No está claro cuán grande es el papel de los antibióticos https://antibioticos-wiki.es en las relaciones competitivas entre los microorganismos en condiciones naturales. Zelman Waxman creía que este papel era mínimo, los antibióticos no se forman sino en culturas limpias en entornos ricos. Posteriormente, sin embargo, se descubrió que en muchos productos, la actividad de síntesis de antibióticos aumenta en presencia de otros tipos o productos específicos de su metabolismo.
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Professional Psychology: Research and Practice
Copyright 2002 by the American Psychological Association, Inc.
Pediatric Psychopharmacology: A Review of New Developments and
Advances in psychopharmacology have revolutionalized the management of emotional and behavioraldisorders in children and adolescents. Recent developments in pediatric psychopharmacology and theprevalence of pharmacotherapy for various psychological disorders in children are examined, and clinicalupdates for classes of psychotropics are provided. Issues including monitoring and assessing drug effects,acceptability and satisfaction, and the social, political, and cultural issues surrounding the use ofpsychotropics in children are discussed. The authors conclude that the current clinical use of psycho-tropics in children exceeds extant efficacy and safety data. The involvement of practicing psychologistsin pediatric psychopharmacology and the need for a firm empirical foundation for pediatric psycho-pharmacology are also discussed.
Nearly every practicing psychologist who has worked with
effects of these medications (Barkley, McMurray, Edelbrock, &
pediatric populations has encountered a patient who is receiving
Robbins, 1990; Drotar, 1995; Stancin, 1999).
psychotropic medication. A systematic effort to contain and drive
In this article, we argue that the clinical use of most psycho-
down the costs of medical care has dramatically changed health
tropic medications far exceeds the data available regarding their
care services in this country (Brown & Freeman, in press). Cost-
safety and efficacy. We surveyed major research programs in an
containment efforts have emphasized limiting referrals to specialty
attempt to provide the major developments in both basic research
providers and using designated points of service within the pri-
and clinical use of psychotropics. Due to limitations in the space
mary care system (American Academy of Pediatrics, 2000). The
provided, the literature reviewed here does not represent an ex-
result has been the decrease in the availability of mental health
haustive review of pediatric psychopharmacology. Rather, the
services for children and placements of limits on psychotherapy
purpose of this article is to illustrate the available empirical data
and specialized mental health services. Because primary care pe-
supporting the efficacy and safety of various psychotropic agents.
diatricians have also become increasingly involved in gatekeeping,
For a complete review, the reader is referred to several compre-
accessing, coordinating, and even providing for mental health
hensive sources on pediatric psychopharmacology (e.g., Brown &
services, it is no surprise that primary care providers (e.g., pedia-
Sawyer, 1998; Phelps, Brown, & Power, 2001; Werry & Aman,
tricians, family care providers) prescribe the majority of psycho-
1999). For other pharmacotherapies in children and adolescents
tropic medications for children (De Leon & Wiggins, 1996). One
including the pharmacological management of pain, the reader is
offshoot of this state of affairs has been an increase in opportuni-
referred to Dahlquist (1999), Tarnowski and Brown (1995), and
ties for practicing psychologists who work with children to enter
Tarnowski, Brown, Dingle, and Dreelin (1998). Although we do
into productive and collaborative relationships with pediatricians,
not provide an exhaustive review of the literature, we do hope that
both to identify types of psychopathology or learning disorders
this article will broaden practicing psychologists’ critical thinking
that may respond to psychotropic medication and to quantifiably
about the use of major psychotropics in pediatric populations and
assess the response to psychotropic agents and the possible adverse
stimulate issues pertaining to research and training in pediatricpsychopharmacology.
RONALD T. BROWN received his PhD in 1978 from Georgia State Univer-
Practicing Psychology and Pediatric Psychopharmacology
sity. He is a professor of pediatrics and health professions and an associatedean in the College of Health Professions at the Medical University
Advances in neuroradiological and electrophysiological assess-
of South Carolina. He is also editor-elect of the Journal of Pediatric
ment techniques, coupled with greater understanding of the roles
of neurotransmitters and structural differences in the brains of
MORGAN T. SAMMONS received his PhD in 1989 from Arizona State
children with learning disorders and various psychopathologies,
University. He is a prescribing psychologist and head of the Mental Health
have permitted a more complete understanding of the psychobiol-
Department at the Naval Medical Clinic, Annapolis, MD.
ogy of learning disorders and other mental problems (for reviews,
OPINIONS EXPRESSED BY MORGAN T. SAMMONS do not relect official policies
see Brown & Donegan, 1995; Brown & Sawyer, 1998; Phelps,
or opinions of the U.S. Navy or the Department of Defense.
Brown, & Power, 2001). The body of knowledge in neural phys-
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Ronald
iology parallels new developments in psychopharmacology and
T. Brown, Department of Pediatrics, Medical University of South Caro-lina, 19 Hagood Avenue, Suite 910, Charleston, South Carolina 29425.
has led to the introduction of a large number of pharmacotherapies
that are specific to cognitive processes, learning, and psychopa-
thology (for reviews, see Brown & Sawyer, 1998; Phelps et al.,
consultation with pediatricians seems a natural next step for psy-
2001). Although advances in neurosciences are undoubtedly re-
chologists who practice with children to take.
sponsible in part for the dramatic recent increase in the use ofpsychotropic medications for pediatric populations, particularly in
A Rationale for Separating Adult and Pediatric
the primary care setting (Zito et al., 2000), other more controver-
sial reasons exist. As Kutcher (2000) observed, in many instancesclinical use has outstripped scientifically based study of these
Phelps et al. (2001) provided a description of the many roles that
drugs. The issue of overprescription of psychotropics in pediatric
practicing psychologists may serve in making medication deci-
populations, especially for those agents lacking rigorous evidence
sions, evaluating treatment effectiveness, and maintaining family
supporting their effectiveness and safety, has achieved preemi-
involvement in the change process. These roles for psychologists
nence in the field of pediatric psychopharmacology. Readers seek-
include assessing emotional and behavioral problems that may beappropriate for pharmacotherapy; identifying intervention goals;
ing clinical guidance from the pharmacological information pre-
selecting empirically supported psychological interventions to ac-
sented in this article would do well to interpret this information in
company pharmacotherapy; and assessing therapy, readiness for
light of this as yet unsettled and highly contentious issue.
change, and the social validity of medication effects. Specific roles
There appears to be a natural affinity between the practice of
for practicing psychologists in the medication process include
psychology and pediatric psychopharmacology. This explains the
designing medication-monitoring protocols, interpreting the re-
significant contributions that practicing child psychologists have
sults of medication-monitoring protocols, and coordinating the
made to research endeavors in pediatric psychopharmacology.
Psychologists’ training in assessment and measurement has re-
A number of factors other than age separate the practice of
sulted in an armamentarium of measures for carefully monitoring
psychopharmacology with children from that with adults. These
medication effects (including actual response to medication within
issues include physiological factors, psychological factors, and
the realm of behavior and learning) as well as quantifying adverse
Children and adolescents (unlike their adult counterparts) rarely
initiate their own referral for behavioral and learning problems. Younger children especially may have little influence on whether
The rate at which medications are absorbed, distributed in the
they receive psychotropic medications. This state of affairs places
body, and metabolized by children differ markedly from adults
greater responsibility on physicians for accurately identifying
(Paxton & Dragunow, 1993; Werry & Aman, 1999). Great care
those children who may appropriately respond to medication, to
must be taken when deciding on particular medications or doses
expose them to the fewest adverse effects, and to protect them
for children, and changes in doses require consultation with the
from being disadvantaged in other ways by medication effects
practitioner who is familiar with physiological functioning in
(Brown & Sawyer, 1998; Phelps et al., 2001). As Gadow, Nolan,
children. When considering additional medications, the practi-
Paolicelli, and Sprafkin (1991) observed, contacts between physi-
tioner must take care to consider any adverse medication interac-
cians and classroom teachers and the use of well-validated instru-
tions that may occur from polypharmacy (the use of more than one
ments often occur sporadically and infrequently. Pediatricians
psychotropic simultaneously), an increasingly common practice in
often rely on reports from caregivers who have little opportunity to
observe children’s behavior at school. Thus, they may be unawareof the adverse effects of psychotropic medication on children’s
learning, behavior, or peer relationships. In these endeavors, psy-
Because young children do not have the cognitive schema from
chologists skilled in both assessment of developmental and learn-
which to describe accurately the physiological or psychological
ing disorders as well as in psychological measurement have made
changes that may be associated with the use of psychotropic
important clinical and research contributions to the field of pedi-
medications (for reviews, see Brown & Sawyer, 1998; Zametkin &
atrics, particularly in the primary care setting (Stancin, 1999). As
Yamada, 1999), the possible adverse events that may be associated
Brown and Sawyer observed, practicing child psychologists and
with these therapies, or the time course related to these changes,
pediatricians may collaborate productively in determining whether
obtaining information from other informants is imperative. Be-
trials of psychotropic medication are appropriate, effective, and
cause the level of agreement among child, parent, and teacher
successful and also whether one particular dose is more effective
reports of behavior is relatively poor (Achenbach, McConaughy,
than another in unstructured versus structured activities. Such
& Howell, 1987), the practitioner assessing medication response or
collaboration requires that both professionals engage in systematic
adverse effects must be skilled in obtaining information across
data collection, guided by a reliable assessment process, to ensure
a comprehensive, cost-effective evaluation. Given the interestamong both pediatricians and psychologists in evidenced-based
medicine and empirically validated treatments, it is anticipated thatthis collaboration among the two disciplines will significantly
Adherence to prescribed psychotropic management is a major
enhance treatment decisions as well as document the efficacy of
factor influencing efficacy of treatment. Unlike adults, children do
particular psychotropic agents. Expanding their scope of practice
not arrange their own appointments for treatment, and because
to include psychopharmacology (American Psychological Associ-
children may be reluctant to use psychotropic medication, pre-
ation, 1996; De Leon & Wiggins, 1996) and pharmacological
scribing medication for children is more complicated than for
SPECIAL SECTION: PEDIATRIC PSYCHOPHARMACOLOGY
adults. Because caregivers typically take responsibility for admin-
affluent homes. Other epidemiological studies, however, have
istration of children’s medication, parental attitudes invariably
reported disparate rates of stimulant prescription among Hispanic
influence children’s use of medication. Caregivers may be ambiv-
or African American youth as compared with their Caucasian
alent about using psychotropic medication, particularly when
counterparts, with minority children being less likely to receive
school staff initiates the referral and when the child’s behavior is
such treatment (Fox, Foster, & Zito, 2000; Zito, Safer, dos Reis, &
not deemed to be a problem at home. It is thus incumbent on
practitioners to be skilled in dealing with pharmacological issueswith both children and parents.
In a relatively recent investigation, Aman, VanBourgodien,
Coordination With Other Treatment Programs
Wolford, and Saphire (1995) conducted a survey of members of
Psychotropic medication in children is only one component in
the Autism Society of North Carolina; drug information was
the overall treatment program for children and adolescents. Psy-
gathered for 838 individuals who ranged in age from infancy to
chotropic medications for children are used to reduce symptom-
adulthood. Findings revealed that nearly one third of the sample
atology so that children are amenable to treatment in other settings,
was receiving psychotropic medication, with the most common
such as family psychotherapy and special education classrooms.
being antipsychotics (12%) or stimulants (7%).
Hence, the provider must not only monitor efficacy and safety ofpsychotropic medications but also coordinate other treatment pro-
grams along with drug therapy. Finally, efficacy and adverse
Compared with other psychiatric disorders in children and ad-
effects associated with medication must also be assessed across
olescents, there is a dearth of treatment studies related to the
pharmacological management of depression in children. Earlierinvestigators (Keller, Lavori, & Beardslee, Wunder, & Ryan,
Prevalence of Pharmacotherapy in Pediatric Populations
1991; Kovacs et al., 1984) reported low rates of pharmacotherapycompared with psychological interventions for depression in chil-
No national database exists that provides comprehensive infor-
dren. More recent investigators (Emslie, Mayes, & Hughes, 2000;
mation regarding the number of children receiving specific phar-
Martin, Kaufman, & Charney, 2000) have noted that the use of
macotherapies for particular disorders (Gadow, 1999). Surveys of
antidepressants in pediatric populations has increased significantly
Medicaid and insurance company databases, however, suggest
in the recent past, in spite of the small number of randomized
increased use of psychotropics in pediatric populations (Vitiello,
controlled trials supporting their use.
2001). Those disorders that have accounted for the majority ofpsychopharmacology prevalence studies include attention deficithyperactivity disorder (ADHD), mental retardation and develop-
mental disabilities, seizure disorders, autism spectrum disorders,
Although it has been estimated that 10% of school children
mood disorders, enuresis, and Tourette’s syndrome.
between 5 and 16 years of age wet their beds (Mellon & McGrath,2000), one investigation has reported that only 2% receive some
Attention Deficit Hyperactivity Disorder
type of pharmacotherapy for enuresis (Foxman, Valdex, & Brook,1986). The primary pharmacotherapies that have been reported are
For the past 3 decades there has been continued interest in
the tricyclic antidepressants or the antidiuretic hormone desmo-
determining whether psychotropic medications were overused or
pressin (Dulcan, Bregman, Weller, & Weller, 1998). Pharmaco-
prescribed capriciously for children with ADHD— or possibly
therapy for enuresis may be somewhat effective in the short-term,
even used as a substitute for school reform (Gadow, 1999). Safer
but relapse rates are very high once medication is discontinued
and Krager (1988) conducted studies of the prevalence of medi-
(Glazener & Evans, 2000). Therefore, behavioral methods are the
cation use for ADHD in schools in Baltimore County, Maryland.
preferred treatment for this childhood disorder.
Findings revealed that prevalence had doubled every 4 –7 yearsand that by 1987, 6% of the school population was receiving
medication for the management of ADHD, with the highest prev-alence during the third grade. Rates were higher for public than for
In the past, haloperidol has been the mainstay of treatment for
private schools. Stimulant medications constituted 99% of pre-
Tourette’s disorder, though discontinuation rates due to adverse
scriptions, and boys were five times more likely than girls to
side effects of this drug have been high (Robertson & Stern, 2000;
receive medication. Safer, Zito, and Fine (1996) reported a 2.5-
Stefl, Bornstein, & Hammond, 1987). More recently, the atypical
fold increase in the number of children receiving stimulant drug
antipsychotics such as olanzapine or ziprasidone have been inves-
treatment, attributed in part to children being managed on stimu-
tigated. Studies in which these agents are used generally find that
lant medication for longer periods of time, a greater frequency of
they are better tolerated than older drugs such as pimozide (cf.
children with learning disabilities and ADHD (primarily inatten-
Onofry, Paci, D’Andreamatteo, & Toma, 2000; Parraga & Parraga,
tive type) receiving stimulant drug therapy, a larger number of
2001). A small (N ϭ 28) placebo-controlled trial supporting the
girls receiving stimulant medication, and the prescribing of stim-
use of ziprasidone has been published (Sallee et al., 2000). In spite
ulant medication during the summer months. Contrary to popular
of the fact that most studies with newer agents are open-label,
lore, children from low socioeconomic backgrounds were no more
uncontrolled trials with small sample sizes and are thus inconclu-
likely to receive stimulant medication than their peers from more
sive, Robertson and Stern (2000) found sufficient evidence to
recommend that haloperidol no longer be considered a first-line
Few studies have examined the long-term clinical effects of the
stimulants, including their safety and efficacy, although the recentclinical trial conducted by the National Institute of Mental Health(Multimodal Treatment Study for Children With ADHD Cooper-
Mental Retardation Comorbid With Behavior Disorders
ative Group [MTA], 1999) has provided important data that sug-
Surveys of pharmacotherapy in institutions serving individuals
gest the efficacy and safety for a controlled trial over the course of
with either severe or profound mental retardation have revealed
14 months. Hinshaw (2000) has recommended that additional
that 30 – 60% of residents have been managed with either stimu-
research be undertaken, particularly those studies that examine the
lants or antipsychotic drugs. Litigation regarding the maltreatment
approach of combining stimulant medication with other behavioral
of institutionalized patients has resulted in a number of studies
indicating that many institutionalized individuals who are mentally
Adverse effects of stimulant medications are classified as either
retarded may be managed with behavioral approaches instead of
short- or long-term. The magnitude of adverse effects of the
medication (Aman & Singh, 1988; Hill, Balow, & Bruininks,
stimulants has been associated with dose of medication; adverse
1985). Gadow (1999) has cautioned that there is little use of
effects generally increase linearly with increased doses. Adverse
standardized instruments to assess response to medication or to
effects reported with both low and high doses include decreased
quantify adverse side effects in children in either institutional or
appetite, insomnia, anxiety, irritability, abdominal pains, and head-
aches (Barkley, McMurray, Edelbrock, & Robbins, 1990). Otheradverse effects have included mood disturbances, tics, anxiety,nightmares, and social withdrawal (DuPaul, Barkley, & Connor,
1998). These adverse effects typically dissipate following cessa-tion of the medication.
Here we review the various classes of psychotropic agents that
It has been estimated that less than 1% of children receiving
have been used with pediatric populations. Specifically, we review
stimulant medication develop abnormal movements or tics, and
stimulants, antidepressants and mood stabilizers, antipsychotics,
this requires that stimulant medication be administered judiciously
anxiolytics, and sedatives. We also provide recent information
for children with a family history of Tourette’s syndrome or
regarding some of the newer approaches used in pediatric psycho-
another tic disorder. More recently, there has been compelling
pharmacology to manage behavioral and mood disorders and the
evidence presented by Gadow (1997) suggesting that stimulants
may be used safely for children with comorbid tic disorders. Untiladditional data are forthcoming, the judicious use of this class of
medication is advised for children predisposed to a tic disorder. Another frequent adverse event of stimulant medication is behav-
Stimulant medications for children have been the most meticu-
ioral rebound, or the deterioration of behavior to a level worse than
lously researched and used medication in child mental health,
baseline. Behavioral rebound is typically managed by adjusting the
particularly for the management of ADHD (Bennett, Brown,
dose of medication and imposing structure during this particular
Craver, & Anderson, 1999; Phelps et al., 2001). The use of
period of the day, as well as increasing the use of behavior
stimulants has increased dramatically over the past several years
management techniques as the beneficial effects of the stimulant
(Safer & Krager, 1988) and there has been a significant increase in
the use of stimulants for preschoolers (Rappley et al., 1999; Zito et
There has been some concern that stimulants may decrease
al., 2000). Although stimulant drug therapy is not a panacea and
prosocial behaviors (Jacobvitz, Sroufe, Stewart, & Leffert, 1990;
should almost always be employed with other psychological and
Whalen, Henker, Hinshaw, & Granger, 1989). Jacobvitz et al.
educational interventions, well-established empirical data have
noted that reduced levels of prosocial behaviors may be associated
consistently demonstrated the potential benefits of the stimulants
with relatively high doses of stimulant medication. However, some
on symptoms associated with ADHD, including inattention, over-
studies examining the effects of stimulant medication on children’s
activity, and impulsivity (for reviews, see Bennett et al., 1999;
social behaviors have been more encouraging (see Hinshaw,
Brown & Sawyer, 1998; Phelps et al., 2001). The findings have
1991). In one controlled trial, children who were receiving placebo
been corroborated on laboratory performance tasks, direct obser-
doses versus stimulants were more negatively engaged, used more
vations of behavior in structured classroom settings, and on be-
aversive leadership techniques, and were also rated as less likable
havioral rating scales completed by caregivers and teachers.
by their peers (Buhrmester, Whalen, Henker, McDonald, & Hin-
Methylphenidate (Ritalin and others), a commonly used stimulant
shaw, 1992). Clearly, much more research is needed in this area to
medication, has been demonstrated to exert significant positive
clarify some of the consistencies with regard to social behaviors,
effects on measures of attention and academic efficiency for chil-
and until further data are forthcoming, careful monitoring must be
dren with ADHD in the classroom setting (DuPaul & Rapport,
1993). There is also a corpus of research to indicate that for
Regarding the long-term effects of stimulant medication, the
children without ADHD, stimulant medication may enhance
majority of studies have focused on height and weight suppression,
mother– child relationships by reducing frequency of commands
cardiovascular effects, and drug dependence and abuse. As a
(Barkley & Cunningham, 1979; Barkley, Karlson, Strezelecki, &
function of stimulant therapies, however, growth suppression ap-
Murphy, 1984). Psychostimulants have also been effectively used
pears to be both dose dependent and transient (Klein & Mannuzza
to reduce aggression in some ADHD children (for a review, see
1988). Nonetheless, because stimulants are frequently prescribed
well into adolescence and even adulthood, ongoing monitoring of
SPECIAL SECTION: PEDIATRIC PSYCHOPHARMACOLOGY
height and weight is imperative (Bennett et al., 1999). There has
groups demonstrated marked reductions in symptoms over time,
also been concern regarding the effects of stimulant medication on
stimulant medication was more effective than behavioral treat-
cardiovascular functioning, due to the fact that stimulants increase
ments for the management of symptoms associated with ADHD.
heart rate, blood pressure, and respiration in the short-term. How-
For children who had comorbidity of symptoms including aggres-
ever, these effects have been found to be clinically insignificant
sion, oppositional behavior, and even internalizing symptoms,
and transient (Zeiner, 1995). Recently, there has been much con-
however, combined treatments of both medication and behavior
cern about patients potentially abusing stimulant medication, par-
therapy proved superior to behavioral treatment used alone or to
ticularly during adolescence, when many youths are at marked risk
traditional treatments provided in the community. This finding is
for drug abuse. Concerns regarding abuse are apt to be highest
important for several reasons. Children with ADHD commonly
when there is comorbidity of other disruptive behavior disorders
present with comorbid diagnoses. Also, in the MTA study, parents
(e.g., conduct disorder). Fortunately, the few available studies
preferred the behavioral therapy condition to the medication-alone
suggest that when children and adolescents are managed on ap-
treatment (MTA Cooperative Group, 1999).
propriate doses of medication, they are at no greater risk forabusing stimulants than are peers who are not managed with
stimulants (American Academy of Pediatrics, 2001).
The most commonly employed stimulants include methylpheni-
The antidepressants traditionally have been used for those target
date, both in immediate and sustained-release preparations
symptoms associated with major depressive disorder, including
(Ritalin, Ritalin-SR, Concerta), dextroamphetamine (Dexadrine)
depressed mood, appetite change (i.e., increase or decrease in
and amphetamine– dextroamphetamine mixtures (Adderall), and,
weight), anhedonia, anergia (lack of energy), decreased concen-
less commonly, pemoline (Cylert). Because of a small number of
tration, changes in psychomotor activity or sleep patterns, and
reports in the United States of acute liver failure, the Food and
recurrent thoughts of death. The clinical use of antidepressants,
Drug Administration (FDA) has recommended that pemoline not
like that of stimulants, continues to grow explosively in pediatric
be ordinarily considered a first-line drug therapy for children
and adolescent populations, although proof of the efficacy of
diagnosed with ADHD (Abbott Pharmaceuticals, 1996).
antidepressants in these age groups remains inconclusive at best
Recently, clinical use of Adderall has gained widespread appeal
(for reviews, see Brown & Sawyer, 1998; Emslie, Walkup,
in the management of children with ADHD. Only three studies can
Pliszka, & Ernst, 1999; Phelps et al., 2001). The antidepressants
be located that have compared Adderall with standard doses of
may be divided into several classes, including the tricyclics, the
Ritalin (Pelham et al., 1999, 2000; Swanson et al., 1999). Findings
selective serotonin reuptake inhibitors (SSRIs), monoamine oxi-
revealed that both stimulants were superior to placebo in improv-
dase inhibitors, and the atypical antidepressants.
ing academic productivity as well as ratings of behavior. Adderall
Studies of tricyclics have not revealed efficacy greater than that
was found to be superior to Ritalin in cases in which the effects of
for placebo (Birmaher, 1998; Boulos et al., 1991; Kutcher et al.,
Ritalin dissipated at midday and in the late afternoon. There was a
1994; Kye et al., 1996). The lack of clearly defined efficacy and
low side-effect profile for both stimulants. Thus, Adderall appears
the adverse side-effect profile of the tricyclic antidepressants (in-
to be at least as effective as Ritalin in the short-term in improving
cluding reports of sudden cardiac death; Riddle, Geller, & Ryan,
behavior and academic productivity for children identified with
1993; Varley & McClelland, 1997; Werry, 1995) suggest that
ADHD. For this reason, Pelham et al. (2000) recommended the use
these agents should not be routinely employed in the management
of Adderall, particularly for children in whom the effects of Ritalin
of depression in children and adolescents.
Since their introduction nearly 15 years ago, the SSRIs have
A final issue regarding the stimulants relates to the relative
been widely prescribed for adults due to their documented safety
efficacy of stimulant medication and behavioral therapy or their
and favorable side-effect profile. SSRI antidepressants currently
combined effects in managing the symptoms associated with
available in the United States are fluoxetine (Prozac), sertraline
ADHD. Of further interest is whether the combination of stimulant
(Zoloft), paroxetine (Paxil), and citalopram (Celexa). Of these,
drug therapy and behavior therapy is more potent than either
only sertraline has received FDA approval for use in pediatric
treatment used alone. This issue has been the topic of the largest
populations. Fluvoxamine (Luvox), though a potent inhibitor of
clinical trial sponsored by the National Institute of Mental Health
serotonin reuptake, is approved only for the treatment of
and is one of the more definitive long-term studies addressing the
obsessive– compulsive disorder in both adults and children. Al-
issue of multimodal therapies in pediatric populations. The Mul-
though preliminary and still emerging, the literature has been
timodal Treatment Study for Children With ADHD (MTA Coop-
generally favorable regarding the efficacy of the SSRIs in the
erative Group, 1999) examined the relative efficacy of 14 months
management of pediatric depression (Alderman, Wolkow, Chung,
of four treatments for managing ADHD in 570 children (7–9 years
& Johnston, 1998; Ambrossini et al., 1999; Apter et al., 1994;
old) with ADHD who were randomly assigned to one of four
Cosgrove, 1994; DeVane & Sallee, 1996; Emslie & Mayes, 2001;
treatment groups. Treatments included (a) behavioral therapy
Emslie, Rush, Weinberg, & Kowatch, 1997; Martin et al., 2000;
alone (i.e., 35 sessions of behavioral parent training, 10 teacher–
Rey-Sanchez & Gutierrez-Casares, 1997; Sallee, Hilial, Dough-
school consultations per school year, a classroom aide, and an
erty, Beach, & Nesbitt, 1998; Wilens, Spencer, Biederman, &
intensive summer treatment program); (b) medication management
Schleifer, 1997). Despite generally positive recommendations,
alone (i.e., stimulant medication administered 7 days/week); (c)
most authors are careful to point out that not enough carefully
combined behavioral training and medication management; and
controlled randomized trials exist to make definitive recommen-
(d) a community control group of children who received traditional
dations. Thus, although the strength of the evidence is as yet
therapies for ADHD. Findings revealed that although all four
undetermined, at least some data suggest that the SSRIs may be
superior to placebo in managing select target symptoms. Adverse
agent be used to reduce psychotic symptoms only as a last resort,
effects, including nausea, overactivity, insomnia, weight loss, and
when children have failed to respond to other antipsychotic agents.
(rarely) dermatitis, are of significant concern, though these have
It is important to note that the overuse of antipsychotics and
generally been reported to be minor and transient. Because of the
mood stabilizers in pediatrics is an area of considerable contro-
promising data in early controlled trials of SSRIs and some spec-
versy. A recent study of institutionalized children found that an-
ulation that prompt treatment with antidepressants may provide
tipsychotics were the most frequently used category of medication
long-term protective effects (Martin et al., 2000), further well-
(35% of all admissions to the facility were studied; Connor,
designed, placebo-controlled, double-blind studies are clearly war-
Ozbayrak, Harrison, & Melloni, 1998), and a high rate of prescrip-
ranted, particularly over the long-term with pediatric populations.
tions of mood stabilizers was found as well. Connor and colleagues
One atypical antidepressant, buproprion (Wellbutrin, Wellbutrin
noted that antipsychotics were generally used in the absence of a
SR, also marketed as Zyban for smoking cessation) has demon-
diagnosis of psychosis, a tic disorder, or bipolar disorder. In a
strated some promise in double-blind clinical trials with children
report on psychoactive drug prescription in pediatric outpatients,
diagnosed with ADHD (Barrickman et al., 1995). In particular,
Kaplan, Simms, and Busner (1994) also noted that 65– 67% of
when children have been refractory to stimulant medication, when
children surveyed were prescribed antipsychotics without a corre-
there has been a remarkable personal family history of tics, or
sponding diagnosis of a psychotic disorder.
when there is a family member at risk for abusing or selling
One antipsychotic medication that has gained popularity in the
stimulant medication, the use of buproprion may be a reasonable
clinical management of psychotic symptoms is risperidone
alternative to the stimulants. Studies suggest that buproprion may
(Risperdal). Open trials have been encouraging and suggest that
reduce symptoms of ADHD (Barrickman et al., 1995), although its
risperidone significantly reduces target symptoms of psychotic
adverse effects are numerous and include insomnia, agitation,
behaviors (Armenteros, Whitaker, Welikson, Stedge, & Gorman,
confusion, irritability, and possible hypertension. Bupropion use is
1997; Zuddas, Pintor, & Cianchetti, 1996), aggression (Horrigan &
contraindicated in patients with histories of eating disorder or
Barnhill, 1998), and behaviors associated with pervasive develop-
mental disorder (Perry, Petaki, Munoz-Silva, Armenteros, & Silva,1997; Purdon, Lit, Labelle, & Jones, 1994); few extrapyramidalsymptoms have been reported in the adult literature. However,
many more controlled trials are needed before the efficacy andsafety of risperdal with pediatric populations can be established.
There is a paucity of data regarding the use of antipsychotic
Similarly, the newer atypical agents ziprasidone (Geodon) and
medications with childhood schizophrenia. Haloperidol (Haldol)
quetiapine (Seroquel) have become increasingly used, largely due
has been the mainstay in the management of childhood-onset
to their improved side-effects profiles. But as with any other
schizophrenia, and the efficacy of haloperidol has been established
atypical antipsychotic, there are no definitive studies regarding
in a number of controlled clinical trials (for a review, see Ernst et
their use in children, so their use cannot be recommended in most
al., 1999). The related drug, pimozide (Orap), was used in the
treatment of severe Tourette’s disorder, but this use is no longer
In summary, the antipsychotics have been the treatment of
generally recommended due to the potential for cardiotoxicity.
choice in the management of psychotic symptoms in pediatric
Haloperidol has the advantage of being relatively less sedating
populations. Those agents that have received at least a glimmer of
than traditional antipsychotics (for a review, see Campbell &
empirical support include clozapine, haloperidol, loxapine, and
Armenteros, 1996), although the incidence of extrapyramidal
risperidone. As noted above, however, clinical use of these agents
symptoms (e.g., involuntary movements, tremors, muscle spasms,
has far exceeded the available literature regarding efficacy and
balance difficulties) is relatively high.
safety. Many more controlled trials are needed before their effi-
The atypical antipsychotics represent a potential advance in the
cacy and safety with pediatric populations can be confirmed.
treatment of child psychosis. Olanzapine (Zyprexa) was approvedfor use by the FDA in 1996 and is considered an atypical neuro-
Mood Stabilizers and Anticonvulsants
leptic with the advantage of having fewer extrapyramidal adverseeffects than haloperidol (Stahl, 1999). Adverse effects include
Lithium carbonate is frequently prescribed in the management
sedation, weight gain (which can often be significant), elevated
of bipolar disorders in adults. Although there are few studies
serum prolactin levels, and anticholinergic effects (e.g., dry eyes,
documenting bipolar disorders in pediatric populations, lithium
mouth, throat, constipation). However, as with many psychotropic
therapy has received widespread clinical use. There are in fact
agents for pediatric populations, many more studies are needed
several controlled trials suggesting that lithium can be effective in
with olanzapine prior to endorsing its efficacy and safety for
the management of symptoms associated with bipolar disorder in
children. There have been several open and double-blind clinical
adolescents (Geller et al., 1998). Campbell and colleagues (Camp-
trials establishing the efficacy of the atypical antipsychotic cloza-
bell et al., 1995; Campbell, Small, & Green, 1984) and Rifkin et al.
pine for childhood psychotic disorders that have been refractory to
(1997) have demonstrated the efficacy of lithium in treating ag-
traditional antipsychotic agents (Fleischaker, Schulz, & Rem-
gressive behavior and conduct disorder; according to their find-
schmidt, 1998; Kumra et al., 1998; Turetz et al., 1997). Clozapine
ings, some children showed marked improvement. No studies
has proved superior to haloperidol in reducing psychotic symp-
could be located that have examined the efficacy of lithium ther-
toms (Kumra et al., 1996). Nonetheless, because of the potential of
apy for young children. Clearly, additional research is needed
severe, possibly fatal, adverse effects associated with clozapine
regarding the safety and efficacy of lithium for pediatric
(agranulocytosis and cardiotoxicity), it is recommended that this
SPECIAL SECTION: PEDIATRIC PSYCHOPHARMACOLOGY
Anticonvulsant or antiepileptic medications have been used
Clomipramine (Anafranil) has been used in the management of
successfully for many years in the management of seizure disor-
obsessive– compulsive disorder. Double-blind controlled trials
ders in children and adolescents. There has been an emerging
with pediatric populations have documented significant decreases
clinical literature to suggest that anticonvulsant agents may also
in obsessive– compulsive symptomatology when comparing clo-
reduce behavioral problems in children who do not have seizure
mipramine to placebos or desipramine (DeVeaugh-Geiss et al.,
disorders (for a review, see Phelps et al., 2001). Anticonvulsant
1992; Leonard et al., 1991). Because clomipramine has a structure
agents include phenobarbital, phenytoin (Dilantin), carbamazepine
that is essentially identical to tricyclic antidepressants, ongoing
(Tegretol), and valproate (Depakote, Depakene) (Brown & Saw-
evaluation of side effects, such as weight gain, anticholinergic side
effects, and cardiotoxicity are imperative (Riddle et al., 1993).
Some investigators have examined valproate (Delitio, Levitan,
Serum drug levels are also required, adding to the cost and incon-
Damore, Hajal, & Zambenedetti, 1997; Papatheodorou & Kutcher,
venience of this agent. The use of clomipramine in children, as in
1993; Papatheodorou, Kutcher, Katic, & Szalai, 1995; West, Keck,
adults, has largely been supplanted by the SSRIs.
& McElroy, 1995) and carbamazepine (Tegretol) for the purpose
Clonazepam (Klonopin) has been found to be effective in the
of reducing manic symptoms in adolescents. Of concern is the
management of separation anxiety and generalized anxiety disor-
report in one investigation of children receiving carbamazepine for
der in children (Graae, Milner, Rizzotto, & Klein, 1994) as well as
aggression. Nearly one third of the participants in the sample
panic disorder in adolescents (Kutcher, Reiter, Gardner, & Klein,
developed behavioral toxicities that included mania, impulsivity,
1992). Adverse effects are dose dependent and include sedation,
and sedation (Pleak, Birmaher, Gavrilescu, Abichandani, & Wil-
dizziness, and ataxia. As with any benzodiazepine, there is the risk
liams, 1988). Valproic acid has been successfully used for both
of long-term physiological dependence, and abrupt cessation of
children and adults with developmental disabilities, including
medication can be potentially dangerous. There is also a concern
mental retardation and cyclic mood disorders (Poindexter et al.,
that treatment with anxiolytics may render exposure-based treat-
1998). Target symptoms of irritability and behavioral cycling
ment interventions ineffective and may thus interfere with behav-
appear to be particularly responsive to valproic acid, although
ioral therapy. These factors are significant and constrain the use of
self-injurious behavior and aggression have also been found to
clonazepam, other benzodiazepines, and similar sedatives in
diminish in open clinical trials (Kastner, Finesmith, & Walsh,
1993). The newer anticonvulsants, including gabapentin (Neuron-
It is recommended that the treatment of pediatric anxiety disor-
tin), tiagabine (Gabitril), and lamotrigine (Lamictal), have been
ders always include psychological interventions (e.g., behavioral,
preliminarily studied in the management of cycling mood disor-
cognitive– behavioral) as a first-line treatment approach and that
ders in children and adolescents, although much more investiga-
medication be considered only when psychological therapies have
tion is needed regarding their safety and efficacy prior to endorsing
failed. Clearly, additional clinical trials are necessary to establish
the safety and efficacy of anxiolytics both in the long- and the
To date, the FDA approves routine use of anticonvulsants only
for the management of seizure disorders and manic phases duringbipolar disorder (Vining, Carpenter, & Aman, 1999). Nonetheless,
Miscellaneous Psychotropic Medications
clinical use of these medications for a number of psychiatricdisorders, including behavioral disorders, has increased markedly
Clonidine (Catapres) is a centrally acting antihypertensive drug
(Vining et al., 1999). Concern remains regarding the overuse of
that has been observed to reduce symptoms associated with
anticonvulsant agents for disorders and for populations for which
ADHD, particularly overactivity, impulsivity, and inattention
research has not established efficacy and safety. In short, clinical
(Hunt, Capper, & O’Connell, 1990). Clonidine has been less useful
use appears to have exceeded available research data. In addition,
for managing symptoms associated with attention and concentra-
the behavioral and cognitive toxicities associated with these med-
tion. Guanfacine (Tenex) is a longer acting medication and has
ications mandate that children’s behavior, learning, and mood
effects similar to those of clonidine, with fewer adverse effects.
receive ongoing monitoring by means of behavioral observation
There had been significant increases of these medications in the
across all settings and psychometric evaluation on at least a yearly
management of ADHD and other disruptive behavior disorders in
basis (American Academy of Pediatrics, 1985).
the early to mid-1990s. Unfortunately clinical use of these psycho-tropic medications has far surpassed research demonstrating their
efficacy and safety. Adverse effects of these medications includehypotension, depressive symptoms, and sedation (Werry & Aman,
There are substantial empirical data supporting the efficacy of
1999). The use of clonidine should be governed by serious con-
behavioral, cognitive– behavioral, and psychosocial interventions
cerns regarding its high degree of toxicity in overdose. The nico-
for the treatment of childhood anxiety disorders (Morris &
tine receptor antagonist mecamylamine (Inversine) has a long
Kratochwill, 1998; Ollendick & King, 1998), although far fewer
history of use in adults in the treatment of hypertension. It has
studies are available regarding psychotropic medications for man-
recently been investigated in the treatment of childhood Gilles de
aging these disorders in children (Allen, Leonard, & Swedo, 1995;
la Tourette disorder (Silver et al., 2001; Young, Shytle, Sanberg, &
Kearney & Silverman, 1998). Unfortunately, as in other classes of
George, 2001). A recent randomized controlled trial did not find it
psychotropics, there is increased use of anxiolytic medications and
to be more effective than placebo in managing Tourette’s disorder
sedatives for pediatric populations due to the movement toward
in children (Silver et al., 2001). This, along with the fact that it is
short-term management of psychiatric disorders and cost contain-
potentially quite toxic, does not support its use in children at the
ment (Allen et al., 1995; Kearney & Silverman, 1998).
Although the use of herbal remedies has recently been consid-
Sawyer (1998) for a complete review. Brain imaging and other
ered in the adult literature, far fewer studies are available in the
specialized assessments (PET and EEG) have been widely used in
pediatric literature. A complete description of available herbal
research programs of medications in various psychiatric popula-
remedies is not possible within the scope of this review, although
tions, but their routine use in monitoring drug response is infea-
we do review St. John’s wort, an herbal remedy that has recently
sible, due to their low yield and high cost.
been investigated with adults and has potential efficacy in the
management of mild depression and dysthymia (Werry & Aman,
fied as unstructured interviews, semistructured interviews, struc-
1999). Its use in children is not recommended until further data
tured interviews, and symptom checklists. Limitations of struc-
regarding its safety and efficacy for the pediatric population are
tured interviews include their length and difficulties with their
forthcoming (Werry & Aman, 1999), particularly in light of recent
sensitivity and specificity to individual symptoms of various dis-
reports of significant interactions with other prescribed drugs and
orders. The semistructured interview does provide some compro-
a randomized controlled trial in adults that did not find it of use in
mise, although significant training is required on the part of the
the treatment of major depression (R. C. Shelton et al., 2001).
interviewer. Finally, the use of symptom checklists provides prac-
Because patients may not readily reveal use of St. John’s wort or
titioners with prompts to assure that all of the major areas of the
similar compounds (Walter & Rey, 1999), clinicians should ask
diagnosis are included. Thus far, structured interviews seem to be
specifically about the use of herbals, and their use should be
the most sensitive to psychotropic drug effects (for a review, see
strongly discouraged if the patient is taking prescribed psycho-
tropics or other agents that have known interactions with herbal
their cost-effectiveness, abundance of normative data that allowfor comparison across children, and the fact that relevant behaviors
Monitoring and Assessing Psychotropic Drug Effects
may be sampled across different settings and domains over time. Most important, rating scales that are well constructed are partic-
There are a number of instruments and procedures for the
ularly sensitive to psychotropic drug effects in children (for re-
assessment and monitoring of psychotropic drug effects in the
views, see Aman & Pearson, 1999; Brown & Sawyer, 1998). The
domains of learning, psychosocial functioning, and physical func-
reader is encouraged to review Aman and Pearson (1999), partic-
tioning. For the medication effects to be fully appreciated, it is
ularly for those rating scales that have demonstrated psychotropic
necessary that monitoring be based on systematic data from a
variety of sources (e.g., school, home) rather than simply on the
clinician’s global impression (Aman & Pearson, 1999).
ically used in practice settings to identify high-frequency and
Prior to prescribing, the clinician should ob-
global behaviors. Their advantages include the ability to provide
tain a baseline medical history and conduct a physical exam to rule
the practitioner with a valid display of children’s behavior in an
out organic causes of mental distress or other central nervous
ecologically valid setting (e.g., classroom, playroom), their ability
system pathology (Zametkin & Yamada, 1999). History should
to allow comparisons between behaviors in test situations and
include information regarding immunizations, previous hospital-
those in more naturalistic settings, their ability to be continuously
izations, trauma, transfusions, allergies, current medication, previ-
repeated without practice effects, and their use with children who
ous substance abuse history, family medical and mental health
have serious psychopathology or who may be generally uncoop-
erative in a structured assessment setting. Limitations of direct
Because psychotropic medications affect many organ systems, a
observations include their labor intensiveness, expense, and
careful review of systems is also necessary. As Zametkin and
changes in ratings that may be a function of observer fatigue rather
Yamada (1999) have observed, some psychological symptoms
than the children’s behavior. Direct observations are particularly
may mimic adverse effects of psychotropic medications, and for
sensitive to psychotropic medications and to various doses of
this reason, establishing a baseline of such symptoms is important.
medications (DuPaul & Kyle, 1995). Several observational codes
A thorough physical and neurological examination is also impor-
are available for clinical use with children diagnosed with various
tant to rule out medical masquerades and to provide a baseline.
psychiatric and developmental disorders, and the interested reader
Because many psychotropic agents have the potential of altering
is referred to Aman and Pearson (1999) and Brown and Sawyer
speech and language skills, assessing speech production, rate,
(1998) for a review of the various direct observational schedules.
volume, and coherence is prudent (Zametkin & Yamada, 1999).
Objective monitoring of medication effects and careful use of
batteries are available to the practitioner for use in assessing
caregivers as informants are required, as children are frequently
children’s responses to psychotropic medication. These include
unreliable reporters of physical symptoms or medication side
performance tests, computerized assessments, and intelligence and
effects. Unfortunately, there is little objective monitoring of psy-
achievement measures. T. Shelton and Barkley (1995) have cau-
chotropic drug effects in the practice setting (Brown & Sawyer,
tioned that performance on various cognitive measures may be
1998), although several rating scales, checklists, laboratory stud-
confounded by other abilities, including attention, memory, lan-
ies, and physical examinations are available. Rating scales are
guage, and intellectual functioning. Computerized assessments
particularly useful in assessing those adverse effects of pharma-
allow for objectivity and standardization, precision, novelty of the
cotherapy that may not necessarily be spontaneously reported by
tasks, and immediate scoring, although disadvantages include high
caregivers. Although a review of rating scales is not possible
cost, questionable ecological validity to natural settings, and psy-
within the scope of the present review, the reader is encouraged to
chometrics that remain to be demonstrated. Finally, intelligence
examine the work of Zametkin and Yamada (1999) and Brown and
and achievement tests are often used in the assessment of medi-
SPECIAL SECTION: PEDIATRIC PSYCHOPHARMACOLOGY
cation effects, although their sensitivity to medication effects is
as well as the concern that drug therapy may replace important
fairly low because they assess stable constructs and global indices
psychotherapy or special education programming because it is
that are rarely affected by psychotropic medication (Brown &
more cost effective in the short-term but not necessarily more
effective in the long-term (Brown & Sawyer, 1998). Informed
Investigators have diligently searched for either a specific in-
consent, the right to refuse treatment, issues of custody, confiden-
strument or package of measures that may predict response to
tiality, and the patient’s best interest remain essential standards of
psychotropic medication. As opposed to the many instruments
practice with pharmacotherapy as with any traditional assessment
available to monitor psychotropic response and adverse effects,
and psychotherapy conducted by practicing psychologists. It also
there does not appear to be a specific instrument available to
is important that children give assent for medication as a means of
predict response to any class of medication. The importance of
fostering a therapeutic alliance and encouraging some autonomy
systematically using multiple objective assessments across settings
and responsibility with the medication regimen (Brown & Sawyer,
rather than the sole reliance on clinical impressions in the office
1998; Krener & Mancina, 1994; Shouten & Duckworth, 1999).
Krener and Mancina have observed that including the child oradolescent in the consent process can help to avoid feelings of
Treatment Acceptability and Satisfaction
coercion on the part of the child and may serve to enhance thetherapeutic goals of treatment and the developmental interests of
It should be of interest to practicing psychologists that in the
the children. Careful attention to risk management must be the
community, psychotropic medication is generally rated less favor-
standard and should include systematic documentation, consulta-
ably than the individual psychotherapies or behavioral approaches
tion with colleagues, and making realistic promises to children and
(Corkum, Rimer, & Schachar, 1999; Pelham, 1999; Power, Hess,
their families regarding medication efficacy and safety (Shouten &
& Bennett, 1995). It should be noted, however, that caregivers are
apt to be more willing to medicate their children when theyparticipate in a systematic drug trial where ongoing efficacy is
documented as well as any adverse side effects (Johnston & Fine,1993). Further, those intervention approaches that involve a com-
Polypharmacy, escalating use of all psychotropics, particularly
bination of pharmacotherapy and psychotherapy have consistently
stimulants and serotonergic antidepressants, and the off-label use
been demonstrated to be more acceptable to caregivers and teach-
of anticonvulsant medications for mental health purposes are in-
ers than medication used alone (Liu, Robin, Brenner, & Eastman,
creasingly common prescribing patterns in modern child practice
1991; Pelham, 1999; Power et al., 1995). Teachers’ attitudes have
(Jensen et al., 1999; Zito et al., 2000). A reasonable amount of
been demonstrated to be similar to caregivers’ attitudes (Power et
support exists for the use of stimulant medications, at least in the
al., 1995) and may be modified by providing teachers with feed-
treatment of certain facets of ADHD. However, well-designed,
back regarding potential for response to medication and ongoing
controlled-outcome studies of anticonvulsant medications, seroto-
treatment efficacy. Children’s attitudes regarding stimulant medi-
nergic antidepressants, and atypical antipsychotics are scarce to the
cation vary according to developmental level and the nature of the
point of nonexistence. Although these agents are of benefit to a
problem and may vary across the course of treatment (for a review,
number of children for whom they are prescribed, relatively little
see Phelps et al., 2001). It is imperative that clinicians evaluate
attention has been paid to the development of rational strategies
carefully the attitudes of all significant individuals who are apt to
designed to optimize their use. A particular deficit in this regard is
be involved in the psychopharmacology treatment program, be-
the general lack of studies that address the important issue of
cause caregiver, teacher, and child attitudes are apt to influence
combined treatment outcome (Weisz & Jensen, 1999).
adherence to medication protocols (Phelps et al., 2001). Finally, it
Practicing psychologists who provide clinical services to chil-
has been demonstrated that provider attitudes significantly affect
dren and adolescents will have increasing opportunities to work
clinical care (Brown, 2002), and attention to practicing psycholo-
with youth who are being managed on psychotropic medication.
gists’ attitudes about pharmacotherapy are likely to determine
This will likely include increased consultation activities with pe-
whether children are managed with pharmacotherapy for behav-
diatricians or family practitioners regarding decisions to use med-
ication and predict response for particular clients. These activities
Even when psychotropic medication is thought to be particularly
will increase concomitantly the demands for training opportunities
beneficial, children and caregivers may fail to adhere to prescribed
at the predoctoral, postdoctoral, and continuing education levels. It
regimens. The stages-of-change model advanced by Prochaska,
is to be hoped that professional psychologists’ greater involvement
DiClemente, and Norcross (1992) provides a useful framework for
as applied researchers and as clinicians who directly provide
understanding the failure of families to initiate treatment and
psychotropic medications will result in greater empirical validation
adhere to it. Thus, whether or not the clinician prescribes medica-
of the practice of pediatric psychopharmacology.
tion, it will still be useful to have a framework for the family’sreadiness for change as well as to understand parents’ and chil-
dren’s attitudes about pharmacotherapy and to incorporate their
Abbot Pharmaceuticals. (1996). Important drug warning [Letter]. North
perceptions into future treatment programs.
It should be noted that a host of ethical and legal considerations
Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/
emerge when psychotropic agents are used to manage children’s
adolescent behavioral and emotional problems: Implications of cross-
behavior (Shouten & Duckworth, 1999). These issues include
informant correlations for situational specificity. Psychological Bulletin,
unresolved questions regarding the long-term safety and efficacy,
Alderman, J., Wolkow, R., Chung, M., & Johnston, H. F. (1998). Sertraline
& Young, E. (1991). Response to desipramine treatment in adolescent
treatment of children and adolescents with obsessive– compulsive dis-
major depression. Psychopharmacology Bulletin, 27, 60 – 65.
order or depression: Pharmacokinetics, tolerability and efficacy. Journal
Brown, R. T. (2002). Society of Pediatric Psychology presidential address:
of American Academy of Child and Adolescent Psychiatry, 37, 386 –394.
Toward a social ecology of pediatric psychology. Journal of Pediatric
Allen, A. J., Leonard, H., & Swedo, S. (1995). Current knowledge of
medications for the treatment of childhood anxiety disorders. Journal of
Brown, R. T., & Donegan, J. E. (1995). The growing impact of neurology. the American Academy of Child and Adolescent Psychiatry, 34, 976 –
In D. K. Reid, W. P. Hresko, & H. L. Swanson (Eds.), Cognitiveapproaches to learning disabilities (3rd ed., pp. 153–211). Austin, TX:
Aman, M. G., & Pearson, D. A. (1999). Monitoring and measuring drug
effects: Part 2. Behavioral, emotional, and cognitive effects. In J. Werry
Brown, R. T., & Freeman, W. S. (in press). Primary care. In D. Marsh &
& M. Aman (Eds.), Practitioner’s guide to psychoactive drugs for
M. Fristad (Eds.), Handbook of serious emotional disturbance in chil-children and adolescents (2nd ed., pp. 99 –164). New York: Plenum. dren and adolescents. New York: Wiley.
Aman, M. G., & Singh, N. N. (1988). Psychopharmacotherapy of the
Brown, R. T., & Sawyer, M. G. (1998). Medications for school-agedevelopmental disabilities. Berlin: Springer-Verlag. children: Effects on learning and behavior. New York: Guilford Press.
Aman, M. G., VanBourgodien, M. E., Wolford, P. L., & Saphire, G.
Buhrmester, D., Whalen, C. K., Henker, B., McDonald, V., & Hinshaw,
(1995). Psychotropic and anticonvulsant drugs in subjects with autism:
S. P. (1992). Prosocial behavior in hyperactive boys: Effects of stimulant
Prevalence and patterns of use. Journal of the American Academy of
medication and comparison normal controls. Journal of Abnormal ChildChild and Adolescent Psychiatry, 34, 1672–1681.
Ambrossini, P., Wagner, K., Biederman, J., Glick, I., Tan, C., Elia, J., et al.
Campbell, M., & Armenteros, J. (1996). Schizophrenia and other psychotic
(1999). Multicenter open-label sertraline study in adolescent outpatients
disorders. In J. Weiner (Ed.), Diagnosis of psychopathology of childhood
with depression. Journal of the American Academy of Child and Ado-and adolescent disorders (2nd ed., pp. 193–227). New York: Wiley. lescent Psychiatry, 37S, 63S– 83S.
Campbell, M., Kafantaris, V., & Cueva, J. E. (1995). An update on the use
American Academy of Pediatrics. (1985). Behavioral and cognitive effects
of lithium carbonate in aggressive children and adolescents with conduct
of anticonvulsant therapy. Pediatrics. 76, 644 – 647.
disorders. Psychopharmacology Bulletin, 31, 93–102.
American Academy of Pediatrics. (2000). Clinical practice guideline:
Campbell, M., Small, A. M., Green, W. H., Jennings, S. J., Perry, R.,
Diagnosis and evaluation of the child with attention-deficit/hyperactivity
Bennett, W., & Anderson, L. (1984). Behavioral efficacy of haloperidol
disorder. Pediatrics, 105, 109 –133.
and lithium carbonate: A comparison in aggressive children with con-
American Academy of Pediatrics. (2001). Clinical practice guideline:
duct disorder. Archives of General Psychiatry, 41, 630 – 636.
Treatment of the child with attention-deficit/hyperactivity disorder. Pe-
Connor, D. F., Ozbayrak, K. R., Harrison, R. J., & Melloni, R. H. (1998).
Prevalence and patterns of psychotropic and anticonvulsant medication
American Psychological Association. (1996, February). Recommended
use in children and adolescents referred to residential treatment. Journalpostdoctoral training in psychopharmacology for prescription privi-of Child and Adolescent Psychopharmacology, 8, 27–38. leges: Interim document approved by council. Washington, DC: Author.
Corkum, P., Rimer, P., & Schachar, R. (1999). Parental knowledge of
Apter, A., Ratzone, G. King, R. A., Weizman, A., Iancu, I., Binder, M.,
attention-deficit hyperactivity disorder and opinions of treatment op-
Riddle, M. A. (1994). Fluvoxamine open-label treatment of adolescent
tions: Impact on enrollment and adherence to a 12-month treatment trial.
inpatients with obsessive– compulsive disorder or depression. Journal ofCanadian Journal of Psychiatry, 44, 1043–1048. the American Academy of Child and Adolescent Psychiatry, 33, 342–
Cosgrove, P. V. F. (1994). Fluvoxamine in the treatment of depressive
illness in children and adolescents. Journal of Psychopharmacology, 8,
Armenteros, J. L., Whitaker, A. H., Welikson, M., Stedge, D. J., &
Gorman, J. (1997). Risperidone in adolescents with schizophrenia: An
Dahlquist, L.M. (1999). Pediatric pain management. New York: Kluwer/
open pilot study. Journal of the American Academy of Child andAdolescent Psychiatry, 36, 694 –700.
De Leon, P. H., & Wiggins, J. G. (1996). Prescription privileges for
Barkley, R. A., & Cunningham, C. E. (1979). The effects of methylpheni-
psychologists. American Psychologist, 51, 198 –206.
date on the mother– child interactions of hyperactive children. Archives
Delitio, J., Levitan, D., Damore, J., Hajal, F., & Zambenedetti, M. (1997). of General Psychiatry, 36, 201–208.
Naturalistic experience with the use of divalproex sodium on an in-
Barkley, R. A., Karlson, J., Strezelecki, E., & Murphy, J. V. (1984). Effects
patient unit for adolescent psychiatric patients. Acta Psychiatrica Scan-
of age and Ritalin dosage on the mother– child interactions of hyperac-
tive children. Journal of Consulting and Clinical Psychology, 52, 750 –
DeVane, C. L., & Sallee, F. R. (1996). Serotonin selective reuptake
inhibitors in child and adolescent psychopharmacology: A review of
Barkley, R. A., McMurray, M. B., Edelbrock, C. S., & Robbins, K. (1990).
published experience. Journal of Clinical Psychiatry, 57, 55– 66.
Side effects of methylphenidate in children with attention deficit hyper-
DeVeaugh-Geiss, J., Moroz, G., Biederman, J., Cantwell, D., Fontaine, R.,
activity disorder: A systematic, placebo-controlled evaluation. Pediat-
Greist, J. A., et al. (1992). Clomipramine hydrochloride in childhood and
adolescent obsessive– compulsive disorder: A multicenter trial. Journal
Barrickman, L., Perry, P. J., Allen, A. J., Kuperman, S., Arndt, S. V.,
of the American Academy of Child and Adolescent Psychiatry, 31,
Hermann, K. J., & Schumacher, E. (1995). Bupropion versus methyl-
phenidate in the treatment of attention deficit disorder. Journal of the
Drotar, D. (1995). Consulting with pediatricians: Psychological perspec-Academy of Child and Adolescent Psychiatry, 34, 649 – 657.
Bennett, F. C., Brown, R. T., Craver, J., & Anderson, D. (1999). Stimulant
Dulcan, M. K., Bregman, J., Weller, E. B., & Weller, R. B. (1998).
medication for the child with attention-deficit hyperactivity disorder.
Treatment of childhood and adolescent disorders. In A. F. Schatzberg &
The Pediatric Clinics of North America, 46, 929 –944.
C. B. Nemeroff (Eds.), Textbook of psychopharmacology (2nd ed., pp.
Birmaher, B. (1998). Should we use antidepressant medication for children
803– 850). Washington, DC: American Psychiatric Press.
and adolescents with depressive disorders? Psychopharmacology Bulle-
DuPaul, G. J., Barkley, R. A., & Conner, D. F. (1998). Stimulants. In R. A.
Barkley (Ed.), Attention deficit hyperactivity disorder: A handbook for
Boulos, C., Kutcher, S., Marton, P., Simeon, J. Ferguson, B., Roberts, N.,
diagnosis and treatment (pp. 510 –551). New York: Guilford Press.
SPECIAL SECTION: PEDIATRIC PSYCHOPHARMACOLOGY
DuPaul, G. J., & Kyle, K. E. (1995). Pediatric pharmacology and psycho-
MTA: Negative/ineffective parenting practices in relations to multimo-
pharmacology. In M. C. Roberts (Ed.), Handbook of pediatric psychol-
dal treatment. Journal of Abnormal Child Psychology, 28, 555–568. ogy (2nd ed., pp. 741–758). New York: Guilford Press.
Horrigan, J. P., & Barnhill, L. J. (1998). Does guanfacine trigger mania in
DuPaul, G. J., & Rapport, M. (1993). Does methylphenidate normalize the
children? Journal of Child and Adolescent Psychopharmacology, 8,
classroom performance of children with attention deficit disorder? Jour-nal of the American Academy of Child and Adolescent Psychiatry, 32,
Hunt, R. D., Capper, L., & O’Connell, P. (1990). Clonidine in child and
adolescent psychiatry. Journal of Child and Adolescent Psychopharma-
Emslie, G. J., & Mayes, T.L. (2001). Mood disorders in children and
adolescents: Psychopharmacological treatment. Biological Psychia-
Jacobovitz, D., Sroufe, L. A., Stewart, M., & Leffert, N. (1990). Treatment
of attentional and hyperactivity problems in children with sympathomi-
Emslie, G. J., Mayes, T. L., & Hughes, C. W. (2000). Update in the
metic drugs: A comprehensive review. Journal of the American Acad-
pharmacological treatment of childhood depression. Psychiatric Clinicsemy of Child and Adolescent Psychiatry, 29, 677– 688. of North America, 23, 811– 821.
Jensen, P. S., Bhatara, V. S., Vitiello, B., Hoagwood, K., Feil, M., &
Emslie, G. J., Rush, A. J., Weinberg, W. A., & Kowatch, R. A. (1997). A
Burke, L. B. (1999). Psychoactive medication prescribing practices for
double-blind randomized, placebo-controlled trial of fluoxetine in chil-
U.S. children: Gaps between research and clinical practice. Journal of
dren and adolescents with depression. Archives of General Psychia-the American Academy of Child and Adolescent Psychiatry, 38, 557–
Emslie, G. J., Walkup, J. T., Pliszka, S. R., & Ernst, M. (1999). Nontri-
Johnston, C., & Fine, S. (1993). Methods of evaluating methylphenidate in
cyclic antidepressants: Current trends in children and adolescents. Jour-
children with attention-deficit hyperactivity disorder: Acceptability, sat-
nal of the American Academy of Child and Adolescent Psychiatry, 38,
isfaction, and compliance. Journal of Pediatric Psychology, 18, 717–
Ernst, M., Malone, R. P., Rowan, A. B., George, R., Gonzalez, N. M., &
Kaplan, S. L., Simms, R. M., & Busner, J. (1994). Prescribing practices of
outpatient child psychiatrists. Journal of the American Academy of Child
Silva, R. R. (1999). Antipsychotics (neuroleptics). In J. S. Werry &
and Adolescent Psychiatry, 33, 35– 44.
M. G. Aman (Eds.), Practitioner’s guide to psychoactive drugs for
Kastner, T., Finesmith, R., & Walsh, K. (1993). Long-term administration
children and adolescents (2nd ed., pp. 297–320). New York: Plenum.
of valproic acid in the treatment of affective symptoms in people with
Fleischaker, C., Schulz, E., & Remschmidt, H. (1998). Biogenic amines as
mental retardation. Journal of Clinical Psychopharmacology, 13, 448 –
predictors of response to clozapine treatment in early-onset schizophre-
nia. Journal of Psychiatric Research, 32, 325–333.
Kearney, C., & Silverman, W. (1998). Critical review of pharmacotherapy
Fox, M. H., Foster, C. H., & Zito, J. M. (2000). Building pharmacoepide-
for youth with anxiety disorders. Journal of Anxiety Disorders, 12,
miological capacity to monitor psychotropic drug use among children
enrolled in Medicaid. American Journal of Medical Quality, 15, 123–
Keller, M. B., Lavori, P. W., & Beardslee, W. R., Wunder, J., & Ryan, N.
(1991). Depression in children and adolescents: New data on “under
Foxman, B., Valdex, R. B., & Brook, R. H. (1986). Childhood enuresis:
treatment” and a literature review on the efficacy of available treatments.
Prevalence, perceived impact, and prescribed treatments. Pediatrics, 77,Journal of Affective Disorders, 21, 163–171.
Klein, R. G., & Mannuzza, S. (1988). Hyperactive boys almost grown up:
Gadow, K. D. (1997). An overview of three decades of research in
Part 3. Methylphenidate effects on ultimate height. Archives of General
pediatric psychopharmacoepidemiology. Journal of Child and Adoles-cent Psychopharmacology, 7, 219 –236.
Kovacs, M., Feinberg, T. L., Crouse-Novak, M., Paulauskas, S. L., Pollock,
Gadow, K. D. (1999). Prevalence of drug therapy. In J. S. Werry & M.
M., & Finkelstein, R. (1984). Depressive disorders in childhood: Vol. 2.
Aman (Eds.), Practitioner’s guide to psychoactive drugs for children
A longitudinal study of the risk for a subsequent major depression. and adolescents (2nd ed., pp. 355–385). New York: Plenum. Archives of General Psychiatry, 41, 643– 649.
Gadow, K. D., Nolan, E. E., Paolicelli, L. M., & Sprafkin, J. (1991). A
Krener, P. K., & Mancina, R. A. (1994). Informed consent or informed
procedure for assessing the effects of methylphenidate in hyperactive
coercion? Decision-making in pediatric psychopharmacology. Journal
children in public school settings. Journal of Clinical Child Psychol-of Child and Adolescent Psychopharmacology, 4, 183–200.
Kumra, S., Frazier, J., Jaconsen, L., McKenna, K., Gordon, C., Lenane, M.,
Geller, B., Cooper, J. B., Sun, K., Zimmerman, B., Frazier, J., Williams,
et al. (1996). Childhood-onset schizophrenia: A double-blind clozapine–
M., & Heath, J. (1998). Double-blind and placebo controlled study of
haloperidol comparison. Archives of General Psychiatry, 53, 1090 –
lithium for adolescent bipolar disorders with secondary substance de-
pendency. Journal of the American Academy of Child and Adolescent
Kumra, S., Jacobsen, L., Lenane, M., Karp, B., Frazier, J., Smith, A., et al.
(1998). Childhood-onset schizophrenia: An open-label study of olanza-
Glazener, C. M., & Evans, J. H. (2000). Tricyclic and related drugs for
pine in adolescents. Journal of the American Academy of Child and
nocturnal enuresis in children. Cochrane Database Systematic Re-Adolescent Psychiatry, 37, 377–386.
Kutcher, S. P. (2000). Practical clinical issues regarding child and adoles-
Graae, F., Milner, J., Rizzotto, L., & Klein, R. G. (1994). Clonazepam in
cent psychopharmacology. Child and Adolescent Psychiatric Clinics of
childhood anxiety disorders. Journal of the American Academy of Childand Adolescent Psychiatry, 33, 372–376.
Kutcher, S., Boulos, C., Ward, B., Marton, P., Simeon, J., Ferguson, B., et
Hill, B. K., Balow, E. A., & Bruininks, R. H. (1985). A national study of
al. (1994). Response to desipramine treatment in adolescent depression:
prescribed drugs in institutions and community residential facilities for
A fixed dose, placebo-controlled trial. Journal of the American Academy
mentally retarded people. Psychopharmacology Bulletin, 21, 279 –284. of Child and Adolescent Psychiatry, 35, 1139 –1144.
Hinshaw, S. P. (1991). Stimulant medication and the treatment of aggres-
Kutcher, S. P., Reiter, S., Gardner, D. M., & Klein, R. G. (1992). The
sion in children with attention deficits. Journal of Clinical Psychol-
pharmacotherapy of anxiety disorders in children and adolescents. Psy-chiatric Clinics of North America, 15, 641– 686.
Hinshaw, S. P. (2000). Family processes and treatment outcomes in the
Kye, C. H., Waterman, G. S., Ryan, N. D., Birmaher, B., Williamson,
D. E., Iyengar, S., & Dachille, S. (1996). A randomized, controlled trial
mazepine. Journal of the Academy of Child and Adolescent Psychia-
of amitriptyline in the acute treatment of adolescent major depression. Journal of the American Academy of Child and Adolescent Psychia-
Poindexter, A. R., Cain, N., Clarke, D. J., Cooke, E. H., Corbett, J. A.,
Levitas, A. (1998). Mood stabilizers. In S. Reiss & M. G. Aman (Eds.),
Leonard, H. L., Swedo, S. E., Lenane, M. C., Rettew, D. C., Cheslow,
Psychotropic medications and developmental disabilities: The interna-
D. L., Hamburger, S. D., & Rapoport, J. L. (1991). A double-blind
tional consensus handbook (pp. 215–228). Columbus: Ohio State Uni-
desipramine substitution during long-term clomipramine treatment in
children and adolescents with obsessive– compulsive disorder. Archives
Power, T. J., Hess, L. E., & Bennett, D. S. (1995). The acceptability of
of General Psychiatry, 48, 922–927.
interventions for attention deficit disorder among elementary and middle
Liu, C., Robin, A. L., Brenner, A., & Eastman, J. (1991). Social accept-
school teachers. Developmental and Behavioral Pediatrics, 16, 238 –
ability of methylphenidate and behavior modification for treating atten-
tion deficit hyperactivity disorder. Pediatrics, 88, 560 –565.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of
Martin, A., Kaufman, J., & Charney, D. (2000). Pharmacotherapy of
how people change: Applications to addictive behaviors. American
early-onset depression: Update and new directions. Child and Adoles-Psychologist, 47, 1101–1114. cent Psychiatric Clinics of North America, 9, 135–157.
Purdon, S. E., Lit, W., Labelle, A., & Jones, B. D. (1994). Risperidone in
Mellon, M. W., & McGrath, M. L. (2000). Empirically supported treat-
the treatment of pervasive developmental disorder. Canadian Journal of
ments in pediatric psychology: Nocturnal enuresis. Journal of Pediatric
Rappley, M. D., Mullan, P. B., Alvarezz, F. J., Eneli, I. U., Wang, J., &
Morris, R. J., & Kratochwill, T. R. (1998). The practice of child therapy
Gardiner, J. C. (1999). Diagnosis of attention-deficit/hyperactivity dis-
(3rd ed.). Boston: Allyn & Bacon.
order and use of psychotropic medication in very young children. Ar-
Multimodal Treatment Study for Children With ADHD Cooperative
chives of Pediatric and Adolescent Medicine, 153, 1039 –1045.
Group. (1999). A 14-month randomized clinical trial of treatment strat-
Rey-Sanchez, F., & Gutierrez-Casares, J. (1997). Paroxetine in children
egies for attention-deficit/hyperactivity disorder. Archives of General
with major depressive disorder: An open trial. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 36, 1143–1147.
Ollendick, T. H., & King, N. J. (1998). Empirically supported treatments
Riddle, M. A., Geller, B., & Ryan, N. (1993). Another sudden death in a
for children with phobic and anxiety disorders. Journal of Clinical Child
child treated with desipramine. Journal of the American Academy ofChild and Adolescent Psychiatry, 32, 792–797.
Onofry, M., Paci, C., D’Andreamatteo, G., & Toma, L. (2000). Olanzapine
Rifkin, A., Karajgi, B., Dicker, R., Perl, E., Boppana, V., Hasan, N., &
in severe Gilles de la Tourette syndrome. Journal of Neurology, 247,
Pollack, S. (1997). Lithium treatment of conduct disorders in adoles-
cents. American Journal of Psychiatry, 154, 554 –555.
Papatheodorou, G., & Kutcher, S. (1993). Divalproex sodium treatment in
Robertson, M. M., & Stern, J. S. (2000). Gilles de la Tourette syndrome:
late adolescent and young adult acute mania. Psychopharmacology
Symptomatic treatment based on evidence. European Child and Ado-lescent Psychiatry, 9(Suppl. 1), 160 –175.
Papatheodorou, G., Kutcher, S., Katic, M., & Szalai, J. P. (1995). The
Safer, D. J., & Krager, J. M. (1988). A survey of medication treatment for
efficacy and safety of divalproex sodium in the treatment of acute mania
hyperactive/inattentive students. Journal of the American Medical As-
in adolescents and young adults: An open clinical trial. Journal ofsociation, 260, 2256 –2258. Clinical Psychopharmacology, 15, 110 –116.
Safer, D. J., Zito, J. M., & Fine, E. M. (1996). Increased methylphenidate
Parraga, H. C., & Parraga, M. I. (2001). Quetiapine treatment in patients
usage for attention deficit disorder in the 1990’s. Pediatrics, 98, 1084 –
with Tourette’s syndrome. Canadian Journal of Psychiatry, 46, 184 –
Sallee, F. R., Goetz, C. G., Singer, J., Scahill, L., Law, G., Dittman, V. M.,
Paxton, J. W., & Dragunow, M. (1993). Pharmacology. In J. S. Werry &
& Chappell, P. B. (2000). Ziprasidone treatment of children and ado-
M. G. Aman (Eds.), Practitioner’s guide to psychoactive drugs for
lescents with Tourette’s syndrome: A pilot study. Journal of the Amer-children and adolescents (pp. 23–25). New York: Plenum. ican Academy of Child and Adolescent Psychiatry, 39, 292–299.
Pelham, W. E. (1999). The NIMH multimodal treatment study for
Sallee, F. R., Hilial, R., Dougherty, D., Beach, K., & Nesbitt, L. (1998).
attention-deficit hyperactivity disorder: Just say yes to drugs alone?
Platelet serotonin transporter in depressed children and adolescents:
Canadian Journal of Psychiatry, 44, 981–990.
33H-paroxetine platelet binding before and after sertaline. Journal of the
Pelham, W. E., Gnagy, E. M., Chronic, A. M., Burrows-MacLean, L.,
American Academy of Child and Adolescent Psychiatry, 37, 777–784.
Fabiano, G. A., Onyango, A. N., et al. (1999). A comparison of morning
Shelton, T., & Barkley, R. A. (1995). The assessment and treatment of
only and morning/late afternoon Adderall to morning-only, twice-daily,
attention deficit hyperactivity disorder in children. In M. Roberts (Ed.),
and three times-daily methylphenidate in children with attention-deficit/
Handbook of pediatric psychology (2nd ed., pp. 663–754). New York:
hyperactivity disorder. Pediatrics, 104, 1300 –1311.
Pelham, W. E., Gnagy, E. M., Greiner, A. R., Hoza, B., Hinshaw, S. P.,
Shelton, R. C., Keller, M. B., Gelenberg, A., Dunner, D. L., Hirschfield, R.,
Swanson, J. M., et al. (2000). Behavioral versus behavioral and phar-
Thase, M. E., et al. (2001). Effectiveness of St. John’s wort in major
macological treatment in ADHD children attending a summer treatment
depression: A randomized controlled trial. Journal of the American
program. Journal of Abnormal Child Psychology, 28, 507–525. Medical Association, 285, 1978 –1986.
Perry, R., Petaki, C., Munoz-Silva, D. M., Armenteros, J., & Silva, R. R.
Shouten, R., & Duckworth, K. S. (1999). Medicolegal and ethical issues in
(1997). Risperidone in children and adolescents with pervasive devel-
the pharmacologic treatment of children. In J. Werry & M. Aman (Eds.),
opmental disorder: Pilot trial and follow-up. Journal of Child andPractitioner’s guide to psychoactive drugs for children and adolescentsAdolescent Psychopharmacology, 7, 167–179.
(2nd ed., pp. 99 –164). New York: Plenum.
Phelps, L., Brown R. T., & Power, T. (2001). Pediatric psychopharma-
Silver, A. A., Shytle, R. D., Sheehan, K. H., Sheehan, D. V., Ramos, A.,
cology: Combining medical and psychosocial intervention. Washington,
& Sanberg, P. R. (2001). Multicenter, double-blind, placebo-controlled
DC: American Psychological Association.
study of mecamylamine monotherapy for Tourette’s disorder. Journal of
Pleak, R. R., Birmaher, B., Gavrilescu, A., Abichandani, C., & Williams,
the American Academy of Child and Adolescent Psychiatry, 40, 1103–
D. T. (1988). Mania and neuropsychiatric excitation following carba-
SPECIAL SECTION: PEDIATRIC PSYCHOPHARMACOLOGY
Stahl, S. M. (1999). Selecting an atypical antipsychotic by combining
Werry, J. S., & Aman, M. G. (1999). Anxiolytics, sedatives, and miscel-
clinical experience with guidelines from clinical trials. Journal of Clin-
laneous drugs. In J. Werry & M. Aman (Eds.), Practitioner’s guide toical Psychiatry, 60(Suppl. 10), 31– 41. psychoactive drugs for children and adolescents (2nd ed., pp. 433– 469).
Stancin, T. (1999). Pediatric mental health services in primary care settings
[Introduction to special issue]. Journal of Pediatric Psychology, 24,
West, S., Keck, P., & McElroy, S. (1995). Oral loading doses in the
valproate treatment of adolescents with mixed bipolar disorder. Journal
Stefl, M. E., Bornstein, R. A., & Hammond, L. (1987). The 1987 Ohioof Child and Adolescent Psychopharmacology, 5, 225–231. Tourette Survey. Milford: Tourette Syndrome Association of Ohio.
Whalen, C. K., Henker, B., Hinshaw, S. P., & Granger, D.A. (1989).
Swanson, J., Gupta, S., Guinta, D., Flynn, D., Agler, D., Lerner, M., et al.
Externalizing behavior disorders, situational generality, and Type A
(1999). Acute tolerance to methylphenidate in the treatment of ADHD in
behavior pattern. Child Development, 60, 1453–1462.
children. Clinical Pharmacological Therapy, 66, 295–305.
Wilens, T., Spencer, T., Biederman, J., & Schleifer, D. (1997). Case study:
Tarnowski, K. J., & Brown, R. T. (1995). Pediatric burns. In M. C. Roberts
Nefazodone for juvenile mood disorders. Journal of the American Acad-
(Ed.), Handbook of pediatric psychology (2nd ed., pp. 446 – 462). New
emy of Child and Adolescent Psychiatry, 36, 481– 485.
Young, J. M., Shytle, R. D., Sanberg, P. R., & George, T. P. (2001).
Tarnowski, K. J., Brown, R. T., Dingle, A. D., & Dreelin, E. (1998).
Mecamylamine: New therapeutic uses and toxicity/risk profile. Clinical
Pediatric pain. In R. T. Ammerman & J. V. Campo (Eds.), Handbook ofpediatric psychology and psychiatry (Vol. 2, pp. 453– 476). Mahwah,
Zametkin, A. J., & Yamada, E. M. (1999). Monitoring and measuring drug
effects: Vol. 1. Physical effects. In J. Werry & M. Aman (Eds.),
Turetz, M., Mozes, T., Toren, P., Chernauzan, N., Yoran-Hegesh, R.,
Practitioner’s guide to psychoactive drugs for children and adolescents
Mester, R., et al. (1997). An open trial of clozapine in neuroleptic-
(2nd ed., pp. 69 –97). New York: Plenum.
resistant childhood-onset schizophrenia. British Journal of Psychiatry,
Zeiner, P. (1995). Body growth and cardiovascular function after extended
treatment (1.75 years) with methylphenidate in boys with attention
Varley, C., & McClellend, J. (1997). Two additional sudden deaths with
deficit hyperactivity disorder. Journal of Child and Adolescent Psycho-
tricyclic antidepressants. Journal of the American Academy of Child andAdolescent Psychiatry, 34, 390 –395.
Zito, J. M., Safer, D. J., dosReis, S., Gardner, J. F., Boles, M., & Lynch,
Vining, E., Carpenter, R. O., & Aman, M. G. (1999). Antiepileptics
F. (2000). Trends in the prescribing of psychotropic medications to
(anticonvulsants). In J. Werry & M. Aman (Eds.), Practitioner’s guide
preschoolers. Journal of the American Medical Association, 283, 1025–
to psychoactive drugs for children and adolescents (2nd ed., pp. 355–
Zito, J. M., Safer, D. J., dos Reis, S., & Riddle, M. A. (1998). Racial
Vitiello, B. (2001). Psychopharmacology for young children: Clinical
disparity in psychotropic medications prescribed for youths with Med-
needs and research opportunities. Pediatrics, 108, 983–989.
icaid insurance in Maryland. Journal of the American Academy of Child
Walter, G., & Rey, R. M. (1999). Use of St. John’s Wort by adolescents
and Adolescent Psychiatry, 37, 179 –184.
with a psychiatric disorder. Journal of Child and Adolescent Psycho-
Zuddas, A., Pintor, M., & Cianchetti, C. (1996). Risperidone for negative
symptoms [Letter]. Journal of the American Academy of Child and
Weisz, J. R., & Jensen, P. S. (1999). Efficacy and effectiveness of child and
Adolescent Psychiatry, 35, 838 – 839.
adolescent psychotherapy and pharmacotherapy. Mental Health ServicesResearch, 1, 125–157.
Werry, J. S. (1995). Resolved: Cardiac arrhythmias make desipramine an
unacceptable choice in children. Journal of the American Academy ofChild and Adolescent Psychiatry, 34, 1239 –1245.
Andrade J C S Ávila Neto V Braile D M Brofman P R S Costa A R B Costa R Galvão Filho S S Gauch P R A Lucchese F AMartinelli Filho M Medeiros P T J Mateos J C P Pimenta J Takeda R T. Consenso Deca/SBCCV - 1999. Diretrizes para oImplante de Marcapasso Cardíaco Permanente. Reblampa 1999; 12(1): 1-9. Consenso Deca/SBCCV 1999 Diretrizes para o Implante de Cardioversor Desfibrilador Impla
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