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Medication for ODD

By James D. Sutton

First of all, I must emphasize that I am a psychologist, not a physician. I do not prescribe. During 30 years of working with youngsters referred for emotional and behavioral conditions, however, I have had exposure to the medical aspects of the management and treatment of this population.

We'll skip the history of the use of pharmaceutical products with emotionally and behaviorally affected youngsters. Suffice it to say, there still is no medication that is prescribed exclusively for the treatment of Oppositional Defiant Disorder and all of its symptoms. What is interesting, however, is the broader application of a group of medications called the "atypical antipsychotics." (Brand names of this group include Risperdal, Clozaril, Abilify and Seroquel.)

Let's go straight to the top. Joe Biederman, M.D.*, a leading pediatric psychopharmacologist working out of Massachusetts General Hospital and Harvard Medical School, states that he prefers the effectiveness of the atypicals in the treatment of pediatric mania (such as bipolar conditions) over the mood stabilizers (which include Depakote and the lithium-based medications).

Although Oppositional Defiant Disorder is a different condition from the bipolar disorders of childhood, they can share some of the same symptoms, like irritability, agitation, defiance, anxiety, depression and episodes of anger and rage. The atypicals can treat these symptoms.

It is my understanding that atypical antipsychotic medications are easier to administer to a child or adolescent, and they hardly ever require that blood be drawn. (This is a huge advantage it itself. Can you imagine trying to get blood from a youngster that is already deficient?)

Side effects of the atypicals include weight gain, which is a greater risk in children than adults and seems to be more of a concern the younger the child. Drowsiness and sleepiness may accompany the start-up phase of treatment, and some of the atypicals pose a higher risk of elevating plasma prolactin levels -- to the point of even causing pubescent girls to lactate, produce milk in their breasts. (This occurred with two patients of mine who were in residential treatment. It was a huge issue. I've never attended to this side effect in boys, but I've been told it can occur.)

Apparently not all atypicals are the same. In a 9-11-03 lecture to healthcare professionals, Dr. Benigno Fernandez, Executive Medical Director for Laurel Ridge Treatment Center in San Antonio, Texas, shared that he prefers the use of quetiapine (brand name Seroquel) because of its effectiveness and tolerability in youngsters in treatment. Quetiapine does not produce sustained elevation in plasma prolactin levels, and weight gain, where noted at all, has been marginal. Dr. Fernandez shared research and findings of others that supported his position. At a later time, I heard another pediatric psychiatrist, Dr. Thomas Matthews, suggest that even drowsiness as a side effect can be a good thing. The medication can be given at bedtime, enabling better sleep for the youngster.

Dr. Fernandez also shared that it is important for physicians to explain carefully to patients and their families that quetiapine is an antipsychotic medication -- that it is being prescribed for its other benefits.

As with most pharmaceuticals on the market, the product testing of atypical antipsychotic medications that led to their approval for sale and use was based on studies done with adults, not children. For this reason, the use of the atypical antipsychotic medications in children is called "off-label" use. It is important to keep this in mind. Long-term studies on their use in pediatrics are essentially nonexistent at this time.

About the Author
James D. Sutton, EdD, Consulting Psychologist
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