Psychiatric Diagnosis and Management: Child

Psychiatric Diagnosis and Management: Child

 

Response to Kimberly

Hello Kimberly,

Your post is quite instructional. Medications play an essential function in treating some psychological ailments. I agree with you that practitioners should consider the dosing procedures and patient safety. The considerations for recommending medications in pediatric medicine encompass the appropriate dose based on the kid’s weight and age and whether it is harmless for kids. Mostly, when pediatricians recommend medicine use, they hardly consider the processes of drug distribution, absorption, elimination, and metabolism in the body. Essentially, the pharmacokinetic procedures vary between healthy adults and kids (Anker, Reed, Allegaert & Kearns, 2018). There are substantial variances between adults and children in drug disposition that impact drug dose-up routines. Some dosing regimens are driven by physiological changes and others related to the ailment. It is significant for prescribers to be informed about these variances. When prescribers are informed about the patient’s present and past medical history, they can determine dosing should be adjusted. Physicians should focus on adapting the medications to the patient’s demands and needs. Child pharmacology varies from adult pharmacology.

Child psychiatric ailments include two broad groupings. The groupings are those principally observed in young populaces and those in adult populaces. Some ailments observed in adult populations include schizophrenia, bipolar affective disorder, somatoform disorder, and unipolar depression (Vitiello & Davico, 2018). Some disorders present in children only are autistic disorder and ADHD (attention deficit hyperactive disorder). The primary concerns in child psychiatry and adult psychiatry encompass problematic diagnosis due to frequent comorbidities and fluctuating presentations and concerns about abuse capability of drugs and continuing drug use. Other primary concerns are contradictory pharmacokinetics and pharmacodynamics compared to the adult populace and the promotion of simultaneous psychotherapy. Overall, prescribers must be aware of the above differences when prescribing psychiatric medications in adult and child populations.

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References

van den Anker, J., Reed, M. D., Allegaert, K., & Kearns, G. L. (2018). Developmental changes in pharmacokinetics and pharmacodynamics. The Journal of Clinical Pharmacology, 58, S10-S25. https://doi.org/10.1002/jcph.1284

Vitiello, B., & Davico, C. (2018). Twenty years of progress in pediatric psychopharmacology: accomplishments and unmet needs. Evidence-Based Mental Health, 21(4), e10-e10. http://dx.doi.org/10.1136/ebmental-2018-300040

 

17 days ago

Kimberly Bernacki 

Compare/Contrast prescribing psych meds children versus adults

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Compare and contrast considerations for prescribing psychiatric medications to children and adolescent versus prescribing to adult and geriatric populations.

There are differences between children, adults, and geriatrics which influence drug dosing, however the treatment protocol and types of medications for psychiatric disorders are mostly similar (Eidelman & Abdel-Rahman, 2016). Some of the differences in dosing are due to the anatomy/physiology of the patient due to age and some are associated with the disease itself (Eidelman & Abdel-Rahman, 2016). In pediatrics, age is on a continuum which adds variability in drug disposition, route of administration, and absorption ((Anker et al., 2018). The preferred method of drug administration in children is via oral route although some reject these medications due to taste and texture (Eidelman & Abdel-Rahman, 2016). Neonates have higher gastric pH, altered intestinal activity, and extra oral drug absorption which influences the stability and bioavailability of orally administered medications (Eidelman & Abdel-Rahman, 2016). Young infants experience lower plasma concentrations for hydrophilic drugs if administered at the same mg/kg dose as in older children, adolescents, and adults due to larger extracellular and total water body stores (Eidelman & Abdel-Rahman, 2016). Neonates have reduced protein binding due to lower circulating protein stores and higher concentrations of bilirubin and fatty acids (Eidelman & Abdel-Rahman, 2016). There are different rates of drug clearance in children and adults due to multiple drug metabolizing enzymes (Eidelman & Abdel-Rahman, 2016). The age of the patient affects the anatomy and size of the kidney which determines the amount of clearance for renally eliminated medications (Eidelman & Abdel-Rahman, 2016).

 

The patient’s age, gender, weight, surface area, associated comorbidities, and probable side effects should all be taken into consideration when pharmacological interventions are indicated for mental health disorders (Sareen & Trivedi, 2013). One way to address management of psychiatric disorders in children is to categorize childhood psychiatric illness: those which are also seen in the adult population such as bipolar, depression, and schizophrenia, or those which are primarily seen in the youth population such as ADHD, autistic disorder, specific learning disorders, or other associated developmental disorders (Sareen & Trivedi, 2013). The drugs for the treatment of pediatric psychiatric disorders are mostly similar to those prescribed to adults but dosages in children are based on weight, psychodynamics, and pharmacokinetics. Some drugs may not be approved for use in children, but this is primarily because of lack of adequate studies done in this population due to ethical issues (Sareen & Trivedi, 2013). Some specific issues in differences of drug administration and management of psychiatric disorders in children and adults are informed consent, continuing maturation changes in youth, concerns about long-term drug use, and potential for drug abuse in adults compared to children and adolescents where abuse is not a major concern (Sareen & Trivedi, 2013). In geriatrics, providers should be cautious of physiological changes with age that affect drug absorption and clearance and consider medication related problems and adverse effects due to polypharmacy in this population (Rosli & Teo, 2020). Dysphagia in older patients may affect their ability to swallow tablets and medications may need to be crushed or prescribed in liquid form (Rosli & Teo, 2020). Geriatric patients may experience changes in absorption due to slowed gastric emptying which can lower or delay peak concentration (Rosli & Teo, 2020). A reduction in hepatic blood flow and size causes reduced microsomal drug activity and reduced hepatic metabolism (Rosli & Teo, 2020). There is often an increase in bioavailability of medications due to reduced first pass metabolism (Rosli & Teo, 2020). Renal clearance is reduced due to decreased renal blood flow and tubular secretion, so providers need to monitor drugs such as lithium and closely monitor signs of toxicity (Rosli & Teo, 2020). Water and volume of distribution reduces in the elderly causing fat-soluble drugs to remain longer with prolonged effects, with implications for sedatives and anxiolytics, including benzodiazepines (Rosli & Teo, 2020). Pharmacodynamics of drugs should also be considered because between 20 to 80 years of age, cerebral blood flow reducers by 30%, weight by 20%, and cortical neuronal density by 30% (Rosli & Teo, 2020). Providers should consider these pharmacodynamic changes in the elderly and be cautious with medications that act on the nervous system, such as dopamine that can place older people at risk for extrapyramidal symptoms with dopamine antagonists, whereas reduced acetylcholine may increase problems of anticholinergic effects with neuroleptics and tricyclic antidepressants (Rosli & Teo, 2020).

 

There are only minor differences for children versus adults in the management plan for psychiatric disorders. Drugs for bipolar disorder may take a longer time to subside an acute episode in children and the dose may be higher than expected because of the higher rates of metabolism in children (Sareen & Trivedi, 2013). More than one mood stabilizer might be required for children versus in an adult patient but the class of drugs to treat the disorder is the same (Sareen & Trivedi, 2013). Treatment guidelines for schizophrenia are similar in children and adults, where SGA’s are given first preference for both age groups and careful monitoring of weight and metabolic parameters are required (Sareen & Trivedi, 2013). Guidelines for obsessive compulsive disorder have similar treatment approaches in both adults and children with a combined approach of medication and some form of behavioral therapy (Sareen & Trivedi, 2013).

 

In summary, all patient age groups require detailed history taking, careful evaluation of the patient, a sound diagnostic formulation, and medications tailored to each patient. Treatment approaches and guidelines are similar; however, differences are in drug delivery due to age, absorption, pharmacodynamics, and pharmacodynamics. Psychotherapies can vary due to cognitive, social, emotional, and physical maturation (Sareen & Trivedi, 2013). When transitioning from adolescent to young adult psychiatric care, providers should re-evaluate current medication regimen, review risks and benefits, and provide additional patient education for indications to increase compliance and help patients further understand their diagnosis (Yoon & Pao, 2015). Older patients may be cognitively impaired so frequent reminders, marked pill boxes, and reduction of dose frequency may be needed. Polypharmacy is common in older people so prescribers should consider deprescribing and take into account life expectancy and consider a holistic approach when appropriate (Rosli & Teo, 2020). Medication adherence, dosing, and effectiveness of treatment are all crucial for maintenance of mental health when making the change from children to adult to geriatric psychiatric care. Providers must be cognizant of differences when managing and transitioning from each age group.

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References

 

Anker, J., Reed, M.D., Allegaert, K., Kearns, G.L. (2018). Developmental changes in

pharmacokinetics and pharmacodynamics. The Journal of Clinical Pharmacology. 58(S10), S10-S25. https://doi.org/10.1002/jcph.1284

 

Eidelman, C., Abdel-Rahman, S.M. (2016). Pharmacokinetic considerations when prescribing in

children. International Journal of Pharmacokinetics, 1(1), 69-80. https://doi.org/10.4155/ipk-2016-0001

 

Rosli, N., & Teo, S. P. (2020). Reducing medication error and polypharmacy in older

people. Asian Journal of Gerontology & Geriatrics, 15(2), 86–90.

 

Sareen, H., Trivedi, J.K. (2013). Child psychopharmacology: Is it more similar than different

from adult psychopharmacology? Indian Journal of Psychiatry, 55 (3), 301-304. https://doi.org/10.4103/0019-5545.117158

 

Yoon, M.J., Pao, M. (2015). Challenges of transitioning from pediatric to adult-oriented care.

Psychiatric Times. 32(12).

 

 

**I have a few articles published older than five years, however, I found the data to be relevant to this discussion post with substantial information so I decided to include them as well.

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