Child Psychopharmacology Tips

Can 5 year olds Kill?

2011-06-10T16:06:00.000-04:00

Rage in any age can kill. In general, you may think that young children don't have homicidal rage. They may not have intent or the understanding to do harm in the terms of planning to kill, but more in the spur of the moment like the case of the five year old drowning a crying toddler. Impulsive rage that is destructive can be seen in children as young as three. The younger the age the rarer it is. I have seen in my practice many 5 to 7 year olds with aggression that can kill under certain circumstances. More often than not these children have underlying problems with both impulse control and mood regulation.

Intuniv: Guanfacine ER tabs

2009-10-15T11:35:00.001-04:00

Here are a few titbits on prescribing
Dose once daily
Do not crush, chew or break
Do not give with high fat meals
Do not substitute for immediate release tabs on a mg per my basis
because of different pharmacokinetic properties
If switching from Tenex first taper and discontinue. Then start
Intuniv at 1mg per day and go up no more than 1mg per week to a max of
4 mg per day.
Monitor Bp and pulse

Use of Seroquel as augmentation in OCD treatment

2009-07-27T17:33:00.001-04:00

If you have a patient with who has responded partially or poorly to
Celexa then it is worth considering the use of Seroquel as an
augmentation strategy.

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Use of Metformin to loose medication induced weight gain.

2009-06-16T12:02:00.002-04:00

It is not uncommon to find that the medication that a child is taking works but has the dreaded side effect of weight gain and the development of the "Metabolic Syndrome." Metformin can be used in such children to help loose or maintain a healthy BMI. You can start at 500 mg per day for children 9 and under and go to up to 1000mg per day for adolescents. Use the extended release version to prevent GI upset like vomiting and nausea.

Risperidone in children: High prolactin levels

2009-06-08T13:21:00.002-04:00

Risperidone is known to cause high prolactin levels in adults and post pubescent children causing endocrine dysregulation and side effets such as galactoria. In pre pubescent children the long term effects of high prolactin levels are not well studied. One study showed that over time the prolactin levels decrease over a span of a year. Sometimes adding a low dose of abilify can decrease the high prolactin levels.

What do you do when medications just don't work.

2009-06-04T16:11:00.002-04:00

Every once in a few years I come across a child whose disorder is so severe and treatment resistant. I am sure every child psychiatrist will at some point have such a patient. Even with today's medications sometimes hardware deficits can be so severe that no combination of medication can bring about reasonable change. This can be a difficult hurdle to cross for both the parent and psychiatrist. The parent might feel cheated that what was hopefully promised was not delivered and the psychiatrist put in a position of not being compitent. Under such circumstances I suggest the medications with the least side effects that have any minimal benefit be used. The child might need the highest level of care for long time. The parent should be supported in every which way and hope that nature takes a different course in neurobiological development.

CLozapine in children: Use lithium to boost wbc count

2009-06-01T11:59:00.002-04:00

Lithium has a bone marrow stimulating property that is useful when you have a child on clozapine whose anc's are below 2. Lithium can be added at 150mg per day and increased to upto 450mg per day. The effects can be seen in a time or sometimes sooner. This is useful in avoiding to go to twice weekly blood draws.

Daytrana patch in children

2009-05-28T13:29:00.002-04:00

Do you have a patient whose parents say that he is all over the place as soon as he gets up? In the rare instance of severe adhd where a child needs medications as soon as they get up in the morning you can ask the parent to apply the patch about 1 hour before the child usually gets up. Remember that the blood levels of methylphenidate is much higher when given by the patch. The effects last for 2 to 3 hours after the patch is removed. Do not use for more than 9 hours.

Lithium and lamictal in children: An effective combination

2009-05-21T09:58:00.002-04:00

Lithium and lamictal can be used effectively in combination in children who have irritability and mood dysregulation that does not respond to a single mood stabilizer. Also for those rapid cyclers who don't respond to other medications. Response can be seen with lower doses of each. One can give all the Lithium at night to prevent headaches. If needed they can both be titrated to a fully therapeutic blood using blood levels as a guide.

Depakote and Lamictal in children

2009-05-19T13:04:00.002-04:00

Using depakote and lamictal together raises the question of the drug interaction between the two. Can it be used safely? Yes it can. I prefer to start the depakote first and titrate it to a therapeutic dose. Then start lamictal at 5mg per day and gradually titrate up by 5mg per week. It is important to know that you will have much higher levels of lamictal at smaller doses. The advantage is that you can reach therapeutic levels sooner. The combination can be effective in treating mood disorders that don't respond to a single mood stabilizer. Be careful and watch for rashes, especially Stevenson Johnson syndrome.

Self abuse in children: Use of Naltrexone

2009-05-18T11:00:00.001-04:00

It is not uncommon to find a child who relentlessly self abuses oneself e.g. Scratching, cutter, head banging and hitting self in the face. In such circumstances when mood stabilizers have failed then Naltrexone can be used in doses ranging from 50mg to 200mg per day in decreasing such behaviors.

Depakote in children: Low WBC's

2009-05-15T13:28:00.000-04:00

Depakote can suppress the bone marrow and the production of WBC's and thereby lowering the total WBC count. Worry only if the ANC is less than 500.

Clozapine in children: Low levels

2009-05-14T09:56:00.001-04:00

It is not uncommon to find a real fast metabolizer and hence not be able to reach therapeutic blood levels of Clozapine. In such cases, adding Cimetidine one time a day will boost Clozapine blood levels without the need to increase the dose. Make sure you closely monitor the blood levels and adjust the dose of Clozapine accordingly.

Lamictal in young children: The dose

2009-05-13T13:54:00.001-04:00

I do find that Lamictal is very useful in treating affective dysregulation in young children. I begin at 10mg per day and increase it by 10mg every week to a maximum daily dose of 400mg per day using blood levels and clinical response as a guide.

Zyprexa in children: Is the weight gain avoidable.

2009-05-12T10:01:00.001-04:00

Most children do get increased appetites when put on Olanzapine. In all the years in practice I have seen only one child not do so. Try using Zydis, it may not cause as much weight gain. Maybe the route of absorption will do the trick. But in the end a very strict diet and exercise program is needed to prevent excessive weight gain. But how does one cut the "hunger reigns" is still a mystery.

Diagnostic simplicity: All treatments fall into these categories.

2009-05-11T13:00:00.000-04:00

In children, most psychiatric issues fall into one of the categories listed below. In a way it is an over simplification but a useful one. There can be one or more of these symptom clusters present.

1. Impulse control issues either due to ADHD or affective impulsivity.
2. Emotional dyscontrol or affective dysregulation. This includes depression, mania and other non specified mood dysregulation.
3. Thinking problems that include thought disorders and other psychotic symptoms.
4. Anxiety related symptoms and disorders.

Now all psychotropic medications used in children address any or all of the catogories above irrespective of the diagnosis. The diagnosis is very important when clear and can be used to guide prescribing of medications safely. Many times in younger children the ability to make a clear diagnosis is very difficult. It is during such times or until more better better diagnostic methods are available that one can go back to a simpler way of thinking while prescribing for symptoms that don't meet a particular category, but only after all non pharmacologic methods have failed.

Lamictal in children: Do blood levels to guide your dosing.

2009-05-10T11:16:00.000-04:00

At present there are no guidelines for the use of Lamictal in children. But you can get blood levels of the drug to make sure you have not crossed the higher threshold. Blood ranges can be between 2 to 20, however I do find that a blood range of 8 to 12 is very effective.

Clozapine in children: Pump up the ANC

2009-05-09T13:31:00.001-04:00

Is the ANC always low in your Clozapine patient. Then have them do exercise or jumping jacks for 10 minutes prior to their CBC blood draw and boost the ANC above 2.

Are you confident in prescribing psychiatric medications to young children.

2009-05-09T11:11:00.000-04:00

Many primary care physicians are more likely to find themselves with a young child on psychiatric medications. Many times they can manage simple drug regimens like those for straight forward ADHD. What happens if the child has multiple psychiatric conditions. Then an expert in children's psychopharmacology is needed. This is a new blog dedicated to prescribing psychiatric medications to children. It is best if one can avoid medications and use other modes of treatment, but sometimes medications become necessary.