Medication and Diet 323that there are no pre-existing arrhythmias or cardiac conduction problems.
Further ECGs should be obtained as the dose is progressively increased, to
monitor for the warning signs of prolonged P-R and Q-T intervals.
Selective serotonin reuptake inhibitors (SSRIs)
These are of proven value in the treatment of obsessive-compulsive dis-
order in children and adolescents (see Chapter 14). Fluoxetine is the only
antidepressant approved by the US Food and Drug Administration (FDA)
for the treatment of depression in children and adolescents, reflecting trial
evidence that is stronger for fluoxetine than other SSRIs. The superiority
of fluoxetine over placebo is clearest for severe depression – the benefits
are less certain for mild and moderate depression. It is currently uncertain
whether fluoxetine has a greater effect when combined with cognitive-
behavioural therapy (see Chapter 10). There are concerns that SSRIs
increase the risk of self-harm or suicide. In the light of reported levels
of adverse effects with different SSRIs, the British Government guidelines
do not support the use of SSRIs other than fluoxetine for depressed
children or adolescents (see Chapter 10). There is limited evidence that
SSRIs may be helpful for some anxiety disorders and selective mutism
(see Chapters 9 and 16). Common side effects include nausea, vomiting,
agitation, insomnia and headaches.
Monoamine oxidase inhibitors (MAOIs)
The availability of a selective and reversible MAOI, moclobemide, has
made this class of drugs easier and safer to prescribe, since adverse
interactions with a normal diet are now very unlikely. Nonetheless, the
use of MAOIs for ADHD, social phobia and resistant depression should be
regarded as experimental approaches for specialist centres only.
Neuroleptics (antipsychotics)
These are particularly useful in the treatment of children and adolescents
with psychotic disorders, tic disorders and mania (see Chapters 11, 15
and 23). They may sometimes be useful for children and adolescents with
autistic spectrum disorders or an intellectual disability (see Chapters 4
and 28). There is limited evidence that low doses of neuroleptics (particu-
larly atypical neuroleptics) can add to the benefits of stimulant treatment
for ADHD. Given the uncertainty and the risk of side effects, this combina-
tion should probably only be tried by specialist clinics. Neuroleptics are not
appropriate long-term treatments for the aggressive behaviour of children
with an intellectual disability (see Chapter 28).
Neuroleptics should always be used with considerable caution because
of their potentially serious side effects. Sedation can interfere with learn-
ing. In the first few weeks of treatment, neuroleptics commonly cause
extrapyramidal side effects such as acute dystonic reactions or Parkinson-
ism – a risk that is lower with atypical neuroleptics. When using typical
neuroleptics, such as haloperidol, there is a case for giving antimuscarinic