by Allan L. Reiss, M.D., Director, Behavioral Genetics Unit
Assistant Professor, Psychiatry and Pediatrics,
The Johns Hopkins University School of Medicine, Baltimore, Maryland
Principles of Medication Treatment
The pharmacologic management of behavioral disorders in children with
developmental disabilities is based on the premise that such treatment
is almost always adjunctive. That is, pharmacologic treatment should
always be in addition to, or supplementing, environmentally based therapies
such as behavioral or family oriented interventions.
Pharmacologic or medication treatment should also be based on the premise that medications are directed toward specific, target behaviors. There are few, if any, medications currently available for treatment of specific behavioral disorders. Therefore, the doctor must rely on his or her knowledge of medication mechanism of action and what specific behaviors are likely to respond to specific treatments.
Likewise, the physician and family must always bear in mind the balance between possible beneficial effects and potential adverse effects. A full accounting of possible adverse as well as beneficial effects should be given to the parents of children whose medication treatment is planned.
Finally, an important principle in medication treatment is that of diligent treatment monitoring. The treating physician or his associates should plan to construct a trial of medication that will provide information as to the effectiveness of the medication. It is not enough to simply believe that medication "works." Frequently utilized monitoring procedures include a weekly behavioral checklist or a trial employing periods on and off medication. Medications to Treat Behavior Problems
The following medications are a small sample from the immense list of medications that have been used in the treatment of childhood behavioral disorders:
1. Stimulant medications (Ritalin, Dexedrine and Cyclert). Stimulant medications are used for the treatment of hyperactivity symptoms, particularly the target behaviors of overactivity and distractibility. These medications work best when the child's symptoms occur across all settings and are not accompanied by autistic behavior. Children without developmental disability have approximately an 80% positive response rate to these medications whereas children with developmental disabilities seem to have approximately a 50% chance of having a positive response to stimulants.
The two most commonly used stimulants, Ritalin and Dexedrine, work for about three to five hours after ingested. Therefore, multiple doses throughout the day may be necessary to control behavior. It is recommended that children have adequate control of their hyperactivity symptoms at home as well as the school setting so they may be more accessible to social interactions with their family and peers as well as have improved attention at school. Therefore, I personally recommend that children take stimulants on the weekends and on vacations unless the family is quite confident in their ability to manage the child's behavior and that it is clear that the hyperactivity symptoms are not interfering with peer social interaction.
These medications have relatively few side effects although, as mentioned above, children with developmental disabilities do not appear to respond as consistently as children without developmental handicaps. Children with developmental disabilities appear particularly likely to develop behavioral side effects including increased irritability, mood changability and crying spells. These behavioral side effects can sometimes be transient or treated with a dosage reduction. Trials off medication should be in a setting in which the child can be closely monitored such as during the school year.
2. Tricyclic medications (Tofranail, Ellavil, Norpramin, Pamelor, etc.). These medications were originally used to treat depression in adults. Over the past several years they have been increasingly utilized in the treatment of childhood behavioral disorders, most commonly, childhood depression and as second-line medications for hyperactivity symptoms. These medications should be administered by a physician who has experience in treating children with tricyclics. Side effects are generally minimal although at times, EKG and blood levels will need to be monitored.
3. Neuroleptic medications (Haldol, Mellarill, etc.). These medications are known to block a specific neurochemical receptor in the brain. One of the functions of the neurochemical receptor which is blocked involves motor function. Therefore, these medications serve to decrease gross motor activity levels and decrease repetitive or stereotypic behaviors.
These medications are often employed in the treatment of aggression or self-injury despite the fact that there is not much scientific evidence indicating that they are effective for these behavioral problems.
There are many short-term and long-term potential side effects including, most prominently, the development of a side effect called tardive dyskinesia, a permanent movement disorder which can develop after months to years on these medications.
Except in urgent or extreme cases, it's recommended that these medications be employed as second or third line agents in the control of childhood behavior problems because of their potential adverse effects.
4. Lithium. This is a medication that was originally discovered to have great usefulness in the treatment of adult manic depressive disorder. Since that time, increased uses for this medication have been discovered including the treatment of aggression, self-injury, and impulse control disorders in both children and adults. Individuals who show clear-cut behavioral cycles such as days or weeks or problematic behavior alternating with periods of improved behavior, are oftentimes benefited by treatment with lithium.
5. Anticonvulsants (Tegretol, Depakene). Both of these medications were originally used for control of seizures in children and adults. They remain highly effective drugs for many types of seizure conditions. Their use in children has been relatively limited although there is preliminary evidence that these medications, like lithium, can be useful in controlling aggressive behavior, self-injury, and behavioral cyclicity.
Conclusion
The goal of medication therapy is to decrease the effect of biologic
factors which may be interfering with the child's ability to learn from,
and respond to, his or her environment. Therefore, medication therapy
is oftentimes not useful without structured environmental interventions
that can allow the child to change or improve his or her behavioral
repertoire.
© Copyright 2000-2008, Lowe Syndrome Association, All Rights Reserved.