Psychological

Treatment
of Children
and
Adolescents
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“Three-quarters of children with

Mental Health mental health problems are seen
in primary care.”

Barriers that prevent children and their families from

obtaining needed mental health services
 Stigma
 Shortage of mental health professionals
 Inadequate coverage of mental health services in public and
private health insurance programs
 Inadequate time for primary care providers to identify mental
health issues
 Fragmented service delivery systems
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Mental Health in the Primary Setting

Recommendation
(1) Screening for and early detection of mental health
problems;
(2) Triage/referral to appropriate mental health treatment;
(3) Timely access to mental health consultation and direct
mental health assessment
(4) Care coordination
(5) access to specialty mental health treatment services; and
(6) Education of primary care practitioners around the
accurate assessment and safe and effective treatment of
child and adolescent psychiatric disorders.
Psychopharmacology

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STIMULANTS AND OTHER

ADHD MEDICATIONS

Stimulants are nervous system and

peripherally by enhancing
sympathomimetic drugs that act both in
the central dopaminergic and
noradrenergic transmission
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A complex idea can be conveyed with just a

single still image, namely making it possible to
absorb large amounts of data quickly.

There is a range of stimulant options, including those with short half-

lives (typically 4 hr) and those with long half-lives (8-12 hr).
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A complex idea can be conveyed with just a

single still image, namely making it possible to
absorb large amounts of data quickly.
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Side Effects Adverse Reactions

• Appetite suppression
• Psychosis
• Sleep disturbances • Mania
• Nervousness • Hypertension
• Headaches • Dependency and
• abuse.
Abdominal pain
• Dizziness
• Palpitations
• Tachycardia have also
been reported.
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ANTIDEPRESSANTS

Antidepressant drugs act on pre- and postsynaptic

receptors affecting the release and reuptake of brain
neurotransmitters, including norepinephrine, serotonin,
and dopamine
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Selective serotonin reuptake inhibitors (SSRIs), which, as

their name suggests, inhibit the reuptake of serotonin,
have a large marginof safety with no appreciable
cardiovascular effects.
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Side Effects
• Irritability “Withdrawal symptoms are
• more common in short-acting
Insomnia
SSRIs (sertraline, citalopram,
• Appetite changes and escitalopram), leading to a
gastrointestinal symptoms recommendation for divided
• Headaches doses if these medications are
• Diaphoresis used.”
• Restlessness
• Behavioral activation
• Sexual dysfunction
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TCAs have mixed mechanisms of action (e.g., clomipramine is

primarily serotonergic; imipramine is both noradrenergic and
serotonergic). They have a narrow therapeutic index, with
overdoses being potentially fatal
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Side Effects
• Anticholinergic symptoms (e.g., dry
mouth, blurred vision, and
constipation)
• TCAs can have cardiac conduction
effects in doses higher than 3.5
mg/kg.
• Blood pressure and
electrocardiographic monitoring is
indicated at doses above this level.
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• Because of their sparse evidence base, they are third-line

medications (after fluoxetine and the other SSRIs) for anxiety
and depressive disorders.
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Side Effects
• Side effects are similar to SSRIs,
including irritability, insomnia,
headaches, anorexia, nervousness,
dizziness, and blood pressure changes.
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• Anxiolytic agents (including lorazepam, clonazepam,

buspirone,and hydroxyzine) have all been effectively
used for acute situational anxiety. Their efficacy as
chronic medication is poorer, particularly when used
as a monotherapy agent.
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ANTIPSYCHOTICS
Based on their mechanism of action, antipsychotic
medications can be divided into typical (blocking
dopamine D2 receptors) and atypical (mixed
dopaminergic and serotoninergic [5-HT2] activity)
agents
Atypical Antipsychotics

 Have relatively strong antagonistic

interactions with 5-HT2 receptors and
perhaps more variable activity at central
adrenergic, cholinergic, and histaminic
sites, which might account for varying side
effects noted among these agents.

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Atypical Antipsychotics

 Have relatively strong antagonistic

interactions with 5-HT2 receptors and
perhaps more variable activity at central
adrenergic, cholinergic, and histaminic
sites, which might account for varying side
effects noted among these agents.

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Side Effects
 Extrapyramidal symptoms (e.g., restlessness
and dyskinesias)
 weight gain, metabolic syndrome, diabetes,
hyperlipidemia, hyperprolactinemia,
 hematologic adverse effects (e.g., leukopenia
or neutropenia)
 Seizures, hepatotoxicity, neuroleptic malignant
syndrome, and cardiovascular effects.
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Typical Antipsychotic: Haloperidol

 High-potency butyrophenone that is the typical

antipsychotic most commonly used.
 This medication is useful in psychosis, Tourette
disorder, and severe agitation.
 Side effects include anticholinergic effects,
weight gain, drowsiness, and extrapyramidal
symptoms (dystonia, rigidity, tremor, and
akathisia).
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MOOD STABILIZERS
have limited use in the treatment of child and adolescent
psychiatric disorders. For the treatment of bipolar
mania in adolescents, atypical antipsychotics are
considered first-line therapy.
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Lithium
 Lithium’s mechanism of action is not well understood; proposed
theories relate to neurotransmission, endocrine effects, circadian
rhythm, and cellular processes.
 Common side effects include polyuria and polydipsia and central
nervous system symptoms (tremor, somnolence, and memory
impairment).
 Periodic monitoring of lithium levels along with thyroid and renal
function is needed
 Lithium serum levels of 0.8-1.2 mEq/L are targeted for acute
episodes and 0.6-0.9 mEq/L are targeted for maintenance therapy
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Valproic Acid
 Valproic acid is an anticonvulsant with a
therapeutic plasma concentration range of 50-100
μg/mL.
 Common side effects include sedation,
gastrointestinal symptoms, and hair thinning.
Idiosyncratic bone marrow suppression and liver
toxicity have been reported, necessitating
monitoring of blood counts as well as liver and
kidney function.
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MEDICATION USE IN
PHYSICAL ILLNESS
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 Hepatic Disease
• Lower doses of medications may be required in in patients
with hepatic disease.
• Initial dosing of medications should be reduced and titration
should proceed slowly.
• Medications with high baseline rates of liver clearance (e.g.,
haloperidol, sertraline, venlafaxine, TCAs) are significantly
affected by hepatic disease.
• Valproic acid can impair the metabolism of the hepatocyte
disproportionate to the degree of hepatocellular damage.
• In patients with valproate-induced liver injury, low albumin,
high prothrombin, and high ammonia may be seen without
significant elevation in liver transaminases.
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 Gastrointestinal Disease
 Medications with anticholinergic side effects can slow
gastrointestinal motility, affecting absorption and causing
constipation.
 SSRIs increase gastric motility and can cause diarrhea. SSRIs
have the potential to increase the risk of gastrointestinal
bleeding
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 Kidney Disease
• It is important to monitor serum concentrations in renal
insufficiency, particularly for medications with a narrow
therapeutic index;
• Lithium, gabapentin, and topiramate are essentially
completely removed by dialysis, and the common practice
is to administer these medications after dialysis.
• Patients on dialysis often have significant fluid shifts and
are at risk for dehydration, with neuroleptic malignant
syndrome being more likely in these situations
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 Heart Disease
• Cardiovascular effects of psychotropic medications can
include orthostatic hypotension, conduction disturbances,
and arrhythmias.
• Quinidine-like effects of TCAs and the antipsychotic agents
can lead to prolongation of the QTc interval, with
increased risk of ventricular tachycardia and ventricular
fibrillation, particularly in patients with structural heart
disease.
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 Respiratory Disease
• Anxiolytic agents can increase the risk of respiratory
suppression in patients with pulmonary disease
• SSRIs and buspirone are good alternative medications for
treating anxiety.
• Consideration should be given to possible airway
compromise due to acute laryngospasm when dopamine-
blocking agents such as antipsychotic or antiemetic
medications are used.
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 Hepatic Disease
• Lower doses of medications may be required in in
patients with hepatic disease.
• Initial dosing of medications should be reduced and
titration should proceed slowly.
• Medications with high baseline rates of liver clearance
(e.g., haloperidol, sertraline, venlafaxine, TCAs) are
significantly affected by hepatic disease.
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 Neurologic Disease
 Psychotropic medications can be used safely with epilepsy
following consideration of potential interactions between
the psychotropic medication, the seizure disorder, and the
anticonvulsant medication.
 Clomipramine and bupropion possess significant seizure
inducing properties and should be avoided when the risk of
seizures is present.
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 Neuroleptic Malignant Syndrome

• A rare and potentially fatal reaction that can occur during
treatment with antipsychotic agents
• The syndrome generally manifests with fever, muscle
rigidity, autonomic instability, and delirium
• It is associated with elevated serum creatine phosphokinase
levels, a metabolic acidosis, and high end-tidal CO2
excretion
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 Serotonin Syndrome
• Serotonin syndrome is characterized by a triad of mental
status changes, autonomic hyperactivity, and
neuromuscular abnormalities
• Result of an excess agonism of the central and peripheral
nervous system serotonergic receptors and can be caused
by a range of drugs including SSRIs, valproate, and lithium
• It is generally self-limited and can resolve spontaneously
after the serotonergic agents are discontinued.
Psychotherapy
The use of psychotherapy involves a series of interconnected
steps including performing an assessment, deciding upon
treatment and a monitoring plan, obtaining treatment assent or
consent, and implementing treatment

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BEHAVIOR THERAPY
 Behavior therapy is based upon both classic (pavlovian) and
operant (skinnerian) conditioning
 The treatment begins with a behavioral assessment with
interview, observation, diary, and rating scale components.
 along with a functional analysis of the setting context,
immediately preceding external events, and real-world
consequences of the behavior
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BEHAVIOR THERAPY
• Modify the maladaptive functions of the behavior, using
tools such as positive and negative reinforcement, social
and tangible rewards, shaping, modeling, and prompting to
increase positive behavior
• Behavior therapy has shown applicability to anxiety
disorders, obsessive-compulsive and related disorders,
posttraumatic stress disorder, behavior disorders, ADHD,
nocturnal enuresis, autism spectrum disorder, and
intellectual disability.
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COGNITIVE-BEHAVIORAL THERAPY
• Based on social and cognitive learning theories and extends
behavior therapy to address the influence of cognitive
processes on behavior.
• CBT is problemoriented treatment that seeks to identify
and change cognitive distortions (e.g., learned helplessness
or irrational fears), identify and avoid distressing
situations, and identify and practice distress-reducing
behavior.
• CBT has shown applicability to the treatment of behavior,
depressive, and anxiety disorders.
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COGNITIVE-BEHAVIORAL THERAPY
• Trauma focused CBT
• involves a combination of psychoeducation, teaching
effective relaxation, affective modulation, and
cognitive coping and processing skills, engaging in a
trauma narrative, mastering trauma reminders, and
enhancing future safety and development
• Dialectical behavioral therapy
• combines standard CBT with concepts of distress
tolerance, emotional regulation, interpersonal
effectiveness, and mindfulness drawn from Buddhist
meditative practice
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COGNITIVE-BEHAVIORAL THERAPY
• Trauma focused CBT
• involves a combination of psychoeducation, teaching
effective relaxation, affective modulation, and
cognitive coping and processing skills, engaging in a
trauma narrative, mastering trauma reminders, and
enhancing future safety and development
• Dialectical behavioral therapy
• combines standard CBT with concepts of distress
tolerance, emotional regulation, interpersonal
effectiveness, and mindfulness drawn from Buddhist
meditative practice
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FAMILY THERAPY
• Family therapy is that the cause of problems in individuals
is thought to lie in patterns of family interaction, with
other family members helping to maintain the problem
• Family therapy begins with an assessment of the family
system, including observing patterns of interaction,
assessing family beliefs and the meanings attached to
behaviors
• Family therapy has shown applicability to anorexia and
substance abuse, and for these disorders is the treatment
of choice
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PSYCHODYNAMIC PSYCHOTHERAPY
• At the core of psychodynamic psychotherapy lies a dynamic
interaction between different parts or aspects of the mind.
• Therapy objectives are to increase self-understanding,
increase acceptance of feelings, shift to mature defense
mechanisms, and develop realistic relationships between
self and others
• Psychodynamic psychotherapy has shown applicability for
the treatment of emotional problems
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SUPPORTIVE PSYCHOTHERAPY
• Aims to minimize levels of emotional distress through the provision of individual and contextual support.
• Treatment is focused on the here and now.
• The therapist is active and helpful in providing the patient with symptomatic relief by containing anxiety,
sadness, and anger.
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PARENTING INTERVENTIONS
• Parenting interventions are based upon attachment and social
learning theory
• Attachment theory proposes that the quality of care provided to
the child, particularly sensitivity and responsiveness, leads to a
secure or insecure attachment, which in turn influences the
development of internal working models of self and others.
• Parenting interventions seek to address both attachment and social
learning deficits by improving both the parent–child relationship
and parenting skills.
• Parenting interventions have shown applicability for the behavior
disorders and ADHD
Psychiatric
Hospitalization
Psychiatric hospital programs are meant to address the
serious risks and severe impairments caused by the most
acute and complex forms of psychiatric disorder that
cannot be managed effectively at any other level of care.

The goal is to produce rapid clinical stabilization that

allows an expeditious, safe, and appropriate treatment
transition to a
less-intensive level of mental healthcare outside of the
hospital. 49
THANK YOU!

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