Obsessive-compulsive disorder. The Pediatric OCD Treatment Study (POTS) Team (2004) epidemiological data suggest that approximately one in 200 young people have obsessive-compulsive disorder (OCD). It may occur at any point throughout the life span. It can severely disrupt academic, social and vocational functioning. Among adults with OCD, one-third to one-half developed the disorder during childhood or adolescence, which suggests that early intervention may prevent long-term morbidity. The efficacy of pharmacotherapy with a serotonin reuptake inhibitor for pediatric OCD has been established for clomipramine(Drug information on clomipramine) (Anafranil), fluvoxamine(Drug information on fluvoxamine) (Luvox), sertraline(Drug information on sertraline) (Zoloft) and fluoxetine(Drug information on fluoxetine). The pediatric literature is consistent with the adult literature in revealing a 30% to 40% reduction in OCD symptoms with pharmacotherapy, which still leaves the majority of patients who respond to medication management with clinically significant residual symptoms (POTS, 2004).
Prospective open-label studies also suggest the potential usefulness of cognitive-behavioral therapy (CBT) for pediatric OCD. One direct comparison of CBT versus clomipramine for pediatric OCD found an advantage for CBT. The results of the POTS (2004) study indicated that children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or with CBT alone. In a study examining the efficacy of group cognitive-behavioral therapy (GCBT) versus the use of sertraline in treatment-naive children and adolescents with OCD, it was found that GCBT may be effective in decreasing symptoms and should be considered as an alternative to either individual CBT or to medication such as sertraline (POTS, 2004).
Posttraumatic stress disorder/acute distress disorder. Posttraumatic stress disorder (PTSD) and acute stress disorder are a constellation of signs and symptoms that derive from extreme experiences that were actual or perceived threats of death or serious injury, either to oneself or to others. There is little empirical support for the use of pharmacotherapy in pediatric PTSD, consisting mostly of small case series or open trials.
For example, an open-label trial reported the use of transdermal clonidine(Drug information on clonidine) (Catapres) as being effective for alleviating seven patients' symptoms, with the main adverse events being skin irritation and rebound hypertension. Similarly, relatively low doses of oral clonidine also have been shown to diminish hyperarousal and impulsivity symptoms in children and adolescents (De Bellis and Van Dillen, 2005). Guanfacine(Drug information on guanfacine) was reported as being helpful in a case report when used to treat nightmares of a 7-year-old patient (De Bellis and Van Dillen, 2005). The SSRIs frequently are used in children with PTSD, based on extrapolation from adult evidence. For example, citalopram(Drug information on citalopram) (Celexa) was useful over eight weeks of open treatment (De Bellis and Van Dillen, 2005). The SSRIs also may be useful in youths with PTSD symptoms and comorbid depressive or panic symptoms. There is limited evidence to support the use of atypical antipsychotic agents in cases of pediatric PTSD (De Bellis and Van Dillen, 2005).
Generalized anxiety disorder. Hallmark symptoms of GAD are broad-based and center on excessive worry and feelings that are difficult to control. The focus of the anxiety and worry is not as specific as in other anxiety disorders. Although studies have documented the safety and efficacy of benzodiazepines in adults, few studies have been conducted in the pediatric age group children with ADHD and comorbid anxiety (separation anxiety disorder, generalized anxiety disorder and/or social phobia) have a response rate to stimulants for ADHD that is comparable with that of children with general ADHD. The benefit of adding fluvoxamine to stimulants for anxiety remains unproven (Abikoff et al., 2005; RUPP Study Group, 2001; Walkup et al., 2002)
In a study done to assess the efficacy of and tolerability of fluoxetine for the acute treatment of children and adolescents with generalized anxiety disorder, separation anxiety disorder and/or social phobia, the authors found fluoxetine to be useful and well tolerated for the acute treatment of anxious youths (Birmaher et al., 2003). Often considered to have a mild side effect profile, an open trial of buspirone(Drug information on buspirone) (BuSpar) in prepubertal children hospitalized with anxiety and aggression (n=25) documented agitation and manic symptoms in a significant number of treated subjects. The efficacy of the SSRIs and scant data supporting the use of buspirone argue against its use in pediatric anxiety (Reinblatt and Walkup, 2005).
Considerable advances have been made in the assessment and treatment of pediatric anxiety disorders. Strong relationships exist between pediatric anxiety disorders and various manifestations of adult psychopathology. Many of these disorders share a common thread and represent a developmental condition characterized by high levels of fear and apprehension. Despite the similarities of these varied disorders, advances in neuroscience will likely continue to assist in differentiating their unique symptom profiles and associated features. One area of research focuses on the amygdala and its role in aberrant processing of emotional information (Easter et al., 2005). There is a pressing need for better treatments for these often impairing conditions, and for comparison and combination studies of those currently available modalities that have proven effective.