Managing Pediatric Behavioral Health with Pharmacological Treatments

What Mental and Behavioral Health Disorders Impact Pediatric Populations?

It is essential to understand that children, adolescents, and teens — like adults — can experience various mental and behavioral health disorders. These conditions can present differently based on the severity, age, gender, social environment, and a patient’s comorbid conditions.

According to the Child Mind Institute, common causes of behavioral problems in pediatric patients include anxiety, ADHD, learning disabilities, sensory processing problems, depression, autism spectrum disorders, and trauma.

Depending on the source, mental and behavioral health disorders can be divided into multiple categories. However, for the sake of this article, pediatric mental and behavioral health disorders will be divided into three categories: emotional disorders, disruptive disorders, and pervasive disorders.

Emotional disorders are the most common mental health disorders, which include depression and anxiety. Disruptive disorders include attention deficit hyperactivity disorder (ADHD) and oppositional, defiant, or conduct disorders. Pervasive disorders usually refer to autism spectrum disorders (ASD).

Disruptive Behavioral Disorders

The Agency for Healthcare Research and Quality (AHRQ) defines disruptive behavioral disorders as conditions that cause children or teens to have trouble managing emotions and behaviors. These conditions include oppositional defiant disorder, conduct disorder, and intermittent explosive disorder.

DBDs impact 3% of children in the United States, with more boys affected than girls. Despite no apparent cause, DBD risk can increase when a patient has experienced abuse or neglect. Additionally, research has pointed to a genetic link for DBD.

According to the Mental Health Global Action Program (mh-GAP), in children 4–18 years old, behavioral health disorders can present as excessive activity, inattention, absent-mindedness, impulsivity, disruptive behavior, and sudden behavioral changes.

Oppositional defiant disorder is a psychiatric disorder that causes mood swings, anger, and irritability. Conduct disorders may present as aggression and intermittent explosive disorder can be characterized by erratic outbursts and changes in a child’s behavior, including aggression, violence, and shouting.

These conditions can be managed using multiple tools. For example, evidence-based psychosocial treatments can improve patient and family interactions.

In addition, parent training programs can educate parents or caregivers on how to manage behavioral issues and support children with behavioral and mental disorders.

DBDs can also be managed through pharmacological treatments, including stimulant medications.

ADHD medications, including Adderall and Ritalin, are approved by the US Food and Drug Administration (FDA) to manage DBD in children six and older.

Non-stimulant ADHD medications may also be used to manage disruptive behaviors. Other treatment options include anticonvulsants and antipsychotics.

Treating Pediatric Mental and Behavioral Health Disorders

The AHRQ notes multiple short-term and long-term treatment options for young children, adolescents, and teens with behavioral health disorders. Treatment options can include psychotherapy, psychotropic medications, or both.

The Centers for Disease Control and Prevention (CDC) notes that group–parent behavior therapy or individual–parent behavior therapy with child participation are the most effective treatments for disruptive behavior disorders.

The Centers for Healthcare Strategies’ Manual of Medications Used for Behavioral and Emotional Disorders notes that medication management for pediatric patients with mental or behavioral health disorders should be managed with the help of a licensed healthcare provider, which may include a pediatrician, psychiatrist, family medicine physician, nurse practitioner, or physician assistant.

While medications may be helpful interventions to manage symptoms, they will not cure a patient’s condition. Alongside other treatments, such as cognitive behavioral therapy (CBT) and lifestyle changes, medications can help patients and their families manage their conditions.

A critical safety consideration for prescribing pharmacological interventions for pediatric behavioral health conditions is side effects. Caregivers are advised to monitor the child carefully for side effects when taking behavioral or mental health medications.

Multiple different types of behavioral or mental health medications can be prescribed for children:

• Antipsychotics
• Antidepressants
• Mood stabilizers
• Attention deficit hyperactivity disorder (ADHD) medications
• Anxiolytics
• Sleep medications
• Other mental health medications

A systematic review and meta-analysis in Nature Scientific Reports found that second-generation antipsychotics were the most effective medication for reducing disruptive symptoms. However, stimulants and non-stimulant ADHD medications are better than a placebo.

Antipsychotics

Antipsychotics address multiple conditions, including schizophrenia, bipolar disorder (BPD), schizoaffective disorder, obsessive–compulsive disorder (OCD), depression, aggression, and mood instability.

There are two categories of antipsychotics: traditional and atypical.

Traditional antipsychotics, such as haloperidol, chlorpromazine, perphenazine, and trifluoperazine, may cause side effects, including tremors, muscle spasms, abnormal movement, vision changes, stiffness, and constipation.

Atypical antipsychotics, such as aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone, can cause low white blood cell count, diabetes, lipid changes, and weight gain.

Antidepressants

Antidepressants can manage depression, anxiety, seasonal affective disorder (SAD), OCD, and post-traumatic stress disorder (PTSD). Antidepressants can fall into three categories: tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), or a final “other” category, which includes bupropion, mirtazapine, and trazodone.

Tricyclic antidepressants, including amitriptyline, desipramine, doxepin, imipramine, and nortriptyline, have been linked to side effects such as dry mouth, constipation, blurry vision, urinary retention, and drowsiness.

SSRIs, such as citalopram, escitalopram, fluoxetine, fluvoxamine, and sertraline, can cause headaches, nausea, insomnia, and weight loss.

Mood Stabilizers

Mood stabilizers, including anticonvulsants, can manage BPD, mood disorders, and aggressive behaviors. Divalproex, carbamazepine, and lamotrigine are anticonvulsants that can cause weight gain, nausea, sedation, liver problems, and clotting disorders.

Lithium has also been used to manage some behavioral problems.

Stimulants

Stimulants are a common medication used to manage ADHD. NYU Langone Health states, “ADHD medications reduce a child’s hyperactivity and impulsivity and improve attention span, as well as the ability to focus, work, and learn.” These medications include the following:

• Guanfacine
• Clonidine
• Methylphenidate
• Dextroamphetamine sulfate
• Mixed amphetamine salts
• Dexmethylphenidate
• Lisdexamfetamine dimesylate
• Buproprion
• Atomoxetine

These medications can be highly addictive and have been known to cause appetite changes, sleep problems, headaches, dysphoria, increased heart rate, and more.

Anxiolytics

Antianxiety medications for anxiety disorders, panic disorders, alcohol withdrawal, PTSD, and OCD can include SSRIs, benzodiazepines, antianxiety drugs, and antihistamines.

Medications in Preschool-Age Children

An article in UpToDate explained that preschoolers are often prescribed behavioral treatments as many medications are not approved for patients that young. However, Boston Children’s Hospital explains that, for preschool patients with persistent symptoms after behavioral therapy, alpha-2-adrenergic agonists (A2As) are effective and present with fewer adverse effects than stimulants.

Additionally, a retrospective study in the Journal of Child and Adolescent Psychopharmacology found that preschool-aged children with ADHD and more than three comorbid conditions were less responsive to psychostimulants than patients without coexisting conditions. However, A2As did not have a similar response.