OBSTACLES, DIFFICULTIES AND PRACTICAL PRINCIPLESOF OPTIMAL PSYCHOACTIVE THERAPY IN CHILDRENAND ADOLESCENTS

ABSTRACT:

1. The optimal use of psychoactive substances in children and adolescents is facing obstacles. They bear the stamp of: biological,psychological and social peculiarities of the suff ering individuals, of their age, of the respective disorder, and of the psychoactivepreparation.
2. Instead of decreasing, the obstacles in front of new optimal medicament solutions for the psychic disorders in children andadolescents become more diverse.
3. The diversification process of obstacles in front of optimal medicament solutions for psychic disorders in children and adolescentsis caused by:
   — a vertiginous rise in number of psychoactive substances;
   — a development of knowledge in psychopharmacology;
   — the need to harmonize the therapeutic options with the ones of the multidisciplinary team, including theones of the patients and of their carers;
   — the requirements of modern medicine to ensure not only the disappearance of the symptoms but also thepatients’ amelioration of their life quality and their optimal inclusion in the community.
4. The optimal solution in the chemotherapy of psychic disorder implies the deliberate assumption of a risk.
5. In order to diminish this risk, the paedopsychiatrist is bound to obey a series of rules, and in order to eliminate his responsibilityhe must assume this risk together with the patients and their carers.

Today psychiatry treats neither aff ections nor syndromes and even lessdiagnoses covered by codes but neurobiological dysfunctions.

1. GENERAL CONSIDERATIONS

a. First of all, it must be pointed out that only inexceptional situations do we have an aetiological treatment;for more that 50 years, we have been witnessinga very active change from a symptomatic perspectiveon the psychic disorders to a more and more pathogenicallydocumented one, and this means signifi cantprogress. Of course this fact requires:

• identifi cation of primary psychic disorders,
• knowledge of their neuro-biological basis and
• existence and access to the means capable tocorrect them.

b. Secondly, it must be mentioned that most of theaspects of chemotherapy used in psychic disorders inchildren and adolescents do not diff er from the sametherapy in adults. The former is more particular due toa number of reasons as follows:

—a more active metabolism in child and adolescent,a shorter halving time and thus, generallyspeaking, a better tolerance on kg/organism/day, atleast for the short term;

—existence of a growing and biologic, psychologicaland social development process which, at leasttheoretically and on the long term, raises the problemof the impact of medication on this process; this is anobstacle that requires our attention because it is wellknown the fact that, in psychiatry, the medication isadministered over long periods of time;

—doubts, with which, from ethical considerations,we look upon testing the tolerance and efficiency of the new psychoactive molecules in childrenand adolescents and thus, the compulsion to use thesemolecules, when needed, only based on the data obtainedfrom adults.

—particular aspects connected with compliance;

—the reduced capacity of the child in generaland especially of the child with psychic disorders torecognise, express and accuse explicitly the secondaryundesirable phenomena induced by medication;

—the fact that the child and the adolescent are totally dependent on their social-familial system.

c. Thirdly, the Hippocratic imperative “primumnon nocere” has today a more rigorous content, onthe one hand there is the compulsion of not doingany harm, on the other hand it is important to improvethe patients’ life quality. But, it is well knownthe fact that the administration of the majority of thepsychoactive substances is accompanied by undesiredside-effects too, that are not only accidental but alsopredictable, which, if we do not want to shrug ourshoulders in front of sufferance, we have to accept.

d. Fourthly, today, the psychiatrist has got an everwider range of preparations, some of them beinghypothetically similar, of minute studies and of everricher knowledge off ered by the current neuro-psycho-pharmacology. We would be tempted to believethat we are closer to the moment when it would beenough to identify and aim at the neurobiologicalbasis of a symptom with “intelligent” chemical moleculesand everything will solve by itself. Unfortunately,the clinical practice demonstrates that we arefar from the implementation of standardised programmesor even of certain therapeutic guides meantto secure a risk-free choice for the patient. In fact, ifthe psychiatrist is responsible, it is not easy for her todecide over a conduit, even if she is more informedthan before. Actually, although more profound andprecise, the present data prove to be more and morecomplex, interdependent and often contradictory. Asa consequence, when choosing the optimal medication,the psychiatrist has to face many diffi culties anddilemmas imposed by: the complexity of the problem,the polymorphism of the neurobiological basis of thepsychic disorders, the still limited knowledge of numerousaspects, the contradictory character of someof the accessible data and the more and more rigorousconditions the psychotherapist is expected to obey.

More than that, there is ever growing access to information,which is often fragmented or, as Werry andAman (1999) state, subjective or lacking a scientifi cbasis. This information is off ered through a multitudeof channels, including the internet, and, on the oneside, it makes the benefi ciaries become more doubtfulor even inclined to incriminate the therapists incase of any inconvenience, on the other side it makesthe latter prefer to protect themselves taking refugein standard solutions lacking the positive valences ofindividualisations.

e. Fifthly, the psychiatrist must also take into considerationsthe fact that the experimental data cannotbe extrapolated automatically from adult to child andeven less from animal to human.

f. Finally, a sixth consideration refers to the factthat the psychiatrist today is more and more facingboth pressures which force him to decide for the bestsolutions from an ethical and economic point of view,and with the fact pointed out by Werry Scott andAman (1999 p. 13) according to which the interestsof the therapist and those of the medicine companiesare not necessarily convergent, and here we refer notonly to the ratio price/quality.

2. OBSTACLES AND DIFFICULTIESFACING OPTIMAL THERAPEUTICCONDUIT 

 In order to adopt an optimal therapeutic conduit,the psychiatrist has to face, first of all, the problemsraised by the interaction among three essential components,namely:

— the patients with their biological, psychologicaland social peculiarities,

— the particular psychic disorder,

— the potentially effi cient pharmacologicalpreparation.

Secondly, the psychiatrist must not forget that themedicaments validated only for adults, even if theyare proved to be very effi cient, can be used with childrenand adolescents only on his own responsibility.

Thirdly, today, the psychiatrist is confronted, onone side with the atheoretical and aetiological systematizationof the psychic disorders, and on the other,with the duty to obey therapeutic guides structuredon such a nosography.

Fourthly, the present day psychiatrist is part of amultidisciplinary team and he must harmonize hisoptions with the ones of the other team members, ina relationship with interdisciplinary character. A specialplace within this team is occupied by the patient’sparents or carers and their role as advised partners.

All these issues have the potential to generate obstacles,some of them difficult to remove because theyare marked by unknown elements, contradictions, incertitudeand subjectivity.

2.1. Obstacles and difficulties pertaining to thepatient and his biological, psychological and socialpeculiarities

 These are numerous and difficult because they arealso generated by still unknown and even unpredict 18 Journal of Romanian Child and Adolescent Neurology and Psychiatry – 2010 – 13th vol. – no. 4able factors. The well known geneticist F. Jacob usedto declare in 1970 (1972) that an individual’s neurobiologicalpattern is as unique as his fi ngerprints. Inthis way, every sick person’s tolerance and reactions totreatment are only probable because each particularpatient hides numerous psychological and biological enigmas.

For example, it is known that the intolerance tomedicaments is genetically determined and that, incertain subjects, they may have paradoxical effects. But,most of the times, the physician has got only anamnesisdata, and even these are approximate, to be allowed toanticipate with certitude both the patient’s toleranceand the patient’s response to treatment, while, in caseof emergencies, he lacks them altogether.

The age of the child, too implies a series of conditions,each psychoactive substance having its limitsand surpassing them can be done only at one’s ownresponsibility. More than that, to all the above issues,one must add the difficulties implied by compliance.They are sometimes amplifi ed because of the profi le ofthe psychic disorders – the absence of the critique ofthe disease, delirious convictions of prejudice, the unacceptablecharacter of the secondary effects, the incapacityto understand the reason of a long duration of thetreatment, etc. These are aspects that, in children andadolescents, acquire a distinctive character linked notonly to age but also to the need to involve the parentsor carers and transform them into advised partners.

If, in connection to their age, children and adolescentshave supplementary resistance to the treatment,which makes them refuse it or accept it formally, thenthrowing it out of the mouth in secret, the present daypatient’s parents or carers have more and more oftenpreconceived opinions based on anterior informationand supported by the medication guides. Theseguides, out of the natural need of the drug manufacturingfi rms to protect themselves, off er an exhaustivepresentation of the possible risks and thus induceresistances which are not easy to surpass. More thanthat and more diffi cult, too, is the situation where thepatient’s carers apply their own initiatives concerningdosage and administration of the drugs, without informingthe physician and even denying them.

2.2. Obstacles and difficulties pertaining to thetargeted psychic suffering

The targeted psychic suffering, the comorbid andassociated aff ections, be they psychic or somatic, eachwith its specifi city and subtleties, bring with themtheir own set of obstacles and difficulties. In what follows,we shall limit our consideration only to thoseaspects which pertain to the basic psychic disorder.Indisputably, for an optimal therapeutic conduit, thepsychiatrist needs a diagnosis as precise, complete,correct, detailed, and fast to establish as possible. Inreality, these challenges are not always easy to reach,thus, most of the time, at the moment of the therapeuticdecision, be it an emergency or not, the diagnosisis, and for a long time remains uncertain andeven unknown. The difficulties in front of a certaindiagnosis are often so great that modern psychiatry,with its component which we have called “administrative”(2009), almost gave up the idea of an authenticdiagnosis. Out of administrative considerations,the modern diagnosis and classifi cation systems ofthe psychic disorders (DSM-III -1980, DSM-III-R-1987, DSM IV-1994) have become too schematic tooformal and too general, a fact that alienates them fromthe therapist’s needs. Their atheoretical, aetiologicaland standardised character has transformed the diagnosisinto descriptive formulas and codes whichsynthetically nominate the association of a number ofsymptoms considered representative. More than that,the diagnosis represents only a minimum number ofrepresentative symptoms considered as being sufficient, and these symptoms are mentioned only incombinations varying from one case to another.

Let us give the example of the diagnosis of conduitdisorder which might be certified based on thepresence of three symptoms in a suite of 15, whichmeans that apart from the possibility of the presenceof other symptoms considered as representative andeven more by the presence of the representative ones,the same diagnosis covers 455 different clinical variants,a number that corresponds to the value of thecombination of 15 objects taken in threes. If we addthe fact that there are no exceptions in the situationsin which it is recommended that the diagnosis of certaintyshould be stated only after a certain time intervalhas passed (for example 6 months for schizophrenia,2 years for somatisation disorder, and so on), thenwe shall understand that there are not few situationsin which, at the moment of the therapeutic decision,the diagnosis is unsure and even unknown.

In this way, the modern diagnosis does not takeinto consideration:

— the symptomatic complex existing in realitywhich defi nes and individualises the patient;

— which of the symptoms considered as representativeare included in the combination and whichare not;

— wthe fact that they are not equal among themselves either as diagnostic value or as therapeutic target;

— wtheir intensity or severity;

— the fact that, in psychiatry, there is almost nopathognomonic symptom or groups of symptoms;

— wany causal arguments;

— in case of psychic disorders, the Hippocraticrequirement “there is no disease but only sick people”,cannot be ignored.

This fact deprives the psychiatrist’s thinking fromlandmarks indispensable for his choice of an optimalconduit and confers the therapeutic guides, focusedon diagnosis and not on the individual, an orientationrole with only an administrative value.

It is true that, from the therapeutic point of view,the psychoactive medication is not aimed at clearly defined clinical entities but especially the neurobiologicalsubstrate of certain target psychopathologic manifestations. However, not even at this level, doesthe modern psychiatric diagnosis offer any information.This fact means that, before establishing thetreatment, often in a very limited time interval andwith insufficient investigation means, the psychiatristis forced to:

— take into consideration all the present symptomatology;

— make a clear difference between the psychicdisorders proper and those that are an expression of certain somatic affections as well as those somatic affectionsthat are a consequence of psychic dysfunctions;

— delimitate primary psychic manifestationsfrom secondary ones;

— identify simulated and over simulated manifestationsas well as manifestations over invested bythe patients’ carers.;

— make pertinent assumptions about the neurobiologicalsubstrate of the psychic manifestations identified as primary because only their targeting assuresthe success of the therapy. He must identify allthe comorbid or associated psychic or somatic aff ectionsas well as the potential negative consequences ofthe medication on them, in a word, all the elementsthat particularize the patient and not only the minimalones which allow the framing in a diagnostic codewhich is aimed only at grouping the patients and notat individualizing them.

More than that, when he must choose a treatment,in spite of being freed from the burden of aetiologicaland theoretic controversies peculiar to the moderndiagnostic systems, the psychiatrist is still obliged toidentify the causes, the biologic and psychologicalmechanisms and the neurobiological substrate of thedisorders because only thus he may act effi caciously.

For example, the present diagnostic criteria formental anorexia may hide disorders such as the deliriousdisorders (dysmorphophobia delirium or poisoningdelirium), phobias and phobic obsessions, both ofthem linked to the physical appearance, a simple lossof weight after a diet or a somatic or endocrinal affection,the latter being invoked too often by thosewho see in amenorrhea the primary disorder. Also,in patients who refuse to communicate, whatever thereason, the refusal to eat, as a consequence of certaindelirious convictions that there is poison in their food,may easily be assimilated wiTheating negativism fromthe catatonic disorder, while the psychomotor inhibitionin the major depression or the neuroleptic impregnationsyndrome may also be taken for the samecatatonic disorder. Movement stereotypes in autismmay falsely suggest an ADHD comorbidity and theenumeration may continue.

Unfortunately, today, the individualisation of thetreatment, especially in children and adolescents, isalso obstructed by the therapeutic guides which, inorder to eliminate the risk of certain indictments ofmalpraxis, suggest the limitation to template schemes,which, in children, from ethical reasons, exclude mostof the new therapeutic solutions, even if these provedto be very effi cient in adults. This fact determines thepaedopsychiatrist to assume on own responsibility thedecision to turn to them. Thus, first of all, he risksthat his prescription might not be honoured by thetoo rigorous health care services and then that he maybe held liable for the eventual negative consequenceseven if in adults these consequences are considerednatural.

We must mention that today, it is known that variouspsychic disorders have are generated by certaindysfunctions of some molecular neurobiological structures,of neuromediators and/or of cerebral receptors.It is these dysfunctions and not the symptoms, syndromes,diagnoses or the codes that represent themthat are targeted by the psychoactive substances. Apparently,these data simplify and consolidate the therapeuticoption based on them. Only apparently, sinceit is still the actual data which reveal the fact that there is not a doubtless correlation between a particularclinic manifestation and the location or the typeof dysfunction identified on the basis of experimentalor clinical studies. This so because there is no psychicdisorder with an elementary character and neither isit the expression of a single cerebral morpho-functionalstructure.

Every time, the psychic functions and dysfunctionsare the expression of the interaction of manymorpho-functional mechanisms, of certain chainedcomplex processes, so that the same symptom mightbe the consequence of different types of dysfunctionsor of their associations. This fact depends on whichof the numerous links in the particular process chainthat lies at the basis is affected. Let us not forget thefact that, in the entire biology, following the existenceof certain interactive relationships, the functional excessor deficiency might be achieved by stimulating,respectively diminishing, the function of the structurewhich generates it, but also by the inhibiting or stimulatingthe system that controls it using feed-backmechanisms.

Maybe the most convincing example for the statementsabove is off ered by depression, a case in which,it has been spoken for a long time (Marinescu 1997and many others) about forms with a neurobiological,serotoninergic, domaninergic, adrenergic, cholinergic,endorphinic or norepinephrinic substrate. The fact has generated and stimulated the emergence ofantidepressants with selective action on each of thesedomains. However, sure clinical markers are absentwhich could allow the clinician to differentiate among them. It is the reason that deprives us bothhere and in front of almost all the psychopathologicalmanifestations of the certitude concerning the type ofneurobiological dysfunction which must be correctedby means of medicamental treatment.

2.3. Difficulties and obstacles that pertain to thepotentially efficient preparation

During the last 30 years the knowledge in the field of psychopharmacology has accumulated in an alertrhythm. Among other things we refer to:

— emergence of new classes of substances andof numerous psychoactive molecules and preparationswith reduced side-effects, that act mono- of bifocallyor in the long run, are more selective and are consideredmore or less similar;

— vertiginous development of knowledge inthe field of pharmacokinetics and pharmacodynamics.It allowed the doctors to know: the halving times;the data concerning biodisponibility; metabolism andexcretion mechanisms; medicament interactions; roleof the cytochrome P450 enzymes, of the numerouscerebral receptors; tropism of the psychoactive substancesfor certain structures of the brain, molecularsites, pre or post-synaptic and for different cerebralmediators and receptors and, very important, the actionand their specifi c effect at these levels;

— The emergence, besides the classic systematizationof the psychoactive substances accordingto the target symptoms (antidepressant, anxiolytic,antihallucinatory, anti delirium, antimanic, hypnotic,antiepileptic, etc.) of a new one based on mechanismsof action. The fi rst classifi cation became less valid(Kaplan şi Sadock -2001), with the evidence of thefact that, on the one side, the psychoactive substancesin one class have much more favourable effects (forexample, the use of antiepileptic drugs in the aff ectivepathology, of antidepressant drugs in psychosesand anxious disorders, etc.) and on the other side, thatsome of the medicaments used in somatic pathologyare also efficient in the treatment of different psychicaff ections. As such, the fi rst classifi cation system promotinga mainly symptomatic therapy (Werry andAman -1999) is double today by another, more rigorousone, with pathogenic potential because it is basedon knowledge in the fi eld of the pharmacokinetics ofpsychoactive substances. Th us, the systematizationof psychoactive substances based on affi nities and totheir specifi c action on different cerebral mediators orreceptors is more and more taken into consideration (Table 1).

Today it is known the fact that all the psychoactivesubstances act concomitantly and in various degreesover more cerebral sites mediators and receptors sothat for every one of them there are descriptions ofboth scales of the intensity of their actions and themultiple effects, some of them necessary sometimes,others always or sometimes unwanted. Th at is why westate that, in spite of the knowledge in the fi eld ofpsychopharmacology that accumulates in a rhythmtoo difficult to keep pace with, the obstacles in frontof an optimal therapeutic option instead of being reducedare amplifi ed in this direction, too.

Table 1. Classes of psychoactive substances according to affinities and to their specific action on different cerebral mediators or receptors

3. PRACTICAL PRINCIPLES OF OPTIMAL PSYCHOACTIVE THERAPY

The above mentioned statements underline the factthat today, in front of any therapeutic option, the paedopsychiatristis confronted with and is forced to accepta smaller or bigger risk coefficient. Of this situation, thefollowing instances must be made conscious: The Health Insurance Company, the instances implied in the assessmentof malpraxis and the whole community. This is more important because in children and adolescentsthere are frequent the situations when the paedopsychiatristis obliged to decide over therapeutic solutionsthat are not included in guides or in ruling documentsof the qualified institutions. In fact, while the therapeuticguides do not allow a series of new psychoactivepreparations to be administered to children, althoughthey are better in many aspects than the former onesbut they have been validated only for adults, their useis often required from paedopsychiatrist by his professionalconscience in case of failure of the already triedor existing solutions, and even by the fact that the data offered by the practice in adults offer the chance of abetter therapeutic solution. However, this solution requiresthe psychiatrist to engage his accountability.

What can be done in order to reduce the risks andthat the possible undesired consequences should notbe imputed to the psychiatrist:

3.1. First of all, the patient will be examined thoroughlywith the aim of obtaining as precise answersas possible to the problems mentioned at point 2.2above.

3.2. Secondly, as a general rule, especially in emergencies,that preparation will be preferred which:

a) statistically speaking is the most efficient for theindividualised primary disorders and which, in orderto avoid polypragmasia, covers by itself better, andmost of the peculiarities of the case. We take into considerationthe availability of, for example, preparationswith multifocal action in which, according to the case,the basic antipsychotic, anti-depressive or anxioliticaction is, on the one hand larger, covering more psycho-pathogenic mechanisms, and on the other hand,it is doubled by other effects: sedative, dynamogenous,antidepressive, anxiolitic, hypnotic, mio-relaxant, etc.¡V necessary according to the case.

b) has the smallest expected and unwanted secondaryeffects in general and especially for a particular patient,both immediate and in the long run. This is becauseit is no longer allowed to ignore the patient¡¦s lifequality, and not only during the remission has period,but also in that of state, even if this means higher immediatecosts. It is not only the recognition of the patient¡¦sright to a better quality existence. Reduced unwantedside effects equally means more rapid and better social,familial, school, professional reintegration, and theseare refl ected by more reduced collateral costs so that,fi nally, in the long run, the overall costs are smaller. For example, it is known that, as a rule, a psychotic episodetreated with classic (cheaper) medication means, becauseof the modest quality of the remissions aff ectedby the neuroleptic impregnation syndrome (trembling,psychic slowness, somnolence, ocular accommodationdisorders, etc) a failed school year, while today, with themodern medication, going back to school is possibleafter approximately 2-3 months. WE do not speak hereonly about the avoidance of an individual drama limitedto a patient who suffers, loses his skills is obliged torepeat the school year and to reconsider his self image.The community as a whole bears the supplementarycosts required by prolonged and repeated hospitalization,by repeating the school year or when one of itsmembers becomes an outsider. On the other hand, it isknown that often, the treatment of the psychic disorderslasts a long and sometimes a very long period oftime, implying the risk of certain tardy disorders. Thisis the reason why we should temper our haste in usingtoo new and insufficiently validated preparations.22 Journal of Romanian Child and Adolescent Neurology and Psychiatry – 2010 – 13th vol. – no. 4

Knowing the profile as well as the prompt and attentive assessment of the peculiarities of the secondarydisorders that appear after the administration ofthe psychoactive drugs give other advantages, too:

— the anticipated profile of the secondary effects may incline the balance of choice towards a certainpreparation if some of them are useful, as it has beenpointed out above, according to case and period.

— the absence or reduced spread of predictableunwanted secondary side-effects, may constitute theproof of a good choice;

— in their turn, as it has been pointed out before,their prompt or too intense occurrence testify the administrationof too big doses or an inadequate choice.According to the specific case, this fact imposes eitherthe diminution of the doses or the change of thepreparation with another one with a different profileconcerning the cerebral receptors and mediators onwhich it acts.

c) proved efficient before, too, either in that particularpatient or in the blood relatives if the doctorconsiders the suffering has a genetic origin.

d) has the most prompt and stable answer. It isknown that, not infrequently, the therapeutic effectmanifests itself after anticipated periods of time varyingbetween days and weeks. We have the convictionthat a shorter than expected latency period is proof ofa good choice and vice versa, a motive for which, wherethere are many possible solutions to choose from, wedo not plead for patience carried on until the maximumaccepted time limit. Of course, impatience is abad adviser, but it is preferred to choose the preparationwhose effect is felt not only faster, but also nearerand especially under the low limit of admitted latencyperiod instead of the one whose effect is waited fortoo much. This is so even if, out of professional pride,the doctor is slow in denying his previous option.

e) does not have a habit ¡Vinducing risk, especiallyif a long treatment is anticipated.

f ) has the longest halving time. One should prefera preparation that due to the long halving timeallows its administration in rarer doses, because inschool children especially, the lunch dose is difficult to control by the parents while the compensatory supplementof the morning dose aff ects the school performance.Nevertheless, if it is possible, we plead forthe avoidance of unique doses. In this way, we obtaina diminution of the daily doses, a uniform plasmaticconcentration and reduced unwanted predictable effects.¡X¡X¡X

g) do not interact negatively with other medicamentswhich, out of various reasons the patient isobliged to take.

h) do not infl uence negatively the contingent affectionswhich the patient suffers from.

i) do not have the toxic dose too near the therapeuticone and which have a specifi c antidote, accessiblein order to avoid the risks of an accidental overdoseor of accidental or voluntary ingestion in suicidalscope. For example, it is known that where lithiumsalts are concerned, although they are advantageousdue to their low costs, the toxic dose is relatively closeto the therapeutically active one and there is no specific antidote.

j) is registered and consequently attested not onlyinternationally, but also by the legislation of the country.Not only that, in the opposite situation, the healthinsurance companies cannot be obliged to compensatethe costs, but also it is the risk that in case ofunpredictable intolerance phenomena, the doctorscould be accused of malpraxis. We remind the factthat, some years before, the natural substitution of thediagnosis of child psychosis with the one of child autismblocked the covering of the costs of prescriptionswith neuroleptic preparations based on the reasonthat, in conformity with the laws in force, the latterare compensated only if prescribed in psychoses.

k) have the most convenient form of presentation.We consider injections for emergencies or uncomplicatedcases, those in form of solution which allow theeasy adjustment of doses and, if we refer to children,the pills or capsules should have a pleasant dimension,aspect and even taste, in order to be accepted bythem.

l) the most fi t for the evolution stage of the disease:in the beginning, in the acute phase, the maintenanceor the prevention of relapses. If in the acute periodof the disease, the unwanted secondary effects canbe more easily accepted, they are unacceptable duringthe other periods in the evolution of the diseasebecause they aff ect the quality of life and the family,school and socio-professional integration of thepatient thus working against the aim of the moderntreatment which cannot be limited only to the controlover the psychopathologic disorders.

m) is the most adequate to the age, sex or weightindex. This means that, for example, we must take intoconsideration: the enzymatic immaturity of the smallchild, the necessity to avoid the preparations that induceweight gain in adolescent girls preoccupied with their appearance or in over weight individuals, or, onthe contrary, accepting them in case of low appetite orunderweight individuals.

n) has a different chemical formula or has a profileof action over the receptors, different from the onewhich at a certain moment proved to lack effi ciencyor it is marked by secondary effects which infl uencethe quality of life negatively.

o) one knows better inclusively from the point ofview of thebiological mechanisms of action since it isonly so that one could make the correct choice andavoid the risk of attributing one¡¦s failures to the patientor to the disease.

p) last, but not least, is produced by a prestigiouscompany which confers the guarantee of the respectfor quality.

3.3. Thirdly, it is necessary that the psychiatristshould be conscious of the fact that no matter how judiciouslyhe might make his choice, he must remain prudentbecause his option might be contradicted, sometimes dramatically, by the clinical reality. This meansthat in every patient apart, the answer to any new psychoactivepreparation must be carefully assessed andsupervised at first. As a consequence, both in hospitaland ambulatory, the administration starts obligatorilywith a single preparation and in small, rapidly increasingdoses, with warning those in the entourage on theeventual negative consequences and the attentive appreciationof the tolerance and of the expected effect.

3.4. Fourthly, it is absolutely necessary that the patient¡¦scarers, the members of the therapeutic team, and,according to the case, the patient should be informedand receive the acceptance for the possible negativeconsequences and for the measures of fighting againstthem. Depending on the situation, but especially incase the psychiatrist is forced to adopt solutions outsidethe accepted standards, he is indebted to obtain a consensusfrom the patient¡¦s carers, eventually in writing.In this case, we must point out that such an obligationcomes only to the psychiatrist because we consider thatit is not recommendable that doctors of other specialtiesshould prescribe such preparations.

Of course, there are situations where we fi nd ourselvesin front of a patient whom we have knownbefore, or for whom we have got credible sources ofinformation concerning the anterior treatment inthe acute and remission period, the quality of its response,tolerance and compliance, and thus the issuesare much simplifi ed. In these cases, only further laboratorytests are needed and the identifi cation of thenew aspects of the clinical picture because it is knownthat there are not rare the situations when the symptomatologychanges in time and this is not only thecase with the bipolar disease. According to the context,one may decide to recommence the treatment, toincrease the doses, to associate new medication andeven to reconsider the therapeutic conduit.

However, there are also special situations where,out of various reasons, we lack data on the history ofthe case or the required medicaments are not at hand;the urgency of the intervention does not allow sufficient time to take a decision; or the somatic aff ectionsnarrow the palette of the therapeutic options.In such cases, the temporisation of the intervention isnecessary, and the following measures may be taken:the isolation of the patients in adequate spaces and,if needed, their immobilisation by means that do notimply any risks; the minute examination both psychicand, we must underline, somatic with the identification of the primary psychic disorders; choice ofa preparation that had been tested administratively,with multifocal action profile and recognised for itstolerance; administration with prudence; permanentsurveillance and instruction of the people in the entourageabout the assumed risks and their profile.

CONCLUSIONS

a) The optimal use of psychoactive substances withchildren and adolescents is confronted by obstacles.They bear the stamp of: biological, psychological andsocial peculiarities of the suffering individuals; oftheir age; of the respective disorder; of the psychoactivepreparation.

b) Instead of decreasing, the obstacles in front ofnew optimal medicament solutions for the psychicdisorders in children and adolescents become morediverse.

c) The diversifi cation process of obstacles in frontof optimal medicament solutions for psychic disordersin children and adolescents is caused by:

— a vertiginous rise in number of psychoactive substances;

— more profound knowledge in psychopharmacology;

— the need to harmonize the therapeutic options with the ones of the multidisciplinary team, includingthe ones of the patients and of their carers;

— the requirements of modern medicine to ensurenot only the disappearance of the symptoms but also the patients’ amelioration of their life quality andtheir optimal inclusion in the community.

d) The optimal solution in the chemotherapy ofpsychic disorder implies the deliberate assumption ofa risk.

e) In order to diminish this risk, the paedopsychiatristis bound to obey a series of rules, and in order toeliminate his responsibility he must assume this risktogether with the patients and their carers.

BIBLIOGRAPHY

1. DSM -III (1980) Diagnostic and Statistical Manual ofMental Disorders (Third Edition ) American PsychiatricAssociation
2. DSM -III -R (1987) Diagnostic and Statistical Manual ofMental Disorders (Th ird Edition Revised) American PsychiatricAssociation
3. DSM IV –TM (1994) Diagnostic and Statistical Manualof Mental Disorders (Fourth Edition) American PsychiatricAssociation
4. DSM- IV-TM -1994 (2000) Manual de Diagnostic şiStatistică Medicală a Tulburărilor Psihice (Ediţia a patra .Asociaţia Psihiatrilor Liberi din România.1.2.3.4.
5. DSM- IV-TR 2000, (2003) Manual de Diagnostic şiStatistică Medicală a Tulburărilor Psihice (Ediţia a patrarevizuită). Asociaţia Psihiatrilor Liberi din România.
6. Jacob F. (1972) Logica viului. Eseu despre ereditate. EdituraEnciclopedică Română
7. Kaplan B J,Sadock VA (2001) Pocket Handbook of PsychiatricDrug Treatment.
8. Lippicott Williams& Wilkins USA, Marinescu D (1997)Tratamentul modern al schizofreniei şi psihozelor afective.Colecţia Hipocrate
9. Milea Şt. (2009) Psihiatrie clinică şi/sau administrativă. Vol:Orientări şi perspective în gândirea psihiatrică româneascăactuală. Vol III Sub redacţia: G Cornuţiu, D. Marinescu.Pg: 78-98
10. Werry Scott J, Aman M G (1999) Practitioner s Guide toPsychoactive Drugs for Children and Adolescents Seconded. Plenum medical Book Company.