1. Discuss trends in usage of psychotropic medications in children and adolescents in the past 25 years.

2. Detail the 3 main contributors to the current trend in psychotropic usage.

3. Explain how the changing threshold for diagnosis and treatment has contributed to this trend.

4. Distinguish factitious disorder and malingering from somatoform disorders in children and adolescents.

5. Diagnose and treat functional pain syndromes in children and adolescents.

Are We Overmedicating Kids with Psychiatric Disturbances?
Richard Dalton, MD, Professor of Psychiatry and Pediatrics, Tulane University School of Medicine, New Orleans, LA

Introduction: since early 1980s, consistent increase seen in use of psychotropic medications across all age groups; majority of prescriptions for children and adolescents written by general practitioners and pediatricians; in survey of 600 pediatricians and family physicians, 72% said they had prescribed antidepressants for children and/or adolescents, but only 15.6% said they felt comfortable doing so, and only 8% said they felt they had adequate training to treat adolescent depression

Explanations for increased use of psychotropic medications: availability of new classes of drugs—9.2% annual growth seen in use of selective serotonin reuptake inhibitors (SSRIs) from 1998 through 2002; rate of antipsychotic (ie, atypicals) use doubled between 1991 and 1995; rates of use of long-acting stimulants have increased dramatically since 1999; change in federal regulations—Food and Drug Administration (FDA) Modernization Act, fully implemented by 1999, loosened restrictions on drug companies’ promotions to physicians of off-label use of medications; direct-to-consumer advertising and other marketing strategies key to encouraging greater use of psychotropics; overall, spending by pharmaceutical industry on television advertising increased 6-fold to $1.5 billion between 1996 and 2000; pharmaceutical marketing, and perhaps, improvement in psychotropics, has probably influenced medical practice, contributing to increased use of psychotropics, but does this increased use represent inappropriate clinical practice? ample evidence that current psychotropics far more effective than older classes of medications in treating childhood and adolescent anxiety, depression, bipolar behaviors, aggression, and attention-deficit/hyperactivity disorder (ADHD); does increased prescribing of psychotropics represent expanded use to those with psychiatric disorders who were previously unable to access care? changing clinical threshold for diagnosis and treatment—6.2% of children and adolescents treated with psychotropics in 1996, compared to 2.5% in 1987; however, 70% of children and adolescents with need for psychiatric services do not receive them; one researcher (Walkup) suggests that expanded psychotropic use necessary to address problems in child and adolescent mental health, and that increasingly effective pharmacotherapies being provided to youths with serious mental health needs; however, another researcher (Zito) says there are no data to support Walkup’s view; nothing known about long-term treatment outcomes with psychotropics currently being used; extent of benefit and satisfaction from expanded use of psychotropics unknown; also unknown whether expanded use of psychotropics means youths who need them actually getting them; administrative and clinical survey data find that diagnoses were generated using nonstandardized diagnostic procedures (therefore, reliability of diagnoses questionable)

Current pharmacotherapy data: among group of children in foster care, antipsychotics prescribed at similar rates for ADHD, depression, and anxiety; 30% of office visits involving prescriptions for psychotropics did not involve psychiatric diagnosis; in one study, only 60% of children given stimulant had diagnosis of ADHD; speaker posits that symptoms and behaviors, disconnected from diagnostic categories, have become focus of clinical decision making about prescribing psychotropic medications; sometimes symptoms treated to reduce risk for, eg, suicidal behavior, but no data to support treating symptoms outside of diagnostic category; eg, no data suggesting that pharmacotherapy of aggression has contributed to less aggression (however, data do suggest efficacy for atypical antipsychotic medications and mood stabilizers in treating childhood and adolescent impulsive [as opposed to instrumental] aggression)

Impulsivity, irritability, and explosiveness: symptoms of variety of diagnoses, including conduct disorder, depression, bipolar disorder, ADHD, anxiety, and posttraumatic stress disorder (PTSD); symptoms that occur with, eg, mood problems, treated differently from those that occur without mood problems

Polypharmacy: in previously mentioned study of foster children, 72% who received psychotropics received >1 medication; no evidence that treating ADHD, conduct disorder, or intermittent explosive disorder with multiple medications is effective; all polypharmacy algorithms should begin with monotherapy

Black youth: in study of office-based prescription practices, black youths 2.5 times less likely to receive prescription for stimulant medications; black children also less likely than white children to receive antidepressant when first diagnosed with depression, and less likely to be treated for mild to moderate depression and anxiety in juvenile justice settings

Conclusions: ample evidence that use of psychotropics in children and adolescents has consistently increased since 1980s, and dramatically since 1990s; evidence explaining this increase less clear; evidence does not clarify whether increase has helped provide treatment to youths who needed it but did not previously receive it; data about current psychotropic practices cause concern and suggest that psychotropics both under- and overused

Suggestions: conduct initial assessment utilizing family and patient clinical interviews and standardized instruments (speaker questions whether primary care physicians have time and/or resources necessary); for preschool-age children, try psychosocial treatment first; for school-age children and adolescents, do not provide pharmacotherapy without also providing appropriate psychosocial treatments; during emergencies, use psychosocial crisis-management techniques before treating with medications; avoid frequent use of emergency medications to control behavior; measure treatment outcomes before and after treatment; use appropriate treatment as first-line therapy for primary disorders (eg, if child exhibiting behavior problem, contingency management and parent-management training ideal mechanisms; risperidone “and other big guns” are not); taper and discontinue antipsychotics in patients who show remission in aggression symptoms for 6 mo; if patient unresponsive to multiple medications, taper and discontinue ≥1 medication; use conservative dosing strategy; use atypical (rather than typical) antipsychotics for aggression; if patient unresponsive to adequate trial of initial antipsychotic, switch to another antipsychotic

Functional Pain Syndromes in Children and Teens
Milton W. Anderson, MD, Section Head, Child and Adolescent Psychiatry, Ochsner Health System, and Assistant Professor of Clinical Psychiatry, Louisiana State University Health Sciences Center, New Orleans

Introduction: primary gain—symptom acts to resolve internal psychologic conflict; eg, school refusal achieves primary gain when it acts to increase proximity to mother figure in separation anxiety disorder, or when it acts to decrease proximity to group social contact or scrutiny in social phobia; factitious disorder, when it acts to provide care in patient role; secondary gain—involves factors that accrue from learning, which act to sustain symptom when no longer needed to resolve primary internal conflict; eg, in school refusal, improved grades from home schooling, or in factitious disorder, trip to amusement park provided by charity organization

Factitious disorder: primary gain is being put in patient role, which puts individual in caring environment; when recurrent or chronic, often called Munchausen syndrome; called factitious disorder by proxy when identified patient not intentional producer of symptom; represents direct child abuse if symptom actual, as opposed to simulated, and case must be reported to child protective services; associated with severe personality disorder or catastrophic social deprivation; “a factitious disorder is a medical problem because it’s a problem that physicians have to deal with; it doesn’t go away simply by chasing the patient away”

Malingering: not technically secondary gain; refers to intentional fraud or similar misconduct performed solely to, eg, acquire compensation, evade criminal prosecution, obtain drugs, avoid military duty; may apply to avoidance of work, if such avoidance does not terminate incentives (eg, payment) to work; can “stir up pretty strong feelings on the part of caregivers”

Somatoform disorders: nonintentional symptom produced for primary gain; symptom resolves internal conflict or expresses nonsomatic psychologic distress; assumed to be unconscious or preconscious; there may be symbolic connection between symptom and psychologic distress; diagnosis applies when, on investigation, more common emotional symptoms do not predominate; somatoform disorders listed in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) include somatization disorder (chronic recurrent polysymptomatic syndrome that has complex definition), undifferentiated somatoform disorder (polysymptomatic syndrome, usually regional, and does not meet criteria for somatization disorder), conversion disorder (single symptom that is neurologic), and somatoform pain disorder (single pain that is pain, not neurologic symptom); hypochondriasis and body dysmorphic disorder also included in category, but speaker questions appropriateness, since hypochondriasis is “pretty obviously an anxiety disorder,” and body dysmorphic disorder “really has very little relationship to the functional pain disorders [that] I’m talking about”

Pediatric pain syndromes: usually called, eg, functional abdominal pain, functional head pain, or functional musculoskeletal pain; associated with pain clustering around certain area of body, pain variability, and sometimes pain-associated disability

Risk factors: intrinsic—low pain threshold; female sex; hypermobility; poor perceived control over pain; difficult temperament; extrinsic—previous pain experiences; social deprivation; physical or sexual abuse; parental modeling of chronic pain behaviors; sleep disturbance; decreased fitness

General approach to management: assume extreme frustration or fear on part of patient and family; provide reassurance, education, and reactivation (eg, exercise, physical therapy, other adjunctive therapies); recommend simple over-the-counter analgesics; interdisciplinary collaboration essential, including planned scheduled visits to pediatrician, cognitive behavioral therapy (CBT), somatic region-focused hypnotherapy, and treatment of comorbid psychiatric disorders and psychiatric diatheses (shown that 60% to 70% of people with functional abdominal pain in childhood have anxiety disorder in adulthood); all caregivers should communicate with each other frequently

Functional head pain: avoid terms “tension headache” and “chronic muscle contraction headache”; use functional head pain instead, which guides caregivers to consider somatic therapies (eg, physical therapy, massage) instead of medication

Watch out for: sleep disorders; nutritional deficiency syndromes; exposures to known toxins (eg, lead, radiation)