Psychopharmacological treatments in children and adolescents. Adequate use or abuse?

J. Rapoport's article is a comprehensive and well-balanced review of pediatric psychopharmacology over four decades. Without any doubt we are now experiencing, not only in the US but in many other countries in the world, an overdiagnosis and overtreatment of mental disorders in children and adolescents. Some authors speak of a “dramatic expansion of the use of psychotropic medications in children in recent years” 1.

This might have different causes: medications are easy to prescribe and to apply, treatments are less time consuming compared to psychotherapy, and in some disorders (such as attention-deficit/hyperactivity disorder, ADHD) there is a large group of quick responders. But it might also have to do with a switch from a categorical to a dimensional model of disease, facilitating the treatment of less severe cases by using lower cut-off points and not taking so much into account the burden of suffering. In this context, the question of cognitive enhancement in young people becomes more and more relevant. The Internet is full of advertisements of “brain doping as a quiet revolution”.

Psychopharmacological treatments in children should always consider the developmental perspective. It is true that our knowledge in that field is still limited. However, the existent knowledge is sometimes not taken into consideration. For example, the ineffectiveness of tricyclic antide pressants in children has to do with the incomplete maturation of the transmitter systems at that age.

Related to the knowledge about brain maturation is the question of qualification of doctors for prescribing psychotropic drugs in children. Due to the uneven distribution of child and adolescent psychiatrists and other specialists with expertise in this field, a significant number of children in need for psychopharmacological treatment receive their medication from general practitioners and other prescribers with varying degrees of interest and training 2.

Not much is known regarding the long-term effects of most psychotropic medications when administered in childhood. In this respect, it is a source of concern that so-called preschool bipolar children are treated with compounds which are not even sufficiently tested in adults, and that new categories like bipolar spectrum disorders are created 3,4. There are also other new labels like “deficient emotional self regulation” still waiting for convincing empirical validation, but already used in medication studies.

Studies like these raise the question of validity of diagnoses. We see a tendency to make diagnoses on the basis of rating scales and checklists, missing the important information which can be collected by thorough interviews and observation of the patients. Even standardized interviews miss major elements of the disorder when not combined with a detailed family history and individual history of the patient.

A further major issue in pediatric psychopharmacology is comorbidity. This applies more or less to all psychopathological disorders in childhood and adolescence. For instance, in a study on autism spectrum disorders, 95% of the patients had three or more psychiatric disorders and 47% had more than five 5. This is a great challenge for medication, since it leads to polypharmacy, with all its consequences.

There is a remarkable shortage of studies on combined treatments (for instance, medication plus cognitive-behavioural therapy, or family interventions, or specific school programs), though it is well known that environmental factors interact significantly with pharmacological treatment. There is also a complete absence of studies on the placebo effect in pediatric psychopharmacology, although clinical experience indicates that this effect is significant also in children.

Interestingly enough, the majority of studies in pediatric psychopharmacology come from a few very productive centers. This raises the question of funding by the pharmaceutical industry and possibly also of conflicts of interests. In this context, the importance of ethical guidelines, such as those produced by the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP), should be emphasized.

As to future perspectives, those which appear most promising to me are the reclassification of syndromes in terms of endophenotypes, allowing a more carefully tailored approach to pharmacological treatment; combined treatment approaches (medication and non-medication treatment); and the development of new medications after clarification of the brain developmental trajectories for different endophenotypes.

There is still in the public, as Rapoport mentions, “a climate against medication for children with mental disorders”. This has to do with widespread misunderstandings, such as that behaviourally defined syndromes are not real disorders and cannot be treated by medication, and that psychotropic drugs poison the brain and cause dependence. Both statements are wrong in this general formulation, but difficult to disprove. The best arguments against these misunderstandings are a clear and restrictive indication for psychopharmacological treatments and their integra tion into a comprehensive treatment plan, including other treatment components (e.g., psychotherapy, family and school interventions). Medication alone is not sufficient in most cases.

Psychopharmacological treatment in children was and is still a long journey. J. Rapoport and her co-workers have made a remarkable contribution along this way.