GA Child Attorney Trial Notebook:: Childhood Disorders

Asperger's Syndrome - a separate Autistic Spectrum disorder which does not meet criteria for other Pervasive Developmental Disorders or Schizophrenia. Features of Asperger's Disorder are severe and sustained impairment in social interaction and the development of repetitive patterns of behavior, interests and activities, and significant impairment in social, occupational and other important areas of functioning. Because there are no significant language delays or cognitive deficits, Asperger's is considered a form of high functioning autism.

Attention Deficit Hyperactivity Disorder (ADHD) - sometimes inaccurately referred to as ADD (There is no clinical term by this name), is a disorder usually first diagnosed in infancy, childhood or adolescence. There are 4 recognized types of ADHD. They are: Predominantly Inattentive type; Predominantly Hyperactive-Impulsive type; Combined type (inattention and hyperactivity-impulsivity); and ADHD - Not Otherwise Specified (NOS). There is a high level of correlation between children with ADHD and other psychiatric illnesses. This included illnesses ranging from behavioral, mood, family, anxiety, cognitive, social to school functioning, with the greatest increase in those with the ADHD - combined subtype

Autism - may manifest in early infancy, with the infant shying away from the parent's touch, not responding to a parent who returns after an absence, and inappropriate gaze behavior. The Autistic child may fail to meet early language and other developmental milestones. And there can be as much as a 3-year delay between the report of symptoms and the diagnosis, which is usually made at around age five.

Childhood Disintegrative Disorder - strikes children who have developed normally through at least their first two years of life. They then become impaired in at least two of the following major functional areas: social, communication, restricted receptive language, or stereotyped movements. Though the age of onset is later, in the most severe cases, these children can resemble autistic children, although the severity is generally less.

Childhood Disorder Not Otherwise Specified NOS (not otherwise specified) - diagnosis used for disorders with onset in infancy, childhood, or adolescence that do not meet the criteria for any specific disorder. According to the ICD-10, there are two sub-categories:

Other specified behavioral and emotional disorders usually occurring in childhood and adolescence and

Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence.

Childhood Eating Disorders -There are 3 feeding and eating disorders of infancy or early childhood. The first is Pica, in which the child persistently eats non-nutritive substances for at least one month. The behavior must be developmentally inappropriate, and not culturally sanctioned. It appears more frequently in young children than adults. The second disorder is rumination disorder, in which the infant or child repeatedly regurgitates and rechews food, after a period of normal functioning. The symptoms must last for at least one month. The last disorder is feeding disorder of infancy or early childhood, in which there is a feeding disturbance manifested by persistent failure to eat enough food and a significant failure to gain weight or weight loss.

Conduct Disorder - essentially a disorder where the person violates the social norms and rights of others. Those with this disorder are habitually in trouble, either with parents, teachers or peers. Despite presenting a tough image to those around them, they have a low self-esteem. Their frustration tolerance, irritability, temper outbursts and recklessness are hallmarks. Conduct Disorder may lead to adult antisocial personality disorder.

Disruptive Behavior Disorder NOS (not otherwise specified) - is utilized when there are conduct or oppositional-defiant behaviors that do not meet the diagnostic criteria for either conduct disorder or oppositional defiant disorder, but in which there is notable impairment.

Dyslexia - specific learning disability that is neurological in origin. It is characterized by difficulties with accurate and / or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction.

Learning Disorders - occur in three major categories: reading, mathematics, and written expression. Reading problems generally occur before the age of 7. This is followed usually by problems with spelling and written language expression by the age of 8. Mathematical learning disorders often are not detected until after rote memorization mathematics work has ended, and application of more abstract skills is necessary. These diagnoses are given only after standardized testing in the particular area is significantly below that expected by the child's chronological age, IQ, and educational level.

Mental Retardation - based on both IQ and deficits in functioning. It is not a single, simple syndrome, but rather a state of impairment. By definition, to have the label Mental Retardation, the person must have an IQ below 70, and impairments in adaptive functioning in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. Finally, the onset must be before age 18. There are 4 levels of Mental Retardation, based on IQ: Mild, with a mental age of 8.5 to 11.0 years; Moderate, with a mental age of 6.0 to 8.5 years; Severe, with a mental age of 3.75 to 6.0 years, and Profound, with a mental age of 0 to 3.75 years.

Mixed-Receptive - Expressive Language Disorder-Children impaired in both the understanding and expressing of language. The receptive and expressive disorders may be acquired, congenital or developmental.

Oppositional Defiant Disorder (ODD) - children ignore or defy adults' requests and rules. They may be passive, finding ways to annoy others, or active, verbally saying "No". They tend to blame others for their mistakes and difficulties. When asked why they are so defiant, they may say that they are only acting against unreasonable rules. They are different from children with conduct disorders in that they do not violate the rights of others. These behaviors are present at home, but not necessarily in other situations, such as school, or with other adults.

Pervasive Developmental Disorder NOS (not otherwise specified)- indicates a severe, pervasive impairment in social interaction or communication skills, or the presence of stereotyped behavior, interests and activities. The criteria for a specific PDD, schizophrenia and schizotypal and avoidant personality disorders are not met. This diagnosis generally has a better outcome than does autistic disorder.

Reactive Attachment Disorder - characterized by the breakdown of social ability of a child. It is associated with the failure of the child to bond with a caretaker in infancy or early childhood. This can be caused by many factors, ranging from child neglect to the child being hospitalized for severe medical problems. The children may display either indiscriminate social extroversion as they grow older (treating all people as if they were their best friend) or showing mistrust of nearly everyone.

Rett's Disorder - disorder exclusive to females. For the first 6 months of life, development is normal. At that point, they begin to exhibit many of the symptoms of autism, such as stereotyped movements, poor social interaction, and impaired communication. In addition, they also have problems with both expressive and receptive language, psychomotor retardation, and poorly coordinated gait and/or trunk movements, along with decreased head growth. They will as they mature, however, gain back a degree of positive social interaction.

Selective Mutism - Anxiety disorder in which children may talk at home but are unable to speak in certain social situations. Their anxiety may affect their ability to communicate in other ways as well. For a diagnosis of Selective Mutism to be made the communication problem must last at least one month. Without treatment SM can persist for years. Onset is usually quite slow, with children showing inhibited temperaments as infants, often displaying Separation Anxiety through their toddler years. SM is often not diagnosed until the child begins school, and sometimes even later due to a lack of awareness in Pediatricians and other Healthcare workers.

Separation Anxiety Disorder - affects children who are afraid to be separated from the main caretakers in their lives, even to go to a friend's house or school. When separated, they are constantly afraid that something horrible will happen to either themselves or to their primary caretaker (they or the caretaker will die, for instance). When the subject of separating is brought up, the child begins to present with somatic symptoms ranging from headaches to nausea and vomiting, with anxiety.

Stuttering - a disturbance in the fluency and time patterning of speech that is inappropriate for the patient's age. It may contain sound repetitions, prolongations, interjections, pauses in words, word substitutions to avoid blocking, and audible or silent blocking.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States.

Axis I: Clinical Disorders, acute or chronic, & conditions that need Clinical treatment.

Axis II: Personality Disorders & Mental Retardation (persistent require clinical treat).

Clinical (Mental) Disorders is used to report various disorders or conditions, as well as noting other conditions that may be a focus of clinical attention.

Personality Disorders and Mental Retardation are recorded so the clinician will give consideration to additional intervention and treatment choices.

Global Assessment of Functioning is for reporting the clinician's judgment of the individual's overall level of functioning and carrying out activities of daily living. This information is useful in planning treatment and measuring its impact, and in predicting outcome. The Global Assessment of Functioning Scale is a 100-point scale that measures a patients overall level of psychological, social, and occupational functioning on a hypothetical continuum.

Basic Psychopharmacology for Children and Adolescents

Prescribing psychoactive medication for children is controversial but at times necessary to assist children with mood, behavior, anxiety, aggression and other difficulties. Generally, one has to come to the conclusion that to not medicate would be more harmful than proceeding with medication treatment.

Disorders of Concentration: Attention and Hyperactivity. One of the most common reasons psychoactive medication is prescribed in children is related to problems associated with disruptive behavior. In particular problems with concentration, and hyperactivity.

Methylphenidate (Ritalin) Methylphenidate (Ritalin) is one of the oldest of the stimulant medications used in the treatment of attention and concentration problems. In general, methylphenidate is well tolerated and works well to increase concentration and attention and to decrease hyperactivity. It works about 80% of the time to reduce up to 80% of the symptoms a person is experiencing.

Methylphenidate (Ritalin) - Side effects include decreased appetite, decreased or disturbed sleep, sometimes headaches and gastrointestinal pains. At times motor or vocal tics emerge. There can also be problems with mood instability and with irritability. In overdose you can see psychotic symptoms or symptoms of delirium.

Methylphenidate (Ritalin) - Problems can also arise with methylphenidate because of the short half-life of the standard formulation. Theoretically dosing can occur every four hours but clinical experience leads to dosing as frequently as very 150 minutes. There are other forms of the medication that have longer duration of action including but not limited to Ritalin LA, Metadate CD, and Concerta.

Mixed Amphetamine Salts Adderall and AdderallXR. Mixed amphetamine salts have also been available in the treatment of attention and concentration for many years. They are currently available in generic and under the trade name of Adderall and AdderallXR. These medications are very effective in decreasing the symptoms of poor attention, poor concentration, and hyperactivity. Their effectiveness is similar to methylphenidate and they are very widely used.

Mixed Amphetamine SaltsAdderall and AdderallXR. Side effects are also similar to those listed above with methylphenidate but in clinical experience they are slightly more likely to create some mood lability and irritability than the other stimulant medications.

Dextroamphetamine - Dextroamphetamine has also been used for years in the treatment of problems with attention, concentration and the regulation of activity level. Sold under the trade name of Dexedrine or Dexedrine Spanules. Dextroamphetamine is effective in reduction of symptoms at a level consistent with the treatments listed above. Side effects are similar to those listed above.

Other Medication Options for Attention, Concentration and Over activity - The mainstay of therapy for problems with concentration and attention is stimulant medication. While stimulants are very effective medications there have been problems with their use because of the relatively short half life of each of these preparations. Even at their longest the medications rarely last greater than 8 hours and often times patients can experience a sort of rebound hyperactivity once the medication has "worn off"

Atomoxitine (Strattera) - A noradrenergic reuptake inhibiter that appears to have relatively good effectiveness in decreasing levels of hyperactivity and in helping with increasing attention, concentration, and organization. It has been approved for use in children as young as 6 years old weighing above forty pounds. It generally has lasting effects throughout the day and into the evening. Problems have included changes in appetite and also nausea along with some sleep problems

Centrally acting alpha adrenergic agonist - Clonidine and guanfacine have also been very useful in decreasing levels of hyperactivity and in increasing attention and concentration. They are not necessarily as effective as stimulant medications but they are effective in a group of very aroused patients. Side effects are limited to problems with drowsiness and with hypotension.

Venflaxamine (Effexor) - Venflaxamine (Effexor) a mixed serotonin and noradrenergic reuptake inhibiter that has been used in the treatment of difficulties related to concentration, attention and regulation of activity level with some limited success. Recently, Venflaxamine has come under increasing scrutiny because of issues related to possible increased suicidal ideation and suicidal behaviors in children and adolescents taking serotonin reuptake inhibiters. Other problems have included increased irritability and possible increases in blood pressure.

Buproprion (Wellbutrin) - Buproprion (Wellbutrin) is an anti-depressant medication that is sometimes used in the treatment of problems with attention and concentration. Buproprion can be reasonably effective in the reduction of symptoms but must be used with caution in children or adolescents with history of seizures, head injury or bulimia. (This medication has also been included in the list of antidepressants where care as to be given secondary to fears of increased suicidal thoughts or behaviors.)

Anxiety Disorders - Anxiety disorders as a group are very common in children in general and are often misdiagnosed or overlooked if a thorough history is not obtained. Misdiagnosis can be of particular concern where medications are concerned. The wrong medication can serve to exacerbate symptoms associated with anxiety and lead to increased morbidity for the child.

Serotonin Reuptake Inhibitors - Since their introduction in the last several years the serotonin reuptake inhibitors have been the treatment of first choice in the treatment of anxiety. Fluoxetine (Prozac), sertraline (Zoloft), paroxitine (Paxil), citalopram (Celexa), escitalopram (Leapro), and fluvoxamine (Luvox). These medications taken as a whole have been very effective in reducing anxiety and also in decreasing anxiety related symptoms associated with perseveration and preoccupation. In general they should be used starting at low doses for most patients but especially with those diagnosed with pervasive developmental disorders. The medications should be gradually titrated to desired effect. Care should be given to look for the emergence of any agitation or irritability and these medications have been known to induce mania in predisposed patients. Also added care should be given to observe for any signs or symptoms associated with increased suicidal ideation or suicidal behaviors.

Benzodiazepines - Benzodiazepines as a class are excellent anti anxiety medications. They can be very effective in the treatment of anxiety related problems in the developmentally disabled. These medications include but are not necessarily limited to diazepam, alprazolam, lorazepam, chlordiazepoxide, clonazepam, chlorazepate, oxazepam, flurazepam, and temazepam. Problems arise in these medications most often relate to somulence, difficulty with short term memory, development of tolerance requiring increasingly higher doses, and also with the half life and active metabolites of some of the medications in this class leading to unwanted prolonged effects.

Buspirone (Buspar) - Buspirone (Buspar) is an anxiolytic that can have some success in the treatment of anxiety. While not always successful in relieving anxiety it is a medication with very few side effects and is well tolerated. Generally, problems arise from needing to dose up to three times a day and it has a relatively slower onset of action sometimes taking up to three weeks to achieve clinically significant effect.

Venflaxamine (Effexor) - Venflaxamine (Effexor) is a combination serotonin reuptake inhibitor and noradrenergic reuptake inhibitor that has been clinically effective in decreasing anxiety symptoms. It has generally been well tolerated but there have been problems with sleep disturbance and even drowsiness on the medication. There have also been problems with elevations in blood pressure.

Tri-cyclic antidepressants - Tri-cyclic antidepressants such as imipramine and nortriptyline can also be effective anxiolytics. However, they may take up to 4 weeks to work effectively once an adequate serum level has been obtained. As when using in these medications in the treatment of other symptoms, care must be given to monitor the EKG to insure a QTc that is within acceptable clinical parameters. Also as stated above problems with high anticholinergic side effects can lead to problems like dry mouth, constipation, and drowsiness.

Anti-histamines - There are times when anti-histamines such as hydroxyzine or diphenhydramine are prescribed to relief anxiety. While these medications may be effective in the short run sedating a patient and calming the "crisis" they are generally not good medications for long-term use in the treatment of ongoing anxiety symptoms.

Affective Disorders including Bipolar Disorder - Depression and mood disorders certainly "exist" in children and often times psychotropic medications can be of assistance. More controversial currently is the diagnosis of Bipolar Disorder in a pediatric population. Great care is needed to ensure an accurate diagnosis so that appropriate treatment is given, especially when it comes to medications.

Major Depression The generally accepted first line of treatment for depression is the choice of a selective serotonin uptake inhibitor.

Serotonin Reuptake Inhibitors - These medications that were listed above include fluoxetine (Prozac), sertraline (Zoloft), citralopram (Celexa), escitralopram (Lexapro), fluvoxamine (Luvox), and paroxetine (Paxil). All of these medications have generally the same level of effectiveness in the treatment of depression and choices are often made based upon side effect profiles or the past response to a particular medication by the patient or a close relative of the patient. These are generally considered safe and effective medications although their use in children has not been extensively studied.

Serotonin Reuptake Inhibitors - Side effects in this class of medication are generally related to gastrointestinal problems, sometimes problems with sleep, and all generally tend to create problems with sexual function (in adults) that is usually related to decreased orgasm but there can also be decreased desire.

Serotonin Reuptake Inhibitors - These medications can also cause problems with increased irritability and at times they can induce mania in individuals with that predisposition. Care should be given especially when giving to individuals with a strong family history of Bipolar Disorder. Individuals with Pervasive Developmental Disorders as well can be very susceptible to side effects of irritability and mood instability. These medications should be used at low doses and with appropriate caution. Care also should be given as mentioned above to issues associated with potential suicidal ideation and behavior.

Buproprion (Wellbutrin) - Buproprion (Wellbutrin) is effective in the treatment of depression and in general has been well tolerated. It has advantages over the other anti depressants used in adults in that it is generally accepted that it has fewer sexual side effects. This medication has also appeared to be less likely to create difficulties with inducing mania in individuals that may be vulnerable.

Buproprion (Wellbutrin) - Buproprion must be used in caution with individuals that have a history of head injury or those with seizure disorder or history of bulimia. These individuals may be at higher risk for seizure on this medication. Newer formulations of buproprion have lengthened the half-life of the medication and this has led to less risk of seizure in individuals. It still should not be given to individuals with the risk factors noted above.

Venflaxamine (Effexor) - Venflaxamine (Effexor) is a combination selective serotonin reuptake inhibitor and noradrenergic reuptake inhibitor. It has been effective in the treatment of depression and is generally well tolerated. There have been problems as noted above with increase blood pressure and there have also been complaints related to sexual function.

Tri-cyclic antidepressants - Tri-cyclic antidepressants have long been and in some circles continue to be the gold standard for the treatment of depression. These medications while they do have quite a few side effects in general have been well tolerated and are effective in relieving symptoms. These medications include imipramine, nortriptyline, amitriptyline, and clomipramine. They all work in varying degrees on the same neurotransmitter systems that have been mentioned above but each to a different degree and with a different level of specificity for a particular neurotransmitter. This difference in neurotransmitter effect and the side effect profiles of each allows a clinician to attempt a good match for treatment with these medications.

Tri-cyclic antidepressants - All of these medications generally have high anticholinergic profiles. Side effects are usually problems with sleepiness, weight gain, dry mouth, constipation, etc. These medications also generally cause an increase in the time interval associated with the QRS complex as measured with an EKG. This can lead to dangerous arrhythmias during the course of treatment.

Tri-cyclic antidepressants - Because of each of the side effect difficulties listed above these medications can be fatal in overdose. This is generally not seen with the other medications that have been listed above for the treatment of depression. Given that by its very nature depression can have as a core symptom of morbid preoccupation and suicidality these medications must be given cautiously and monitored closely.

Other medications - Other medications have been used effectively as adjuncts to those listed above when treating depression. So called mood stabilizers such as lithium or valproic acid or other anticonvulsants have been used to try and decrease symptoms in a marginally responsive or non-responsive patient. Other medications that have been used with some effectiveness include stimulants and even thyroid hormone supplementation. Adolescent girls, who have achieved menarche, and women sometimes respond well to adjuncts of oral or depo contraceptive medications for depressive symptoms.

Electroconvulsive Therapy - While medications have been very effective in relieving the symptoms of depression it should also be noted that electroconvulsive therapy is also a very effective somatic treatment. There are side effects associated with short-term memory problems and the risk associated with anesthesia but overall the patients respond well and quickly to this somatic treatment. Many centers have even moved to offering this treatment in a day hospital setting with no over night stays.

Bipolar Disorder - Bipolar Disorder is seen in children and while it is a discussion not within the scope of this discussion it can often present in an atypical fashion. Determining core symptoms of grandiosity, racing thoughts or flight of ideas with increased goal oriented pursuits may be difficult to discern and features related to irritability and hyper sexuality may be difficult to tease from behaviors of other disorders or problems. Medications used to treat bipolar disorder are generally called mood stabilizers but there are mood stabilizers in several different classes of medications.

Lithium - Lithium has long been the treatment standard in the psychopharmacologic treatment of bipolar disorder. It is an exceptionally effective mood stabilizer and is generally well tolerated. It does however have several side effects and has a very narrow therapeutic window making it potentially dangerous in overdose. Side effects include weight gain, diarrhea, acne and less commonly problems with renal function, possible hypothyroidism, and cardiac rhythm problems. Blood levels need to be monitored carefully and care has to be taken in patients that are on medications or participate in activities that would potentially increase the drug's serum level.

Divalproex (Depakote) - Divalproex (Depakote) is also a very effective mood stabilizing medication. It is generally used as an anticonvulsant but it does currently have approval from the FDA for use as a treatment of acute mania. Most patients tolerate divalproex (Depakote) with few problems but there can be side effects. It can lead to some gastrointestinal problems and there can be increased appetite with weight gain. Additionally, in women there has been a correlation between divalproex (Depakote) use and polycysitic ovaries. There have also been problems with liver function, bone marrow changes usually with a decrease in megakaryocytes and subsequently platelets. In very rare cases critical pancreatitis has been a problem. Blood levels need to be monitored while the patient is on divalproex (Depakote) in addition to laboratory investigation of other systems that might be affected.

Other anticonvulsants - Other anticonvulsants used to treat bipolar disorder include but are not necessarily limited to Neurontin, Lamictil, Tegretol, Trileptal, and Topomax. These medications have been generally helpful in treating some of the symptoms of Bipolar Disorder. They have been generally well tolerated, some more than others. They have varying side effects and require different levels of monitoring but all are currently part of the armentareum used for treatment.

"Atypical" Anti-Psychotic Medications - Some of the new so-called "atypical" anti psychotic medications are also being used in the treatment of Bipolar Disorder especially to treat acute manic phase. These include Zyprexa, Geodon, Abilify, Risperdal, and Seroquel. These medications too have been well tolerated by patients but there are some concerning side effects. While they do not have the risk of tardive dyskensia associated with them that the so-called "typical" anti psychotics possess there is still a risk of this potentially irreversible movement disorder. Also each carries risk of acute extra pyramidal side effects including acute dystonias, parkinsonism, and akathesia. All have generally been associated with increased appetite and weight gain and possible increase in baseline glucose levels and lipid levels.

Obsessive compulsive Disorder (OCD) - Obsessive compulsive disorder usually responds well to an appropriate medication regimen. In addition to medication treatment however cognitive and behavioral therapies are important. Also symptoms of preoccupations and perseveration are not necessarily OCD. Psychopharmacologic treatment for OCD revolves around the use of medications that affect the serotonergic functions in the brain.Obsessive compulsive Disorder (OCD) - Any of the selective serotonergic reuptake inhibitors can be very useful in the treatment of OCD. As noted above these medications are well tolerated and possess few side effects. Dosages used to treat OCD are sometimes greater than those used for the treatment of depression and other anxiety disorders.

Selective Serotonergic Reuptake Inhibitors - These medications include the ones listed above, fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). As noted above, care should be taken in prescribing these medications related to recent concerns about increased suicidal ideations and/or suicidal behavior in children and adolescents taking these medications.

Clomipramine (Anafranil) - Clomipramine (Anafranil) is a Tricyclic antidepressant medication that has a primary serotonergic action in the brain that has been used for many years in the treatment of Obsessive/Compulsive Disorder symptoms.

Clomipramine (Anafranil) - Side effects with clomipramine (Anafranil) include the usual side effects associated with Tricyclic antidepressants. These are anticholinergic side effects that include increased appetite and weight gain, dry mouth, and constipation. There are also the same concerns associated with a widening in the QRS complex as seen on an EKG. Such a widening in the QRS complex as noted above can lead to problematic arrhythmias. This medication is also extremely toxic in overdose and can lead to death because of the anticholinergic and cardiac side effects associated with it.

Clomipramine (Anafranil) - Routinely, Clomipramine (Anafranil) - serum levels should be evaluated periodically. Baseline EKG with routine follow up EKG should be part of the post-prescription care given with this medication

Other medications - Other medications are used to treat symptoms associated with OCD. These medications include other medications that help relieve anxiety. These medications are medications in the Benzodiazepine class and medications, in addition to Clomipramine, that are in the tricyclic antidepressant class. There are at times severe OCD symptoms that seem to be helped by the addition of antipsychotic medications, in particular the newer atypical antipsychotic medications that we have discussed above.

Tourette's Disorder - Tourette's Disorder is a collection of symptoms associated with chronic vocal and motor tics. Sometimes these tics can be very complex. In addition to the chronic vocal and motor tics, comorbid issues associated with emotional lability and attention/concentration problems can also be present. OCD is also likely to be comorbid in individuals and in families of individuals with Tourette's. Both Tourette's Disorder and OCD can be the result of a post-strep infection autoimmune syndrome.

Tourette's Disorder - Medications that have been used to treat Tourette's Disorder include medications that inhibit tic production and also those that decrease anxiety. Of the medications that inhibit tic symptoms whether vocal or motor, the most effective group of medications is the antipsychotic group. These seem to be helpful because they block dopamine activity in the subcortical structures of the brain that are associated with movement. They are generally quite effective in reducing tics, both vocal and motor but do have substantial side effects, as have been noted above.

Risperdal - A frequently used antipsychotic medication in the treatment of Tourette's is Risperdal. Just as in the treatment of other disorders with antipsychotic medications, care has to be given to monitor for both short-term acute side effects that include extrapyramidal symptoms of parkinsonism, akathisia, and acute dystonias as well as longer-term side effects such as tardive dyskinesia. Additionally, with the chronic use of Risperdal as well as most of the older so-called "typical" antipsychotics, prolactin levels are increased and this can lead to difficulties associated with possible gynecomastia in males, particularly adolescents, and possible lactation and decreased menstruation in females. These atypical anti-psychotics, as noted above, are also possibly linked to increased glucose levels in individuals taking the medication and possible increased lipid levels.

Other Atypical Antipsychotics - Other atypical antipsychotics that have been used in the treatment of Tourette's Disorder include Geodon, Seroquel, and Zyprexa. The newer atypical antipsychotic Abilify, would probably also be useful in decreasing tics in these patients.

Older So-Called Typical Antipsychotics or Neuroleptics - Older so-called typical antipsychotics such as Pimozide and Haloperidol have also been shown to be very effective in the treatment of Tourette's Disorder. These medications decrease disruption secondary to tics, both vocal and motor. Both Haloperidol and Pimozide have substantial side effects. These side effects occur at a somewhat higher rate than the typical antipsychotic group. They have been associated with permanent, long-term side effects such as tardive dyskinesia and at a much higher rate than the atypical antipsychotics. Older antipsychotics are also much more likely to have problems associated with acute extrapyramidal side effects. At times, adjunctive anticholinergic medications are needed to decrease some of the worrisome acute side effects of movement associated with the older antipsychotics. Such medicines as Cogentin, Vistoril, Artane, and Benadryl have been used.

Other Medications To Treat Tourette's Disorder - Other medications have also been used with relative success in decreasing tics in patients with Tourette's Disorder. They also may have some adjunctive effect in decreasing some of the anxiety associated with Tourette's Disorder and in helping with some of the comorbid symptomatology associated with decreased attention and concentration. The medications most often used in this particular category are the alpha adrenergic agonists that are centrally acting. These include Quanfacine and Clonidine. Both of these are essentially antihypertensives and acting centrally seem to have some effect on the decrease in tic production. Also by decreasing the overall arousal level, they seem to have a mild anxiolytic effect and seem to increase concentration and attention. Side effects associated with these medications include sleepiness and/or feelings of being tired, both associated with a somnolent effect of the medications and their ability to decrease blood pressure. Care has to be given to monitor blood pressure to ensure that blood pressure does not drop too precipitously. Usually, patients need to be slowly titrated onto these medications and then subsequently slowly titrated off.

Other Medications - To Treat Tourette's Disorder These include the anxiolytics that have been noted above, including but not limited to, Benzodiazepines, selective serotonin reuptake inhibitors, Tricyclic antidepressants, and other more atypical anxiolytics, including BuSpar.

Psychotic Disorders - Psychotic disorders do occur in children and adolescents but they are not seen as often in this population as in adults.

Anti-psychotic medications - Anti-psychotic medications, both the newer atypical antipsychotic medications and the older typical antipsychotic medications are the mainstays for treatment of psychosis in any individual. The medications that are used in the treatment of psychotic disorders are those that have been mentioned above, including but not limited to, Risperdal, Zyprexa, Geodone, Seroquel, Abilify, and the older more typical antipsychotic medications that include Haldol, Thorazine, Prolixin, Mellaril, Loxitane, and many others. All of these medications, as has been noted above, have substantial side effects associated with them, not the least of which is the possibility of permanent movement difficulty associated with syndromes of tardive dyskinesia.

Benzodiazepines - In addition to these antipsychotic medications in the treatment of psychosis. Benzodiazepines can also sometimes be helpful in treating agitation and irritability that exists alongside the psychotic symptomatology. The use of Benzodiazepines such as Ativan, Klonopin, Valium, etc., can be very helpful in decreasing the morbidity associated with psychotic symptoms.

Conclusion - Psychotropic medications can be helpful adjuncts to mental health treatment in children and adolescents but care needs to be given to ensure appropriate diagnosis and follow up by a professional trained to evaluate and use these medications. Judicious use in a collaborative atmosphere is essential to success and safety.

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