Therapeutic and Side Effects of Psychotropics

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Published: 07th July 2010
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Antidepressants: Use of the newer antidepressants (SSRIs, Effexor, Serzone, Remeron, and Wellbutrin) in children now exceeds that of the older tricyclic antidepressants primarily because of the lack of risk for severe cardiac side effects. The antidepressants may have side effects including gastrointestinal discomfort, headaches, sleep and behavioral disturbances, and weight loss or gain. Remeron is sedating and is often associated with significant weight gain. Because of these side effects, it is now occasionally used with children having the side effects of appetite and sleep difficulties due to the use of stimulants. Wellbutrin is contraindicated in persons with a history of seizures or tics, and can cause weight loss.





Although prescribed for depression, enuresis and ADHD are the only established indications for the tricyclics. Tricyclic side effects are dry mouth, constipation, blurred vision, weight change, and decreased blood pressure. Treatment requires electrocardiographic monitoring, and the monitoring of blood serum levels is recommended. Tricyclics are the most lethal of the psychotropics in an overdose. Psychostimulants: The stimulant medications commonly used with ADHD children are very well researched and considered safe and effective (Barkley, DuPaul & Costello, 1993). Common side effects include insomnia, decreased appetite, and headache. Less frequently, they may cause agitation, enuresis, and depression. Rarely, tics and psychotic symptoms may occur. Antipsychotics: The neuroleptic medications are used with a variety of symptoms and disorders. These include psychosis, bipolar disorders, aggression, and tic disorders. Common side effects include dry mouth, constipation, blurred vision, sedation, stiffness, and in some cases of chronic administration, tardive dyskinesia.



The newer atypical antipsychotics may lead to significant weight gain, but also are less likely to be associated with tardive dyskinesia. Cogentin [benztropine] and Benadryl are anticholinergic medications commonly used to treat stiffness caused by the neuroleptics. Lithium: Lithium is used for bipolar disorders in children, to augment the treatment of depression, with schizoaffective disorder, and with aggression. Common side effects include polyuria, polydipsia, gastrointestinal upset, tremor, nausea, diarrhea, weight gain, acne, and possible thyroid and renal effects with chronic administration. Treatment requires monitoring blood serum levels, and thyroid and kidney tests. Electrocardiogram [EKG] monitoring has also been recommended Antianxiety Agents:

The benzodiazepines, although used sparingly with children, have been administered effectively with sleep disorders and in overanxious and avoidant children. Possible side effects are drowsiness, disinhibition, agitation, confusion, and depression.



Other Medications: Catapres, although indicated for hypertension, has been successful with Tourettes symptoms, ADHD and aggression. Possible side effects include sedation, hypotension, dry mouth, confusion and depression. There have been recent concerns about the potential for clonidine to cause serious cardiac events. Tenex is similar to Catapres, but is longer acting and less sedating. Inderal has been administered for anxiety disorders, aggression, and self-abusive behaviors. The potential side effects are essentially similar to clonidine. Its use is contraindicated in the presence of diabetes or asthma. Depakote and Tegretol are anti-convulsant medications used in bipolar disorder and aggression. Possible side effects include bone marrow suppression, dizziness, sedation, rashes and nausea. It requires blood serum monitoring.



Medicine and Child Therapy

The child therapist who is educated about the basics of child psychopharmacology is a better advocate for his or her client, both in the therapy room and in the psychiatrists office. An initial consideration is the advantage of doing therapy with an appropriately medicated child. The concurrence of pharmacotherapy and child therapy could provide the ideal milieu for a child. If medications could increase the capacity for benefiting from child therapy and are not prescribed, the potential efficacy of the therapy is diminished. Many researchers now advocate concurrent psychosocial interventions as being crucial to the lasting therapeutic effects of psychoactive agents (Brown & Levers, 1999; Campbell, Godfrey & Magee, 1992). The psychosocial effects of medication on the child are an issue very appropriately dealt with in the child therapy setting.



Taking medications, particularly A C evaluation for the prescribing physician. The baseline assessment necessary to appropriately initiate pharmacotherapy is often inadequate if the psychiatrist must rely solely on parent report and observation of a child in an office. The child therapist will often have greater insight into the childs basic mental status. Providing this input is not only an ethical obligation, but is clearly in the best interests of the child client. The child therapist also provides valuable interpretation of the childs therapy activity. It is possible to misinterpret a childs in-session behavior if that behavior is being acted out by an unmedicated child who is in legitimate need of psychopharmacological intervention. For example, a childs agitated shifting from one activity to another may be an indication of personal anxietyâ€"due to the new experience of being in the room, getting closer to intrapsychic issues, and so forth.



It may also be that the child is an undiagnosed ADHD client who would appropriately respond to stimulant medication. Some children may be improperly medicated for biologically-based symptoms, when in fact, the child is behaviorally responding to an emotional trauma or inappropriate parenting.

For example, a child who has been severely physically or sexually abused may respond by enacting bizarre defense mechanisms, to protect against further adult intrusion. These bizarre behaviors may be interpreted as some level of psychosis, which would appear to indicate the need for neuroleptic medication. These behaviors may well ameliorate in the child therapy process, where the safety of boundaries and the therapeutic relationship make processing of emotional pain possible. A final issue that the child therapist might consider is in working with the child who is uncooperative with psychiatric treatment. It is not uncommon to work with children who are noncompliant with respect to taking medications. In addition to the basic opportunity to process their possible anger, frustration or over an extended period of time, may affect the childs or adolescents self-concept. It could begin a process of chronic self-esteem difficulties.



The child who is medicated may identify himself or herself as being a â€"problem, and may further identify the medication as a mechanism of control. Child therapy should provide a child with an opportunity to learn self-control, to respect themselves, to make choices and to accept themselves (Landreth, 1991). Golden (1983) noted in his play therapy work that a child can restore a sense of mastery when being medically treated through the playâ€"â€"the goal of the play therapist is to help the child become involved in his or her own treatment (even if only in some small way) and to help the child retain a sense of competence (p. 226). A related issue is where medications are presented as a coercive form of behavioral control rather than as a therapeutic adjunct (Gitlin, 1995).



Although this is hopefully an exceptional situation, the perceived need by parents, teachers and therapists for an instant panacea may lead to this concern. Children in this case have not only lost a sense of power and control, but have been manipulated and intruded upon. Child therapy offers these children opportunities to process these issues. Children can begin to make sense of, and bring organization to, their confusing world. They can manage an unmanageable situation through the fantasy of a play therapy or other expressive intervention.



They can express the grief and anger that often result from being â€"controlled in the above manner. The attitude of both parents and children towards psychotropic medications is related to both compliance and efficacy (Rappaport & Chubinsky, 2000). The valuable contribution that a child therapist might offer to the psychiatric assessment was noted previously. With the proper authorization to release information, the child therapist is in a unique position to provide both initial input and ongoing fear in their own language, the therapist has the opportunity to utilize directive techniques if deemed appropriate. This may involve cognitive or expressive techniques, such as structured doll play, artwork or storytelling.



Conclusion

The child therapist has an obligation to be educated on issues of child psychopharmacology. There is additionally an obligation to the profession-at-large. Biederman (1992) noted that the longterm outlook for pediatric psychopharmacology is dependent on research to balance the potential risks with the real benefits to suffering children. Child therapists must be a part of this process, which will certainly progress with or without child therapy input. Psychiatrist, Greg Fisher, asserts that â€"…it is important to realize that medication is just one part of the treatment plan, and it is imperative that one tend to the patients full spectrum of needs, including his or her spiritual needs.



It is also imperative that the prescribing physician collaborate closely with the childs Christian counselor (1997, p.27). An element of this process must involve a willingness to interact and cooperate with the medical profession. Certainly in the same way that child therapists need education on psychiatric matters, the psychiatrist may need education about aspects of child therapy. As previously noted, multidisciplinary cooperation advances the best interests of the children and the profession. One therapist noted a common frustration and a compelling view of medication: â€"There used to be a sense of shame when you put clients on medication. It was like an admission of failure that therapy wasnt working, and that you, the therapist, had to get help (Markowitz, 1991, p. 26). The real shame would be to remain ignorant. Awareness, growth, and balance will help map the better future of becoming competent caregivers and advocates of our children.



Ross J. Tatum, M.D., is a board-certified child and adolescent psychiatrist in private practice. He speaks and writes on child and parenting issues. Take help from telephone psychologist .



Daniel S. Sweeney, Ph.D., is an associate professor of counseling and clinical director in the Graduate Department of Counseling at George Fox University, and director of the NW Center for Play Therapy Studies.

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