Combined Treatment

Medication what role does and should it play in treating children and teens
By Horacio Hojman
Published in cooperation with Bradley Hospital

July 2011
Vol. 27, No. 7 ISSN 1058-1073 Online ISSN 1556-7575

Highlights
Our top story this month looks at how, why, and when medications are being used in the treatment of children with psychiatric disorders, and whether a greater emphasis on psychotherapeutic interventions need to be reconsidered. Keep Your Eye On See page 2 APA proposes key changes to organizational structure of DSM-5 Adding CBT to antidepressants for teen depression Should age play a role in diagnosing pediatric bipolar disorder? Whats New in Research See pages 35 Academic performance only minimally improved by stimulants Childhood psychopathology and predictors of adult depression Massachusetts study looks at bullying in middle and high school students

A real, current dilemma troubles me in my own clinical work and in teaching medical students in our training program. Have we become so focused on psychopharmacologic treatment that we are at a loss to help children who do not respond to medication or the many adolescents who refuse to take medication? Does our ever-increasing focus on medication affect our ability to provide necessary and sufficient psychotherapeutic intervention? Would robust psychotherapeutic intervention, especially when used in conjunction with medication, enhance our patients development and long-term outcome? I wonder why child and adolescent psychiatrists in the United States are mostly

treating children and adolescents with medication, and losing sight of the possibility of enhancing developmental interventions, working with the school, engaging in parenting work, and employing psychotherapy. This was not the case in the past, when psychotherapy was a very solid, and core, component of being a child and adolescent psychiatrist.

Medications as adjunct
When the medication formulary for children and adolescents was scant, their use was seen as adjunctive to the psychosocial and psychotherapeutic interventions, which were thoughtfully constructed
See Combined Treatment, page 5

The Changing Brain

Neuroplasticity: The wave of the neuroscience future

By Laurence M. Hirshberg, Ph.D.
Perhaps the most important neuroscience finding of the past 15 years is the recognition that the brain is constantly reorganizing its function, redeploying available resources to meet lifes demands for adaptation. New connections among neurons are formed, new patterns or networks of neural firing develop, and in some areas of the brain, new neurons are even developing. The name for this phenomenon is neuroplasticity, and it is the wave of the near future in mental health. Those who push the envelope in psychiatric, mental, and behavioral health research and practice are now working to develop and sharpen tools to focus or direct this capacity to treat symptoms and disorders, and improve mental and behavioral health.

Evidence of the brains plasticity

A great deal of research has accumulated demonstrating the enormous changeability of the brain; some of the simplest studies have done so most clearly. For example, a very early study (Pascual-Leone, 2005) examined brain activation patterns in an expert Braille reader who was born blind. First, his speed and accuracy in reading Braille were recorded. When he was placed in a brain scanner while reading Braille, the researchers saw a section of his pariSee Changing Brain, page 6

Guest Commentary

Sticks and stones: Violence and the power of words By Lewis P. Lipsitt, Founding Editor See page 8 Free Parent Handout

ADHD Basics For Parents

Monthly reports on the problems of children and adolescents growing up

View this newsletter online at wileyonlinelibrary.com DOI: 10.1002/cbl.20143

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I started to taper some of their medications and saw no major deterioration in their behavior. Some children were discharged from our school with minimal medication, or none whatsoever. On the other hand, in some children in whom we tried different kinds of therapies for depression, anxiety, or trauma, even with building a good working alliance, their impairing symptoms were unchanged. Once I saw enough to better formulate the case and revise the treatment, I started medication to target specific symptoms, aiming for a synergistic effect between the medication and psychotherapeutic interventions. These children and adolescents responded and as symptoms receded, perhaps making depression less severe or removing anxiety, their ability to utilize therapy increased and the process improved. My impression from this experience is that to do psychopharmacologic treatments well, effectively, and efficiently, the treatment needs to be contained in a solid psychotherapeutic relationship with the child and their parents, rather than the reverse. This is necessary in order to zero in on the diagnosis, reestablish compliance with medication where it has been lost, avoid escalating polypharmacy, and treat medication nonresponders.

cent of adolescents diagnosed with MDD responded to fluoxetine, and 35 percent to placebo, after 12 weeks of treatment (March et al., 2006). In terms of compliance, there are also a significant percentage of children and adolescents that are noncompliant with their psychopharmacological treatment. According to DelBello et al. (2007), 1 year after initial hospitalization for a manic or mixed episode, 39 percent of adolescents had achieved symptomatic and functional recovery. Interestingly, only 35 percent reported being fully compliant with their medication regimen. Wilens and Spencer (2000) reported that 25 to 35 percent of patients are not benefited by stimulants because of insufficient symptom relief, side effects, or nonadherence. With respect to recurrences, Birmaher et al. (2006) in a 2-year prospective study of bipolar children and adolescents (mean age 13 years) found that 70 percent recovered from the index episode, but half of them experienced recurrence. Taken together, these studies suggest that nearly a third of patients will either fail to adequately respond to a drug, struggle with compliance, or experience recurrences.

prescribing based on increasing demands for services for a troubled child, as well as the appropriate therapeutic wish to relieve suffering quickly. However, these widespread empirical practices of prescribing expose children to medical risks. The challenge is to do an adequate trial of psychotherapeutic and psychosocial interventions to clarify which conditions truly require medication.

A critical ingredient: Parents

Finally, psychoeducation given to parents is a valuable piece of the treatment. Parents should be educated regarding the importance of psychotherapy in combination with psychopharmacological management. Parents should know about evidence-based studies, for example, in depression and anxiety disorders in children and adolescents, in terms of medication alone not being as effective without the psychotherapy component. Sometimes parents do not take as seriously the use of therapies to treat children and adolescents compared to medication management. We should not miss the opportunity to educate parents about the full range of therapies supported by todays research. Parents should know that therapy is a process and a commitment they have to follow for a better outcome. When psychotherapy is indicated, I discuss with parents that it should be taken analogous to another extracurricular activity (such as a sport or a musical instrument). They often pause with some surprise, realizing this is an interesting way to think about therapy, which can bring balance to a comprehensive view of physical and mental health in the childs everyday life.

Horacio Hojman, M.D., is Child & Adolescent Psychiatry Attending, Child and Family Psychiatry Outpatient Department, Rhode Island Hospital and Clinical Assistant Professor in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University. A version of this article first appeared in the March/ April 2010 edition of AACAP News.

Off-label
A common occurrence in clinical settings is the off-label, trial and error targetsymptom oriented use of psychiatric medications in treating children and adolescents. This kind of prescribing relies on the competence and judgment of the prescribing clinicians rather than an evidence base of clinical trials. In this way an empirical approach replaces the traditional medical approach of diagnosing before treating as a standard for prescribing (Bloch, 1995). This can also be seen as a result of an unclear diagnosis, leaving the prescriber to target impairing symptoms. Often clinicians do not spend enough time getting to know the patient, making a formulation, and offering psychotherapeutic interventions. In this situation, clinicians are frequently

Placebo effect, compliance, recurrence

Psychopharmacological research has grown through the years and has been a very valuable addition to the child and adolescent psychiatrists toolbox. Children with biological predisposition to suffer from depression, anxiety and attention-deficit/ hyperactivity disorder (ADHD), for example, have had positive recoveries that were not possible prior to recent advances in psychopharmacology, even with the best efforts using psychotherapeutic treatments alone. However, it is also important to recognize that all placebo-controlled studies demonstrate that a certain percentage of children respond to the placebo effect of the drug and not to the drug itself. Emslie et al. (1997) report that symptoms of 56 percent of children and adolescents treated with fluoxetine (Prozac), and 22 percent of those treated with placebo, for major depressive disorder (MDD) were rated much or very much improved. The collaborative Treatment for Adolescents with Depression (TADS) study found that 61 per-

Changing Brain
From page 1

etal cortex activate in both hemispheres, as expected since this area was known to be involved in touch processing. But they also found that his occipital cortex was activated.

This was a surprise since that area is use for visual processing. The research team hypothesized that this mans brain had reorganized its own function, recruiting neuronal resources in the occipital area to assist in the much more intensive processing of tactile information necessary for Braille reading. (Those neu-

The Brown University Child and Adolescent Behavior Letter July 2011

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rons would otherwise be idle, since there was no visual information to process.) To further test this hypothesis, they utilized repetitive transcranial magnetic stimulation (rTMS) to temporarily shut down his occipital cortex. When this was accomplished he could no longer read Braille at all. This confirmed that the researchers hypothesis that the brain had in some fundamental way reorganized its networks of neurons so that the unused visual neurons could be used to assist with touch processing. The reorganization was fundamental since the function could no longer be performed without it. A follow-up study with sighted subjects who were blindfolded and taught Braille for 2 days showed that this reorganization happens quickly. After only 24 hours, the brains of these subjects had started to use visual neurons for touch processing. There are many other such examples, such as the finding that cab drivers in London have a significantly larger hippocampus the part of the brain used for visual spatial memory than other Londoners. The reason is obvious: they need and more repetitively use this part of their brain. Similarly, violin players have a larger patch of cortex devoted to sensation and fine control of their left hands than nonviolinists, again functionally advantageous to the violinist. attempts to discover opportunities in the daily life of patients to practice activities that include elements of the change they are seeking; monitoring of this practice and fine tuning the practice; and emphasizing the very small steps and successes that represent progress toward plastic change. to develop more formal brain training methods. The first of these approaches to receive significant research support involves exercise to train working memory, a function closely linked to attention. Carefully designed, well controlled research has shown that this method of working memory training results in lasting improvement in working memory, attention, and learning in children and adolescents with attention-deficit/hyperactivity disorder (ADHD; Klingberg, 2005). Computerized brain training exercises to increase mental or cognitive flexibility and ability to shift cognitive set are in development, although to my knowledge, research has not yet been published. Another emerging intervention that attempts to capitalize on neuroplasticity is EEG biofeedback. This method involves highly repetitive operant conditioning or feedback-guided learning to alter patterns of electrical activity in the brain in the direction of improved function. A growing body of evidence supports the effectiveness of this form of neural training for a variety of disorders and symptoms (Hirshberg, 2005). Finally, another set of emerging applied neuroscience approaches have growing research support and could be said to rely upon brain plasticity for their method of action. Noninvasive brain stimulation methods such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) have shown efficacy with a range of disorders or functions including depression, traumatic brain injury, working and semantic memory, and other forms of information processing.

Laurence M. Hirshberg, Ph.D., is a licensed clinical psychologist, and serves on the faculty of the Department of Psychiatry and Human Behavior of the Alpert Medical School as Clinical Assistant Professor. Dr. Hirshberg recently served as Guest Editor and contributor to a special issue of Child and Adolescent Psychiatric Clinics of North America devoted to emerging interventions in applied neuroscience, including neurofeedback and other brain-based interventions.

Encouraging flexible brains in children

Such plastic change is a goal in children who show cognitive or mental rigidity, in the form of anxious or depressive ruminations or behavioral rigidity; formal obsessions and compulsions; perseverations in autism spectrum disorders; stuck thinking and behavior in oppositional-defiant disorder. The parents of these children are coached to build into daily life practice an emphasis on mental flexibility and ability to switch gears. The approach is designed to be enjoyable even silly for the kids. In this approach, formal gear switching practice takes place daily. For example, perhaps the target child gets an extra half hour of TV watching, but the parent gets to change the channel at regular intervals. Family members may change seats at the table frequently or a family may vary their bedtime routine. When driving in the car, a mental flexibility game involves a group story wherein each rider contributes one sentence, resulting in unexpected, unusual plot shifts. One creative mom invented such a game. She called it Yum and Yuck. She and her rigid child would take turns inventing new food combinations, one which sounded good, accompanied by shared exclamation of Yum! and one which sounded bad, accompanied by an enthusiastic shared Yuck! I will also frequently assign computerized training exercises in cognitive or mental set shifting. Without hard data on the utility of this approach, I still believe it is effective. The kids and parents engage in the activities, enjoy them, and regularly report increased flexibility (such as wider food choices, less distress with change, and decreased rumination). Formal research into the value of such methods is needed.

Neuroplasticity in psychotherapy
Therapists have actually been making use of neuroplasticity from the beginning. Successful psychotherapy of obsessive compulsive disorder and of depression results in plastic changes to the brain in the direction of normal function. It can be argued that cognitive behavioral psychotherapy anticipated the importance of neuroplasticity with its emphasis on frequent practice of learned skills in daily life. Efforts are being made in many quarters to develop new approaches to psychotherapy that more fully, more intentionally make use of neuroplasticity. Psychotherapy practitioners are writing about their efforts to embed in psychotherapy a basic recognition of the power of neuroplasticity. (Joseph Cozolinos book The Neuroscience of Psychotherapy is only one among many examples of this approach.) My own approach in psychotherapy increasingly incorporates a focus on brain plasticity. This includes educating patients (children and adults) about the importance of brain change and how it happens;

References
Cozolino L: The Neuroscience of Psychotherapy. WW Norton, NY; 2002. Pacual-Leone A, et al.: Annu Rev Neurosci 2005; 28:377401. Klingberg T, et al: J Am Acad Child Adolesc Psychiatry 2005; 44(2):177186. Hirshberg L, et al.: Child Adolesc Psychiatric Clin N Am 2005; 14:119.

Neuroplasticity through formal brain training

We know that mindfulness meditation training results in neuroplastic brain changes and there is substantial and growing evidence of improvement in mood and anxiety symptoms. Meanwhile, work is underway

The Brown University Child and Adolescent Behavior Letter July 2011

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