and graduate student at California State University, San Bernardino.

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Table 1
Time of Onset and Half-life for Psychostimulants

Generic Name
(Brand Name)
Onset of Action Plasma Half-Life
Methylphenidate
(Ritalin)
30-60 minutes, up to 3 hours for Sustained Release 1-2 hours
Dextroamphetamine sulfate
(Dexedrine)
30-60 minutes, 1-2 hours for spansule 6-8 hours
Magnesium pemoline
(Cylert)
2-4 hours 8-12 hours

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Table 2
Psychostimulant Characteristics

Indications Contraindications Known Side Effects
FDA Approved Indications
  • ADHD in childhood and adolescents
  • Narcolepsy
  • Exogenous obesity
  • Absolute
    None
    Common
  • Insomnia
  • Decreased Appetite
  • Gastrointestinal pain
  • Irritability
  • Increased Heart rate (clinically insignificant)
  • Paradoxical worsening Sx
  • Possible Indications
  • ADHD in preschool children
  • Undifferentiated attention-deficit disorder
  • ADHD in intellectually subaverage children & adolescents
  • ADHD symptoms in children and adolescents with Fragile X syndrome
  • ADHD symptoms in children and adolescents with PDD (autism)
  • ADHD symptoms in children and adolescents with head trauma
  • ADHD symptoms in children and adolescents with tic disorders (i.e., Tourette's syndrome)
  • Relative
  • Psychosis Pregnancy
  • History of substance abuse in patient and/or family
  • Tic Disorders (Touretts's) in child and/or family
  • History of adverse reaction to stimulants
  • Height/growth retardation
  • Cardias/blood pressure anomalies
  • Impaired liver functoning (Cylert)
  • Patient being treated with MAOI
  • Uncommon
  • Psychosis
  • Sadness/isolation
  • Major depressive episodes
  • Cognitive impairment
  • Growth retardation
  • Tic disorders
  • Increased heart rate (clinically significant)
  • Impaired liver function (pemoline only)
  • Increased blood presssure
  • Dizziness, lethargy, fatigue
  • Nausea, constipation
  • Rash/hives
  • Hyperacusis
  • Formication
  • Necrotizing angitis brain
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    Table 3
    Tricyclic Antidepressant Characteristics (TCAs)

    Indications Contraindications Known Side Effects
    FDA Approved Indications
  • Enuresis
  • Absolute
  • Pregnancy
  • Prior hypersensitivity reaction
  • Currently on MAOI
  • Cardiac
  • Anticholinergic
  • Psychosis
  • Mania
  • Seizures
  • Hypertension
  • Confusion
  • Insomnia/nightmares
  • Rash
  • Tics
  • Tremor
  • Incoordination
  • Anxiety
  • Sexual dysfunction
  • Photosensitization
  • Established Indications
  • Enuresis
  • ADHD in children and adolescents
  • Relative
  • Epilepsy
  • Psychosis
  • Cardiac
  • Thyroid
  • Diabetes
  • Probable indications
  • ADHD in adults
  • School absenteeism/ school phobia
  • OCD
  • Depression
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    Table 4
    Most Commonly Prescribed TCAs

    Drug Available Forms
    Imipramine Generic
    Tofranil
    Imipramine pamoate
    Desipramine Norpramin
    Pertofrane
    Amitriptyline Generic
    Elavil
    Endep
    Nortriptyline Pamelor
    Maprotilene Generic
    Ludiomil

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    Table 5
    Time of Onset and Half-life for Novel Antidepressants (SSUIs)

    Generic Name
    (Brand Name)
    Onset of Action Plasma Half-Life
    Fluoxetine
    (Prozac)
    2-4 weeks 2-3 days
    Sertraline
    (Zoloft)
    2-3 weeks 26 hours
    Paroxetine
    (Paxil)
    2-3 weeks 14 hours

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    Table 6
    Novel (Atypical) Antidepressant Characteristics (SSUIs)

    Indications Contraindications Known Side Effects
    FDA Established Indications
  • None
  • Absolute
  • Known hypersensitivity reaction
  • On MAOI or fluoxetine within past five weeks
  • On sertraline within past two weeks
  • Pregnancy
  • Liver disease
  • Common
  • GI (Nausea, diarrhea, dyspepsia)
  • Decreased appetite
  • Weight loss (fluoxetine)
  • Nervousness
  • Insomnia
  • Excess sweating
  • Sedation
  • Dream intensification
  • Motor restlessness
  • Dry mouth
  • Male sexual dysfunction, anorgasmia
  • Probable Indications
  • None
  • Relative
  • Epilepsy
  • Psychosis
  • Cardiac
  • Thyroid
  • Diabetes
  • Occasional
  • Social disinhibition
  • Subjective sensation of excitation
  • Hypomania/mania
  • Rash/allergic reactions
  • Seizure
  • Hair loss
  • Possible Indications
  • MDD/dysthymia
  • ADHD
  • OCD
  • Trichotillomania
  • Compulsive impulse control disorders
  • Panic disorder
  • Anorexia nevosa
  • Bulima nevosa
  • Prader-Willi Syndrome
  • Self-injurious behavior
  • Borderline personality disorder
  • PTSD
  • Drug craving
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    Table 7
    Characteristics of Other Atypical Antidepressants

    Drug Indications Contraindications Side Effects
    Trazadone
  • Not recommended for routine use in children and adolescents
  • Used for depression in adults with accompanying sleep disturbances
  • History of liver or kidney disorders
  • Sedation
  • Orthostatic Hypotension
  • Dizziness
  • Headache
  • Nausea/vomiting
  • Bupropion Established Indications
  • None

    Possible Indications

  • ADHD
  • MDD
  • Absolute
  • Known hypersensitivity
  • Pregnancy
  • On MAOI
  • Hx of eating disorders
  • Seizure disorder
  • Organic brain disease
  • Hx of head trauma
  • CNS tumor
  • EEG abnormalities
  • Recent withdrawal from alcohol

    Relative

  • Concomitant administration of psychotrophics known to lower seizure threshold
  • Hepatic disease
  • Renal disease
  • Seizures
  • Agitation
  • Weight loss
  • Headache
  • Nausea
  • Upper respiratory complaints
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    Table 8
    Characteristics of Monoamine Oxidase Inhibitors (MAOIs)

    Drug Indications * Contraindications Side Effects
    Nonselective
  • Iponiazid (Marsalid)
  • Isocarboxazid (Marplan)
  • Phenelzine (Nardil)
  • Tranylcypromine (Parnate)

    Selective MAO-A

  • Clorgyline
  • Moclobemide

    Selective MAO-B

  • I-Deprenyl (selegiline)
  • Pargyline (Eutonyl)

    Uncharacterized

  • Furazolidone (Furoxone)
  • Procarbazine (Matulane)
  • Approved
  • Antidepressant
  • Refractory depression
  • Atypical depression
  • Major depression w/o melancholia
    * No MAOI compound is currently FDA approved for psychiatric use in children under 16 years of age.

    Probable

  • Major depression
  • Panic disorder
  • Social phobia
  • Borderline personality disorder with depression

    Experimental

  • ADHD
  • Childhood depression
  • Anorexia and bulimia
  • Borderline personality disorder
  • Separation anxiety disorder/school phobia
  • Inability to maintain dietary restrictions
  • Concurrent use of other MAOIs
  • Concurrent use of SSUIs
  • Hypertension
  • Liver disease
  • Impending surgery
  • Asthma
  • Sedation
  • Orthostatic Hypotension
  • Dizziness
  • Headache
  • Nausea/vomiting
  • Hepatic failure
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    Table 9
    Characteristerics of Antipsychotic (Neuroleptic) Agents

    Drug Indications * Contraindications Side Effects
    Phenothiazines
  • Thorazine
  • Mellaril
  • Serentil
  • Stelazine
  • Prolixin
  • Triafon
  • Compazine

    Thioxanthenes

  • Taractan
  • Navane

    Indolic compounds

  • Moban

    Diphenylbutylipiperdines

  • Orap

    Butyrophenones

  • Haldol

    Dibenzoxapines

  • Loxitane
  • Clozaril
  • Approved
  • Psychosis
  • SBD
  • ADHD
  • Mania
  • Nonpsychotic anxiety
  • Tourette's Disorder

    Other Uses

  • Nausea/vomiting
  • Intractable hiccups
  • Preoperative restlessness
  • Allergic reaction
  • Motion sickness
  • Sedation and sleep

    *Neuroleptic drugs are not recommended for children less than 12 years of age.

  • Hypersensitivity to neuroleptics
  • Agranulocytosis
  • Concurrent CNS depressants
  • Subcortical temperature
  • Pregnancy
  • Extrapyramidal symptoms
  • Acute dystonia
  • Cardiac arrythmias
  • Akathisia
  • Sedation
  • Affective blunting
  • Cognitive dulling
  • Social withdrawal
  • Tardive dyskinesia
  • Hepatic toxicity
  • Neuroleptic Malignant Syndrome
  • Sudden death
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    Table 10
    Characteristerics of Lithium

    Drug Indications * Contraindications Side Effects
    Lithium Carbonate Approved
  • Bipolar disorder with acute mania
  • Prophylaxis for bipolar disorder

    Possible

  • Bipolar disorder with acute depression
  • Unipolar depression
  • Cyclothymia
  • Psychosis
  • Aggression and violent behavior
  • ADHD
  • Alcohol abuse/dependence
  • Bulimia
  • Personality disorder
  • Functional encopresis

    * Lithium is not FDA approved for children less than 12 years of age.

  • Allergic drug reaction
  • Pregnancy
  • Renal disease
  • Cardiovascular disease
  • Thyroid disease
  • Severe dehydration/sodim depletion
  • Common
  • GI (nausea/vomiting, diarrhea)
  • Tremor
  • Leukocytosis
  • Malaise

    Uncommon

  • Renal problems
  • Ocular irritation
  • Hypothyroidism
  • Dermatologic
  • Cardiovascular
  • Weight gain/edema
  • Diabetes
  • Hair loss
  • Growth and development delays
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    Table 11
    Characteristerics of Anticonvulsants

    Drug Indications * Contraindications Side Effects
    Carbamazepine (Tegretol) Psychiatric
  • Bipolar disorder in adults
  • Alcohol withdrawal
  • Chronic pain associated with nerve injury

    Possible

  • Bipolar disorder in children and adolescents
  • Major depression
  • ADHD
  • Conduct disorders
  • Psychotic disorders
  • Funcyional enuresis
  • Sleep terror disorder
  • Absolute
  • Known hypersensitivity
  • History of bone marrow depression
  • On MAOI
  • Pregnancy

    Relative

  • Liver disease
  • Kidney disease
  • Common
  • Diplopia
  • Drowsiness
  • Incoordination
  • Nystagmus
  • Nausea
  • Leukopenia
  • Skin rashes

    Uncommon

  • Liver toxicity
  • Neurotoxicity
  • Mania
  • Increase behavior problems
  • Valporic Acid (Depakene) same as above Absolute
  • Known hypersensitivity
  • History of bone marrow depression
  • Pregnancy

    Relative

  • Liver disease
  • Kidney disease
  • Common
  • GI upset
  • Increased appetite/weight gain
  • Sedation
  • Tremor

    Uncommon

  • Liver toxicity
  • Neural tube defects
  • Pancreatitis
  • Hyperglycinemia
  • Menstrual irregularity
  • Phenytoin (Dilantin) same as above Absolute
  • Known hypersensitivity
  • Pregnancy

    Relative

  • Liver disease
  • Kidney disease
  • Alcohol use/dependence
  • Diabetes
  • Cardiac disorders
  • Common
  • Hirsutism
  • Gum hypertrophy
  • Folate deficiency\Psychomotor retardation

    Uncommon

  • Encephalopathy
  • Altered vitamin D/calcium metabolism
  • Biotin deficiency
  • Vitamin E deficiency
  • Liver toxicity
  • Neurotoxicity
  • Headache
  • Hyperglycemia
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