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Psychotropic medications: an update for school psychologists

Psychology in the Schools, Vol. 50(6), 2013  2013 Wiley Periodicals, Inc.
View this article online at wileyonlinelibrary.com/journal/pits DOI: 10.1002/pits.21696 PSYCHOTROPIC MEDICATIONS: AN UPDATE FOR SCHOOL PSYCHOLOGISTS NANCY RAPPAPORT AND DEBORAH KULICK University at Buffalo This article provides an overview of medications used frequently in the treatment of pediatricdepression, anxiety, and bipolar disorder. The need for a collaborative relationship between theprescribing physician, school personnel, and the family is outlined. School psychologists can playcrucial roles by providing the physician with information at the time of referral, developing school-based psychosocial interventions that augment pharmacological treatment, completing periodicevaluations to assist in symptom monitoring, and alerting the family and physician to any adverseside effects. C  2013 Wiley Periodicals, Inc.
Approximately one in every four to five youths in the United States will meet the diagnostic criteria for a psychiatric disorder during their childhood or adolescence (Merikangas et al., 2010).
Prompt identification and treatment of psychiatric illness in childhood is vital. If left untreated, thesechildren are at risk for persistent mental health issues, including school failure, delinquency, familyconflict, relationship problems, substance abuse, and accident risk. When psychopharmacologicalinterventions are necessary, school personnel are important members of the teams that care for thesechildren. Crucial roles for school psychologists include: (a) developing school-based psychosocialinterventions that augment medication trials; (b) creating a bridge among physicians, parents, andteachers for interdisciplinary collaboration; (c) advocating for appropriate educational services inthe least restrictive setting; and (d) alerting the family and prescribing physician if adverse sideeffects are evident (Abrams, Flood, & Phelps, 2006).
In recent years, the use of psychotropic interventions with youth has increased dramatically (American Academy of Child and Adolescent Psychiatry [AACAP], 2009). The most evident reasonsfor this expansion are an improved knowledge of the biological bases of mental disorders, a greaterevidence base to support the efficacy and safety of psychotropic medications, better advocacy effortsto identify and treat children, and reduced stigma associated with receiving treatment (Phelps, Brown,& Power, 2002). Changes in mental health reimbursement and increased pharmaceutical marketingefforts are also troubling reasons for this trend. There can be a "quick fix" mentality, but it is importantto remember that both physicians and mental health clinicians rarely advise medication withoutconcurrent comprehensive therapeutic services. Because pharmacological treatment of attentiondeficit and hyperactivity disorder (ADHD) has been covered extensively (e.g., Vaughan, Roberts,& Needleman, 2009), this review will focus on medications utilized in the treatment of pediatricdepression, anxiety, and bipolar disorder.
PSYCHIATRIC EVALUATION PROCESS The referral and evaluation of a child by a psychiatrist is ideally a collaborative process. We recommend that the evaluation include interviewing the child and parents, obtaining informationfrom the school and other health care providers, and using screening instruments and/or rating scalescompleted by the child, family, and teachers. These instruments may include Achenbach's Child Correspondence to: LeAdelle Phelps, 409 Baldy Hall, University at Buffalo, SUNY, Buffalo, NY 14260. E-mail: Rappaport, Kulick, and Phelps Behavior Checklist (Achenbach, 1991a), Teacher Report Form (Achenbach, 1991b), and Youth Self-Report (Achenbach, 1991c). Scales specific to the reason for referral such as the Beck DepressionInventory-II (Beck, Steer, & Brown, 1996), Children's Depression Inventory 2 (Kovacs, 2004),Multidimensional Anxiety Scale for Children (March, 1997), Screen for Child Anxiety RelatedDisorders (Birmaher, Khetarpal, Brent, & Cully, 1997), and the Youth Mania Rating Scale (Young,Biggs, Ziegler, & Meyer, 1978) are recommended. These types of instruments establish a baselineand help track a child's response to treatment.
Because school personnel have critical information about a child's academic performance, social–emotional functioning, and behavior at school, it is very useful to have a signed releasepermitting the classroom teacher, school mental health professionals, and child psychiatrist tocollaborate. To obtain a signed release, it is usually necessary to explain to the parents the advantagesof streamlining the flow of information. Although parents may be initially reluctant to approve suchcommunication, assuring them that they are an active part of the treatment team and that informationwill be shared with discretion usually resolves their concerns.
KEY PRINCIPLES OF PEDIATRIC PSYCHOPHARMACOLOGY The first tenet of any treatment is to do no harm, and a physician's decision to prescribe a psychotropic medication is not made lightly. Medications are intended to reduce symptoms, improvefunctioning, and facilitate client utilization of psychosocial interventions. Key considerations inthe decision to medicate are the severity of symptoms and the degree of functional impairment.
Medication may not have the same effect in all children with the same disorder, and frequent anddetailed monitoring of the prescribed medication is needed to evaluate drug efficacy.
Another key principle is related to adverse side effects. Children are often more sensitive to psychotropic medications than adults are, making it essential to monitor not only positive outcomesbut also negative consequences. To avoid possible side effects, medication is usually started at alow dose and gradually increased, until reaching a recommended dose that reduces symptoms. Inaddition, the physician needs to obtain a thorough medical history and record of current medications.
Not only does an interaction of medications need to be considered, but also side effects commonto medications may compound negative reactions. For example, both antiseizure and antianxietymedications may result in drowsiness and fatigue, and if taken together, this side effect may bemagnified. Some children are prescribed multiple psychotropic medications to treat a combinationof presenting problems, such as depression, anxiety, and irritability. It is important for physicians toperiodically reevaluate the medications and consider altering the regimen as symptoms change.
The third key principle is that psychopharmacological interventions are only one aspect of the treatment plan. Although cautious use of medications may be lifesaving, most children needadditional interventions to stabilize the home, learn emotional regulation skills, improve peer rela-tions, and receive appropriate educational services (Zito et al., 2008). Consideration of behavioral,cognitive–behavioral, group skills training, and/or family support interventions should always havea role in pediatric mental health services (AACAP, 1998, 2002, 2007a, 2007b). For mild to moderatesymptoms of any psychiatric condition, evidence-based therapeutic interventions may precede amedication trial. For moderate to severe symptoms, such as depression with suicidal ideation ormania, a combination of psychotropic and psychosocial interventions are best (AACAP, 2009).
MAJOR DEPRESSIVE DISORDER Depression in children may be difficult to detect. Symptoms vary considerably across devel- opmental stages and diverse ethnic groups (AACAP, 1998). Preschoolers often exhibit irritability,apathy, and regression. School-age children may display a sad or irritable mood, crying spells, so-matic complaints such as headaches, and lack of pleasure. Depressed adolescents are often intensely Psychology in the Schools DOI: 10.1002/pits Psychotropic Medications: An Update for School Psychologists moody, irritable, and sensitive to criticism. For these reasons, pediatric depression is more difficultto diagnose and treat than mood disorders in adults.
The treatment of pediatric depressive disorders needs to always incorporate psychological (e.g., cognitive–behavioral, behavioral, interpersonal) interventions, with medication viewed as a possibleaugmentation. In support of this combined approach, the Treatment for Adolescents with DepressionStudy, funded by the National Institute of Mental Health (NIMH), found that the optimal treatmentwas a combination of medication (e.g., fluoxetine [Prozac]) and cognitive–behavioral therapy (CBT;Glass, 2005). Seventy-one percent of participants responded to this combination compared with61% for medication alone, 43% for therapy alone, and 35% placebo. Additionally, the combinationtreatment group had the greatest reduction in suicidal thinking (Glass, 2005), although suicidalthinking decreased with all four treatments, even placebo, highlighting the importance of carefulmonitoring and attention.
Psychotropic Medications to Treat Major Depressive Disorder Based on rigorous studies demonstrating safety and efficacy, the Food and Drug Administration (FDA) approves medications for specific disorders. Although FDA approval for drugs used with thepediatric population offers some degree of assurance, many medications in child psychiatry areprescribed "off label" (i.e., no FDA approval for that specific disorder) because of an overall paucityof supporting data. Given that caveat, the first line of pharmacological treatment for pediatricdepression is the selective serotonin reuptake inhibitors (SSRIs). The FDA has approved two SSRIsfor use with children: escitalopram (Lexapro) and fluoxetine. As a second line of treatment, a selectiveserotonin-norepinephrine reuptake inhibitor (SNRI), such as desvenlafaxine (Pristiq) or venlafaxine(Effexor), may be used. Finally, bupropion (Wellbutrin) may be considered. For a complete listingof antidepressant medications, their possible side effects, and FDA approval, refer to Table 1.
Dosage Considerations and Side Effects. It is important to note that it may take up to 4 weeks before the effects of antidepressant medication are evident. The goal of treatment is remission ofsymptoms after 12 weeks. Starting at a low dose, the medication is increased gradually until thereis evidence of a positive response. If there is minimal or no response after 8 weeks, an alternativemedication is considered. If there is a partial response, an augmentation strategy may be tried.
This involves adding a second medication in an effort to achieve a full remission, such as addingbupropion to an existing regiment of fluoxetine.
Medication is usually prescribed for 6 to 12 months before the dose is tapered off, ideally during a school recess period. A longer course of treatment may be considered if: (a) there is a family historyof depression (i.e., strong genetic loading), (b) there was a suicide attempt, or (c) several medicationtrials were necessary to achieve an effective response. Youth should be monitored closely followingthe discontinuation of medication treatment because approximately 40% of children and adolescentsare susceptible to relapse between 6 to 12 months after discontinuing medication treatment (AACAP,2007b).
Common side effects of SSRIs are gastrointestinal distress, headaches, anxiety, agitation, insomnia, and sedation. The SNRIs may prompt nausea, sedation, elevated blood pressure, andweight gain. With bupropion, patients may experience dry mouth, decreased appetite, and a loweredseizure threshold. Nausea can be decreased by taking the medication with food and usually abatesafter the first week of treatment. Although medications are commonly taken in the morning, thedose can be switched to evening if fatigue is present during the school day. Some research (e.g.,Walkup & Labellarte, 2001) has indicated that pediatric patients may experience agitation, anxiety,and insomnia for up to 6 weeks after an antidepressant is started. This reaction is often dose related(i.e., evident with higher doses), appears more frequently in younger patients, and may occur up to Psychology in the Schools DOI: 10.1002/pits Rappaport, Kulick, and Phelps Table 1Medications Prescribed for Major Depressive Disorder Class of Medication Generic Name (Trade Name) Bupropion (Wellbutrin) Serious: seizures, confusion, hallucinations, unusual Reuptake Inhibitor thoughts, fever, rash Less serious: headache, dizziness, shaking, insomnia, nausea, vomiting, dry mouth, appetite changes, mild rash, increased sweating Contraindications: seizure disorder, eating disorder, substance abuse, certain medical problems Citalopram (Celexa) Serious: serotonin syndrome, mania, seizures, Escitalopram (Lexapro) hyponatremia (low sodium), arrhythmias, abnormal Fluoxetine (Prozac) Sertraline (Zoloft) Less serious: nausea, dry mouth, sleep and appetite changes, tremor, diarrhea, flu syndrome, decreased Additional serious side effects: vasculitis, glaucoma, growth suppression, hypotension Desvenlafaxine (Pristiq) Serious: hypertension (high blood pressure), Venlafaxine (Effexor) arrhythmias, seizures, abnormal bleeding, pancreatitis, growth suppression, skin reactions Less serious: nausea, headache, sleep and appetite changes, bowel changes, blurred vision, high cholesterol, tremor, abnormal dreams, paresthesia, tachycardia (increased heart rate) Note. SSRIs = selective serotonin reuptake inhibitors; SNRIs = serotonin norepinephrine reuptake inhibitors. Only fluoxetine(8–18 y) and escitalopram (12–17 y) have Food and Drug Administration approval for treatment of major depressive disorder.
All have a black box warning to monitor for suicidality and serious neuropsychiatric events.
20% of the time (Leibenluft, 2011). In addition, approximately 10% to 20% of children receivingSSRIs may evidence persistent lability of mood (Martin et al., 2004). Dose reductions or switchingto a different antidepressant, even within the same class (i.e., SSRI, SNRI), may be effective fortreating the side effects.
Black Box Warning. In 2004, the FDA directed manufacturers to add a "black box warning" about the increased risk of suicidality in children and adolescents being treated with an antidepressant(http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/UCM096273). This advisory wasbased on a meta-analysis of 24 placebo-controlled, double-blind clinical trials that evaluated morethan 4,000 children and adolescents who had a primary diagnosis of depression. The rate of suicidalideation, intent, or attempt was 3.8% for those prescribed an SSRI versus 2.1% for those takinga placebo (Hammad, Laughren, & Racoosin, 2006). Following this FDA warning, the number ofantidepressant prescriptions written for children and adolescents decreased dramatically (Nemeroffet al., 2007).
Using a meta-analysis of randomized, controlled trials conducted between 1988 and 2006, including seven additional studies that were not available at the time of the FDA report, Bridgeet al. (2007) concluded that the benefits of antidepressants likely outweighed the risks to childrenand adolescents with major depression and anxiety disorders. Although the data indicated that therewas a small but increased risk of suicidality in the first 9 days after initiation of treatment, the Psychology in the Schools DOI: 10.1002/pits Psychotropic Medications: An Update for School Psychologists pooled random-effects risk differences of suicidal ideation/suicide attempt were less than 1% andnot statistically significant. Other researchers have analyzed the risk–benefit relationship followingthe FDA warning and agreed with Bridge's conclusion (e.g., Jick, Kaye, & Jick, 2004; Kratochvilet al., 2006). However, careful observation is essential. The FDA has recommended weekly face-to-face follow-ups with the prescribing physician for the first 4 weeks. This should then be followedby monthly visits.
ANXIETY DISORDERS Anxiety disorders involve developmentally inappropriate fears that interfere with the child's daily life. These disorders include generalized anxiety disorder (GAD), phobias, separation anxietydisorder, social phobia, panic disorder, obsessive–compulsive disorder (OCD), acute stress disorder,and post-traumatic stress disorder (PTSD). These disorders may be evidenced in the school settingby the child being unusually fearful, irritable, angry, or distracted; having difficulty completingwork; reporting somatic complaints, such as stomachaches and headaches; worrying about gettingeverything right; and crying frequently. Because children are not likely to identify that what they arefeeling is anxiety, the difficulties may go untreated for some time.
There is substantial evidence-based support for behavioral, cognitive–behavioral, and psychoso- cial interventions for the treatment of childhood anxiety disorders (Weisz et al., 2012). However,when the anxiety level is such that the child or adolescent cannot participate actively in such inter-ventions, medication is warranted as an augmentation. Several studies support such an integrativeapproach. For example, Walkup and colleagues (2008) completed a randomized study comparing aplacebo drug alone, CBT alone, sertraline (Zoloft) alone, and a combination of CBT and sertralinewith 128 children aged 6 to 17 years, who were diagnosed with GAD, social phobia, or separationanxiety. There was a significant difference (p ≤ .001) between the treatment groups, with 81% ofthe combination medication/CBT group showing notable improvement, compared with 60% forCBT alone, 55% for sertraline alone, and 24% for placebo. An NIMH clinical trial, the PediatricObsessive–Compulsive Disorder Treatment Study (POTS), assessed treatment options for OCD with112 children aged 7 to 17 years. The randomized, placebo-controlled study found that a combinationof sertraline and CBT was most effective (54% remission), compared with 39% for CBT alone, and21% for sertraline alone (POTS Team, 2004).
Psychotropic Medications for Anxiety Disorders AACAP guidelines (2007a) recommend pharmacological treatment for anxiety disorders if the disorder is moderate to severe, if the child has a comorbid disorder (such as depression), or if thereis only a partial response to therapy. As with pediatric depression, the SSRIs are the medications ofchoice for anxiety disorders. SSRIs that have proven more effective than a placebo in randomized,double-blind studies include fluoxetine (Birmaher et al., 2003), fluvoxamine (Luvox; Walkup et al.,2001), paroxetine (Paxil; Geller et al., 2003), and, as described earlier, sertraline (POTS Team, 2004).
When utilizing SSRIs, the side effects and black box warning discussed earlier are to be taken intoconsideration.
Clomipramine (Anafranil) is a tricylic antidepressant that has proven efficacy via double- blind studies with pediatric OCD (e.g., Geller et al., 2003). Clomipramine is rarely a first choicebecause of poor tolerability and the risk of fatal overdose. There is anecdotal evidence for the useof benzodiazepines, but they are used only as short-term adjunct treatments with SSRIs until theSSRIs begin to work. However, there are significant concerns about prescribing benzodiazepinesin the pediatric population because of the possibility of dependency, notable sedative side effects,respiratory depression when used with alcohol, and paradoxical disinhibition (i.e., agitation rather Psychology in the Schools DOI: 10.1002/pits Rappaport, Kulick, and Phelps Table 2Medications Prescribed for Anxiety Disorders Class of Medication Generic Name (Trade Name) Alpha-2 Adrenergic Clonidine (Catapres, Kapvay) Serious: syncope (fainting), bradycardia (slowed heart Guanfacine (Tenex, Intuniv) rate), rebound hypertension (high blood pressure) Less serious: dry mouth, drowsiness, fatigue, dizziness, headache, impotence Lorazepam (Ativan) Serious: dependency/abuse, respiratory depression if Diazepam (Valium) combined with other CNS depressants (i.e., alcohol), Clonazepam (Klonopin) withdrawal, agitation Less serious: sedation, dizziness, hypotension (low blood pressure), amnesia, disinhibition, irritability Citalopram (Celexa) Serious: serotonin syndrome; mania; seizures; Escitalopram (Lexapro) hypo-natremia (low sodium); arrhythmias; abnormal Fluoxetine (Prozac) Fluvoxamine (Luvox) Less serious: GI upset, headaches, nausea, dry mouth, Sertraline (Zoloft) sleep and appetite changes, tremor, diarrhea, flu syndrome, decreased libido, sweating Other Antianxiety Agents Buspirone (Buspar) Serious: serotonin syndrome; movement disorders; Less serious: dizziness, drowsiness, nausea, headache, fatigue, decreased concentration, numbness, weakness, GI upset Note. CNS = central nervous system; SSRIs = selective serotonin reuptake inhibitors. Fluoxetine has Food and DrugAdministration (FDA) approval for obsessive–compulsive disorder (OCD) in ages 7–17 y; sertraline has FDA approval forOCD in ages 6–17 y; clomipramine and fluvoxamine have FDA approval for OCD in >6 y.
than sedation; AACAP, 2007a). Finally, the alpha-2 adrenergic agents guanfacine (Tenex) andclonidine (Catapres) are considered alternative medications if the anxiety proves refractory to theSSRIs. Table 2 reviews medications prescribed for anxiety disorders.
PEDIATRIC BIPOLAR DISORDER The public and research communities have engaged in significant debate about the validity of pediatric cases of bipolar disorder (Carlson, 2005; Pavuluri, Birmaher, & Naylor, 2005). Sufficientdocumentation now exists to indicate that there are youth who present with symptoms similar tothose seen in adult cases. The typical presentation in pediatric cases is often depression coupledwith hyperactivity. Mania may follow this initial presentation, which is usually manifested as moodlability, severe irritability, reckless behavior, pressured speech, racing thoughts, decreased need forsleep and aggression lasting hours to a few days (AACP, 2007b; Geller et al., 2002; Geller, Tillman,Carney, & Bolhofner, 2004). Children may also show inflated self-esteem, hypersexuality, and/orgrandiosity (e.g., taking on numerous impractical tasks, having an unrealistic view of their owntalents; Geller et al., 2002). The cyclical illness characterized by distinct periods of mania anddepression, as seen with adults, is often not evident in youth.
The disorder has a strong genetic component with a four- to six-fold increase in the risk of a child having the disorder if there is a first-degree relative who is affected (Huang et al., 2010;Patel et al., 2010). Current research is focusing on identifying genes specific to bipolar disorder andschizophrenia, which is viewed as having a related genotype (e.g., Ivleva et al., 2010).
Psychology in the Schools DOI: 10.1002/pits Psychotropic Medications: An Update for School Psychologists Diagnostic Issues in Pediatric Bipolar Disorder In an effort to address the confusion about the diagnostic presentation of juvenile bipolar disor- der versus severe chronic mood lability, researchers have proposed a new Diagnostic and StatisticalManual of Mental Disorders (5th edition) category referred to as disruptive mood dysregulation. Thisdiagnosis will encompass chronically irritable children between 7 and 17 years of age and requiretwo components: (a) temper outbursts that are developmentally inappropriate, frequent, and extreme;and (b) negatively valenced mood (anger or sadness) that occurs between outbursts. Symptoms mustbe severe, cause functional impairment in at least one of three contexts (home, school, peers), andbe present for at least 1 year (Leibenluft, 2011).
Additional diagnostic concerns arise because there can be a great deal of overlap among the symptoms of mania, ADHD (e.g., motor hyperactivity, impulsivity, and distractibility), and PTSD(e.g., emotional dysregulation, aggression, and irritability; Leibenluft & Rich, 2008). Because apsychiatric diagnosis results frequently in the prescription of a specific type of medication (e.g.,antidepressant, antipsychotic, or stimulant), this confusion can have a significant negative impacton treatment (AACAP, 2007b). Clinicians have also raised the concern that although a diagnosis ofbipolar disorder results in access to more intensive therapeutic services, it may also lead to childrenbeing exposed to medications that may have significant side effects (Thomas, Stansifer, & Findling,2011).
Psychotropic Medications for Pediatric Bipolar Disorder Atypical antipsychotics are the standard pharmacological treatment for bipolar disorder (AACAP, 2007b). The atypical antipsychotics include aripiprazole (Abilify), olanzapine (Zyprexa),quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon). These medications arevery effective as mood stabilizers because they work quickly (Thomas et al., 2011). The mostcommon side effects of atypical antipsychotics include weight gain, sedation, dizziness, and drymouth. Other possible side effects are an increase in fasting glucose and insulin resistance, ele-vated triglyceride and cholesterol levels, muscle stiffness, akathisia (restless limbs), extrapyramidalsymptoms (emotional blunting, muscle spasms, and abnormal movements), and tardive dyskine-sia (irreversible, involuntary, repetitive movements). For these reasons, the prescribing psychiatristmonitors the patient closely for side effects. Regular measurements of weight, blood pressure, pulserate, fasting glucose, liver functions, and cholesterol are necessary because of the added risk of dia-betes and cardiovascular disease. For example, a 2007 study found that the average weight gain after11 weeks of first-time use of the atypical antipsychotics ranged from 10 to 19 pounds, compared with0.42 pounds for untreated children (Correll, 2007). It is critical that children who are medicated adopthealthy lifestyle behaviors (i.e., diet and exercise) to help counteract the metabolic side effects. Be-fore prescribing these medications, the psychiatrist shares the risks and benefits to assist the familyin making an informed decision.
Lithium carbonate (Lithobid) is another possible medication for the treatment of bipolar disor- der, especially for long-term therapy. A mixed salt mood stabilizer that affects several neurotransmit-ter systems, it has been approved by the FDA for both acute mania and maintenance treatment withthe pediatric population. It has additionally been found to have some antidepressant properties andto reduce suicidal behavior (Smarty & Findling, 2007). However, research has indicated that thereis considerable variability in response to lithium in children (Findling et al., 2010). To determinelong-term efficacy and dosing recommendations with the pediatric population, the CollaborativeLithium Trials (CoLT) are being conducted under the auspices of the National Institute of ChildHealth and Human Development (Findling et al., 2008).
Psychology in the Schools DOI: 10.1002/pits Rappaport, Kulick, and Phelps Lithium side effects may include weight gain, polyuria (frequent urination), polydipsia (ex- cessive thirst), lethargy, tremor, acne, gastrointestinal upset, and cognitive dulling. This medicationrequires careful dispensing and monitoring because it has a narrow therapeutic index (i.e., smallwindow between therapeutic response and toxic side effects) and can be lethal in overdose. Lithiumtoxicity is a medical emergency and can present with tremor, nausea, ataxia, confusion, delirium,and seizures. Before starting lithium, a child's blood count, kidney functioning, and thyroid must beevaluated. Blood lithium levels are to be checked with each change in dose. Finally, all laboratoryvalues need to be repeated every 3 to 6 months.
Valproic acid (Depakote) is an anticonvulsant mood stabilizer that has been used by clinicians to treat pediatric bipolar disorder. It does not have FDA approval for the treatment of childhoodmania and has not been shown to be an effective maintenance treatment. For example, a double-blindstudy using 150 10- to 17-year-olds found no significant difference between this medication andthe placebo (Wagner et al., 2009). However, it is used to treat severe aggression in adolescent boysdiagnosed with bipolar disorder. Because it can cause polycystic ovary syndrome (cysts on the outeredge of each ovary, excess hair growth, infrequent menstrual cycles, acne, and obesity) and is aknown teratogenic (i.e., can disturb the development of the embryo), it is not generally prescribed tofemales. Common side effects of valproic acid include weight gain, sedation, lowered blood counts,and hair loss. This medication also requires that baseline liver function and blood tests be repeatedevery 6 months, along with a valproic acid blood level with any dose change (Smarty & Findling,2007).
Lamotrigine (Lamictal) is another anticonvulsant drug that is used to address symptoms in bipolar depression (Thomas et al., 2011). Although lamotrigine does not need monitoring of blooddrug levels, it requires a slow titration over 1 to 2 months to attain an effective dose. Possible sideeffects include nausea, dizziness, headache, and blurred vision. The most feared side effect, Stevens-Johnson syndrome, is a life-threatening rash that is quite rare (incidence of eight per 1,000 in people16 years of age and older). The risk of this syndrome is higher at times of treatment initiation, doseincrease, or if multiple doses are missed and then the typical dose is resumed (Smarty & Findling,2007).
There is considerable controversy over whether it is advisable to use antidepressants to treat pediatric bipolar depressive episodes (Kowatch & DelBello, 2005; Leibenluft, 2011). Typically, thisis done only if the child is at a therapeutic dose on a mood stabilizer or atypical antipsychotic andstill has depressive symptoms. Even then, the concern is that the antidepressant could flip the childinto an acute manic episode (Kowatch & DelBello, 2005). Clearly, more evidence-based researchevaluating medication efficacy for pediatric bipolar disorder is needed. Table 3 lists the medicationsused to treat bipolar disorders.
Other Medication Issues With Pediatric Bipolar Disorder When working with children and families affected by bipolar disorder, it is important to discuss the need for continued maintenance treatment. For those who have had repeated episodes of severedepression or mania threatening their safety and requiring hospitalization, long-term medicationstrategies are essential. For children and adolescents with less severe and chronic symptoms, itis suggested that they remain on maintenance treatment for 12 to 24 months before consideringa medication-free trial, with close monitoring (AACAP, 2007b). Relapses of mood episodes canbe high, even with effective treatment; however, continuing psychopharmacologic treatment canprevent these episodes from becoming more frequent or severe.
Careful diagnostic clarification is necessary when a child presents with difficulty focus- ing, hyperactivity, and mood symptoms because ADHD and pediatric bipolar disorder can have Psychology in the Schools DOI: 10.1002/pits Psychotropic Medications: An Update for School Psychologists Table 3Medications Prescribed for Pediatric Bipolar Disorder Class of Medication Generic Name (Trade Name) Atypical Antipsychotics Aripiprazole (Abilify) Serious: metabolic disorders (diabetes), movement Olanzapine (Zyprexa) disorders, tardive dyskinesia, neuroleptic malignant Quetiapine (Seroquel) syndrome, seizures, arrhythmias, stroke Risperidone (Risperdal) Less serious: increased appetite, fatigue, nausea, dizziness, Ziprasidone (Geodon) headache, akathisia, tremor, photosensitivity, increased Lithium (Lithobid) Serious: lithium poisoning (vomiting, confusion, lack of coordination), seizures, kidney problems, Less serious: tremor, increased thirst and urination, weight gain, acne, drowsiness, cognitive dulling Mood Stabilizers/ Lamotrigine (Lamictal) Serious: Stevens–Johnson syndrome (life-threatening rash), multiple organ failure, blood disorders, liver failure, pancreatitis, worsened depression Less serious: nausea, dizziness, tiredness, headache, GI upset, tremor, photosensitivity Divalproex sodium (Depakote) Serious: liver failure, platelet depression, other blood disorders, pancreatitis, Stevens–Johnson, psychosis, encephalopathy, confusion, polycystic ovary syndrome Less serious: weight gain, nausea, tremor, GI upset, dizziness, hair loss, depression, blurred vision, Note. Food and Drug Administration (FDA) approval for schizophrenia for ages 13–17 y: aripiprazole, olanzapine, quetiapine,risperidone. FDA approval for bipolar manic/mixed for ages 10–17 y: aripiprazole, olanzapine, quetiapine, risperidone. FDAapproval for bipolar mania ages ≥12 y: lithium. FDA approval for autistic disorder irritability for ages 5–17 y: aripiprazole,risperidone.
overlapping symptoms or can be comorbid (i.e., both disorders are present and require treatment).
The psychiatrist then decides what symptom to address first, which can be challenging. Sometimes,if children are treated for ADHD with a stimulant, their irritability may improve. However, othertimes a stimulant may make a child's mood symptoms worsen, requiring a mood stabilizer firstbefore a stimulant trial may ensue to address impulsivity and hyperactivity (AACAP, 2007b).
A key differential is to determine whether severe aggression is a presenting symptom of mental illness, a reaction to being threatened, or a maladaptive response (Conner, 2004). Determiningwhether aggression is a manifestation of bipolar disorder or another illness, such as ADHD, PTSD,anxiety, or OCD, will influence the choice of medication. An assessment of the chronicity, frequency,and severity of the aggressive acts provides a context for this determination. If maladaptive aggressionappears in the absence of antecedent social cues (i.e., no specific events are linked to the outbursts),is impulsive, out of proportion in intensity, frequency, duration, or severity, and does not terminateappropriately, then psychopharmacological intervention may be warranted (Bambauer & Connor,2005).
Treatment of aggressive behavior usually begins with cognitive–behavioral therapy and de- escalation strategies, along with family guidance (AACAP, 2002). If therapy alone is unsuccessfuland the symptoms are severe, medication may be used. It is common clinical practice to identifytarget symptoms in an aggressive child, such as irritability, impulsivity, or affective lability. Because Psychology in the Schools DOI: 10.1002/pits Rappaport, Kulick, and Phelps there are no specific pharmacological agents that target aggression, medication trials focus on theseother symptoms. There are some drugs, including the atypical antipsychotics, anticonvulsant moodstabilizers, benzodiazepines, alpha-2 adrenergic agonists, and stimulants, that are used for their ca-pacity to decrease aggression. Because of the possible side effects, antipsychotics are recommendedonly when other treatments have failed or if the child is at imminent risk for harming someone(AACAP, 2007b). The atypical antipsychotic risperidone has the best evidence-based support fortreating maladaptive aggression across a variety of diagnoses (e.g., autism, conduct disorder, bipolardisorder, pervasive developmental disorder), as well as with youngsters who have below-averageintelligence (McCracken et al., 2002). Mood stabilizers, such as lithium and valproic acid, are usedoccasionally for extreme aggression but have not consistently been shown to be effective. AlthoughSSRIs have been found to be helpful in treating aggression in adults, there is little evidence to supporttheir use for aggression in children (Thomas et al., 2011).
School psychologists play crucial roles for children with psychiatric diagnoses, including identifying students who may need a more intensive evaluation by a psychiatrist and encouragingfamilies and school personnel to recognize the significance of behaviors such as irritability, moodlability, and disengagement. The school psychologist can provide the treatment team with criticalobservations of how the student functions at school and assessment of the efficacy of a medicationtrial. Finally, the school psychologist may provide psychosocial interventions, assisting the child todevelop necessary interpersonal skills.
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