Pharmacotherapy

Description of the Strategy

Pharmacotherapy as a treatment modality for children and adolescents is a relatively young discipline that is based more on the collective experiences of clinicians than on empirical verification of the effects of various classes of psychoactive medications on children's psychiatric disorders. Because of the paucity of empirical data, pharmacotherapy was regarded as the treatment of last resort in this population until the mid-1990s. Indeed, clinicians did not consider it during initial treatment formulation until all other treatment modalities had been tried.

The situation today, however, is somewhat different. Although there are still few empirically based studies on the use of psychotropic drugs in the treatment of childhood disorders, pharmacotherapy is considered, along with other treatment modalities, an integral part of a treatment plan. Like any other single modality treatment, pharmacotherapy is limited in scope because it focuses on only one aspect of the child. Given that children develop in an interactional biological, psychological, social, and cultural matrix, effective interventions must be multimodal, multifocused, and interdisciplinary in nature.

A comprehensive psychiatric assessment is necessary before a child or adolescent can be considered for pharmacotherapy. The assessment provides the basis for determining the child's psychopathological condition, indications for treatment, and the nature of the proposed treatment. It is multidimensional and interdisciplinary, incorporating assessments of the child's symptoms and functioning across multiple domains, as well as an evaluation of his or her family history and physical and cultural environment. Typically, a baseline assessment includes (a) the source of and reason for referral, including the target symptoms that may be the focus of treatment, (b) history of the presenting symptoms, (c) psychiatric history and current mental status, (d) developmental and medical history, (e) family and education/school history, and (f) an evaluation of cultural context of the family (e.g., determine if the family has any specific religious, spiritual, or cultural beliefs that may interact with the child's psychiatric treatment in general and psychopharmacological treatment in particular).

In general, the psychiatrist's goal is to understand the presenting problems or symptoms at the highest level of diagnostic sophistication that can be achieved based on a comprehensive interdisciplinary assessment. There are four levels of diagnostic sophistication: (1) symptomatic, which includes isolated symptoms (e.g., auditory hallucinations) that provide an indication of a possible diagnosis (e.g., psychotic disorder not otherwise specified), (2) syndromic, which includes the constellation of signs and symptoms that have been present for a given time, and standardized inclusionary and exclusionary criteria can be used to derive a diagnosis (e.g., depression), (3) pathophysiologic, [Page 956]which includes structural or biochemical changes that indicate the diagnosis (e.g., an individual presenting with anxiety, depression, or manic excitement, weakness, excessive sweating, tremors, and, in some cases, with disturbances of thought and cognition may have elevated thyroid function tests that suggest a diagnosis of hyperthyroidism, and (4) etiologic, in which the diagnosis is based on known causative factors.

With children, most psychiatric diagnoses are at the symptomatic and syndromic levels of sophistication because we currently do not have a thorough understanding of the pathophysiology or etiology of many childhood disorders. Thus, it is not uncommon to find wide variability in treatment outcomes in children diagnosed with the same syndrome because they have similar presentations but substantially different underlying mechanisms. This means that at times we treat children's behavioral symptoms or psychiatric disorders without fully appreciating the biological and genetic underpinnings or how these factors transact with the children's physical, psychosocial, and cultural environments.

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