Drugs treat disorders not behaviours and even Right drugs do not fix the wrong environment - Dr. Shujat Ali Naqvi

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Workshop on Paediatric Psychopharmacology at SIMS

Drugs treat disorders not behaviours and even
Right drugs do not fix the wrong
environment - Dr. Shujat Ali Naqvi

Talk to the children alone, they won’t give history of
domestic violence, abuse in the presence of parents

Psychotropic’s use in children has increased in the last
two decades but there are concerns about diagnosis

LAHORE: Drugs treat disorders but not behaviours. Even the use of right drugs will not fix the wrong environment. One has to talk to the children alone as they may not give the history of domestic violence, sexual abuse in the presence of their parents. During the last two decades, the use of psychotropic drugs has increased in children however; there are concerns about diagnosis which has lead to barriers. This was stated by Dr.Shujat Ali Naqvi, Consultant Child and Adolescent Psychiatrist from United States. He was speaking at a workshop on Paediatric Psychopharmacology in the new Millennium at Dept. of Psychiatry, Services Institute of Medical Sciences on November 4th 2013.This workshop was a part of the four days Asia Pacific Conference on Psychosocial Rehabilitation held here from November 1-4th 2013. The workshop was very well attended by faculty members of the department besides postgraduates and house officers. Dr.Nazish Imran, Head of the Dept. of Child and Family Psychiatry at KEMU/Mayo Hospital was also present on this occasion.

Dr. Shujat Ali Naqvi

Speaking about the model care of child and adolescents, Dr. Shujat Ali Naqvi mentioned about biological, psychological, social, educational as well as spiritual interventions in detail. As regards best practice principles, Dr.Shujat Ali Naqvi said that one must develop treatment and monitoring plans, do complete psychiatric evaluation, document consent of the patient. Manage the patient irrespective of the fact whether the response is as expected or not. Follow principles of discontinuation of medications. Spend little time alone with the patient while taking history. Assessment, development of treatment plan and psycho education was all extremely important in managing these patients, he added.
Continuing Dr. Naqvi said that do not miss learning disabilities. Start with low dose and then gradually build up the dose. Never crack a walnut with a heavy hammer. Do not start with two or three drugs except in special cases of psychosis and mania as it is unethical. There is a need for justification for using two to three drugs. Always start with one drug except in special situations. He then referred to the laws of paediatric psychopharmacology in detail. Autism, he pointed out, will never be cured .Sit with the mother and talk to them and tell them there is no drug for autism. Older drugs still work better and one should not opt for newer psychotropics without any justification. Ensure to stabilize the patient and then consolidate your gains which should be followed by growth and development. Learning is verbal as well non-verbal. When mouth is silent, eyes talk. Child psychiatry, Dr. Naqvi remarked is very complex. In case of disruptive behaviour disorders, first start with non-stimulants. In case of ADHD monitor symptoms with rating scales from teachers and parents. Call the patient for office visit once a month in follow up. Never use atypical antipsychotics alone for treatment of ADHD. Titrate in one to three weeks as needed. Remember ADHD cannot be diagnosed on parental report alone. One needs at least two to three sittings to diagnose ADHD. Stimulants may be used in pre-school children but dosage should be conservative. Clonidine is a good drug for adolescents, short release drugs work much better.
Speaking about ADHD and co-morbidities, Dr. Shujat Naqvi mentioned about bipolar disorders, TICS/Tourettes, Anxiety/Obsessive Compulsive Disorders and substance abuse. Make sure to use the appropriate drugs which are not only safe but effective as well. There are certain guidelines for use of stimulants. One must obtain the baseline blood pressure, height and weight. Take personal and family cardiac history, monitor vital signs. He suggested multimodal treatment approach consisting of psychotherapy, pharmacology, psychosocial interventions for treating anxiety disorders. SSRIs are the first choice of drugs. Be cautious in use of benzodiazepines. Tricyclics work very well. Sertaline or CBZ alone are also effective though SSRIS remains the first line of treatment. There is about 70% relapse in OCD. Fluoxetine, Fluvoxamine, Sertaline, Clomipramine are all effective. Dr.Naqvi cautioned about the use of grey fruit over psychotropic’s though one can take Kino and orange.
As regards treatment of Post Traumatic Stress Disorders (PTSD) trauma focused CBT, Dr. Naqvi said is the first line of treatment. Never use mental retardation which has now been replaced with intellectual disability. He then talked about the rational of psychopharmacology in detail. Pregabalin in divided doses is good for older children as it gives good effects. In case of explosive, un-provoked aggression in children, look for underlying neurological disorders, suspect paroxysmal etiology and try an anti-epileptic drug indicated for focal seizures. It works very well in children. Children and adolescents rapidly gaining weight on medications like olanzapine, add metformin as an anorexic. For mania prophylaxis in bipolar disorders use lamotrigine. Do not use amphetamine for treating hyperactivity in children with autism. Do not use two or more drugs with same mechanism of action, Dr. Shujat Ali Naqvi concluded.
This was an excellent presentation on the subject with lot of useful information on which drugs to use and which not to be used in various disorders in children and adolescents and Dr.Naqwi made it much more interesting by making it interactive, asking questions from the participants and encouraging them to participate in the deliberations.
Earlier Dr. Nasar Sayeed Khan, Head of the Dept.of Psychiatry at SIMS who was also Chairman of the organizing committee of the congress in his introductory remarks welcomed the participants and also introduced the guest speaker Dr.Shujat Ali Naqvi and Dr.Nazish Imran.He urged the participants to make best use of the presence of these experts which will not only improve their knowledge but eventually improve the patient care as well.

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