Straight Talk about Psychiatric Medications for Kids

Straight Talk about Psychiatric Medications for Kids

by Timothy E. Wilens, Guilford Press

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ISBN-13: 9781572302044
Publisher: Guilford Publications, Inc.
Publication date: 05/15/2000
Edition description: First Edition
Pages: 280
Product dimensions: 6.00(w) x 9.00(h) x (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. Board-certified in child, adolescent, adult, and addiction psychiatry, Dr. Wilens has researched and published widely on psychiatric medications and their uses.

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Chapter One

PART I
What Every Parent Should Know
about Psychiatric Medications
for Children


    When your child has a psychiatric problem for which medication may be prescribed, a thousand questions beg to be answered. Parents come to me with an urgently felt need for information--and often more than a little anxiety as well. In this section, I've compiled the questions that usually come up--in my office as well as at the talks I give about four times a month for professional and parent support groups across the United States, the United Kingdom, and Europe--with the most current, most complete answers that can be given in a book meant to speak to a broad cross-section of parents.

    As is stressed throughout the book, you are a key player in your child's mental health care. To fill that role optimally, you need to stay as well informed as you can about your child's problem and the treatments available for it. This involves asking the right questions as well as getting reliable answers. I hope the following questions, posed by hundreds of caring, concerned parents before you, will get you thinking as a proactive collaborator in the care of your child. And I hope the answers will give you some of the comfort and reassurance that knowledge provides. Always remember, though, that your child's situation is unique. The right answers for your son or daughter will always come mainly from the cooperative efforts of you and the qualified professionals you have chosen to care for your child.

    The following questions and answers have been divided into four groups, based on when in the diagnosis and treatment process they usually arise. Questions asked by parents who are just considering seeking help for their child come first. Next are questions and answers for those currently involved in the evaluation process. The third section addresses questions about the diagnosis and the treatment proposal that emerge from the evaluation. The last section addresses issues that come up when a child is already being treated with medications for a psychiatric or psychological disorder. Read all of Part I for an overview or turn to the individual sections and questions within them as needed. Either way, I hope you will find what you need to know. If not, please ask your child's practitioners--that's what they are there for.


THE PRELIMINARIES

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 longstanding 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 becoming aware that medication is a viable option for treating many psychiatric problems in children, but the field is new enough to leave numerous gaps in our collective understanding. At this preliminary 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 simply don't respond to what we call the "talking therapies." Others are treated most successfully with a combination of psychotherapy and pharmacology. 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 last 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.


dysfunction: The state of not working properly.

etiology: The biological or psychological cause of a disorder. The actual disturbances in the body organs or brain causing the disorder are called the pathophysiology.

pervasive: Occurring, more often than not, in many settings and for more than a few months.


    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 longstanding 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 head 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. 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, amphetamines bring improvement in a way that no "talking" therapy or other form of treatment has been able to do. Similarly, 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, which is always the right kind. 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 U 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 an option for helping your child. Be prepared to balance its benefits against the risks of the medication and the risks of leaving your child's problems unresolved.


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.

    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 a raving lunatic. 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.


disorder. A cluster of symptoms and objective findings that, grouped together, are related to a specific problem.

symptom: A manifestation of a disorder. Cough and fever are symptoms of pneumonia; sadness and lack of petite are symptoms of depression.


    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.


psychotherapy: An umbrella term that covers the broad range of "talking" therapies.

pharmacotherapy: Treatment of a condition using medications.


    Because psychiatric disorders almost invariably affect a child's behavior, behavioral modification therapies are common forms of treatment. 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. Behavior modification can alleviate the primary symptoms of some psychiatric disorders (such as hair pulling 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 behavioral therapy cannot do. Often it will not affect the underlying disorder, such as an imbalance in the brain chemicals called neurotransmitters. A child who has bipolar disorder cannot be expected to learn not to have mood swings, but she may be able to learn to recognize the signs of mood changes and what actions to take when she does experience them.


neurotransmitters: Chemical messengers that are the main communications link between nerve cells.


    Other forms of therapy for the child include interpersonal and dynamic-oriented therapies. Interpersonal therapies are based on the way the child interacts with others, such as family members. Psychodynamic therapies relate past experiences with current distress and try to explore with the patient how to find healthier ways of coping. A traumatized child, for example, may benefit from exploring through play (with a young child) or conversation (with an adolescent) the lingering effects of the trauma. Your child may be treated individually or in a group. Relaxation techniques for anxiety disorders, coping skills training for impulsivity or delinquency issues, and 12-step programs for substance abuse all may be appropriate. Just beware the "kitchen-sink" approach of having your child in every type of therapy the profession has to offer. Identifying the most promising therapy based on the child's disorder(s), unique family and social circumstances, maturity, and abilities is much more likely to be successful than the throw-everything-at-him-and-see-what-sticks approach. You can always try something else after the well-thought-out choice fails.

    The same precautions apply to treating the rest of the household. Family-based therapies can be invaluable not only in educating parents and siblings about what is wrong with the child but also in identifying and changing family patterns that are part of the problem--either because they have developed as a result of it or because they are contributing to it. But avoid becoming professional clients, running from family therapy sessions to parent training classes in child management techniques to individual psychotherapy appointments. Try to find out from your child's mental health provider which issues have a high priority and which form of counseling if any might be of greatest help right now.

    How aggressively your child is treated will depend largely on the urgency of improving the child's condition. When the child is a danger to herself or others, or the child or family is suffering greatly from the child's disorder, you will not want to take a wait-and-see attitude. On the other hand, parents and the doctor should not rush into a treatment recommendation without sensitivity to the child's possible reactions. With an oppositional, depressed teenager, for example, it might be crucial to develop a trusting relationship through talking therapies before trying medication. To push medication immediately could very well cause the child to get angry at the doctor and compromise the relationship and future care.

    Ask the doctor to help you weigh the risks of medication treatment against the risks of delaying the treatment. Ask questions like "What do you think would happen if we tried psychotherapy first?" and "Can you list the major pros and cons of starting medication right away?"


If we're patient, won't the problem just go away as my child gets older?

Whereas some behavioral, cognitive, and emotional problems improve with the child's development--autism, separation anxiety, and ADHD are three examples--others may persist. Depression and generalized anxiety, for instance, do not seem to disappear as the child ages; they merely manifest themselves in different ways. Depression, for example, may appear as irritability, withdrawal, and lack of interest (apathy) in younger kids, while depressed teenagers may complain of sadness, lack of energy, social problems, and suicidal thoughts. You'll find more on this subject in the chapters on specific disorders in Part II, and your child's mental health care providers can tell you what the future may hold for your child.


cognitive: Related to thinking or knowing.


    Even with disorders that sometimes go into remission with maturity, though, it is a mistake to ignore the problem in the expectation that it will just go away. It is always difficult to predict when a disorder will abate, and in the meantime, doing nothing can damage your child. The reports of many adults confirm what we intuitively know: Neglecting treatment in a child with behavioral and emotional problems causes future problems. We simply do not know when those scars develop but speculate that it is an ongoing process over years born of underachievement, demoralization, lack of confidence, and poor self-esteem. Eight-year-old Justin, for example, who has severe overanxious disorder (excessive worrying), began avoiding social situations despite wanting friends. Aggressive treatment of his condition with behavioral modification and Tranxene reduced his anxiety substantially, allowed him to socialize normally, and improved his self-esteem and confidence greatly.

    Clearly, if your child is achieving below her potential and seems discouraged and down on herself, you should take action, whether that means seeking an initial psychiatric evaluation, switching from psychotherapy to drug or combined therapy, or trying a new medication regimen. Other troubling signs include loss of interest in learning, long-standing displeasure, and poor social skills and relationships for the child's age.


When my brother heard that our pediatrician thinks Jenny is suffering from depression, he started telling me about his symptoms, which are so different that I started to have doubts about what's wrong with Jenny. Should I question the pediatrician?

Certainly you should always ask questions when you have doubts or concerns about anything your child's doctor tells you. You may also want to have your pediatrician refer you to a mental health specialist so you can be sure you know everything you need to know about your daughter's condition. But don't assume that differences between Jenny's symptoms and your adult brother's symptoms mean the pediatrician is wrong. There is a growing notion in the scientific literature that psychiatric disorders starting in childhood are often somewhat different from those in adulthood. Juvenile-onset bipolar disorder, for one, often features intertwined depression and mania rather than the more typically distinct phases of either depression or mania seen in the adult-onset form. It is important to understand these distinctions because they may explain why a child's response to medications sometimes differs from the adult responses with which you may already be familiar. For developmental reasons, a child with a particular disorder may have different symptoms from an adult with the disorder of the same name. The course may differ as well. As a general rule, with notable exceptions, psychiatric disorders that begin in early childhood often are more severe, tend to be chronic (sustained), and often run in families.


course: What happens to a condition over time.


Current thinking indicates that a sizable number of children who have childhood disorders have genetic vulnerabilities to the disorder that were passed on by their parents and grandparents. These vulnerabilities may be turned on spontaneously or by an environmental problem or stressor. In the case of seven-year-old Molly, whose parents both suffered from depression, feelings of sadness, isolation, and withdrawal began following the death of her grandmother, continued for four months, and were accompanied by school and social difficulties. After a month of psychotherapy, Molly's depression was reduced dramatically. We suspected that the stress of losing her grandmother had triggered in Molly a depression stemming from a biological predisposition toward depression inherited from her parents.

    As a parent, you've witnessed the differences between medical illnesses in children and those in adults. You may also be aware of the differences in common chronic diseases like diabetes and rheumatoid arthritis. Compared to adult-onset diabetes, juvenile-onset diabetes mellitus (type I) requires insulin injections, does not appear to be inherited (genetic), and tends to be more severe. Juvenile rheumatoid arthritis is very different from the adult version in the joint regions affected, genetic vulnerabilities, and overall course. It should be no surprise, then, that psychiatric disorders that begin in childhood can also look quite different from those that begin in adulthood. Very recent work on bipolar disorder (manic-depression) in children and adolescents, for example, indicates that children may have severe symptoms of both mania ("high") and depression at the same time for extended periods. In contrast, adults more typically have distinct cycles of mania and then depression and often have periods of normal mood. At least half of children with bipolar disorder, not surprisingly, have a close relative with the same disorder.

    Unfortunately, we still have a poor understanding of what psychiatric disorders in childhood will evolve into over time and into adulthood. Whereas there is relatively solid evidence that conduct disorder often progresses to the antisocial personality disorder of adulthood (the prognosis is worse with early onset, under age 10, than when conduct disorder begins after age 10), less is known about the adult fate of depressed children. Many adults with anxiety disorders report that their problems began in adolescence, but the exact path of anxiety from childhood to adulthood remains unclear. Of interest, some new studies indicate that infants with a type of temperament (hard-wired personality traits) known as behavioral inhibition may be predisposed to developing more severe anxiety problems or shyness as children.

    The good news is that a number of disorders that affect children appear to get better, to some degree, with time. Such is the case with autism and pervasive developmental disorders (see page 144). Children with these disorders, especially those receiving certain types of therapy, see an improvement in their socialization and language skills. Similarly, younger children appear to grow out of severe anxiety related to separation from their parents or primary caregivers with time. Kids with oppositionality also commonly outgrow their argumentative and annoying features as young adults. Another common example is ADHD, which is thought to disappear (remit) by adulthood in roughly half of the children affected, particularly the hyperactivity symptoms of the disorder.

    Another feature of childhood psychiatric problems is that many young people have two or three different disorders simultaneously. Whether these disorders just happen to run together, as is the case for some children with conduct disorder and ADHD, or one disorder leads to another, as may happen in children with longstanding obsessive-compulsive disorder who develop depressive symptoms because of demoralization, is unclear. Whatever the suspected cause, the occurrence of two or more disorders together is called comorbidity. A child with depression and anxiety, for example, would be said to have comorbid anxiety and depression, without any causality being implied.

    It is important to keep the possibility of comorbidity in mind because, in many children, new symptoms or problems surface once the diagnosed disorder is treated successfully. Rather than just writing this off to the environment or, worse, a dysfunctional family that will not "let" the child get better, it is medically sound to evaluate the child for the presence of another disorder. Fourteen-year-old Mike's severe obsessionality was greatly reduced when his obsessive-compulsive disorder was treated with 200 mg of Zoloft a day, but his academic problems continued. As it turned out, those problems were caused by inattention and distractibility related to ADHD, which had gone undiagnosed because of the severity of his obsessive-compulsive condition. Additional stimulant treatment for the ADHD proved very effective.

    If you suspect that your child has more than one problem, be prepared to enumerate all the specific symptoms with the practitioner who ends up doing the evaluation. By carefully asking questions about the more common behavioral and emotional disorders in children, your child's doctor can disentangle the overlap of symptoms and make reasonable sense of your child's condition. If a child has rather clear-cut depression, for instance, the presence of other common disorders such as anxiety, ADHD, and substance abuse should be considered. Some commonly co-occurring conditions include depression and anxiety, substance abuse and depression, ADHD and anxiety, Tourette's disorder and ADHD, and anorexia and obsessive-compulsive disorder.


substance abuse: A pattern of misuse of drugs or alcohol generally resulting in interpersonal, occupational, legal, or medical problems.


If drugs work so well in treating children with mental and emotional problems, why do I hear such conflicting reports about them?

Conflicting reports abound mainly because child psychopharmacology is a relatively new science. You'll hear many more firm conclusions on the subject in the near future because so much information is being gathered in clinics and research labs right now, but significant developments have been a long time in coming. Psychoactive substances have been a standard psychiatric treatment for adults for only about 50 years; for children, only about 20. The realization that drugs could benefit children with emotional and behavioral disorders is a fascinating example of how separate branches of science--along with a few fortuitous accidents--can intersect to produce a groundbreaking discovery.


psychoactive: Affecting the central nervous system, resulting in changes in thinking, behavior, or emotion. Synonymous with psychotropic and psychopharmacological.


    Until the middle of this century, patients with longstanding and severe psychiatric disorders were usually institutionalized. Theories about mental illness relied heavily on the influence of very early life experiences, generally related to parenting, on all later problems. The medical community simply didn't know what to do with people suffering from psychoses such as schizophrenia except stash them away where they couldn't hurt themselves or others. In the 1950s, however, Thorazine and similar agents with a tranquilizing effect were developed to suppress psychotic behavior, making patients less dangerous, and many patients were moved out of the large "insane asylums" and into the communities. The trend toward deinstitutionalization had begun.

    The great success of Thorazine and similar agents spurred research into other psychoactive agents. It was also during the mid-1950s that a new class of agents, the benzodiazepines, thought to be nonaddictive, replaced the highly addictive sedatives phenobarbital, pentobarbital, and other barbiturates. Librium (chlordiazepoxide) was among the first of this new class. In 1958, imipramine (brand name Tofranil) became one of the first effective tricyclic antidepressants. Over the next decade, scientists channeled their enthusiasm toward these new drugs into extensive testing of their pharmacological properties, the symptoms and disorders that they benefited, and any toxic effects they might have. One subject of research was lithium, a chemical that had first been used in the United States as a salt substitute but was then found to have sedative properties as well as a certain toxicity at high doses. The research efforts of the 1960s amply demonstrated its mood-stabilizing effects, and in 1970, lithium was approved for psychiatric use. Meanwhile, advances in chemistry allowed the development and synthesis of new agents from all of these classes of drugs.


toxic: Essentially harmful to the human body. Toxicity results from too much of a compound being in the body.


    On yet another front, the field of psychiatry began to develop strict definitions of clinical syndromes--the sets of symptoms psychiatrists were seeing in their practices--in the 1970s. In the process, researchers made a number of important findings: that certain disorders ran in families and may be genetic; that they were associated with problems in the brain and in thought processes; that they persisted in many cases; and that they had predictable responses to treatment. This new perspective led to a research focus on brain chemistry, which in turn led to investigations of new pharmacological agents for different disorders. Researchers continue to focus attention on better understanding the clinical picture of a disorder, including commonly co-occurring other disorders, brain changes found by taking pictures of the brain, electrical and chemical activity of the brain, the neuropsychological profiles of the different disorders, the pharmacotherapy/psychotherapy treatments, and most recently the genetic basis for disorders. The understanding of how drugs work on the brain that these studies produced is explained on page 25. Suffice it to say here that, as more and more information on brain biochemistry and structure suggested that psychiatric disorders had a biological cause, new and different medications were developed and tested, and further biological studies were undertaken.


neuropsychological: Related to the interface between brain functioning and thinking processes (perception, processing, and problem solving). Generally refers to the interference of brain functioning on thinking and vice versa.


    The 1990s, "the decade of the brain," have seen a near revolution in thinking about children's psychiatric disorders. Until recently, children's emotional and behavioral problems were believed to be rooted entirely in disturbed parenting. But the findings of genetics, neurobiology, and brain imaging studies began to lead mental health and other medical practitioners toward an interactional model. Individuals are now viewed as biological beings interacting with the environment, with each factor influencing the others. This perspective has completely transformed psychiatric views of cause and effect. Now a so-called neurotic child is more likely to be viewed as having a nervous temperament (biology) that induces those around her to be overprotective (environment) than as a child whose overprotective parents have caused her to become "neurotic." Parents were once categorically blamed for the lack of interaction with the environment that characterized autism, but now autism is known to be caused by biologically based abnormalities in the brain. Similarly, ADHD, Tourette's disorder, obsessive--compulsive disorder, and mood disorders have been found to run in families and in some cases appear to be genetic. In fact, while you are reading this, scientists are working to isolate the genes responsible for the different disorders and to develop replacement therapy to correct, at a chromosomal level, the neurochemical disturbances underlying specific conditions.


neurobiology: The basic science underpinning nerves and the nervous system.

neurochemical: Referring to the elemental makeup of the messengers of the nervous system.


    You'll be exposed to such developments as time goes on. For now, though, news is sporadic for two reasons: The press hesitates to disseminate information on medication treatments that have not completed the laboriously long process of Food and Drug Administration (FDA) approval, and parents are protective of their children's privacy. As you will learn in Parts II and III, your child's doctor may view a certain drug as standard treatment for a particular childhood disorder despite lack of FDA approval for its use in children because a wealth of clinical evidence has been amassed in its favor.


If child psychopharmacology is so new, how do we know the medications are safe?

    As long as your child takes the medication as prescribed, psychotropic medications are very safe. Many agents listed in this book have been used in children for over two decades with a solid track record. Specific medications, including Tegretol, Depakote, Cylert, desipramine, imipramine, and clonidine, have been known to produce rare severe side effects, so children taking these drugs are monitored closely by the prescriber. Also, we know that the antipsychotics (Stelazine, Trilafon, Mellaril, Thorazine, and others in this family) can cause abnormal muscle movements, called tardive dyskinesia, in a small group of kids exposed to these agents for years, so the subtle effects of long-term medication use need to be monitored as well. Of interest, Ritalin and Prozac, medications that parents view as the most dangerous because of media exposure, turn out to be among the safest being used in children (and adults)!


psychopharmacology: The study of compounds that affect the central nervous system, resulting in changes in thinking, behavior, or emotion. Synonymous with psychotropic and psychoactive.

psychotropics: Usually agents that affect the central nervous system, resulting in changes in thinking, behavior, or emotion. Synonymous with psychopharmacological and psychoactive agents.


    Because use of psychotropic drugs in children is relatively recent, many of these agents have not yet gained FDA approval for pediatric use. Though the confidence that our stringent regulatory process instills has great value, lack of FDA approval does not mean a drug is unsafe for psychiatric use in children. In many cases, in fact, unapproved drugs have a wealth of clinical evidence to back up their safety and effectiveness; see page 88 for details. We should also be seeing much more safety data in the coming years. In a major step toward recognizing pharmacology as treatment for children with psychiatric disorders, Congress recently passed legislation requiring American drug manufacturers to study medications in children with the potential for use in youth before the drug can gain FDA approval for use in adults.

    In the meantime, there is no doubt that the greatest danger of medications is an overdose. Although children with certain disorders such as depression are at risk for harming themselves, the bulk of lethal overdoses are accidental and occur in family members or friends, such as when a younger sibling thinks the medication is candy. It is important to remember that medications that are safe in daily administration can be very dangerous in overdose. That is why you have to designate a special storage place (locked cabinet) and policy for your child's medication if drugs become a part of his treatment regimen. And, remember, parents or legal guardians--not the child--should be responsible at all times for the medications.


What do we know about the effects these drugs might have on the child years later?

Again, although generally safe over the short term, the older-generation antipsychotic medications have been associated with tardive dyskinesia, an irreversible muscular movement that was noted in some adults who had been exposed to Thorazine-like medications for years; it was later reported in children as well. In addition, studies in the field of neurology have shown that certain anticonvulsants cause gum disease and mildly reduced intellectual development over time.


antipsychotic: A medication used to treat disturbances in the perception of reality (psychosis). Synonymous with neuroleptic.

anticonvulsant: A medication used to treat seizure (convulsion) disorders. Anticonvulsants are also used in psychiatry for behavioral outbursts and mood swings.


    Beyond this, though, we know little about the long-term side effects of most medications, and what we do know is shrouded in myth. For example, many people are concerned about the growth stunting they have read about in children receiving stimulant medications for ADHD despite the fact that this effect has been observed in only a minority of children. Furthermore, our group at Harvard recently published a study showing that these are actually growth delays and are probably related more closely to the ADHD than to the stimulants prescribed to treat it. Unfortunately, few studies of the long-term effects of various agents in children have been available to debunk such myths, due in part to the fact that children have not been taking these medications long enough for their effects to be studied. That is all changing, however, and data from long-term studies should become increasingly available in the future.

    For now, as a parent who will be responsible for the everyday monitoring of your child while she is on medication, it is important to recognize that some side effects are inevitable because of the way our current medications work in the brain. As I will explain on page 29, we have not yet reached the point where we can isolate a drug's action so it affects only the targeted function within a brain region or the targeted molecules in certain neurochemicals. This leaves us with medication that can control hallucinations but may also cause muscle spasms and with drugs that alleviate depression but may also sedate the child.

    Until we come up with medications that have a very narrow focus of action, parents should be prepared to monitor their children closely for any side effects, short- or long-term, and discuss them with the child's practitioner.


How do the medications work?

We've known for centuries that nerves are the body's messengers and that the brain is essentially an enormously complex network of nerves. Think of the brain as "communications central"--the place where information about what we are experiencing is processed, eliciting certain responses from the body and mind. You want to touch an object, and the nerves in your hand send a message to your brain where other nerves instantaneously set into motion the action of moving your hand to the object. That's a pretty amazing facility by itself. Now add in the brain's capacity to store and analyze information. Over time, these processes produce the overall spiritual and conscious understanding of who you are, what you feel, and your place in relation to others and the world. We call it the human mind, a facility of such mind-boggling sophistication and infinite ability that its workings seem unfathomable.

    We still have a long way to go before we unravel the machinery of the human brain, but recent brain research has produced information invaluable to the treatment of psychiatric disorders. Studies of brain structure have shown that some disorders originate in certain regions of the brain, and advances in neurochemistry have revealed that certain brain chemicals may be the source of other problems.

    Like other organs, the brain is susceptible to illness. Within behavioral and emotional disorders, these problems are thought, to a large degree, to be related to neurotransmission, or the communication between nerve cells. The medications used in children and adolescents appear to operate by normalizing many of these biochemical disturbances. The scientific community is currently in the process of disentangling which disorder is related to what area of the brain and what neuron-to-neuron pathway.


What happens where in the brain?

The brain has regions that are associated with various cognitive and motor functions. These regions communicate with each other via nerve cells (neurons). Much of your emotional processing occurs deep in your brain in the collective region referred to as the limbic structures. Disturbances in these areas, such as occur with temporal lobe epilepsy, can lead to rage attacks, deepened emotions, and irritability. Normal inhibitions are thought to originate predominately in the front area of your brain, in the frontal lobe (behind your forehead). Hence, disturbances in inhibition or impulsivity, like those typical of ADHD, appear to have their source located to some degree within the frontal lobes. Another important structure in the brain, called the striatum, is related to attention and reward centers. It is thought that problems in this small section of the brain may be important in a wide array of disorders, including ADHD and drug abuse. In addition, certain parts of the striatum are related to your movements. That is why many of the medications used to correct disturbances in reality, such as eliminating hallucinations, may cause muscular spasms or involuntary movements (dyskinesias).


cognitive functions: Activities related to the ability to think--take in and process information, reason, memorize, learn, and communicate.

motor functions: Activities related to the ability to move.


    The brain communicates with itself and other parts of the body through nerve connections. The area in which the nerve cells connect and communicate with each other is called the synapse. Every thought and physical action is related to activity in the synapse. Two or more nerves may communicate in a single synapse, similar to highways merging together. One nerve will send a signal to another nerve cell "downstream."

    Nerve communication is carried out by neurotransmitters, such as dopamine, serotonin, norepinephrine, GABA, and glutamine. Currently, there are thought to be over 200 different neurotransmitters in the brain. Many emotional and behavioral disorders are thought to be related to disturbances in the flow of neurotransmitters from one cell to another.

    The synapse is composed of three basic parts: (1) the nerve cell sending the signal (presynaptic neuron); (2) the channel between the nerve cells (cleft); and (3) the nerve cell receiving the signal (postsynaptic neuron). The receiving nerve cell contains receptors, which essentially catch the neurotransmitters, sort of like a complicated baseball glove. Upon catching a very specific area of a neurotransmitter, the receptor will start a complex set of events. Often these events lead to the receiving cell's briefly being "turned on" or "off."


receptor: A chemical structure on the surface of sending and receiving nerve cells that binds or catches the chemical messengers (neurotransmitters), causing other reactions in the nerve cell.


    The process of neurotransmission goes something like this: A molecule of a neurotransmitter is released from the sending nerve cell, goes across the channel, binds to the biological "baseball glove," and activates the receiving neuron. The neurotransmitter is then taken back up into the presynaptic neuron by a process called reuptake. Reuptake serves two major purposes: (1) to dampen the amount of neurotransmitter in the area between the nerve cells (synaptic cleft); and (2) to conserve neurotransmitter as it is broken down and reused. Not surprisingly, the body is quite an efficient recycling machine!


Which neurotransmitters are involved in which disorders?

The synapses are the area where the psychotropic medications are thought to act. The psychoactive medications may act directly to release the neurotransmitters (as the stimulants do) or to block the reuptake of the neurotransmitter (as antidepressants do). Blocking the reuptake allows the neurotransmitter to accumulate in the synaptic cleft, making more of it available to stimulate the receiving nerve cell. Prozac, Celexa, Zoloft, Luvox, and Paxil inhibit the reuptake of serotonin and are referred to by physicians as the serotonin reuptake inhibitors (SRIs). Similarly, the class of medications called the tricyclic antidepressants (desipramine, nortriptyline, and others) act to prevent the reuptake of norepinephrine and, to a lesser extent, serotonin.

    Recent imaging and biochemistry studies have assisted us in better understanding what neurotransmitter systems are related to the various neuropsychiatric disorders. It is thought that in some cases of obsessive-compulsive disorder there is inadequate serotonin, which is boosted with the use of selective serotonin reuptake inhibitors (Prozac-like medications). ADHD is thought to be related to deficiencies in the action of both dopamine and norepinephrine. Not surprisingly, those medications that increase norepinephrine or dopamine appear to be the most effective for the treatment of ADHD.

    Unfortunately, the pharmacology is not as simple as it sounds. There is not only a large degree of overlap between the various neurotransmitter systems, but certain neurotransmitters may play a role in a number of different neuropsychiatric disorders. For example, the Valium-like medications (benzodiazepines) affect the neurotransmitter GABA and are used for a wide variety of conditions, including anxiety disorders, alcohol withdrawal, and seizure control.


neuropsychiatric: Related to the interface of psychiatry and neurology; referring to the set of mental operations that are related to both thinking/emotional states and neurological operations.


    To complicate pharmacotherapy further, one brain region may be the originating point of a disorder but may also govern other functions, so when a drug targets that region, it may affect the other functions while it is alleviating the disorder. The striatum, for example, governs movement as well as being the source of hallucinations, so when a drug corrects a disturbance in reality, it may also cause muscle spasms. Also, because we have not found a way to isolate the effects of a drug so that only the targeted molecules are affected, a drug may have unwanted effects along with the desired effect. One example is the older antidepressants, many of which, by blocking histamine receptors, not only alleviate depression but also commonly lead to sedation. Fortunately, doctors sometimes take advantage of such side effects, recommending nighttime administration of a sedating drug to a child who has insomnia. Similarly, stimulant medication and some antidepressants (Wellbutrin) used for ADHD may make tics worse, perhaps by nature of their dopamine-enhancing properties. In addition, high doses of agents that affect dopamine may also affect norepinephrine and serotonin.

(Continues ...)

Table of Contents

I. What Every Parent Should Know about Psychiatric Medications for Children
*The Preliminaries: Building a Foundation of Knowledge
*The Psychopharmacological Evaluation: Finding Out What's Wrong
*The Diagnosis and Treatment Plan: Laying Out a Strategy to Help Your Child
*Treatment and Beyond: Collaborating in Your Child's Ongoing Care
II. Common Childhood Psychiatric Disorders
*Attentional and Disruptive Behavioral Disorders
*Autism and Pervasive Developmental Disorders
*The Mood Disorders
*Anxiety-Related Disorders
*Schizophrenia and Other Psychotic Disorders
*Disorders of Known Medical and Neurological Origin
*Other Mental Health Disturbances Affecting Children and Adolescents
III. The Psychotropic Medications
*The Stimulants
*The Antidepressants
*The Mood Stabilizers
*The Anxiety-Breaking Medications
*The Antihypertensives
*The Antipsychotics
* Medications for Sleep, Bedwetting, and Other Problems

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