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Although usually upbeat, Zach became tearful and withdrawn over the ensuing weeks, and he would not participate in physical therapy.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 Table 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.1
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.2-4
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.3
Karnik and colleagues5 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 colleagues6 used typical and atypical antipsychotics to treat delirium symptoms in 40 ICU pediatric patients. Munzig and colleagues7 also reported success with atypical antipsychotics in patients (aged 1 to 18 years) who had delirium.
1. Turkel SB, Trzepacz PT, Tavaré CJ. Comparing symptoms of delirium in adults and children. Psychosomatics. 2006;47:320-324.
2. Kurtz BP, Abrams AN. Psychiatric aspects of pediatric cancer. Child Adolesc Psychiatr Clin N Am. 2010;19:401-421, x-xi.
3. 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.
4. Apter A, Farbstein I, Yaniv I. Psychiatric aspects of pediatric cancer. Child Adolesc Psychiatr Clin N Am. 2003;12:473-492, vii.
5. Karnik NS, Joshi SV, Paterno C, Shaw R. Subtypes of pediatric delirium: a treatment algorithm. Psychosomatics. 2007;48:253-257.
6. 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. Intensive Care Med. 2007;33:1033-1040.
7. 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.
8. 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. Psychosomatics. 2009;50:227-233.
9. 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. Gen Hosp Psychiatry. 2005;27:44-56.
10. Fenton WS, Stover ES. Mood disorders: cardiovascular and diabetes comorbidity. Curr Opin Psychiatry. 2006;19:421-427.
11. Garrison MM, Katon WJ, Richardson LP. The impact of psychiatric comorbidities on readmissions for diabetes in youth. Diabetes Care. 2005;28:2150-2154.
12. Kersun LS, Elia J. Depressive symptoms and SSRI use in pediatric oncology patients. Pediatr Blood Cancer. 2007;49:881-887.
13. Szigethy E, Levy-Warren A, Whitton S, et al. Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study. J Pediatr Gastroenterol Nutr. 2004;39:395-403.
14. Pao M, Lyon M, D’Angelo LJ, et al. Psychiatric diagnoses in adolescents seropositive for the human immunodeficiency virus. Arch Pediatr Adolesc Med. 2000;154:240-244.
15. Ballard E, Bosk A, Snyder D, et al. Patients’ opinions about suicide screening in a pediatric emergency department. Pediatr Emerg Care. In press.
16. Gothelf D, Rubinstein M, Shemesh E, et al. Pilot study: fluvoxamine treatment for depression and anxiety disorders in children and adolescents with cancer. J Am Acad Child Adolesc Psychiatry. 2005;44:1258-1262.
17. DeJong M, Fombonne E. Citalopram to treat depression in pediatric oncology. J Child Adolesc Psychopharmacol. 2007;17:371-377.
18. Indiana University School of Medicine, Division of Clinical Pharmacology. P450 Drug Interaction Table. http://medicine.iupui.edu/clinpharm/ddis/table.aspx. Accessed September 28, 2011.
19. 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. Accessed September 28, 2011.
20. 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.
21. Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, et al. Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol. 1997;65:366-380.
22. Patel A, Schieble T, Davidson M, et al. Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatr Anaesth. 2006;16:1019-1027.
23. US Food and Drug Administration. FDA Approved Drug Products. http://www.accessdata.fda.gov/scripts/cder/drugsatfda. Accessed October 7, 2011.