General guidelines for drug treatment in children and adolescents

The treatment of children and adolescents with psychoactive drugs should be carried out by physicians with specific training in psychopharmacology and appropriate experience with this age group. Prescribing medication for behavioural or emotional problems in children should not be regarded as a routine matter that can be dealt with by general practitioners who have minimal time to devote to the patient. Each young patient receiving psychoactive drug treatment should be cared for by a physician with sufficient resources to perform a proper evaluation and work-up, to discuss the treatment rationale with child and family (and sometimes others, including teachers), and to undertake periodic reassessments of drug response and side-effects. Ideally, responsible clinicians should prescribe only drugs that have been shown in research to be both safe and efficacious by at least two independent centres.

Generally speaking, pharmacological treatment should rarely, if ever, be the only mode of treatment in children with psychiatric disorder. Educational and psychological interventions should usually be considered before psychopharmacological interventions are discussed. The medication dose should always be the lowest possible and given only as many times per day as necessary to achieve optimal management of the child's behaviour. Titration of the dosage should start at a low level, except in the rare instance of an emergency situation, followed by small dose increments at intervals sufficiently separated to allow proper evaluation of the efficacy of each dosage. It is usually wise to avoid polypharmacy. However, with growing awareness that comorbidity is the rule rather than the exception in child psychiatry, and that many drugs target symptoms rather than disorders, the prescription of more than one drug can sometimes be seen as a rational step. Multiple assessments by several informants should be employed whenever possible. Parents should be discouraged from adjusting the medication dosage without consulting the physician in charge of the child's treatment. The whole family (child, parents and, sometimes, siblings) should be informed about the benefits and hazards of medication.

There are special problems associated with the prescription of psychoactive drugs for children and adolescents with behavioural and/or emotional problems and concomitant mental retardation and/or seizure disorder.(!) It seems clear that there has been considerable overmedication and failure of drug monitoring in people with mental retardation. Although psychiatric disorder is frequent in this population, few studies have demonstrated any positive effects of psychoactive drugs in mentally retarded children and adolescents, and medication can be withdrawn from many individuals without an increase in problems. (2) Therefore it seems reasonable to assume that unnecessary pharmacotherapy is commonplace in this group. Those with seizure disorders, with or without mental retardation, also have elevated rates of psychiatric disorder. It is surprising that, in this psychiatrically disturbed group with seizure disorder, there have been few studies of psychoactive drugs and even anticonvulsive drug therapies have been poorly evaluated. The indications for the psychoactive drug treatment of children and adolescents with mental retardation or seizure disorders are basically the same as for individuals without these complicating features. However, for some drugs and in certain circumstances, side-effects and poorer efficacy make psychoactive drugs less appealing for individuals with mental retardation and/or seizure disorder. For example, central stimulants produce a low response rate in severely retarded people and tend to lower seizure thresholds.

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