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|Publisher:||Guilford Publications, Inc.|
|Edition description:||Third Edition|
|Product dimensions:||6.40(w) x 9.00(h) x 1.30(d)|
About the Author
Timothy E. Wilens, MD, Associate Professor of Psychiatry at Harvard Medical School, specializes in pediatric and adult psychopharmacology in his clinical work at Massachusetts General Hospital, where he is currently Director of Adolescent Substance Abuse Services. Board certified in child, adolescent, adult, and addiction psychiatry, Dr. Wilens is a leading researcher and publishes widely on child and adolescent psychiatric issues.
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Straight Talk About Psychiatric Medications For Kids
By Timothy E. Wilens
The Guilford PressCopyright © 2009 Timothy E. Wilens
All rights reserved.
Building a Foundation of Knowledge
It is never easy to face the fact that your child may need help for a mental, emotional, or behavioral problem. A tough situation becomes harder when, like most parents, you know little about the subject of childhood psychiatric disorders and their treatment. It gets even more difficult when you're plagued by the misconceptions and myths that abound.
Perhaps you've just consulted your child's pediatrician because your son or daughter has been behaving differently, and the doctor has told you that he or she suspects a certain disorder is present for which medication is usually the recommended treatment. Or you may be wondering if medication could help your child now that a long-standing problem is worsening and no longer manageable by other means. Maybe you're just beginning to believe something might be wrong with your child, and what you've read about similar problems has left you confused and a little alarmed. You're not alone. More and more people—parents and professionals alike—are considering medication as a viable option for treating many psychiatric problems in children. The field may not be as young as it was when this book first came out, but new myths and misconceptions seem to arise to fill the void left by discarded ones, and of course we still have a lot to learn. The result is that numerous gaps in our collective understanding remain. At this point, parents want to know everything from "Why is medication necessary?" and "Isn't there any other treatment?" to "What will happen if we just wait and watch?" and "How do we know drugs designated for this purpose are safe?" If you are at this stage with your child, the following background should help you decide whether to go ahead and have your child evaluated for possible medical treatment.
What makes the doctor think my child needs medication?
There is no simple answer to why any child may need medications for a psychiatric or psychological problem. Each child's situation is unique, complex, and constantly evolving. Any decision regarding the child's care and treatment should be the result of a thorough evaluation of the many factors involved and a thoughtful consideration of all the alternative solutions available. As I hope to reinforce throughout this book, however, you have an absolute right to seek a satisfactory explanation for any decision about your child's case from the doctor who has made that decision. Never be afraid to ask. You should have a good grasp of the conclusions your child's doctor has reached and the rationale that led the doctor to the recommendation before your child embarks on any form of treatment. In fact the entire evaluation, diagnosis, and treatment process should be a collaborative effort between you and your child's health care providers. To broach the subject with your child's doctor, try saying something like "I'm trying to understand your decision-making process. Can you walk me through it?"
Whether your child needs medication depends on the problem, its causes, and its effects on your child's life. Some mental and emotional disturbances are treated successfully with psychotherapy. Others are treated most effectively with a combination of psychotherapy and pharmacology or just medication alone. Typically, a doctor may consider medication based on the belief that the child's problem has a medical cause, or etiology (it's not just "all in the kid's head"), especially one that usually worsens with time or with stresses in the child's life. In cases like this, the child may seem perfectly healthy physically even though the cause of the problem originates in the body. Such medical conditions are frequently unlikely to go away on their own, and the child's symptoms may very well get worse if ignored. Many of the childhood psychiatric conditions for which medication has been used over the past decade fit this description. Attention-deficit/hyperactivity disorder (ADHD) is one example that many parents have read about. Scientists now believe that the impulsivity, short attention span, and other symptoms associated with ADHD are caused by a specific dysfunction in the brain that often is inherited. How severely impaired the child is by the ADHD, however, depends on the severity of the ADHD and on environmental factors such as whether the child's parents and teachers take the child's disability into account in rearing and educating the child. A child whose disability is ignored is likely to suffer academically and socially. In turn, these experiences tend to aggravate the symptoms of ADHD and may even spawn additional problems, such as defiant, destructive behavior. So if your child's condition is causing even moderate distress and is pervasive, the doctor may have good reason to consider medication management.
Like many other psychological disorders, ADHD starts with a problem in the body (the brain), but its whole profile in any one child is formed by a number of interwoven factors. To decide whether medication might be an appropriate treatment for your child's problem, the doctor must take all these ingredients into account. Each human being carries a unique set of experiences and vulnerabilities that combine to make the person more or less susceptible to psychiatric disorders. Some of these factors are environmental (people, events, and stressors in the child's surroundings), some biological (genetic), and most a complex interplay of the two. Depression is a common example in children, with an inherited predisposition often triggered by some external event, such as loss of a loved one.
To diagnose the problem and treat it wisely, the doctor has to understand these factors as thoroughly as possible. Before I could treat 12-year-old Joy, for example, I had to find out not only that she had remained withdrawn, apathetic, and listless for months following her dog's death but also that her mother had been treated for long-standing depression. A tendency toward depression that she may have inherited from her mother was activated by the trauma of losing her beloved pet. In turn, one symptom of depression, Joy's withdrawal from family and friends, increased the environmental impact on her psychological health by removing needed support. This in turn made her depression worse. (I won't go into the details here, but most recent psychiatric research suggests that these environmental factors can cause biological and neurological changes that may appear to be inborn biological abnormalities.)
These complexities present a formidable diagnostic and treatment task that demands input from those who know the child best—the child's parents. Your insight can point the doctor in the right treatment direction, shortening what can be a somewhat lengthy process of trial and error. In fact your child's doctor may suggest psychopharmacological treatment—treatment with drugs designed to treat psychiatric problems—after getting less-than satisfactory results from other forms of treatment. Although the efficacy of drugs is becoming more widely known, psychotherapy is often the first-line treatment for mental, emotional, and behavioral problems in both children and adults. However, there has been a shift in categorically recommending psychotherapy as the first line for all psychiatric disorders in children and adults. As you may already know if you were initially referred to a psychologist by your child's pediatrician or teacher, various types of psychotherapy have been developed in this burgeoning field. If your child is already seeing a therapist without noticeable improvement, the therapist may have referred you to a psychiatrist (or back to your pediatrician) for further evaluation. Many children, for example, worry excessively after their parents' divorce. But if a child continues worrying excessively for more than a year despite counseling, other treatments, including pharmacotherapy, may be worth considering. The practitioner may conclude that psychotherapy alone is not sufficient in your child's particular situation. Or the doctor may be aware, from personal clinical experience or psychiatric literature, that medication has been shown to work more effectively for your child's disorder than psychotherapy alone.
If a doctor suggests medication for your child, it is not necessarily cause for alarm. With most health problems, we tend to believe that the need for medical treatment—as opposed to lifestyle changes or no treatment at all—is a sign that the problem is relatively severe. This is not always the case with psychiatric disorders. Sometimes a medication offers the straightforward solution to the child's problem because some agent specifically targets the medical cause of the disorder. In ADHD, for example, medicines bring improvement in a way that no other form of treatment alone has been able to do. Likewise, bipolar disorder in children generally cannot be managed without a mood-stabilizing medication. Thus medication may be a powerful mechanism to help alleviate your child's problem, either as a single treatment or in concert with psychotherapy.
A good way to approach the issue of medications for your child is to stay as open-minded as you can. Objective information gathering will help you make an informed decision. Try not to let fear of the unknown sway you before you tap all the sources available to increase your understanding. Later in this section, I'll go into more detail about when medication generally benefits children and how it works. (And for more specific information, consult the chapters in Parts II and III that cover your child's disorder, if it has already been diagnosed, or the medication that is being recommended, if you've already had such recommendations from the doctor.) For now, view medication as one option for helping your child. Be prepared to balance its benefits against both the risks of the medication itself and the risks of not using medication (taking a "wait-and-see" approach).
If my child takes medications, everyone—teachers, babysitters, relatives, friends—will know something is really wrong. Won't this make things even harder for my son?
Again, remember that the need for medication is not necessarily a sign of severity. If anyone who knows about your son's treatment expresses undue alarm about it, share the information you have gathered about medication's role in treating this type of problem. Knowing that medication is one of the treatments of choice for many childhood psychiatric disorders often reassures and prevents people from overreacting in ways that will make your son self-conscious. In general, though, you should probably discuss your child's disorder only on a need-to-know basis. Before you air any aspect of the subject, ask yourself whether this person needs the information to protect your child's well-being. If not, treat the information as private and confidential: Keep it to yourself. (Note, too, that extended-release forms of the stimulants used to treat ADHD have recently become available, meaning in many cases that children no longer have to "announce" their problem through regular trips to the nurse's office at school. See pages 212–216 for more information.)
Sadly, there are people who will use their knowledge of your son's treatment as a weapon ("Oh, Johnny's on medication—no wonder he's so impossible"). There are also many people today who still harbor misconceptions about psychiatric disorders. It is your job to protect your child from the myths and prejudices that range from labeling your child as "feeble-minded" to portraying him as "crazy." Share what you have learned, but also examine your own attitudes.
Many parents seem to come to grips with medical disorders such as diabetes or seizures but have great difficulty accepting emotional and behavioral problems in children. Are you among those who hold an irrational fear of mental illness or who look down on those with psychiatric disorders? Defensiveness about your child's condition may stem from your own lingering doubts. Try to remember that you may very well be dealing with just another type of medical problem. Emerging findings suggest that the bulk of emotional, cognitive, and behavioral disorders are caused by subtle chemical differences in the brains of children. The medications that are prescribed normalize the transmission of these chemical signals and thus reduce the child's symptoms.
Passing this information on to others can go a long way toward erasing the stigma surrounding psychiatric disorders, especially because it eliminates the need to assign blame for the child's condition. Any anxiety you may be feeling about your child's problem can be exaggerated by the conventional notion that mental and emotional disturbances are caused solely by the way you are raising your child. Parents of my patients often seem to encounter this bias at their child's school. Despite the plethora of teachers, guidance counselors, and other school staff who understand and empathize with families who are struggling with psychiatric problems, there always seem to be a vocal few who are quick to point the finger of blame. If you run into this attitude, remember that school personnel do not live with your family and often cannot fully appreciate the scope of the situation. You may be tagged as "the nervous type" because your child's behavior is not so disruptive in the relative structure of the school setting. Or you may be considered irresponsible if you express little concern about behavior problems you don't see at home—such as the peer problems and academic problems that tend to appear mainly at school.
Here, too, the solution is education. Explain to those at your child's school and elsewhere what you have learned about the biological causes of the child's disorder. Remind those who remain skeptical that it wasn't until recently that scientists discovered a biological basis for alcoholism and drug addiction. We don't blame others for causing someone's alcoholism today, and we should not blame parents or anyone else for causing a child's psychiatric disorder. Your child's problem is not necessarily your fault.
Nor is it your child's fault. Make sure your child does not view the disorder as some sort of personal failing or weakness. Explain, in understandable terms that take the child's age into account, that the child has a problem that he can't help having. (For fairness and simplicity's sake, I will alternate between male and female pronouns.) Say that this problem is largely physical in the same way Aunt Alice's asthma is physical or Daddy's high blood pressure is physical. If medication is a possibility, tell your child that it's no different from the inhaler that helps Aunt Alice breathe or the pills that keep Daddy's blood pressure under control. Also assure the child that many other kids take medications without anyone else knowing about it—maybe including some of your son's or daughter's friends. You may have to offer these reassurances repeatedly over a long period if this problem has been emerging and causing distress gradually over time.
What options do we have besides medication?
The answer depends on which disorder your child has. Check the chapter in Part II that addresses your child's problem for more specific information on the standard treatment choices. Generally, though, the options break down into psychotherapy and pharmacotherapy, and often a combination of the two proves most effective. There is a bewildering array of psychotherapies available today. To unravel the possibilities, you might need to ask your doctor, your friends, or others who have some firsthand experience about the options.
Because psychiatric disorders almost invariably affect a child's behavior, a variety of interventions that target behavior are commonly used. Using clinically proven methods, therapists can help children with bipolar disorder (manic–depression) and ADHD control their impulsivity, help those with Tourette's disorder lessen their disruptive verbalizing, and teach teenagers with eating disorders to regain the proper perspective on the role of food in their lives. Behavioral and cognitive therapies can alleviate the primary symptoms of some psychiatric disorders (such as hair pulling [trichotillomania] and obsessive–compulsive disorder) and in other cases can address behavioral problems that are an offshoot of the disorder. For example, a child with ADHD can be taught to pause before acting on an impulse; one who has oppositional defiant disorder can learn to comply rather than defy when the parents habitually punctuate positive behavior and ignore negative behavior. Most important is understanding what any therapy chosen for your child can be expected to change in a given disorder. Recent research is beginning to show, for example, that a type of cognitive-behavioral therapy has the same beneficial effects on neurotransmitters as the use of medication. But in the case of bipolar disorder, behavioral interventions cannot cure the child of the biological tendency toward mood swings, even though it may be able to help her learn to recognize the signs of mood changes and what actions to take when she does experience them.
Excerpted from Straight Talk About Psychiatric Medications For Kids by Timothy E. Wilens. Copyright © 2009 Timothy E. Wilens. Excerpted by permission of The Guilford Press.
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Table of Contents
I. What Every Parent Should Know about Psychiatric Medications for Children
1. The Preliminaries: Building a Foundation of Knowledge
2. The Psychopharmacological Evaluation: Finding Out What's Wrong
3. The Diagnosis and Treatment Plan: Laying Out a Strategy to Help Your Child
4. Treatment and Beyond: Collaborating in Your Child's Ongoing Care
II. Common Childhood Psychiatric Disorders
5. Attentional and Disruptive Behavioral Disorders
6. Autism and Pervasive Developmental Disorders
7. The Mood Disorders
8. Anxiety-Related Disorders
9. Schizophrenia and Other Psychotic Disorders
10. Disorders of Known Medical and Neurological Origin
11. Other Mental Health Disturbances Affecting Children and Adolescents
III. The Psychotropic Medications
12. The Stimulants and Nonstimulants for ADHD
13. The Antidepressants
14. The Mood Stabilizers
15. The Anxiety-Breaking Medications
16. The Antihypertensives
17. The Antipsychotics
18. Medications for Sleep, Bedwetting, and Other Problems
Appendix: Representative Medication Preparations and Sizes Used for the Treatment of Childhood Emotional and Behavioral Disorders; Example of a Completed Medication Log; Medication Log; Resources
Parents seeking a reliable, accessible source of information; mental health professionals, who may wish to recommend the book to clients.