Maryland Pao, MD

A. State you cannot work with him if he discontinues his medication

B. Contact his parents to bring them into the next session to discuss concerns about medication nonadherence

C. Review indications and informed consent for each medication to understand his history of treatment and current ambivalence

D. Agree to discontinue medications if he appears stable and keep close clinical watch while building a therapeutic alliance

It is common for young adults to express a desire to discontinue medications taken since childhood.

To encourage treatment adherence, it is appropriate to redo the informed consent process and review indications for each medication. This will remind the patient of how a medication can help him in functioning and reaching goals.

Because the effects and adverse effects that the patient's parents or guardian agreed to in the past may no longer be acceptable, it is important to present the risks and benefits of each medication.

Closely screen for the patient’s current level of substance use, which may have changed with decreased supervision, for the possible impact on regimen adherence, medication levels, and treatment effectiveness.

Challenges of Transitioning From Pediatric to Adult-Oriented Care

,” by Margaret J. Yoon, MD and Maryland Pao, MD, on which this quiz was based.

Poll

A 19-year-old new patient comes to you wanting to discontinue all his childhood psychiatric medications. What is the best next step?

Mini Quiz: New Patient Consult

Young adult psychiatry addresses the needs of transitional-age youth typically between the ages of 15 and 26 years. The phenomena of transitional age difficulties are a result of cultural and societal changes in which physiologic maturity (as marked by chronological age and biological development) and the acquisition of skills necessary for independent adult life in modern society are not aligned; this may be due to chronic illness in childhood, which is on the rise, or changes in parenting or other psychosocial difficulties. Society is confused about the roles and responsibilities of youth, as noted by Giedd:

Age-of-consent questions are particularly enmeshed in political and social contexts. For example, currently in the United States a person must be at least 15 to 17 years old . . . to drive, at least 18 to vote, buy cigarettes, or be in the military, and at least 21 to drink alcohol. The minimum age for holding political office varies . . . some municipalities allow mayors as young as 16 . . . , governors from 18 to 30. The age of consent to sexual relations varies worldwide from puberty . . . to age 18.

The inverse situation is illustrated in the legal entity of emancipated minors, which recognizes certain youth as developmentally or functionally advanced beyond their chronological age of less than 18 years once they demonstrate certain adult competencies (eg, financial self-sufficiency, marriage, caretaking of children, military service).

[[{"type":"media","view_mode":"media_crop","fid":"44425","attributes":{"alt":"Â© Alex Tor/shutterstock.com","class":"media-image media-image-right","id":"media_crop_8283121832594","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4965","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 94px; width: 150px; float: right;","title":"Â© Alex Tor/shutterstock.com","typeof":"foaf:Image"}}]]Young adulthood is a time of increased motivation, opportunity, and risk-taking, but also of increased risk for the onset of multiple, highly prevalent psychiatric disorders. Mood and anxiety disorders typically present during late adolescence and in the early twenties. There is a heightened risk of substance abuse disorders due to incompletely developed impulse control coupled with increased access to drugs. Eating disorders and the first break for early-onset psychosis also peak within this age range.

Disorders from childhood and adolescence, such as ADHD and autism spectrum disorders, continue to affect function, but at a higher degree that cannot be as easily accommodated by families and educational or therapeutic systems. Popular expressions such as “extended adolescence” or “failure to launch” focus concern on the individual’s deficits, but it is important to consider a developmental perspective that recognizes the challenges of the family and the clinical system in transitioning youth as well. So, who is responsible for treating the adolescent and young adult and when and how should transitions in care occur?

When to refer a young patient to an adult psychiatrist

Child and adolescent psychiatrists practice within a moving developmental frame and may work with adolescents and young adults as they enter adulthood for continuity of care. However, pediatric psychiatrists may choose to refer the patient to an adult psychiatrist for several reasons. The volume of emerging young adults would quickly saturate pediatric providers’ patient load. Educational or employment transitions can result in a geographic move that makes access to childhood providers difficult. Child and adolescent psychiatrists may treat multiple members of a family, and referral to another clinician may help separation and foster the patient’s individuation process.

When a patient is reluctant to transition to adult services, pediatric psychiatrists may recognize dynamics that resist change to the treatment configuration, such as avoidance due to anxiety about more independent functioning, leaving an established doctor-patient relationship, unacknowledged dependence on the family support that pediatric treatment providers offer, and reaction to an enactment of parental loss or abandonment. With support, the patient can be guided through the sense of loss and normal grief in such a transition. Thus, planning for the transition, on the part of the child psychiatrist as well as the receiving adult psychiatrist, requires forethought as much as a year before the actual transition if possible.

Issues in accepting transitioning patients

When adult providers begin to work with adolescents and young adults and their families who have transitioned from child psychiatry, reviewing confidentiality and setting treatment boundaries avoid confusion between the treatment models. Pediatric psychiatrists operate with a family-informed developmental model that may incorporate routine communication with parents to direct supportive changes in the home. Families may have the expectation that their child’s treating psychiatrist will freely release information. A review of confidentiality policies at the first meeting should outline how information (that will be more regulated in its release and with the child’s permission) will be exchanged by the adult psychiatrist with the family.

As children negotiate their own space apart from parents, there may be a greater need to establish clear boundaries. Information-gathering meetings with the family should be discussed beforehand with patients to define the level of disclosure and role of the session. Family sessions may also be balanced with separate meetings with significant others and families of choice, as this recognizes the importance of extra-familial relationships and invites other adult perspectives on a patient’s history.

Developmental discontinuity to adult functioning

There are several situations that can hinder a smooth segue to adult functioning. Young adulthood is a period when mood or psychotic disorders may first present, and it may be a difficult, clinically unstable period. For youths who have had periods of severe symptomatology, their caretakers may have provided too much accommodation out of a sense of overprotection, thereby enabling avoidance of challenges during adolescence. Consequently, these youths may not have had opportunities to develop skills to function autonomously, and they may stall from anxiety or regress when adult expectations are placed on them.

Alternately, if an adolescent received inadequate supervision, there may be hidden or minimized development of symptoms that worsened with disengagement from treatment. With the additional loss of parental support at 18, these youths fall off the treatment radar until nonadherence results in relapse. With decreased supervision, young adults may have increased access to settings where recreational drugs are available, just as they have also reached the legal age limit for the purchase of alcohol. Some vulnerable youth may have undertreated substance abuse or be self-treating mood and anxiety symptoms with substances, all of which can undermine appropriate adult coping.

Not every young person has mastered skills of independent functioning by the age of 18, so the transitional age range reflects the discontinuity that can appear between chronological age and developmental maturity. Some families (such as those with high-conflict divorces or another family member with chronic illness) may be dependent on the child’s presence or other benefits they bring to the household, and the family destabilizes when the adolescent attempts to functionally individuate or leave. The young adult experiences himself or herself as the cause of the family’s distress and delays transitioning in order to stabilize the family.

J is a 17-year-old high-performing junior at a competitive high school when she presents for psychiatric care for acute MDD with suicidal ideation and prominent anxiety features, in the context of increasing academic demands, declining grades, new-onset self-injury, and social withdrawal. She requires 2 inpatient hospitalizations for recurrent suicidal ideation of jumping in front of the subway en route to school.

Her distress decreases as academic adjustments are discussed, antidepressant medication is initiated, and her parents agree to therapeutic support for her. However, she has difficulty stepping down to a partial hospitalization program as she finds family meetings hard to tolerate because of the high level of tension between her parents, and she is often absent from the program the day after family meetings. She engages in individual outpatient medication management and psychotherapy more easily but is nonverbal or angry during periodic family sessions. This is followed by worsening urges for self-injury and thoughts of self-denigration and punishment.

J is unable to return for her senior year in high school because of exacerbation of symptoms, and she ambivalently receives home instruction. She continues in outpatient treatment, but with no clear progress developmentally or educationally.

After several months, J discloses in therapy that there is longstanding, mutual physical domestic violence between her parents, and she is frequently drawn into the fights in her attempts to stop their conflicts. She is concerned about her mother’s apparent depression and her father’s dissociative reactions after fights.

It is identified that the mother’s strong positive transference to J’s individual therapist has been particularly helpful in opening up the parents to treatment, but this secret has never been revealed outside the home. J realizes her perfectionism and academic excellence had initially served to refocus her parents and reduced the number of fights at home in her early years, and now the onset of her MDD and academic failure serves the same purpose. She states that she is afraid to leave home for fear that without her presence and intervention, her parents could inadvertently disable or kill each other.

After a discussion with the entire family, child protective services is contacted and the report is filed with a concurrent request from the parents for voluntary home-based services. The parents also agree to begin couples’ therapy to address relationship dynamics that existed before J was born, and to start to consider individual treatment. This allows J to release some of the caretaking and sense of responsibility she has toward her parents. J chooses to pursue her senior year of high school at a therapeutic boarding school that offers support for her anxiety and depression symptoms, and she is able to consider applying to local colleges.

As J’s 18th birthday approaches, transition to adult care is discussed with her and her parents. Although J has a strong therapeutic alliance with her adolescent psychiatrist and psychotherapist who have worked with her since her first hospitalization, she expresses a desire to find treatment closer to her boarding school and to separate from those who are working collaboratively with her parents. She feels that her parents will continue to struggle with safety in their relationship; although she restricts communication, her mother continues to leave messages for J’s therapist.

Several options that accept J’s insurance are identified and discussed with her over several months. She chooses an adult mental health center that offers group therapy options and specialized treatment for trauma. She allows communication between her pediatric and new adult teams, but restricts communication with her parents despite their expressed preference. She successfully transitions to living in a dorm at a college within the state but outside of her hometown.

Because adolescents and young adults have experience with pediatric providers who use a range of developmental approaches and may be family focused, transition-age patients are usually more comfortable with a practical, emotionally “real” therapeutic engagement with adult therapists. Changes in continuity of care are always challenging. When providing care to transitional patients, consider selective, therapeutically appropriate emotional disclosure during initial sessions to convey your concern, worry, or interest to foster the patient’s engagement and trust.

Building a quick alliance by joining a rejecting stance toward the family of origin is equivalent to building on sand, because this serves to externalize blame and erodes opportunities for reflection and practicing mature responsibility. This also sets up a framework for the projection of blame onto other responsible adults in the young adult’s life, such as bosses, teachers, and friends, which may later extend to the new therapist.

If families are too easily blamed for mistakes that the young adult makes, it impedes the patient from being motivated to problem-solve and may later emotionally block the patient from reaching out to his family when the family can be a supportive resource. A more balanced stance toward the family as a resource-available but separate from the patient-is less likely to result in scapegoating and emotional isolation. Recognize the practical support that families provide to young adults (financial, educational, access to health care, cultural, interpersonal) rather than discard access to these resources, while balancing appropriate boundaries to allow room for individuation.

Assume that young adult patients have not yet mastered independent living skills or achieved functional autonomy, although they may present themselves as doing so. Ask for examples of functioning, and listen for feedback from peers and family members to assess the actual level of independence. Colluding with a young adult’s self-idealization will create a therapeutic dilemma when the patient must acknowledge that he is in trouble. The patient may instead present with a series of crises or perceived victimizations over time due to repeated losses of jobs, housing, and relationships due to unperceived skills deficits.

Make an opportunity early in treatment to hear concerns from the family, and then openly review these concerns with the patient with therapeutic curiosity in a separate session. Note the specific language that is used by families to describe the patient’s historical roles or symptoms, because these labels and stories will be a window into the patient’s view of himself.

Managing confidential information and records

The ability to control access to confidential medical information comes with legal adult status. Youths may not be aware of how their treatment information was released or managed in the past, so a careful review of this history with parents can avoid unpleasant surprises. Young adults may need to be encouraged to allow transfer of medical files and records from pediatric services, and guided through the decision to release information to work or educational settings for appropriate support. Some patients benefit from receiving a hard copy of their records followed by a review with a clinician; this will enable patients to answer questions about their treatment and learn how to provide a medical and psychiatric history.

Spend some time reviewing who should receive updates on treatment, and ask the patient to sign appropriate release forms in sessions without the presence of parents to minimize pressure on the patient to release information. Proactively addressing the change in communication with the parents will avoid conflicts that can later arise from perceived rejection or estrangement. Review with family members that providers may receive unrestricted information from the outside, but are limited by confidentiality to release information, so that the parents understand that sharing their concerns with providers continues to be a valuable way to support their child.

Young adults beginning treatment with new adult providers benefit from a thorough review of their medication. They may have assumed independent management of their medication administration and can benefit from a simplified regimen if possible to maximize adherence. It is common for young adults to express a desire to discontinue medications taken since childhood. This may stem from differing views on pathology, a symbolic pushing away of parental labels, or a desire to distance themselves from their illness history. To avoid nonadherence, it is appropriate to redo the informed consent process and review indications for each medication, which will remind the patient of how the medication can help him in functioning and reaching goals. Risks and benefits of each medication should be presented to the patient, because the effects and adverse effects that his parents agreed to in the past may no longer be acceptable. Closely screen for the patient’s current level of substance use, which may have changed with decreased supervision, for the possible impact on regimen adherence, medication levels, and treatment effectiveness.

Patients who have both psychiatric and medical illnesses, particularly young adults with chronic illness (autism spectrum disorder, HIV infection, diabetes) or severe or terminal illnesses (which may require timely review of end-of-life planning), may require additional supports. Maintenance of health in young adults with chronic illnesses strongly depends on a smooth transition to adult care.

Although experiencing the loss of a caring doctor-patient relationship is difficult, providers reluctant to transfer care after long-term work may need to assess their own countertransference. Consider transitioning in a graduated stepwise manner, or plan a multidisciplinary meeting and structured communication between pediatric and adult services; consider including parents, especially if the parents are divorced and there is considerable animosity. The 

 provides suggestions for making the transition easier.

Young adults who are transitioning out of foster care, state custody, or probation placement must master adult skills without the normal scaffolding of family support and may also require additional meetings with agency providers. The presence of a developmental delay or intellectual or other permanent disabilities presents additional challenges. Services may be divided into separate treatment tunnels (eg, school services, employment support, family treatment, therapeutic services) and require extra communication to transition services.

Dr Yoon is an Assistant Attending Psychiatrist at the New York Presbyterian Hospital and an Assistant Professor of Psychiatry in the Division of Child and Adolescent Psychiatry at Weill Cornell Medical College in New York. Dr Pao is Clinical Professor in the Department of Psychiatry at the Georgetown University School of Medicine and Clinical Director of the National Institute of Mental Health, National Institutes of Health, in Bethesda, MD.

 Giedd J. Adolescent brain maturation. Encyclopedia on Early Childhood Development. November 2010. 

http://www.child-encyclopedia.com/brain/according-experts/adolescent-brain-maturation

 Turkel S, Pao M. Late consequences of pediatric chronic illness. 

• AACAP’s Youth in Transition: Moving into Adulthood Resource Center: 

http://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Home.aspx

• National Alliance on Mental Illness (NAMI) Teens & Young Adults Section 

http://www.nami.org/Find-Support/Teens-and-Young-Adults

• Got Transition by the nonprofit Center for Health Care 

• National Collaborative on Workforce & Disability for Youth (NCWD-Youth) 

Articles

Who is responsible for treating the adolescent and young adult with psychiatric issues -- and when and how should transitions in care occur? 

Almost one-fifth of US children younger than 18 years (14.2 million) have a chronic illness that results in the need for special health care. Recent advances in medical and surgical technology, such as chemotherapy and immunotherapy, bone marrow transplant, and implantable devices, have increased survival rates and changed the lives of ill children and their families. Health care providers promote normal physical, motor, language, cognitive, sexual, and emotional development in children with chronic illnesses when possible, and foster coping and adjustment when there are limitations.

In adapting to physical illness, it is clear that a child’s poor adjustment is not directly related to the severity of the medical condition alone and that outcomes vary widely. Approximately 20% of children with chronic medical conditions have behavioral and emotional symptoms-twice the rate seen in the general population. These symptoms are normal responses to illness and hospitalization, but when they become pathological and impair a child’s development, early intervention and perhaps even prevention are needed.

Zach is a 15-year-old with a rare primary immunodeficiency disorder that was diagnosed a year earlier. Before his diagnosis, he had been developing typically; he was doing well in school, was participating in sports, and was socially active. During a protracted hospitalization for a bone marrow transplant, multiple medical complications-including central line infections and renal failure-developed, followed by an embolic stroke with residual right-sided weakness; his speech was not affected. Endocarditis necessitated prolonged antibiotic therapy.

Although usually upbeat, Zach became tearful and withdrawn over the ensuing weeks, and he would not participate in physical therapy. Depression was diagnosed by the pediatric psychiatry consultation liaison team, and a low-dose SSRI was prescribed. Soon after, he began to participate in physical therapy. He was less tearful and his mood improved. Because of concerns about possible adverse effects, however, the SSRI was discontinued. Within a week, Zach lacked motivation for physical therapy. After a multidisciplinary meeting, psychopharmacological therapy with the SSRI was reinstated, and he was discharged.


 Pediatric psychosomatic medicine services (also known as pediatric psychiatric consultation liaison services) bridge the gap between psychiatric and pediatric training to improve the emotional health and quality of life of children and adolescents with chronic illness. Psychiatrists who specialize in psychosomatic medicine provide collaborative care in general medical hospitals, on medical psychiatry inpatient units, and in primary care and other outpatient settings. The psychosomatic medicine consultant helps medical teams determine whether:

• Patients have an underlying or preexisting psychiatric disorder

• Patients have a psychiatric disorder that is the direct consequence of a primary medical condition (eg, brain tumor, Cushing syndrome, stroke sequela) or medical treatment (eg, interferon, high-dose corticosteroids, efavirenz)

• Patients have a somatoform disorder (ie, physical symptoms that seem out of proportion to medi-cal findings, or psychological factors that affect a general medical condition)

Untangling the differential diagnosis is daunting and requires expertise. Now that the health care field includes numerous subspecialists and hospitalists, integrated multidisciplinary care in medicine is more important than ever.

Consideration of pediatric psychopharmacology in the context of medical illness begins with a careful review of all current medications, including over-the-counter drugs as well as herbal, complementary, and alternative preparations. An evaluation of the recommended medication’s route of administration is needed because it may be affected by hepatic, GI, renal, and cardiac diseases. Adverse-effect profiles are also considered (eg, drowsiness may be helpful in a child who is agitated or has insomnia).

There is limited research on the pharmacokinetics and pharmacodynamics of medications across developmental stages, but most psychosomatic medicine specialists follow the principle: “Go low and go slow.” Choose medications with a short half-life, avoid introducing more than one medication at a time, and monitor and document target symptoms closely.

There is limited research on pharmacokinetics and pharmacodynamics of drugs across developmental stages . . . most psychosomatic medicine specialists . . . “go low and go slow.”

In pediatric psychosomatic medicine services, delirium, depression, and anxiety commonly precipitate consultation and psychopharmacological medication. However, there are no FDA-approved indications for psychopharmacological medications in medically ill children with delirium, depression, or anxiety.

The child’s family needs to be fully informed of the reason to use psychotropic medications and of their indications, therapeutic alternatives, and anticipated benefits. Each time a psychotropic medication is used, the risks to benefits ratio needs to be considered. It is essential to keep up-to-date about all FDA black box warnings.

Because of the lack of approved indications for psychotropics in children with medical illness, use is generally extrapolated from literature on medically ill adults or use in physically healthy children with psychiatric conditions. See the 

 for commonly prescribed psychotropic medications in medically ill children.

In children, delirium is an acute mental status change characterized by sleep-wake disturbance, fluctuating symptoms, impaired attention, irritability, agitation, affective lability, and confusion caused by an underlying medical illness. Adults have waxing and waning consciousness accompanied more noticeably by impaired memory, depressed mood, speech disturbance, delusions, and paranoia. Both adults and children have similar rates of impaired alertness, apathy, anxiety, disorientation, and hallucinations.

In medically ill pediatric patients, delirium is frequently caused by seizures; CNS tumors or infections; exposure to toxins; metabolic irregularities; drug-drug interactions; drug withdrawals; inadequate pain management; fever; or treatment with corticosteroids, interferon, chemotherapy, radiation, narcotics, or anticholinergic agents.

Treatment of the underlying medical condition is the most effective means of resolving symptoms of delirium. Environmental and pharmacological interventions can offer relief while medical evaluation takes place. Environmental interventions include frequent reorientation to time, place, and person; an environment that is neither overstimulating nor understimulating; and information for the patient and family on the relationship between altered mental status and physiological mechanisms.

 suggest treating hyperactive delirium with haloperidol or another typical antipsychotic medication. Risperidone or another atypical antipsychotic medication can improve hypoactive/mixed delirium symptoms. Schieveld and colleagues

 used typical and atypical antipsychotics to treat delirium symptoms in 40 ICU pediatric patients. Munzig and colleagues

 also reported success with atypical antipsychotics in patients (aged 1 to 18 years) who had delirium.

Symptoms of depression and anxiety, such as insomnia, loss of appetite, and fatigue, are common in chronically ill patients and can be overlooked or undertreated. Depressive symptoms add to the burden of illness and have been associated with poorer medical outcomes, treatment nonadherence, repeated hospitalizations, and disease-related complications in medically ill patients.

The prevalence of major depressive disorder and depressive symptoms has been found to be as high as 68% in pediatric patients with serious medical illness.

 Most studies use self-rating scales or semi-structured interviews. In evaluating a child or adolescent with depressive symptoms, it is important to distinguish whether the symptoms are attributable to the medical condition and to the effects of treatment or to an underlying psychiatric disorder.

Causes of depression include immune system and cytokine dysfunction, medication complications, endocrine abnormalities or deficien-cies, nutrition-related neurological or medical conditions, and CNS metastases.

 A full medical workup needs to be done to rule out underlying physiological mechanisms before the treatment decision is made.

Focus on the cognitive symptoms of depression, such as poor concentration, low self-esteem, feelings of guilt or of being a burden to others, and any suicidal thoughts (passive or active). Evidence suggests that asking patients, even young children, directly about their suicidal thoughts is the best method to assess suicide risk.

 Medical patients are a vulnerable population at higher risk for suicidal thoughts and behaviors-suicide risk varies by diagnosis, severity of disease, physical functioning, pain management, and prognosis.

When symptoms are attributed to an underlying mood disorder or are causing moderate to severe functional impairment, target antidepressants to specific symptoms. While psychotropic medications have not been studied in medically ill patients in a large-scale systematic manner, one small (N = 15) open-label trial demonstrated that fluvoxamine was well tolerated and significantly improved symptoms of anxiety and depression in pediatric cancer patients.

 Another case report describes citalopram as being well tolerated and effective in treating depression in 4 children with cancer.

Fluoxetine is an FDA-approved SSRI for depression in children older than 6 years. Fluoxetine, with its active metabolite norfluoxetine, and fluvoxamine are potent inhibitors of cytochrome P-450 (CYP) 3A3 and CYP3A4 and are best avoided, when possible, in combination with macrolide antibiotics, azole antifungal agents, and several other commonly used medications.

Citalopram has been widely used in medical settings because of its short half-life and low tendency to interact with other drugs.

However, the recent FDA warning that dosages greater than 40 mg/d can cause QTc prolongation may curb this practice.

 Escitalopram is approved for depression in 12- to 17-year-olds, and amitriptyline is approved for depression in patients aged 12 years or older.

Although difficult to tolerate in high doses because of anticholinergic symptoms and tachycardia, tricyclic antidepressants are often used in low doses to treat insomnia, weight loss, anxiety, and some pain syndromes. Other antidepressants, such as bupropion and duloxetine, have been found to have clinical utility under careful monitoring.

SSRIs and selective noradrenergic reuptake inhibitors are used with caution since the FDA black box warnings about increased risk of suicidal behavior in children and adolescents using these medications. This underscores the need for careful, weekly monitoring of all children treated with antidepressants. In general, it is unusual for medically ill patients to be suicidal without premorbid depression or with adequate pain management.

Pediatric patients with a history of multiple hospitalizations commonly experience anxiety (particularly separation anxiety), procedural anxiety, and adjustment disorders with anxious mood. A number of factors can contribute to the presence of anxiety symptoms: illness-related biological mechanisms, a response to diagnosis or being in the hospital, genetic and psychosocial causes, or a combination of all of these.

Behavioral and cognitive approaches are recommended as first-line treatment for anxiety symptoms. Medical play therapy, cognitive-behavioral therapy, prizes and incentives for procedures, and distraction techniques such as virtual reality and video game interventions, have demonstrated efficacy in ameliorating anxiety symptoms.

For symptoms that persist or become clinically significant, psychopharmacological treatments can be an important adjunct. Benzodiazepines, such as lorazepam, used in low doses in conjunction with nonpharmacological distraction techniques may be appropriate for procedures that provoke significant anxiety in children. Clonazepam, a longer-acting benzodiazepine, may be helpful with more pervasive and prolonged anxiety symptoms.

Benzodiazepines can cause sedation, confusion, and behavioral disinhibition, so their use should be carefully monitored, especially in those with CNS dysfunction. Benzodiazepine withdrawal precipitated by abrupt discontinuation often occurs on transfer out of intensive care settings, so special care should be taken not to discontinue benzodiazepines too abruptly.

In addition, antihistamines are frequently used to sedate anxious children. While diphenhydramine may be helpful for occasional insomnia, antihistamines are not helpful for persistent anxiety, and their anticholinergic properties can precipitate or worsen delirium.

Escitalopram (approved in healthy children older than 12 for depression) and citalopram are used to treat anxiety as well and may lead to fewer drug-drug interactions in medically ill patients.

Psychopharmacology may supplement psychotherapies such as cognitive-behavioral therapy, behavior work, and family therapy in reducing symptoms of anxiety, depression, and delirium in pediatric medically ill patients-particularly when the disorders are causing significant functional impairment. Left untreated, psychiatric disorders can negatively affect quality of life, symptom management, treatment adherence, medical outcome, and somatic complaints, and they can impede com-pliance with medical procedures. Targeted psychopharmacological treatment, in conjunction with environmental or behavioral interventions, can lessen the severity of mood, sleep, and appetite problems; help medically ill children develop better coping skills surrounding diagnosis, treatment, and procedures; and improve quality of life and functioning in multiple domains.

 Turkel SB, Trzepacz PT, TavarÃ© CJ. Comparing symptoms of delirium in adults and children. 

 Kurtz BP, Abrams AN. Psychiatric aspects of pediatric cancer. 

 Martini DR, Pao M. Psychiatric emergencies. In: Wiener LS, Pao M, Kazak AE, et al, eds. 

Quick Reference for Pediatric Oncology Clinicians: The Psychiatric and Psychological Dimensions of Pediatric Cancer Symptom Management

. Charlottesville, VA: IPOS Press; 2009:121-129.


 Apter A, Farbstein I, Yaniv I. Psychiatric aspects of pediatric cancer. 

 Karnik NS, Joshi SV, Paterno C, Shaw R. Subtypes of pediatric delirium: a treatment algorithm. 

 Schieveld JN, Leroy PL, van Os J, et al. Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit. 

 Munzig E, Turkel S, Jacobson J, et al. Diagnosis and treatment of pediatric delirium. Poster presented at: Academy of Psychosomatic Medicine; November 20, 2008; Miami.


 de Jonge PD, Hadj FB, Boffa D, et al. Prevention of major depression in complex medically ill patients: preliminary results from a randomized, controlled trial. 

 Koopmans GT, Donker MC, Rutten FH. Length of hospital stay and health service use of medical inpatients with comorbid noncognitive mental disorders: a review of the literature. 

 Fenton WS, Stover ES. Mood disorders: cardiovascular and diabetes comorbidity. 

 Garrison MM, Katon WJ, Richardson LP. The impact of psychiatric comorbidities on readmissions for diabetes in youth. 

 Kersun LS, Elia J. Depressive symptoms and SSRI use in pediatric oncology patients. 

 Szigethy E, Levy-Warren A, Whitton S, et al. Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study. 

 Pao M, Lyon M, D’Angelo LJ, et al. Psychiatric diagnoses in adolescents seropositive for the human immunodeficiency virus. 

 Ballard E, Bosk A, Snyder D, et al. Patients’ opinions about suicide screening in a pediatric emergency department. 

 Gothelf D, Rubinstein M, Shemesh E, et al. Pilot study: fluvoxamine treatment for depression and anxiety disorders in children and adolescents with cancer. 

 DeJong M, Fombonne E. Citalopram to treat depression in pediatric oncology. 

 Indiana University School of Medicine, Division of Clinical Pharmacology. P450 Drug Interaction Table. 

http://medicine.iupui.edu/clinpharm/ddis/table.aspx

 US Food and Drug Administration. FDA Drug Safety Communication: Abnormal Heart Rhythms Associated With High Doses of Celexa (Citalopram Hydrobromide). August 2011. 

http://www.fda.gov/Drugs/DrugSafety/ucm269086.htm

 Stuber ML, Seacord D. Psychiatric impact of childhood cancer. In: Kreitler S, Ben Arush MW, eds. 

Psychosocial Aspects of Pediatric Oncology. 

West Sussex, England: John Wiley & Sons Ltd; 2004:211-228.


 Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, et al. Therapy for youths with anxiety disorders: a second randomized clinical trial. 

 Patel A, Schieble T, Davidson M, et al. Distraction with a hand-held video game reduces pediatric preoperative anxiety. 

 US Food and Drug Administration. FDA Approved Drug Products.

 http://www.accessdata.fda.gov/scripts/cder/drugsatfda

Understanding pediatric psychopharmacology in the context of medical illness.

Psychosomatic Symptoms in Children With Chronic Medical Illness

In 2007, cancer was diagnosed in 10,400 children and adolescents under the age of 15 years.

 While cancer remains the second leading cause of death in children, increasing numbers of children with cancer are surviving into adulthood.

 Over the past 30 years, 5-year survival rates for children with cancer have significantly improved, from 59% in 1975 to 1977 to 80% in 1996 to 2004.

 Pediatric cancer, increasingly considered a chronic rather than an acute condition, is an intense emotional and physical experience for patients and their families.

Comprehensive psychiatric assessment of these children is complicated by symptoms of medical comorbidities that overlap mental health conditions. Few resources exist to guide clinicians in the psychiatric treatment of children with cancer. This article describes the sparse research from small clinical studies on the extent of psychiatric treatment in children with cancer and evidence from outcome studies of medication use in these children. Minimal knowledge on the role of antidepressants in such children motivated us to examine the question in a broad population-based approach.

One area of interest in caring for children with cancer is the prevalence of psychiatric diagnoses. Assessment of psychiatric disorders in these children from either research or community settings is difficult because of the complex medical and emotional presentation of illness.

 criteria for mood disorders, for example, include both somatic and cognitive symptom criteria, and clinicians must decide which symptoms are caused by the illness and treatment and which are related to a separate psychiatric diagnosis.

In addition, doctors and nurses may overestimate psychosocial distress and symptoms in children and adolescents with cancer.6 Assessment tools for psychiatric disorders are not often validated in children with medical illnesses, which may lead in part to the varying research prevalence of psychiatric disorders in this population.

Reports of psychiatric illness in children with cancer range from a high of 17% to rates that do not differ significantly from those for the general population.

Specific cancers and their treatments may also contribute to the variable rates of depression. Without more precise estimates that generalize to large youth populations, it is unclear whether children with cancer are at higher risk for a psychiatric disorder than children who are not medically ill.

Regardless of whether a patient fulfills all criteria for a psychiatric disorder, mood symptoms are commonly reported by children with cancer.

 In a clinical study of adolescents who had recently received a diagnosis of cancer, 12% had clinically significant symptoms of anxiety and 21% had clinically significant symptoms of depression.

Adolescent cancer survivors have been shown to be at higher risk than sibling controls for depression, anxiety, and attention deficit symptoms as well as antisocial behaviors. Survivors of childhood cancer may be at increased risk for suicidal ideation and suicide attempts later in life.

 Posttraumatic stress symptoms are another concern in children with cancer: diagnosis and medical treatments can become a traumatic stressor for these patients.

 As a result, clinicians who treat children with cancer may focus on treating particular symptoms, such as mood, anxiety, or fatigue, rather than on a specific diagnosis.

Options for symptomatic treatment are limited, and their efficacy has not been established in children with cancer. Psychological interventions have shown promise in decreasing distress, but they have not shown an effect on clinical outcomes.14 Psychopharmacological efficacy studies have been limited to an open-label trial of fluvoxamine in 15 children and adolescents with cancer, which showed good tolerability and improvement in psychiatric symptoms. There was also an open trial of citalopram in 4 children with cancer, which also showed good tolerability and a decrease in depressive symptoms.

Fluoxetine has been shown to be effective in treating depression in randomized controlled trials of children and adolescents who are not medically ill. This agent is the only SSRI currently approved for treatment of depression in youth.

 Nevertheless, SSRIs and other antidepressants are often used off-label at the discretion of the clinician; this suggests the need to estimate the frequency with which these agents are used to address specific conditions in children with cancer where the need may be both acute and ongoing.

Many children with cancer are being treated for mood or physical symptoms with psychotropic medications. A survey of pediatric oncologists found that half had prescribed an SSRI for a patient, often without consultation from a mental health clinician.

In addition, a review of hospitalized children reported that 10% of children with cancer had received an antidepressant medication within a year of the cancer diagnosis.

 In another study, a psychotropic medication had been prescribed for 14% of children with cancer when they were admitted to an NIH clinical center.

These sparse study findings are not sufficient to understand the extent of antidepressant use in community-based practice and suggest the need for a large population-based study.

A large pediatric cross-sectional pharmacoepidemiological study was undertaken with administrative claims data for 2000 and 2001 from 2.7 million patients aged 2 through 17 years who had had 3 or more months of Medicaid coverage. There were 1040 patients with at least 2 

International Classification of Diseases,

 9th revision, Clinical Modification diagnosis claims for cancer treatment. A randomly selected age-, gender-, and race/ethnicity-matched group of 10 controls for each case was developed (n = 10,400).

After controlling for gender, age, race/ethnicity, and psychiatric comorbidities, the likelihood of antidepressant use was nearly twice as common in youths with cancer as in the control group (1.87; 95% confidence interval, 1.43-2.44). Specifically, antidepressants were prescribed for 8.8% of youths with cancer compared with 5.2% of matched controls.

Irrespective of the cancer diagnosis, antidepressant use was 5.4 times more likely in youths who had attention-deficit/hyperactivity disorder (ADHD). Likewise, African American and Hispanic youth were 60% less likely to have received an antidepressant, irrespective of the cancer diagnosis. These demographic and comorbidity treatment findings reemphasize the well-established role of race/ethnicity in explaining disparities in health services and demonstrate possible indications for off-label use of antidepressants in pedi-atric ADHD.

The estimated prevalence of antidepressant use in the Medicaid-insured youth with cancer was about 9% versus about 5.2% in those aged 2 through 17 years who did not have cancer.

 By comparison, in an HMO youth cohort, the prevalence of antidepressant use was 1.75% among 5- to 17-year-olds in 2000 and 2001.

Thus, it appears that children with cancer are being treated with psychotropic medications, particularly antidepressants, at a higher rate than matched noncancer controls or community-treated populations. The data suggest that clinicians may be responding to high levels of symptoms and poor functioning.

Given the greater prevalence of antidepressant use and the higher prevalence of psychiatric symptoms in children with cancer than in the general pediatric population, further research is imperative. Prioritizing antidepressant research would help ensure a solid evidence base of efficacy, safety, and tolerability in youths undergoing cancer treatment.

To date, only youths with Medicaid insurance have been studied. This population probably includes many chronically ill youths, for whom cancer is a significant condition. The need to expand the research evidence on the role of antidepressants in youths with cancer is further heightened by the current controversy surrounding SSRI use in children. Well-designed studies with adequate assessment and follow-up are essential. Current studies are limited by sample size, few comparison groups, and failure to assess comprehensive treatment interventions. In addition, validated instruments to assess psychiatric symptoms in pediatric oncology populations are needed to best identify those patients in need of treatment.

The increased prevalence of antidepressant use among Medicaid-insured pediatric oncology patients suggests that clinicians may be responding to some form of distress in their patients that is possibly biologically triggered. Further research will elucidate the most effective and safe treatments for these patients.

It is also important to remember that medications are only one aspect of comprehensive psychosocial care of children with cancer. Nonpharmacological interventions such as cognitive-behavioral therapy, guided imagery, and hypnosis may help manage symptoms, and further research is needed to see the effect of these treatments on clinical outcomes. Collaborative efforts by pediatric oncologists, psychiatrists, and other mental health clinicians will no doubt enhance resilience in this population by ensuring that they receive comprehensive psychosocial care to maintain the best possible quality of life in the face of physical challenges.

 American Cancer Society. Cancer Facts and Figures 2007. Atlanta: American Cancer Society. 

http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf

 Heron MP, Smith BL. Deaths: Leading causes for 2003. National Vital Statistics Reports. Vol 55, No 10. Hyattsville, MD: National Center for Health Statistics; March 15, 2007. 

http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_10.pdf

 Ries LAG, Melbert D, Krapcho M, et al, eds. 

SEER Cancer Statistics Review, 1975-2005.

 Bethesda, MD: National Cancer Institute. 

Clinical Manual of Pediatric Psychosomatic Medicine.

 Washington, DC: American Psychiatric Publishing, Inc; 2006.


 Shemesh E, Bartell A, Newcorn JH. Assessment and treatment of depression in medically ill children. 

 HedstrÃ¶m M, Kreuger A, Ljungman G, et al. Accuracy of assessment of distress, anxiety, and depression by physicians and nurses in adolescents recently diagnosed with cancer. 

 Canning EH, Hanser SB, Shade KA, Boyce WT. Mental disorders in chronically ill children: parent-child discrepancy and physician identification. 

 Bennett DS. Depression among children with chronic medical problems: a meta-analysis. 

 HedstrÃ¶m M, Ljungman G, von Essen L. Perceptions of distress among adolescents recently diagnosed with cancer. 

 Schultz KA, Ness KK, Whitton J, et al. Behavioral and social outcomes in adolescent survivors of childhood cancer: a report from the childhood cancer survivor study. 

 Recklitis CJ, Lockwood RA, Rothwell MA, Diller LR. Suicidal ideation and attempts in adult survivors of childhood cancer. 

In 2007, cancer was diagnosed in 10,400 children and adolescents under the age of 15 years.1 While cancer remains the second leading cause of death in children, increasing numbers of children with cancer are surviving into adulthood.2 Over the past 30 years, 5-year survival rates for children with cancer have significantly improved, from 59% in 1975 to 1977 to 80% in 1996 to 2004.3 Pediatric cancer, increasingly considered a chronic rather than an acute condition, is an intense emotional and physical experience for patients and their families.4

Antidepressant Use in Children With Cancer

With the advent of new treatmentsfor medical diseasessuch as cancer, asthma, HIVinfection, and cystic fibrosis, more childrenand adolescents are living withchronic illness than ever before. Seventyyears ago, persons with cystic fibrosissurvived an average of 5 years, whilecurrently the life expectancy for patientswith cystic fibrosis is more than 30years.

 For children with cancer, the 5-year survival rate has improved dramaticallyto 79% for the period of 1995 to2000.

 Increased survival, however, hasbrought new morbidities.

 Childrenwith chronic illnesses are more likelyto have emotional, behavioral, andpsychiatric symptoms than healthychildren

 and may be psychologicallyaffected or traumatized by medicaltreatment.

Pediatric psychosomatic medicine,also called pediatric consultation-liaisonpsychiatry, investigates the psychiatricissues affecting medically illyouths in the context of their development,cognition, communication, familialinteractions, and pharmacokineticdynamics. With the recent addition ofpsychosomatic medicine as a subspecialtyfield of psychiatry,

 the field ofpediatric psychosomatics has becomean increasingly active area of clinicalcare and research.

Pediatric consultation-liaison psychiatrists,in collaboration with pediatricians,are called on to assess chronicallyill children and adolescents for psychiatricillness, to address nonadherence,to investigate unexplained physicalsymptoms, and to attend to psychosocialstressors. Three aspects of psychiatricconsultation in the medically andsurgically ill that are specific to workingwith young patients are:

 An awareness of the cognitive andemotional developmental levels ofthe patient.

An appreciation of the essential roleof the family.

 A focus on facilitating coping andadjustment to illness, rather thanconcentrating on psychopathology,in order to encourage an optimaldevelopmental trajectory.

Pediatric psychosomatic research shows that emotional, behavioral, and psychiatric symptoms are found more often in children and adolescents with chronic illnesses than in healthy children.

Author | Maryland Pao, MD

Articles

Mini Quiz: New Patient Consult

Challenges of Transitioning From Pediatric to Adult-Oriented Care

Psychosomatic Symptoms in Children With Chronic Medical Illness

Antidepressant Use in Children With Cancer

Essential Issues in Pediatric Psychosomatic Medicine