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When any psychotropic drug is to be given to either a very young or an elderly patient, the general rule is to start with the lowest dose that is therapeutically beneficial in contrast to the standard dose that would be given to a young adult. There are a number of reasons for this practice. The rates of drug absorption, metabolism and distribution differ. In the case of the young child and aged person, hepatic microsomal enzyme metabolism, which is largely responsible for the metabolism of psychotropic drugs, is suboptimal. In the elderly patient, the cardiac output and renal perfusion rates are substantially decreased, even in the physically healthy person. There is also evidence that tissue sensitivity to many psychotropic drugs is altered at the extremes of age. Thus the general rule is to start at the lowest possible dose and, if necessary, increase the dose slowly until optimal therapeutic benefit is achieved.

In the treatment of psychiatric disorders of children, the clinician is faced with a problem which is less apparent in the adult patient. In adult psychiatry, the diagnosis of the condition assists in ensuring optimal treatment. For example, the treatment of the symptoms of anxiety will depend on the underlying condition with which the anxiety is associated. Thus the type of drug used will depend, for example, on whether the patient is an anxious schizophrenic, an anxious depressive or a patient with panic disorder. As psychiatric diagnosis of childhood disorders is at a more elementary stage than it is in adult psychiatry, the diagnostic approach to treatment still leaves much to be desired. This chapter will therefore be confined to a discussion of those disorders of childhood for which there seems to be reasonable agreement over diagnosis and treatment.

Despite the success in the use of psychotropic drugs for the treatment of psychiatric disorders in adults, and to some extent in adolescents, the application of psychotropic drugs for the treatment of children has been less encouraging. This has been due to the use of invalid diagnostic

Fundamentals of Psychopharmacology. Third Edition. By Brian E. Leonard © 2003 John Wiley & Sons, Ltd. ISBN 0 471 52178 7

classifications, limitation of the methods for measuring response to treatment and the utilization of concepts drawn from adult psychiatry being inappropriately applied to children. These difficulties are reflected in the greater variability in the use of psychotropic drugs in children. This unfortunate situation is reflected in the fact that methylphenidate, imipramine and chlorpromazine still form the bulk of the prescriptions of child psychiatrists.

There are four main areas where psychotropic drugs are useful in children:

1. To provide relief from symptoms until the child matures, for example, in enuresis.

2. As an adjunct to other treatments as, for example, when a child refuses to attend school.

3. To suppress symptoms and thereby prevent the negative effects on other psychogical parameters. An example of this would be a child who suffers from tic disorders which causes embarrassment.

4. In severe conduct disorders when other non-drug-based methods have been unsuccessful.

It must be emphasized that the use of psychotropic drugs is only part of the treatment process, particularly when considering children.

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