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Risperdol and the treatment of ODD...

Hello Mark, What do you know about Risperdol and the treatment of ODD?

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In choosing drugs for ODD, look for drugs that have been proven safe in children, have no long term side effects, and have been found in research studies to be effective in extremely aggressive children and adolescents or in Comorbid conditions which children with CD often have. Each drug has certain problems that need to be watched for. The current medical literature suggests three basic principles when using psychiatric drugs in children:

1. Start low
2. Go slow, and
3. Monitor carefully

Start low means that you do not start any of these drugs at the usual dose, or the maximum dose. When you have pneumonia, it can be a real emergency. You want to give people plenty of medicine right away, and if there are problems, then you reduce it. Unfortunately, many people use this same strategy in the medical treatment of ODD. The problem is that big doses can cause big problems, and when the problems affect your mind and personality, this usually means trouble for the person taking the medicines. So start with the lowest dose possible. For example, if you use a drug called Clonidine, for a boy about 60 lb., know that the dose that will probably work for most boys that size is two pills a day. If you gave him that to start out with, you might win and it would work. But if he happens to be sensitive to that drug, he could have big problems. Although they would be reversible problems, it would probably make most children and adolescents and or parents never want to take the drug again. So what do you do? Start with a half of a pill a day, about 25% of the usual dose. That way if the child is sensitive to the drug, it causes little problems. Many children respond to drugs at very low doses, far below the usual recommendations.

Re: go slow. ODD is not an acute illness. Less than 10% of the people I see with this need to be treated very quickly. Most people whom I see with this problem have had it for years. As a result, there is no need to increase the dose quickly. By going slowly, it is a lot easier to manage any side effects because things don't happen suddenly. Also, it is easier to find the lowest effective dose.

Re: monitor. For each of the medical treatments for ODD, there are specific side effects, which need to be checked regularly. Some common ones are monitoring weight so that people are gaining weight, watch for tics, watch for depression, checking blood pressure and pulse, checking blood tests and EKGs, and making sure parents know what the side effects are of the different medications. In this way, if there is a problem, you can pick it up early and avoid the horror stories, some of which are true, about the medical treatment of this problem.

The following are drugs which have been tested in adults and children who are violent and aggressive for a variety of reasons – from ADHD to brain damage, to Conduct Disorder, and of course ODD:

Atypical Antipsychotics—These drugs were first used for schizophrenia, and that is how they got this name. They are now commonly used for many conditions where people are not psychotic. As you can see, these are not benign medications. All of them can have serious side effects. As a result, they are not used for small problems.

Risperidone (Risperidal)—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 and aggression. These studies are probably the most exciting news for the medical treatment of CD in 20 years. Risperidone is called Risperidal and comes in a variety of sizes; .25mg, .5 mg, 1mg, 2mg and liquid. It also helps Tourettes and psychosis. Usually this is given twice a day. This drug usually shows an effect within hours of a dose. There are more studies done on this drug than all the other atypical antipsychotics combined.

Olanzapine (Zyprexa)—This drug was recently approved for mania in adults. It has been studied less in children. However the early reports are positive. The usual dose is about 5-15 mg a day. It comes in 2.5 mg, 5mg and 10 mg. It is also called Zyprexa. It is more expensive than Risperidone and in adults is associated with more weight gain. This can be given once a day.

Quetiapine (Seroquel)—This drug is a little different than the above drugs as it seems to cause very little problems with things like tremor and stiffness. In adolescents it can lower the blood pressure so the dose has to be increased slower. The dosage range is 200-800 mg a day. There are only a few articles on its use in children and adolescents, but these have been quite positive for mood disorders. I do not know of any study on using in CD. It comes in a 25mg and 100 mg size and has to be given twice a day. It is called Seroquel.

Mark Hutten, M.A.

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