ODD-CD medications

This drug was originally developed for treating blood pressure and it is very safe.  It turns out to be useful for a lot of things.  Tics, severe ADHD, detoxifying Heroin addicts, menopausal flushing, and sometimes autism with hyperactivity or severe aggression are the usual indications.  The good thing about this is that it never aggravates tics, works when autism is present, and works in very aggressive children and adolescents who never sleep.  It is safe for pre-schoolers and comes in a pill called dixarit that is sweet tasting and looks exactly like smarties.  As a result, children and adolescents will easily take it.  It also comes in a larger size.  It is my first choice when tics are present.  It is also used in autism, preschoolers, and very aggressive children and adolescents with ADHD and insomnia.

About one out of every 10 to 20 people who take this will become depressed.  It comes on within about 3-4 days and after the drug is stopped, it can take 3-4 days to clear.  However, if you are not watching for this, you might think the child is depressed for another reason, and never stop the drug, thus leaving the child depressed.  With careful monitoring, you will always pick this up if it appears.

This drug also has an effect on the heart.  It can lower the pulse and blood pressure.  To be cautious, I check an EKG before I start the drug and once the child is on it.  I also check their blood pressure and pulse at every visit.

It will make some children sedated, but usually by cutting back the dose you can avoid this.

This drug was initially developed to be a safer drug for adult schizophrenia.  It was then found to be effective in children with schizophrenia and other psychoses.  Then it was found to be helpful in some children with Tic disorders.  Based on those findings it has been used in Conduct Disorder.  There are some promising studies that show that this drug can help some of the core conduct disorder symptoms.  When a group of hospitalized aggressive children with conduct disorder and borderline mental retardation were given an average of 2 mg of Risperidal a day about half of the children were a lot better and another quarter were somewhat better.  Violence against others, verbal abuse and property damage all significantly decreased.  Another recent study found that risperidone was very helpful to children with conduct disorder when compared to placebo. These drugs were very well tolerated.  These studies are probably the most exciting news for the medical treatment of CD in 20 years.

Risperidone comes in .25 mg, .5 mg, 1mg and 2mg sizes.  I usually start with .5 mg a day and slowly increase the dosage.  It does not take very long (a week or so usually) to see a change if there is going to be one.

This drug can also cause something called Neuroleptic Malignant Syndrome.  This is a rare reaction to antipsychotic medication where people are very ill and have a fever, stiffness, and they are not thinking clear.  It can be very serious and has even caused deaths.  But it is very rare.  With the older drugs, it was found in about 3-4 cases out of 1000.  With the newer drugs it is harder to say.  Risperidone is the most prescribed antipsychotic for children and adults in Canada.  In all the world's literature, there are 8 clear cases of Risperidone causing this syndrome in adults.  I am not aware of any cases in children or adolescents with the newer drugs, but there have been cases with the older drugs.  Since the 1960's, 77 cases in children with the older drugs have been published.  That would make it very, very, very rare, and rarer still with the newer drugs.  However, if a child is suddenly started showing these changes while taking these medications, it should be considered.

There are two other drugs in the same famiy as resperidone which are new.  One is Zyprexa (olanzepine).  It has some of the same side effects as Resperidone but has only been used in a small number of children.  The other is Seroquel, (quetiapine).  This has also been tried on only a few children with conduct disorder.  However, it is quite likely that these drugs will also be found to be helpful in CD.

It has been known for sometime that children and adults with brain damage can have severe temper problems.  The drugs Tegretol (Carbamazepine) and Epival (Depakane in the USA, Valproate) have successfully been used to treat the temper problems in people with brain damage.  These drugs are usually used for seizures and bipolar disorder.  Recently, there have been some studies of these drugs in children and adults with severe problems with aggression and temper who do no have any brain damage.  Most of these are in adults and show some of the same difficult personality characteristics that children with ODD show.  Although there is not a lot of data, so far it does look promising.

While both Epival and Tegretol are safe to use in children, they are not without side effects.

Nuisance side effects Occasionally this drug will cause nausea, vomiting, or diarrhea.  It can be sedating in some people. It can affect balance.

Ovaries - In certain cases, this drug can make cysts on the ovaries and make a woman produce more male hormones.  This can change the hair pattern on the woman and also make her less fertile and cause troubles with her period.  The big question is how often does this happen and is it reversible upon stopping the drug?  There is not a good answer to either of these questions at this point.  One group of researchers found that 80% of women under age 20 who were put on this drug developed this side effect.  However, all these women had epilepsy, which is also associated with changes like this in the ovaries.  So the big question is, was it the drug or the epilepsy?  At this point no one knows.

Weight gain - In women under age 20 with epilepsy, 82% gained a substantial amount of weight.  The same question comes up as before.  Is it the epilepsy or the drug?  In this case, it is more clear.  Probably it is the drug.

Liver - this drug can affect the liver in rare cases so the liver tests need to be checked regularly, like every four months or so.

Pregnancy - It can cause serious birth defects if it is taken during pregnancy.

The drug comes in 250mg and 500 mg pills called Epival.  You can start taking nearly the full dose right away.  The dose in milligrams is usually ten times the weight in pounds each day.  Blood levels are checked at regular intervals.

Tegretol - At the moment there is less data supporting the use of this drug.  There are side effects which are rare but can be serious plus other nuisance side effects.  It can affect the liver and the salts in your body.  It also can cause a very serious rash or decrease your blood count.  It sometimes gives people an upset stomach and can make people tired or off balance.