Medications and Children: What Counselors Need to Know

CHILDREN AND DRUGS. Can you think of a more sobering topic? It is often a challenge to work with children who are experiencing significant emotional or behavioral turmoil. During the course of treatment it may be necessary to refer them for psychopharmacological evaluation and therapy. Sure we have all heard the horror stories of overmedication, or of the lack of consistent medical oversight, but there are wonderful success stories too. The responsible child therapist should have at least a rudimentary knowledge of psychopharmacology, and should be willing to make an appropriate psychiatric referral when necessary. Unfortunately, this often does not happen. This oversight may be compounded by the helpers bias against medication or by the parents belief that it is not scriptural.

Some think that prescribing psychotropic medications amounts to an admission of parental failure. Medications AND Children What Counselors Need to Know While respecting their beliefs and convictions, therapists should educate parents about the potential value and appropriate use of medications, and help them understand that psychopharmacology may be a necessary part of the overall treatment program. Christian therapists working with children should recognize the benefits and limitations of medications as an adjunct treatment tool. The child therapist, in order to best meet the needs of the child client, must be able to assess the necessity for a psychiatric referral and become knowledgeable about psychopharmacology.

Psychopharmacology with Children

Although the body of research is increasing, there is unfortunately a want of extensive empirical study of the efficacy and safety of psychotropic medication with children (Biederman, 1992; Brown & Levers, 1999; Ellis & Singh, 1999; Gitlin, 1995). The use of psychotropics with children has not generally been addressed by the Food and Drug Administration, even though an increasing number of family doctors and nonpsychiatric physicians are prescribing psychotropics for children. Despite these concerns, the use of psychotropic medications for treating children has increased dramatically beyond the common use of stimulants for Attention Deficit Hyperactivity Disorder [ADHD] (Wilens, Spencer, Frazier & Biederman, 1998).

These include antidepressants for major depression, anxiety disorders and ADHD; lithium for bipolar disorders, neuroleptics for psychotic disorders; and some antihypertensive agents for dyscontrol (Biederman, 1992). The discovery of new pharmacological treatments and the evaluation of psychotropic uses for non-psychiatric drugs have led to a significant increase in the pharmacologic treatment of childhood mental health issues (Gadow, 1992). â€Å"For prepubertal children, biochemical and neurophysiological correlates exist for several disorders. Research has implicated neurotransmitter dysfunction in a variety of psychopathologic behaviors and disordersâ€Â� (Bukstein, 1993, p. 14). There are multiple pre-treatment and treatment considerations, which although primarily the concern of the prescribing physician, the child therapist should be aware. It should be noted that several medications may be utilized for a variety of symptoms or diagnoses.

Specific psychotropics may be effective for dissimilar disorders because of their influence on neurotransmitters and psychoendocrine events in the brain along common routes (Green, 1995). Developmental issues must be considered. Children are, from a biological standpoint, immature and growing organisms, and thus metabolize chemical agents differently than adults. Children may respond differently to psychotropic medication taken by the similarly diagnosed adult (Arnold, 1993; Biederman & Steingard, 1991; Vitiello & Jensen, 1995). Issues of absorption and disposition are primary concerns, and the prescribing physician may look to adjust dosage strength and frequency to achieve the maximum therapeutic T effect of a medication. Blood levels may be closely monitored. Another consideration in prescribing psychotropics to children is the absolute necessity of a complete physiologic and psychiatric assessment (Kutcher, 2000).

Biederman and Steingard (1991) summarized the fundamental goal: â€Å"Psychopharmacologic evaluation of the child should address the basic question of whether the patient has a psychiatric disorder (or disorders) that may respond to psychotropicsâ€Â� (p. 343). If this inquiry is answered affirmatively, a complete physical examination (sometimes including laboratory tests), psychosocial history, and baseline behavioral assessment must be conducted. The contribution of the child therapist to this process is extremely valuable. A final concern must be the consideration of alternative and/or concurrent treatment approaches in the psychiatric intervention with children. Green (1995) stressed that treatment with psychotropic drugs must be part of a more comprehensive treatment regimen and as such is rarely appropriate as the sole intervention for children. The effects of concurrent treatment interventions and environmental influences should be considered when examining the efficacy of psychopharmacology (Bukstein, 1993; Green, 1995; Wilens et al., 1998).



Pharmacologic Treatment of Childhood Disorders

Although children are brought in for psychiatric evaluation primarily to address unwanted symptoms, treatment planning generally occurs according to diagnostic category. Table 1 provides a summary of DSM-IV (American Psychiatric Association, 2000) diagnoses and the medications that may be indicated. Attention-Deficit Hyperactivity Disorder: ADHD has been the most researched area in the psychopharmacological treatment of children (Spencer, Biederman & Wilens, 2000). The most commonly prescribed medications for the ADHD diagnosis are the stimulants: Ritalin [methylphenidate], Dexedrine [dextroamphetamine], Adderall [mix of amphetamine salts], and Cylert [pemoline].

Cylert is now used much less frequently due to concern over possible liver dysfunction. The manufacturer of Cylert now recommends bi-weekly blood tests. The antidepressants Effexor [venlafaxine] and Wellbutrin [bupropion] are also used with ADHD. Tricyclic antidepressants (Tofranil [imipramine], Pamelor [nortriptyline], and Norpramin [desipramine]) have also been used successfully and safely, although tricyclics are used less frequently due to cardiac events that have led to the deaths of several children. Some psychiatrists recommend discontinuing use of desipramine with children altogether. Catapres [clonidine] and Tenex [guanfacine] are frequently used to augment partial responses to stimulants. There is, however, some concern over the safety and efficacy of these medications with children.

Affective Disorders: Although prescribing antidepressants for children is a common practice, their efficacy in treating childhood depression has been difficult to establish. The medications commonly used include Effexor, Zoloft [sertraline], Paxil [paroxetine], Prozac [fluoxetine], and Celexa [citalopram]. Wellbutrin and Serzone [nefazodone] are occasionally used, and the tricyclics are now used less frequently. Monoamine oxidase inhibitors (MAOIs) are generally not prescribed for children due to the severe dietary restrictions that are required. Lithium is sometimes used to augment a partial response to antidepressants. For symptoms of mania, lithium and anticonvulsants, such as Depakote [valproic acid] and Tegretol [carbamazepine] have been used. Neuroleptics (also known as antipsychotics) and benzodiazepines can be used to treat the acute agitation of mania. Long-term use of neuroleptics for the treatment of bipolar disorder is not recommended because of the risk of tardive dyskinesiaâ€"involuntary movements that can result from the use of neuroleptics.

A Anxiety Disorders: Because they have a better safety profile, the newer SSRI antidepressants are most often used in the treatment of child anxiety problems. In addition to the antidepressants, benzodiazepines, such as Xanadu [alprazolam] are used with children having separation anxiety disorder. Obsessive-compulsive disorder has been shown to respond to SSRI medications, such as Zoloft, Paxil, Prozac, Celeriac, Luvs [fluvoxamine], and Anafranil [Gewurztraminer]. Treatment of post-traumatic stress disorder (PTSD) is generally based on the treatment of Comoran anxiety or mood disorders. Antidepressants are used most often. Indexer [propranolol] and Catapults have also been used.

According to clinical reports, both antidepressants and benzodiazepines may be helpful in treating children with panic disorder (Popper, 1993). Schizophrenia: Onset of schizophrenia in prepubescent children is rare, as is research in this population (Pomeroy & Gadow, 1998). The newer atypical antipsychotics, Risperdal [risperidone] and Zyprexa [olanzapine] are progressively being used as an initial intervention. High potency neuroleptics, such as Haldol [haloperidol] and Navane [thiothixene], likely cause less problems with learning (but more problems with stiffness) than low potency neuroleptics such as Mellaril [thioridazine] and Thorazine [chlorpromazine], which are more sedating (Campbell & Spencer, 1988). Clozaril [clozapine] has been used in some adolescents showing a poor response to traditional neuroleptics. It is only infrequently used with children. Enuresis: The initial approach to enuresis should involve behavioral methods or a bed alarm.

After these approaches have failed, medication may be quite appropriate. The antidiuretic hormone, DDAVP [desmopressin] is administered intranasally or in pill form. Low doses of tricyclic antidepressants are also used. Relapse following discontinuation of medication is common. Sleep Disorders: Although sleep disorders in children are not commonly medicated, some psychiatrists use Benadryl [diphenhydramine] for brief periods for children and adolescents experiencing difficulty falling asleep. Catapres is also used to treat the insomnia that may be associated with stimulant use. There is increased use of Remeron [mirtazapine] and Desyrel [trazodone] for sleep difficulties. Some benzodiazepines, such as Valium [diazepam] and tricyclics, have been prescribed for night terrors and sleepwalking.

Tourettes Syndrome: Haldol and Orap [pimozide] are used to reduce tic behaviors (Gadow, 1991; Green, 1995). The tics may also respond to Catapres. Some of the newer antipsychotics, such as Risperdal, have shown some efficacy with tics and have a lower rate of tardive dyskinesia. Using the new neuroleptics may avoid the serious cardiovascular side effects that may be associated with clonidine. Aggression: Aggression, while not a diagnostic category itself, is a common complaint and cuts across many diagnostic categories. Successful intervention considers comorbid symptoms such as impulsivity, depression, bipolar disorder, and psychosis. Antipsychotics have been effective in reducing aggressive behavior in hyperactive and conduct-disordered children, as well as children with mental retardation and autism. Because of the risks associated with these medications, they should be used long term only after other options have failed. Lithium, Inderal, and Tegretol have also been used to treat aggression.

Depakote may also be of some benefit. Other Disorders: The diagnosis of an eating disorder itself does not call for the use of pharmacotherapy. Severe anxiety, obsessive-compulsive symptoms, or psychosis that may accompany the eating disorder symptoms may be treated with appropriate medications. Likewise, severe depression may be treated with an appropriate antidepressant. Studies with adults have noted that antidepressants can decrease the severity of binge eating (Mayer & Walsh, 1998). In general, developmental disorders are treated according to specific indications. This is another area where the newer atypical antipsychotics are finding increased use. Take help from telephone psychologist .Neuroleptics, such as Haldol, and Trexan [naltrexone], an opiate antagonist, have been used with positive results in children with autism (Green, 1995; Kutcher, 1997). Again, children on neuroleptics must be monitored closely for the development of movement disorders. Comorbid symptoms associated with developmental disorders such as anxiety, depression, obsessive-compulsive behavior, and hyperactivity may be treated accordingly.