Pediatric Psychopharmacology What’s your decision?

1. Pediatric PsychopharmacologyWhat’s your decision? IACAP Seminar on child and adolescent psychopharmacology Ordibehesht 1393

2. Strong climateagainst medication for children withmental disorders Past • Psychoanalytically oriented psychotherapy was the generally preferred treatment (until the late 1970) . The eventual acceptance of medication use was based on the growing evidence of efficacy of drug treatments with large ESs for disorders that had been resistant to psychological treatments. Stimulants responsible for the actual “start”

3. Dramatic expansion of the use of psychotropicmedications in children in recent years Different causes: • medications are easy to prescribe and to apply • treatments are less time consuming compared to psychotherapy • in some disorders (such as ADHD) there is a large group of quick responders

4. A switch from a categorical to a dimensional model of disease, facilitating the treatment of less severe cases by using lower cut-off points and not taking so much into account the burden of suffering. • The Internet is full of advertisements of “brain doping as a quiet revolution”.

5. This period of success has been followedby a series of challenges • Poly pharmacy • long term adverse effects of medications • the inadequacy of long-term drug surveillance • the growing alienation of the media from psychiatric illness: medications unnecessary diagnoses unscientific / harmful

6. Strong climateagainst medication for children withmental disorders Today concerns • Children are being over treated with medication, especially in the US. • Stimulants • Antipsychotic medications usage in children 5 times higher than in adults.

7. Current medications are only partially successful, with 40–50% of patients having incomplete response/ intolerance. • Most of drugs still act on the monoaminergic & glutaminergic targets.

8. Under treatment is perhaps a bigger problem globally thanovermedication

9. WHO’s definition • hyperkinetic disorder (about 1% of school-age children) • those children with ADHD that falls short of hyperkinetic disorder (about 4%) who fail to respond to behavioral interventions (perhaps half of that 4%) • then there would be approximately 30 per 1,000 children eligible for treatment

10. Stimulants use rates 73 per 1,000 in the USA Europe 9.2 / 1,000 (6–12y) in the UK 7.4/ 1,000 (13–17y) in the UK 1.8 per 1,000 in France a few centers in Italy (preschool use too rare)

11. Child Psychopharmacologyin LMIC Outside the university settings, children are seen: • with inadequate diagnosis • being treated with ineffective doses for short periods of time • with medications not supported by empirical evidence • frequently with poly pharmacy • by non-specialists ( the lack of adequate training)

12. In fact in LMIC, , ordinarily, only those from middle-high to high income class families have access to the few child psychiatrists in these regions by paying out of their pockets.

13. What factorsinfluence these startling differences?

14. 1 - Availability of prescribers Medication clinics in the US PMT in the UK : available and free lack of child psychiatric services in general, and of professionals qualified to prescribe in particular

15. 2 - Perceived efficacy of drugs and alternatives In some low-prescribing countries, non pharmaceutical interventions are regarded as more or less equivalent to drugs ( European Guidelines and those in the NICE) childhood depression: SSRIs after 3 months of psychological therapy • Recent studies arguing that the combination of both is more effective and safer than either treatment alone

16. A recent meta-analysis of non-pharmacological interventions in ADHD casts some doubt on the value of treatments such as behaviorally oriented parent training and most dietary interventions. Need to be some re-evaluation of the power of medication relative to psychological interventions

17. 3 – Cultural factors • The perceived overuse of medication in the USA has generated widespread media criticism in Europe. • Opposition to biological psychiatry, e.g., from sociological and psychoanalytic perspectives • The resulting polarization can get in the way of balanced and discriminating use.

18. 4 - Adverse effects • Differing perceptions of drug dangers influence regulatory authorities and prescribers. • The hazards of stimulants are few/manageable . • Oral administration especially of extended action preparations is unlikely to lead to misuse.

19. 5 - Uncertainty of indications • Most of the problems of child mental health are distributed in the population as continuous dimensions. • A real difficulty to decide where to place cut-offs for the use of medication, or how to decide on the balance between medication and psychological therapy.

20. A large part of pediatric psychopharmacological literature comes from the US and European countries. • only about 10% of randomized clinical mental health trials for children and adolescents come from LMIC, while almost 90% of children and adolescents live in those countries.

21. Different ethnic groups metabolize drugs differently, and hence safety and efficacy in one group cannot be easily generalized to the others. • While we have a great deal of efficacy data, true real-world effectiveness data and real functional outcomes as dependentvariables are sorely missing.

22. What we really want to know, as in other areas of medicine, is how our treatments impact on the natural history of the disorders. • Do antidepressants decrease suicides in adolescence? • Do ADHD medications reduce school repetitions and accidents at home?

23. The stigma • some drugs used in child psychiatry have larger effect sizes than those used in other areas of medicine ( asthma , headache or atopic dermatitis / ADHD) . Still, they are much less controversial. • We should not allow the stigma related to mental disease to preclude us from providing the right treatment to our patients.

24. Psychopharmacological treatmentsin children should always consider the developmental perspective

25. Child psychopharmacology means prescribing medication for individuals with a developing brain and, most of the time, for long periods. • In order to develop new drug targets, we need to expand our knowledge on the normal trajectories of brain development and how child mental disorders impact on it. • We need to pursue effective ways to interfere on these trajectories as early as possible, addressing the so-called “at risk” conditions.

26. The future of pediatric psychopharmacology seems bright • With the recognition of financial conflicts of interests and increased governmental funding to test various psycho tropics for different conditions in children and adolescents, • with the development of psychiatric pharmacogenomics: more targeted drugs and understand genetic variations which influence treatment response, thus moving from empirical selection of medications to personalized medicine in true sense.

27. One opportunity is the increasingly accepted view that we should move towards early intervention and prevention and that most psychiatric conditions develop during childhood and adolescence. • That should shift the target, not only of drug discovery but also of therapeutic approaches in general ,toward a younger population than is typically included in clinical trials.

28. Parents are usually fearful of administering psycho tropics to their children and often prefer psychological treatments over pharmacological agents • Clinician should not ignore the need to assess patients’ and caregivers’ attitudes and concerns. Clinicians should work with them to clarify possible erroneous beliefs and misconceptions associated with use of medications in childhood and adolescence.

29. Gold Standard for Clinical Assessment • In light of not having clear-cut laboratory tests to validate psychiatric diagnoses or • clinical assessment instruments, Spitzer (1983) introduced a provisional gold standard, the • LEAD standard. LEAD encompasses three core concepts: “Longitudinal, Expert, and All • Data”

30. “Longitudinal” means that clients’ symptoms are monitored over time. Past, • present, and future symptoms are factored into diagnostic decisions (with diagnoses being • revised in light of new information).

31. “Expert” refers to clinicians who can make reliable • diagnoses based on independent evaluation of the available data, comprehensive clinical • interviews, and discussion with other experts around any diagnostic disagreement. Expert • clinicians ultimately make consensus diagnoses that serve as the criterion measure.

32. “All • Data” refers to multiple sources of information, such as secondary informant reports from • parents or teachers and data provided by other professionals (e.g., psychiatric history, etc.).

33. LEAD standard represents a comprehensive and thorough approach to psychiatricevaluation.

35. LEAD standard represents a comprehensive and thorough approach to psychiatricevaluation.