An update on publicly funded multisite trials in pediatric psychopharmacology

Challenges and Opportunities of Pediatric Mental Health Practice in Rural America

Youth living in Rural America have increased rates of mental illness and inadequate resources to address their mental health concerns. Programs and systems are currently available to build capacity in pediatric clinicians to care for youth with mental illness and to recruit and support rural clinicians. Such programs should continue to be supported with federal and state funding and additional novel programs aimed at addressing the youth mental health crisis in North America should be developed and funded.

Multimodal treatments versus pharmacotherapy alone in children with psychiatric disorders: implications of access, effectiveness, and contextual treatment

Practice guidelines for the treatment of youth with mental health problems tend to endorse integrating psychopharmacologic treatment with psychosocial interventions, such as psychotherapy and parent skills training. However, poor access to pediatric mental health specialists and inadequate training of primary care physicians in psychosocial interventions make it difficult for families to receive this standard of care. Large pediatric randomized, multicenter trials, including the Multimodal Treatment Study of ADHD (attention deficit hyperactivity disorder) [MTA] and the Treatment for Adolescents with Depression Study (TADS), have begun to identify specific advantages of multimodal treatment compared with psychopharmacology alone. Advantages of combined treatment include improvement of both symptoms and family functioning. More research is needed to determine effective and appropriate multimodal interventions for complex and severe pediatric mental illness. Advantages of multimodal treatment must be balanced with the treatment burden on the family system.

Recent developments and strategies in pediatric pharmacology research in the USA

Research in pediatric pharmacology has undergone major changes in the last ten years, with an expansion in both publicly and privately funded activities. A number of pharmacokinetics studies and multi-site controlled efficacy trials have been conducted, so that treatment of children and adolescents can now be better informed and evidence-based. Regulatory financial incentives to industry in return for studies on drugs still covered by patent exclusivity have resulted in a substantial increase in pediatric research funded by pharmaceutical companies. In parallel, public funding has supported research on off-patent medications and other clinical important aspects of treatment, such as comparisons between active treatments, including non-pharmacological interventions. With greater interest by industry in pediatric research, the role of government funding agencies has been redefined to avoid duplication and ensure better integration of efforts and utilization of resources. The present review discusses some of the recent developments in pediatric pharmacology with focus on psychiatric medications.

Management of children with autism spectrum disorders

Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child's ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed.

The status of pharmacotherapy for autism spectrum disorders

The use of pharmacologic agents as a component of treatment for children and adults with autism spectrum disorders is common and a substantial body of literature describing controlled and open-label clinical trials now exists to guide clinical practice. Empiric evidence of efficacy of risperidone, methylphenidate and some selective serotonin re-uptake inhibitors for maladaptive behaviors commonly associated with autism spectrum disorders has increased substantially in recent years. Preliminary controlled trials of valproate, atomoxetine, alpha-2 adrenergic agonists and olanzapine are promising. In addition to traditional psychotropic medications, investigators have examined the potential role of a variety of agents with glutamatergic or cholinergic mechanisms, and the results warrant further investigation. Although psychotropic medications are effective in treating some important associated behaviors, evidence of significant impact on the core features of autism spectrum disorders is very limited.

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVE

To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking.

METHOD

A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents.

RESULTS

Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment.

CONCLUSIONS

Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.

Research in child and adolescent psychopharmacology: recent accomplishments and new challenges

RATIONALE

Research in pediatric psychopharmacology has expanded considerably in the last 10 years. Still, controversy remains about the effectiveness and safety of commonly used psychotropics and their role in child treatment, thus pointing to the need for more in-depth and targeted investigations.

OBJECTIVES

To review recent accomplishments and current limitations of pediatric psychopharmacology, and discuss approaches to further research.

METHODS

Selective review of the relevant literature and research in progress.

RESULTS

Controlled clinical trials have been conducted in many common psychiatric disorders in children and adolescents, thus providing a basis on which evidence-based treatment guidelines can be constructed. Little innovation has, however, occurred in treatment development and testing. Safety concerns are prominent and have a major influence on clinical practice and drug utilization.

CONCLUSIONS

While a research infrastructure has been successfully built for conducting pediatric clinical trials, important aspects such as long-term treatment effects, optimal sequencing and individualization of interventions, and integration of neuroscience findings into innovative, theory-driven treatment development remain to be addressed.