Professional Documents
Culture Documents
Medication what role does and should it play in treating children and teens
By Horacio Hojman
Published in cooperation with Bradley Hospital
July 2011
Vol. 27, No. 7 ISSN 1058-1073 Online ISSN 1556-7575
Highlights
Our top story this month looks at how, why, and when medications are being used in the treatment of children with psychiatric disorders, and whether a greater emphasis on psychotherapeutic interventions need to be reconsidered. Keep Your Eye On See page 2 APA proposes key changes to organizational structure of DSM-5 Adding CBT to antidepressants for teen depression Should age play a role in diagnosing pediatric bipolar disorder? Whats New in Research See pages 35 Academic performance only minimally improved by stimulants Childhood psychopathology and predictors of adult depression Massachusetts study looks at bullying in middle and high school students
A real, current dilemma troubles me in my own clinical work and in teaching medical students in our training program. Have we become so focused on psychopharmacologic treatment that we are at a loss to help children who do not respond to medication or the many adolescents who refuse to take medication? Does our ever-increasing focus on medication affect our ability to provide necessary and sufficient psychotherapeutic intervention? Would robust psychotherapeutic intervention, especially when used in conjunction with medication, enhance our patients development and long-term outcome? I wonder why child and adolescent psychiatrists in the United States are mostly
treating children and adolescents with medication, and losing sight of the possibility of enhancing developmental interventions, working with the school, engaging in parenting work, and employing psychotherapy. This was not the case in the past, when psychotherapy was a very solid, and core, component of being a child and adolescent psychiatrist.
Medications as adjunct
When the medication formulary for children and adolescents was scant, their use was seen as adjunctive to the psychosocial and psychotherapeutic interventions, which were thoughtfully constructed
See Combined Treatment, page 5
Guest Commentary
Sticks and stones: Violence and the power of words By Lewis P. Lipsitt, Founding Editor See page 8 Free Parent Handout
6
Continued from previous page
I started to taper some of their medications and saw no major deterioration in their behavior. Some children were discharged from our school with minimal medication, or none whatsoever. On the other hand, in some children in whom we tried different kinds of therapies for depression, anxiety, or trauma, even with building a good working alliance, their impairing symptoms were unchanged. Once I saw enough to better formulate the case and revise the treatment, I started medication to target specific symptoms, aiming for a synergistic effect between the medication and psychotherapeutic interventions. These children and adolescents responded and as symptoms receded, perhaps making depression less severe or removing anxiety, their ability to utilize therapy increased and the process improved. My impression from this experience is that to do psychopharmacologic treatments well, effectively, and efficiently, the treatment needs to be contained in a solid psychotherapeutic relationship with the child and their parents, rather than the reverse. This is necessary in order to zero in on the diagnosis, reestablish compliance with medication where it has been lost, avoid escalating polypharmacy, and treat medication nonresponders.
cent of adolescents diagnosed with MDD responded to fluoxetine, and 35 percent to placebo, after 12 weeks of treatment (March et al., 2006). In terms of compliance, there are also a significant percentage of children and adolescents that are noncompliant with their psychopharmacological treatment. According to DelBello et al. (2007), 1 year after initial hospitalization for a manic or mixed episode, 39 percent of adolescents had achieved symptomatic and functional recovery. Interestingly, only 35 percent reported being fully compliant with their medication regimen. Wilens and Spencer (2000) reported that 25 to 35 percent of patients are not benefited by stimulants because of insufficient symptom relief, side effects, or nonadherence. With respect to recurrences, Birmaher et al. (2006) in a 2-year prospective study of bipolar children and adolescents (mean age 13 years) found that 70 percent recovered from the index episode, but half of them experienced recurrence. Taken together, these studies suggest that nearly a third of patients will either fail to adequately respond to a drug, struggle with compliance, or experience recurrences.
prescribing based on increasing demands for services for a troubled child, as well as the appropriate therapeutic wish to relieve suffering quickly. However, these widespread empirical practices of prescribing expose children to medical risks. The challenge is to do an adequate trial of psychotherapeutic and psychosocial interventions to clarify which conditions truly require medication.
Horacio Hojman, M.D., is Child & Adolescent Psychiatry Attending, Child and Family Psychiatry Outpatient Department, Rhode Island Hospital and Clinical Assistant Professor in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University. A version of this article first appeared in the March/ April 2010 edition of AACAP News.
Off-label
A common occurrence in clinical settings is the off-label, trial and error targetsymptom oriented use of psychiatric medications in treating children and adolescents. This kind of prescribing relies on the competence and judgment of the prescribing clinicians rather than an evidence base of clinical trials. In this way an empirical approach replaces the traditional medical approach of diagnosing before treating as a standard for prescribing (Bloch, 1995). This can also be seen as a result of an unclear diagnosis, leaving the prescriber to target impairing symptoms. Often clinicians do not spend enough time getting to know the patient, making a formulation, and offering psychotherapeutic interventions. In this situation, clinicians are frequently
Changing Brain
From page 1
etal cortex activate in both hemispheres, as expected since this area was known to be involved in touch processing. But they also found that his occipital cortex was activated.
This was a surprise since that area is use for visual processing. The research team hypothesized that this mans brain had reorganized its own function, recruiting neuronal resources in the occipital area to assist in the much more intensive processing of tactile information necessary for Braille reading. (Those neu-
The Brown University Child and Adolescent Behavior Letter July 2011
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rons would otherwise be idle, since there was no visual information to process.) To further test this hypothesis, they utilized repetitive transcranial magnetic stimulation (rTMS) to temporarily shut down his occipital cortex. When this was accomplished he could no longer read Braille at all. This confirmed that the researchers hypothesis that the brain had in some fundamental way reorganized its networks of neurons so that the unused visual neurons could be used to assist with touch processing. The reorganization was fundamental since the function could no longer be performed without it. A follow-up study with sighted subjects who were blindfolded and taught Braille for 2 days showed that this reorganization happens quickly. After only 24 hours, the brains of these subjects had started to use visual neurons for touch processing. There are many other such examples, such as the finding that cab drivers in London have a significantly larger hippocampus the part of the brain used for visual spatial memory than other Londoners. The reason is obvious: they need and more repetitively use this part of their brain. Similarly, violin players have a larger patch of cortex devoted to sensation and fine control of their left hands than nonviolinists, again functionally advantageous to the violinist. attempts to discover opportunities in the daily life of patients to practice activities that include elements of the change they are seeking; monitoring of this practice and fine tuning the practice; and emphasizing the very small steps and successes that represent progress toward plastic change. to develop more formal brain training methods. The first of these approaches to receive significant research support involves exercise to train working memory, a function closely linked to attention. Carefully designed, well controlled research has shown that this method of working memory training results in lasting improvement in working memory, attention, and learning in children and adolescents with attention-deficit/hyperactivity disorder (ADHD; Klingberg, 2005). Computerized brain training exercises to increase mental or cognitive flexibility and ability to shift cognitive set are in development, although to my knowledge, research has not yet been published. Another emerging intervention that attempts to capitalize on neuroplasticity is EEG biofeedback. This method involves highly repetitive operant conditioning or feedback-guided learning to alter patterns of electrical activity in the brain in the direction of improved function. A growing body of evidence supports the effectiveness of this form of neural training for a variety of disorders and symptoms (Hirshberg, 2005). Finally, another set of emerging applied neuroscience approaches have growing research support and could be said to rely upon brain plasticity for their method of action. Noninvasive brain stimulation methods such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) have shown efficacy with a range of disorders or functions including depression, traumatic brain injury, working and semantic memory, and other forms of information processing.
Laurence M. Hirshberg, Ph.D., is a licensed clinical psychologist, and serves on the faculty of the Department of Psychiatry and Human Behavior of the Alpert Medical School as Clinical Assistant Professor. Dr. Hirshberg recently served as Guest Editor and contributor to a special issue of Child and Adolescent Psychiatric Clinics of North America devoted to emerging interventions in applied neuroscience, including neurofeedback and other brain-based interventions.
Neuroplasticity in psychotherapy
Therapists have actually been making use of neuroplasticity from the beginning. Successful psychotherapy of obsessive compulsive disorder and of depression results in plastic changes to the brain in the direction of normal function. It can be argued that cognitive behavioral psychotherapy anticipated the importance of neuroplasticity with its emphasis on frequent practice of learned skills in daily life. Efforts are being made in many quarters to develop new approaches to psychotherapy that more fully, more intentionally make use of neuroplasticity. Psychotherapy practitioners are writing about their efforts to embed in psychotherapy a basic recognition of the power of neuroplasticity. (Joseph Cozolinos book The Neuroscience of Psychotherapy is only one among many examples of this approach.) My own approach in psychotherapy increasingly incorporates a focus on brain plasticity. This includes educating patients (children and adults) about the importance of brain change and how it happens;
References
Cozolino L: The Neuroscience of Psychotherapy. WW Norton, NY; 2002. Pacual-Leone A, et al.: Annu Rev Neurosci 2005; 28:377401. Klingberg T, et al: J Am Acad Child Adolesc Psychiatry 2005; 44(2):177186. Hirshberg L, et al.: Child Adolesc Psychiatric Clin N Am 2005; 14:119.
The Brown University Child and Adolescent Behavior Letter July 2011
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