Can 5 year olds Kill?

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

Here are a few pearls 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 blood pressure and pulse, it can cause Bradycardia

Use of Seroquel as augmentation in OCD treatment

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.

Use of Metformin to loose medication induced weight gain.

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

Risperidone is known to cause high prolactin levels in adults and post pubescent children causing endocrine dysregulation and side effects 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. This can be used especially if the child needs their primary anti-psychotic medication. This should be done under the supervision of a treating psychiatrist.

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

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

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.