Children's medication and Children's mental health October Edition 2020
Introduction
Ognjen Ivetić Science Coordinator 2020/2021
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Why do drugs act differently in children compared to adults? -Pharmacokinetics of children The pharmacokinetics of many drugs are different in children compared to adults. The pharmacokinetic processes of absorption, distribution, metabolism and excretion undergo changes due to growth and development. It is particularly difficult to predict pharmacological effects in neonates as development occurs quickly, resulting in rapid changes in drug metabolism over short periods of time which create difficulty in predicting doses. Finding the correct doses for children is complicated by a lack of pharmacokinetic studies. Currently, most of drugs in children are dosed according to body weight expressed as mg/kg/day or mg/kg/dose or body surface area (BSA) mg/m2. These doses often need adjustment depending on the child and the clinical response. In general, the vast majority of clinical trials are carried out with adults and children’s doses cannot always be extrapolated directly from adult studies. Consequently, much remains unknown about how the immature physiology of children and babies impacts on drug disposition. The lack of pediatric clinical trials and dosing information has been highlighted by the European Medicines Agency as areas of clinical need, and there is now a requirement for more pediatric data in the evaluation of new drugs. In pediatric population, when choosing the dosage of a drug that has a narrow therapeutic index or high potential to cause adverse effects, the following pharmacokinetic processes should be kept in mind:
Absorption The composition of intestinal fluids and the permeability of the gut can vary significantly during childhood. Absorption of orally administered drugs is affected by changes in gastric pH which decreases during infancy to reach adult values by two years of age. Children are at higher risk of toxicity via skin absorption due to a larger surface area to volume ratio and they also absorb more of a drug across skin due to their thinner stratum corneum. This is an explanation why infants have an increased risk of methaemoglobinaemia with topical anaesthetics. Usually the absorption in children is reduced. The main reasons are decreased gastric secretion, absorption surface, intestinal bloodflow and motility. On the other hand, percutaneous and pulmonary absorption are increased, therefore the dosage of the drugs should be reduced. EPSA – European Pharmaceutical Students’ Association
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Distribution It is known that volume of distribution changes throughout childhood as stores of fat and water change. Infants usually have a higher percentage of extracellular water than adults, that implies that volume of distribution is increased for water-soluble drugs and so, their dose and dosing interval should be adjusted to this parameter because even minor changes in volume of distribution can alter the drug’s half-life. Dosing of digoxin is one of the typical examples where this kind of problem can occur. Since children are the population that has the most variable body weight during growth, their stores of body fat can easily increase and decrease throughout childhood. Currently, dosing information for obese children is quite limited and has been identified as an area for research. Therefore, it is recommended that obese children should be dosed by using ideal body weight and the dose adjusted based on clinical effect. In the end, it is also important to note that infants have lower concentrations of circulating plasma proteins that can reduce protein binding of drugs. This results in higher volume of distribution and lower peak concentrations of protein-bound drugs such as cefazolin.
Metabolism Speaking about drug metabolism, it is the most complex difference between adults and children. Cytochrome P450 (CYP) enzymes are relatively active in the fetus and enzyme activity begins to increase during the later stages of pregnancy with different rates of individual enzyme development. The activity of enzymes changes over the first few months of life in order to reach adult levels at around two years of age. While most enzymes increase in activity over the first few months of life, some enzymes such as CYP3A7 are replaced by other, in this case CYP3A4. The development of metabolic processes, such as glucuronidation, is less clear, but is thought to take at least three years to achieve full activity. Liver blood flow may be relatively high in infants. This could affect first-pass metabolism particularly for drugs with a high extraction ratio, like propranolol.
Elimination When the baby is born, its kidneys are usually undeveloped because the glomerular filtration rates reach adult levels by about two years of age. Therefore, it is necessary to be careful with the dosage of drugs that are eliminated by the kidneys, like aminoglycosides, digoxin, sulfonamides and penicillins. In general, it is important to say that drugs with a wide safety margin are good options for treating children as pharmacokinetic changes are unlikely to result in toxicity or ineffectiveness. For drugs with narrow safety margins, such as gentamicin or phenytoin, even small changes can cause serious toxicity. New developing techniques will assist in creating safer dosing information for children over time by reducing the burden of pharmacokinetic studies. Even if it is improving, no
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mathematical method of dose estimation can replace clinical studies using actual outcomes, surrogate measures or therapeutic drug monitoring.
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Reye’s syndrome and aspirin Reye's syndrome is a rare but serious condition that causes swelling in the liver and brain. This syndrome most often affects children and teenagers recovering from a viral infection, most commonly the flu or chickenpox. The exact cause of it is still unknown, although several factors may play a role in its development. So far, it is known that Reye’s syndrome can be triggered by using aspirin to treat a viral illness or infection - particularly flu (influenza) and chickenpox — in children and teenagers who have an underlying fatty acid oxidation disorder. Fatty acid oxidation disorders are a group of inherited metabolic disorders in which the body is unable to break down fatty acids because an enzyme is missing or not working properly. Some studies suggest that salicylates and other aspirin metabolites have structural similarities to the acyl-portions of substrate and product of the 3-hydroxyacyl-CoA dehydrogenase activity of the β-oxidation pathway, so their presence can inhibit β-oxidation of medium and long-chain fatty and later, this effect on β-oxidation can cause the inhibition of lactate-driven gluconeogenesis. In Reye's syndrome, a child's blood sugar level typically drops while the levels of ammonia and acidity in his or her blood rise. At the same time, the liver may swell and develop fatty deposits. Swelling may also occur in the brain, which can cause seizures, convulsions or loss of consciousness. The signs and symptoms of Reye's syndrome typically appear about three to five days after the onset of a viral infection, such as the flu (influenza) or chickenpox, or an upper respiratory infection, such as a cold. But symptoms such as confusion, seizures and loss of consciousness require emergency treatment. Early diagnosis and treatment of Reye's syndrome can save a child's life. Therefore, use caution when giving aspirin to children or teenagers. Though in some countries, aspirin is approved for use in children younger than age 12, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin and medications that contain aspirin. However, there's an exception to the aspirin rule. Children and teenagers who have certain chronic diseases, such as Kawasaki disease, may need long-term treatment with drugs that contain aspirin. For the treatment of fever or pain, it should be considered giving your child infants' or children's over-the-counter fever and pain medications such as paracetamol or NSAIDs like ibuprofen and naproxen as a safer alternative to aspirin.
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The use of chloramphenicol and Gray baby syndrome Chloramphenicol is a bacteriostatic man-made antibiotic that was discovered in 1947. Only twelve years after its discovery, the first case report of a potentially fatal adverse reaction to chloramphenicol was identified in newborns. It was noticed that, when the chloramphenicol was given to neonates born at less than 37 weeks gestation in an intravenous or oral formulation, they began to develop abdominal distention, vomiting, hypothermia, cyanosis, and cardiovascular instability. Vasomotor collapse resulting in mottling of skin and eventual ashen-gray skin discoloration led to the naming of this reaction as "gray-baby syndrome." Gray-baby syndrome usually begins between 2 to 9 days after chloramphenicol was administered oraly or intravenously and the presentation of the syndrome usually varies depending on the level of toxicity from chloramphenicol. High levels of chloramphenicol in the plasma result from two different pathophysiologic processes. A normally functioning liver will metabolize the chloramphenicol molecule (primarily by glucuronidation), but the problem occurs in immature neonatal liver. Due to its immaturity, neonatal liver is unable to synthesize and recycle the UDPglucuronyltransferase enzyme efficiently. Similarly, the neonatal kidneys are unable to excrete chloramphenicol and its metabolites efficiently. These two deficiencies result in increased serum levels of chloramphenicol. Such serum levels of chloramphenicol can impair electron transport within the mitochondrial and consequently cellular respiration, leading to direct cellular toxicity. It is known that chloramphenicol molecule removes unconjugated bilirubin from albumin, which can lead to kernicterus and later to death if it is left untreated.
Preventive measures and the treatment Instead of using chloramphenicol to treat bacterial infections in neonates, it is recommended an empiric administration of wide-spectrum antibiotics such as vancomycin, ampicillin, and a third-generation cephalosporin such as ceftriaxone or cefotaxime. In case it is a life-threatening situation, patients should be hemodynamically stabilized, appropriately oxygenated, ventilated and aggressive rewarming should be considered. Some of the modalities that have been used for the treatment of gray-baby syndrome are primarily aimed towards direct removal of the chloramphenicol molecule. This has been achieved through charcoal hemoperfusion and exchange transfusion. There have also been reports of phenobarbital being used for induction of the UDP-
glucuronyltransferase enzyme, to decrease the time that is necessary to metabolize chloramphenicol. Additional consideration should also be given to empiric prostaglandin administration in gray/cyanotic neonates in order to dilate blood vessels and to treat symptoms like hypothermia and cyanosis. In summary, Gray baby syndrome is a preventable problem. With the number of antibiotics available today, there should be no valid reason to use this agent for the management of infection in babies. As the pharmacist, you should fully question the prescription of this antibiotic for neonates and infants and recommend mentioned alternatives that will not cause this life-threatening effect.
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All the other drugs that can cause serious adverse effects in children Some other drugs worth mentioning that can cause side effects during their pediatric use are: Dopamine antagonists like chlorpromazine, haloperidol and metoclopramide. It is known that they can cause severe adverse effects such as acute dystonia, increased risk of respiratory depression, extravasation and even death if they used intravenously. Therefore, it is recommended that they should be avoided in infants, but used with caution in children. Topical corticosteroids that are categorized with medium, high and very high potency, because of their higher rate of systemic absorption in children than adults, can easily cause adrenal suppression. It is important to mention that, even though hydrocortisone is one of the least potent topical corticosteroids, experts advise that skin creams with hydrocortisone should not be used in children under 10 years old unless their doctor recommends it. The reason is because it is noticed that in rare cases, using hydrocortisone skin cream for a long time can slow down the normal growth of children and teenagers. Macrolides like Azithromycin and Erythromycin can cause hypertrophic pyloric stenosis and they should be avoided in neonates unless treating Bortadella pertussis with azithromycin or Chlamydia trachomatis pneumonia with azithromycin or erythromycin. Tetracyclines are widely known for their tooth discoloration, enamel hypoplasia, retardation of skeletal development and bone growth in premature neonates. Other antibiotics, with which caution should be exercised in children are Sulfadiazine -side effect kernicterus and neomycin – increased absorption and therefore higher chances of causing side effects. The pediatric use of tricyclic antidepressants such as imipramine, desipramine was related with sudden cardiac death. When it comes to antiepileptics, most importantly is to mention Valproic acid and its derivatives. For them, it has been proven that have many adverse effects, but in pediatric use the most serious are pancreatitis and fatal hepatotoxicity. It is recommended to avoid them in infants and in younger than 6 years to use them only if necessary, but with great caution.
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Anesthetics like benzocaine and propofol. Benzocaine can cause methemoglobinemia and should be avoided in infants for teething or pharyngitis. On the other side, propofol-related infusion syndrome can occur in higher rate in children than adults because higher relative doses of propofol are needed, especially in status epilepticus. Therefore, doses higher than 4 mg/kg/h should not be exceeded when propofol is used for more than 48h. As far as opioids are concerned, it is important to point out that in infants with diarrhea, loperamid should not be used because of its potential to cause fatal episodes of paralytic ileus. Naloxone is related to seizures and should be used in neonates for postpartum resuscitation. Terpenes extracted from plants, like camphor and levomenthol, can also be dangerous for infants. Camphor is generally used as a mild pain reliever, but it is known to be toxic and must be avoided in young children. Menthol provides a cooling sensation when applied to the skin, but it can cause laryngospasm. Some studies suggest that other terpenes, given to children with colds, may provoke a convulsive effect. For those who want to learn more: If you want to find out what excipients should be avoided in children’s medicines: • https://www.medicinesforchildren.org.uk/sites/default/files/files/Excipients%20i n%20medicines.pdf • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7134587/
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Mental health disorders in children Worldwide between 10 and 20% of children and adolescents experience mental disorders. Half of all mental illnesses begin by the age of 14 and almost three-quarters by mid-20s. Neuropsychiatric conditions are the leading cause of disability in young people in all regions. If untreated, these conditions severely influence children’s development, their educational attainments and their potential to live fulfilling and productive lives. Children with mental disorders face major challenges with stigma, isolation and discrimination.
What mental health disorders commonly occur in children? Mental health disorders in children or developmental disorders may include the following: • Anxiety disorders in children are persistent fears, worries or anxiety that disrupts their ability to participate in play, school or typical age-appropriate social situations. Diagnoses include social anxiety, generalized anxiety and obsessive-compulsive disorders. • Attention-deficit/hyperactivity disorder (ADHD). Compared with most children of the same age, children with ADHD have difficulty with attention, impulsive behaviors, hyperactivity or some combination of these problems. In general, many more boys than girls are affected, but the causes of ADHD aren't fully understood. • Autism spectrum disorder (ASD) is a neurological condition that appears in early childhood — usually before age 3. Although the severity of ASD varies, a child with this disorder has difficulties in communicating and interacting with others. • Eating disorders are defined as a preoccupation with an ideal body type, disordered thinking about weight and weight loss, and unsafe eating and dieting habits. Eating disorders such as anorexia nervosa, bulimia nervosa and bingeeating disorder can result in emotional and social dysfunction and lifethreatening physical complications. They usually start in the teenage years and are more common in girls than boys and they can have serious consequences for their physical health and development. • Depression and other mood disorders. Depression is persistent feelings of sadness and loss of interest that disrupt a child's ability to function in school and interact with others. Nowadays more children and young people are affected than in the last few decades, but it is still more common in adults. On the other side, bipolar disorder results in extreme mood swings between depression and extreme emotional or behavioral highs that may be unguarded, risky or unsafe. • Post-traumatic stress disorder (PTSD) is prolonged emotional distress, anxiety, distressing memories, nightmares and disruptive behaviors in response to violence, abuse, injury or other traumatic events. • Schizophrenia is a disorder in perceptions and thoughts that cause a person to lose touch with reality (psychosis). Most often appearing in the late teens through the 20s, schizophrenia results in hallucinations, delusions, and disordered thinking and behaviors. EPSA – European Pharmaceutical Students’ Association
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Self-harm nowadays becomes very common problem among young people. Some people find it helps them manage intense emotional pain if they harm themselves, through cutting or burning, for example. They may not wish to take their own life.
What are the warning signs of mental illness in children? The most common warning signs that a child may have in mental health disorder include: persistent sadness for two or more weeks, drastic changes in mood, behavior or personality, withdrawing from or avoiding social interactions, outbursts or extreme irritability, difficulty concentrating and changes in eating habits. Some of the serious symptoms for which help should be sought immediately are: hurting oneself or talking about hurting oneself, extreme loss of weight, chronic sleep difficulties and frequent headaches or stomachaches.
How is mental illness in children treated? Common treatment options for children who have mental health conditions include: • Psychotherapy, also known as talk therapy or behavior therapy, is a way to address mental health concerns by talking with a psychologist or other mental health professional. With young children, psychotherapy may include play time or games, as well as talk about what happens while playing. During psychotherapy, children and adolescents learn how to talk about thoughts and feelings, how to respond to them, and how to learn new behaviors and coping skills. • Medication. Doctor or mental health professional may recommend a medication such as a stimulant, antidepressant, anti-anxiety medication, antipsychotic or mood stabilizer as part of the treatment plan.
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Barriers to treating childhood mental health disorders Sometimes it can be difficult to understand mental health disorders in children because normal childhood development is a process that involves many changes. Additionally, the symptoms of a disorder may differ depending on a child's age, and children may not be able to explain how they feel or why they are behaving a certain way. Concerns about the stigma associated with mental illness, the use of medications, and the cost or logistical challenges of treatment might also prevent parents from seeking care for a child who has a suspected mental illness.
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Drug abuse during pregnancy - consequences for the mental health of the child? Substance exposure in pregnancy represents a serious and increasing public health problem. Estimates of illicit drug use among pregnant women suggest that the annual prevalence of use is approximately 6%. Prevalence is higher among young pregnant women, around 18.3% among women age 15 to 17 and 3.4% among those from 26 to 44. Approximately 1.6% of pregnant women meet criteria for a drug use disorder. Prenatal substance exposure is a major risk factor and often can result in neurodevelopmental disorders in children. Some of the most commonly used substances that affect a child's mental health are: Alcohol is recognized as the most commonly used substance among pregnant women. Alcohol easily crosses the placenta and can affect the fetus through direct effects on fetal development and indirectly through pharmacological effects on the pregnant mother. It is a well-known teratogenic substance and exposure to alcohol during pregnancy may result in fetal alcohol spectrum disorders (FASD). FASD comprises a spectrum of conditions presenting with mild to severe neurodevelopmental consequences such as cognitive impairment and an increased risk of specific learning disabilities, attention-deficit/hyperactivity disorder (ADHD), and anxiety and mood disorders. Prenatal alcohol exposure can also be linked to poor physical growth, lower intelligence and academic underachievement. Maternal opioid and polydrug use, including opioid maintenance treatment in pregnancy, has been related to a range of adverse outcomes, such as an increased risk of preterm birth, visual impairments, reduced fine motor skills, poor school performance and lower cognitive abilities, as well as disorders in attention, memory, executive function, impulse control and hyperactive behavior. Cocaine use during pregnancy can impact on child health and behavior in numerous ways. By blocking the presynaptic reuptake of neurotransmitters, cocaine has a potential to directly and permanently damage the developing central nervous system of the fetus, resulting in later behavioral and learning disabilities. Studies have shown that there are long-term consequences of prenatal cocaine exposure. This exposure has been associated with lower intelligence, and impairments in attention, language, and executive functions, as well as emotional and behavioral problems. Children were thought to be emotionally disrupted, cognitively impaired, less likely to socially interact, and more likely to die from sudden infant death syndrome (SIDS). Thus, the term “crack-baby” was introduced to describe children exposed to cocaine prenatally. Amphetamine and methamphetamine are also psychostimulants. Because amphetamine and methamphetamine use during pregnancy has become prolific only recently, there are few studies defining its long-term consequences. So far, it is known that children exposed to methamphetamine or amphetamine during prenatal development show decreased arousal, increased stress, decreased school achievements, movement disturbances and low birth weight (a high risk factor for special needs programs at school age). Also, several neurocognitive testings have showed that these children score lower on sustained attention, long-term spatial and verbal memory, and visual motor integration. EPSA – European Pharmaceutical Students’ Association
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The use of cannabis among pregnant women has become very frequent nowadays. The problem with marijuana is that when is ingested or smoked during pregnancy, exogenous cannabinoids enter the mother’s blood and cross easily through the placental barrier and appear in the child's bloodstream. Some studies have shown that children who were exposed to cannabis in the womb were slightly more likely to have adverse outcomes, which included: more psychotic-like experiences, more common problems with depression and anxiety, as well as ADHD, impulsivity, sleep disturbance and also lower cognitive performance. Therefore, it is advised to warn women about the risks of using cannabis during pregnancy in order to minimize the possible consequences, which as mentioned, mainly include affective disorders and ADHD. Maternal smoking during pregnancy is associated with many adverse effects in children. These effects can occur in physical domains like lowered birth weight and childhood asthma, or cognitive and behavioral domains such as lowered intelligence, increased hyperactivity and impulsivity. Exposure to tobacco/nicotine during pregnancy has been linked to later behavior problems like ADHD. Regarding their mechanism of action, it is currently assumed that numerous cigarette components can disrupt neurodevelopment by having effects on maturing neurotransmitter systems and brain architecture in regions associated with stress and mood regulation. A summary table with substances and their most important effects on the mental health of children:
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ADHD - Attention-deficit/hyperactivity disorder ADHD is a common neurodevelopmental disorder that typically appears in early childhood, usually before the age of seven. ADHD makes it difficult for children to inhibit their spontaneous responses— responses that can involve everything from movement to speech to attentiveness. In general, it can be difficult to distinguish between ADHD and normal “kid behavior.” If only a few signs are spotted, or the symptoms appear only in some situations, it’s probably not ADHD. On the other hand, if a child shows a number of ADHD signs and symptoms that are present across all situations—at home, at school, and at play—it is an indicator to take a closer look. ADHD can occur in people of any intellectual ability, although it's more common in people with learning difficulties. As ADHD is a developmental disorder, it's believed it cannot develop in adults without it first appearing during childhood. By the age of 25, an estimated 15% of people diagnosed with ADHD as children still have a full range of symptoms, and 65% still have some symptoms that affect their daily lives. The exact cause of ADHD is unknown, but the condition has been shown to run in families. Some factors suggested as potentially having a role in ADHD include: being born prematurely (before the 37th week of pregnancy), having a low birthweight or smoking or alcohol or drug abuse during pregnancy.
Myths and Facts about ADHD Myth: All kids with ADHD are hyperactive. Fact: Some children with ADHD are hyperactive, but many others with attention problems are not. Children with ADHD who are inattentive, but not overly active, may appear to be spacey and unmotivated. Myth: Kids with ADHD can never pay attention. Fact: Children with ADHD are often able to concentrate on activities they enjoy. But no matter how hard they try, they have trouble maintaining focus when the task at hand is boring or repetitive. Myth: Kids with ADHD could behave better if they wanted to. Fact: Children with ADHD may do their best to be good, but still be unable to sit still, stay quiet, or pay attention. They may appear disobedient, but that doesn’t mean they’re acting out on purpose. EPSA – European Pharmaceutical Students’ Association
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Symptoms of ADHD The symptoms of ADHD can be categorised into 2 types of behavioural problems: inattentiveness, and hyperactivity and impulsiveness. These symptoms can cause significant problems in a child's life, such as underachievement at school, poor social interaction with other children and adults, and problems with discipline. Most people with ADHD have problems that fall into both these categories, but this is not always the case. The main signs of inattentiveness are: • having a short attention span and being easily distracted; • appearing forgetful or losing things; • being unable to stick to tasks that are tedious or time-consuming; • appearing to be unable to listen to or carry out instructions. The main signs of hyperactivity and impulsiveness are: • being unable to sit still, especially in calm or quiet surroundings; • being unable to concentrate on tasks; • excessive physical movement and talking; • being unable to wait their turn.
Therapy Although there's no cure for ADHD, it can be managed with appropriate educational support, advice and support for parents and affected children, alongside medicine, if necessary. Medicine is often the first treatment offered to adults with ADHD, although psychological therapies such as cognitive behavioural therapy (CBT) may also help. Treatment for ADHD can help relieve the symptoms and make the condition much less of a problem in day-to-day life. Medicines that are used for the treatment of ADHD are: • methylphenidate, • dexamfetamine, • lisdexamfetamine, • atomoxetine, • guanfacine.
Methylphenidate By far the most commonly used medicine for ADHD. It belongs to a group of medicines called stimulants, which work by increasing activity in the brain, particularly in areas that play a part in controlling attention and behaviour. Common side effects of methylphenidate mostly include: increase in blood pressure and heart rate, weight loss or poor weight gain, trouble sleeping, stomach aches and mood swings.
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All in all, even it can be difficult at times, it's important to remember that a child with ADHD cannot help their behaviour. People with ADHD find it difficult to suppress impulses, which means they do not stop to consider a situation, or the consequences, before they act. Some interesting videos to watch related to this topic: • https://www.youtube.com/watch?v=kWOavIudlXc – How does it look like to have ADHD (first person view) • https://www.youtube.com/watch?v=-IO6zqIm88s – ADHD and non-ADHD child are giving answers on the same questions
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Autism spectrum disorder (ASD) Autism is a lifelong developmental disability which affects how people communicate and interact with the world. It is a spectrum condition and affects people in different ways. Like all people, autistic people have their own strengths and weaknesses. Autism is a spectrum. This means everybody with autism is different. Some autistic people need little or no support. Others may need help from a parent or carer every day. Autistic people usually have difficulties with interpreting both verbal and nonverbal language like gestures or tone of voice. Some autistic people are unable to speak or have limited speech while other autistic people have very good language skills but struggle to understand sarcasm or tone of voice. Being autistic does not mean that it is an illness or disease. It only means that brain works in a different way from other people.
Causes and signs Nobody knows what causes autism, or if it has a cause. For now, it is only certain that autism is not caused by: • bad parenting; • vaccines, such as the MMR vaccine; • diets; • an infection you can spread to other people.
Signs of autism in young children include: • • • • • • •
not responding to their name; avoiding eye contact; not smiling when you smile at them; getting very upset if they do not like a certain taste, smell or sound; repetitive movements; not talking as much as other children; repeating the same phrases.
Signs of autism in older children include: • • • • •
not seeming to understand what others are thinking or feeling; finding it hard to say how they feel; liking a strict daily routine and getting very upset if it changes; having a very keen interest in certain subjects or activities; finding it hard to make friends or preferring to be on their own.
ASD is often difficult because there is no medical test to diagnose the disorder. Doctors look at the child’s developmental history and behavior to make a diagnosis. ASD is rarely detected at 18 months or younger, but by age 2, a diagnosis by an experienced professional can be considered very reliable. However, many children do EPSA – European Pharmaceutical Students’ Association
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not receive a final diagnosis until much older. Sometimes it happens that some people are not diagnosed until they are adolescents or adults.
Therapy Although there is no known efficacious pharmacotherapy for core symptoms of ASD, psychotropic medications are commonly prescribed for behavioral/emotional symptoms associated with ASD. Common symptoms in children with autism that can be treated with drugs are: • high intensity hyperactivity; • poor attention; • impulsive behavior; • irritability, upset; • aggression, self-harm, anger attacks; • sleep problems, anxiety, depression, mood problems. Atypical antipsychotics, particularly risperidone and aripiprazole, are effective in reducing irritability, stereotypy and hyperactivity. Antiepileptic drugs and selective serotonin reuptake inhibitors have shown promising results, but there are no specific indications for them as of yet.
For some things it is known that they do not work and should be avoided because they could be harmful: • • • •
special diets ; bleaching – also called chlorine dioxide (CD) or Mineral Miracle Solution (MMS); medicines – including medicines to help with memory, change hormone levels or remove metal from the body (like chelation); hyperbaric oxygen therapy – treatment with oxygen in a pressurised chamber.
Some advice how to have a better communication with autistic people: • • • • •
keep language simple and clear; speak slowly and clearly; use simple gestures or pictures to support what you're saying; allow extra time for your child to understand what you have said; try not to say things that could have different meanings, such as "pull your socks up" or "break a leg".
Some interesting videos to watch: • https://www.youtube.com/watch?v=bQcWvYi5EqY - If you want to understand more about the ASD condition • https://www.youtube.com/watch?v=OtwOz1GVkDg – How does it look like to have Autism spectrum disorder (first person view)
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For those who want to read more about other mental disorders: -
Eating disorders: https://www.nhs.uk/conditions/eating-disorders/ Self harm: https://www.nhs.uk/conditions/self-harm/getting-help/
References: - Pharmacokinetics of children: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5155058/ 2. https://researchfeatures.com/drug-dosing-children-paediatric-pharmacology/ - Reyes syndrome: 1. https://www.mayoclinic.org/diseases-conditions/reyes-syndrome/symptomscauses/syc20377255#:~:text=Reye's%20(Reye)%20syndrome%20is%20a,commonly%2 0the%20flu%20or%20chickenpox.https://researchfeatures.com/drug-dosingchildren-paediatric-pharmacology/ 2. https://www.sciencedirect.com/science/article/pii/S0925443999000253 3. https://www.researchgate.net/profile/Leslie_Shaw/publication/21671084_Acut e_aspirin_overdose_Mechanisms_of_toxicity/links/5625150d08aed3d3f136fd c1/Acute-aspirin-overdose-Mechanisms-of-toxicity.pdf - The use of chloramphenicol and Gray baby syndrome: 1. https://www.ncbi.nlm.nih.gov/books/NBK448133/ 2. https://www.sciencedirect.com/topics/pharmacology-toxicology-andpharmaceutical-science/gray-baby-syndrome - All the other drugs that can cause serious adverse effects in children: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7134587/ 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6208605/#:~:text=Other%20co mmonly%20dispensed%20drugs%20that,neomycin%2Fpolymyxin%20B%20a nd%20lidocaine. - Mental health disorders in children: 1. https://www.who.int/mental_health/maternal-child/child_adolescent/en/ 2. https://www.mentalhealth.org.uk/a-to-z/c/children-and-young-people 3. https://www.mayoclinic.org/healthy-lifestyle/childrens-health/in-depth/mentalillness-in-children/art-20046577 - Drug abuse during pregnancy: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4068964/#:~:text=Estimates% 20of%20illicit%20drug%20use,that%20of%20non%2Dpregnant%20women.&t ext=Prevalence%20is%20highest%20among%20young,among%20those%20 26%E2%80%9344) 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4180095/ 3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862371/ 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027300/ 5. https://mjbizdaily.com/link-between-cannabis-and-mental-health-risks/ 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314755/#:~:text=Maternal%2 0smoking%20during%20pregnancy%20(MSDP)%20is%20associated%20with %20numerous%20adverse,problems%20%5B6%2D10%5D. - ADHD - Attention-deficit/hyperactivity disorder: 1. https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorderadhd/diagnosis/ 2. https://www.helpguide.org/articles/add-adhd/attention-deficit-disorder-adhd-inchildren.htm EPSA – European Pharmaceutical Students’ Association
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- Autism spectrum disorder: 1. https://www.cdc.gov/ncbddd/autism/screening.html#:~:text=Diagnosing%20au tism%20spectrum%20disorder%20(ASD,at%2018%20months%20or%20youn ger. 2. https://pubmed.ncbi.nlm.nih.gov/25602248/#:~:text=Purpose%20of%20review %3A%20Although%20there,emotional%20symptoms%20associated%20with %20ASD. 3. https://www.sciencedirect.com/science/article/abs/pii/S0387760412000927 Pictures: 1. https://www.crohnsandcolitis.org.uk/about-crohns-andcolitis/publications/taking-medicines 2. https://www.healthychildren.org/English/safety-prevention/athome/medication-safety/Pages/default.aspx 3. https://parenting.firstcry.com/articles/gray-baby-syndrome-causes-symptomstreatment-and-more/ 4. https://familydoctor.org/otc-cough-and-cold-medicines-and-my-child/ 5. https://www.additudemag.com/what-is-autism-spectrum-disorder-asd/ 6. https://www.samhealth.org/about-samaritan/news-search/2020/06/08/how-dodrugs-affect-babys-development-during-pregnancy 7. https://sites.reading.ac.uk/academictutors/event/adhd-effectively-supportingstudents/ 8. https://autismawarenesscentre.com/the-positives-of-autism/
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