Duncan Gill, M.D.
The Use of Psychiatric Medication in Children and Adolescents
There are few issues in psychiatric practice today that stir up so much controversy as the subject of using medication with children and adolescents. It’s a subject I’ve become very familiar with in my work with children and families, and one that remains complicated, challenging, and always worthy of discussion and consideration.
I’d like to stress up front that medication certainly isn’t the only treatment available for children and adolescents who appear to have emotional or psychiatric difficulties. Much of the work we do is helping parents sort out what’s “normal” and what’s not for children and adolescents at certain ages. We can also be of assistance in the helping parents develop strategies for dealing with their child’s problematic behavior at home, school, or in the community. For many of the children and adolescents who do need services, we believe strongly that individual, family, or group therapy is the way to go.
And there are times when we do make recommendations involving the use of medication. Most parents are initially apprehensive about this prospect, and understandably so.
The fact of the matter is, however, that – like adults – there are some kids out there who simply do much better on medicine than off medicine. For them, therapy and the other treatment interventions I previously mentioned may be only partially helpful, or not helpful at all. Often, these kids have parents who have or have had similar problems, whether it be problems with anxiety, moodiness, depression, trouble paying attention, or whatever. Their problems seem to have to do less with – and sometimes not at all with — what’s going on around them. They seem more internal (or “biological”) than external (or “environmental”). Sometimes it is very difficult, if not impossible, to separate the two types of problems. More often, it’s a mixture of the two.
The point is, for some kids with the more “biological” psychiatric symptoms, the right medication can be extremely helpful. At times, it works like absolute magic. It makes such a difference in a child or adolescent’s daily life that it makes all of the hassle and risk of taking medicine in the first place worth it. Sometimes, for some kids and adults, medicine is literally lifesaving, just as it is for high blood pressure, diabetes, infection, or any other serious medical problem. I’ve worked with some parents and children who were totally opposed to the use of medication initially and ultimately came back to see me months later to give it a try, and now they swear by their medication. Many say they wish they had tried it sooner.
Common Parental Questions and Concerns About Use of Medication in Children
1. “How do you know if my kid will respond to medicine? How do you know which medicine will work with my kid?”
To be perfectly honest, we don’t know. But, based on knowledge about psychiatric disorders in children, and based on clinical experience, we have a good idea who will respond to medication and which medication is likely to be the most helpful. But the only way to know for sure is to try.
2. “I don’t want my kid looking like a zombie or all doped up.”
That makes two of us! Any side effect causing a kid to look like a zombie, feel over-sedated, spacey, anything like that, is unacceptable – the medication needs to be changed or stopped. As I tell all my patients (and their parents), I don’t want them taking any medication that makes them feel funny, lightheaded, or anything else they don’t like. And I don’t want them taking a medicine if they don’t think its helping.
3. “How long will my kid have to take medication?”
That depends. Starting on a psychiatric medication is not a life sentence – the vast majority of medications are easy to start and stop, though we do recommend discussing any treatment change with your doctor beforehand. Many kids “outgrow” certain types of psychiatric problems. Some don’t. Some problems wax and wane over the years. It’s a decision we can make together over time, and, ultimately, the decision is the parents’.
4. “What about side effects?”
Side effects are possible with any medication. The question is whether the potential benefits of the medication outweigh the potential risks of trying it, and that is something you can only determine on a case-by-case basis by talking with your doctor. For every medication (over-the-counter or prescription), you can obtain a list of all known possible side effects: some mild and more common, some serious and more rare. Psychiatric medications are no different. The good news is that most of the newer psychiatric medications (since the 1980’s or so) are relatively safe. Many patients don’t experience any side effects at all. If they do, it’s up to them whether they think it is worth continuing the medication or not.
5. “I just saw this T.V. Program (or newspaper article, or internet posting, or whatever) saying that Ritalin (or Prozac, or Depakote, or whatever) causes stunted growth (or homicidal rages, or sterilization, or hair to turn green, or whatever).”
Definitely any concern is worth talking to your doctor about. However, a word of caution: there is tremendous variability in the quality, accuracy, and scientific merit of coverage of mental health issues provided by the media. There are some programs and articles that do a good job of it, some that don’t do a good job, and some that are frankly awful. The problem is that it can be very difficult for people who don’t work in the field to tell which is which. So I’d advise folks to discuss any concerns with your doctor, but also to be wary of where your information is coming from.
6. I’ve heard that many medications used in child psychiatry aren’t really approved for use in children and adolescents. It is true that there are very few medications that have received official Food and Drug Administration indications for treating psychiatric disorders in children and adolescents?
The few that have been approved tend to be older medications, for the simple reason they have been around longer. As an example, Prozac has been around since the early 1980’s, but it did not receive the indication to treat depression in children and adolescents for about 20 years. There are a number of factors that result in long delays before medications receive FDA approval for certain disorders, the most important of which is the great difficulty in conducting the types of rigorous studies the FDA requires. Probably the biggest hurdle is the ethical dilemma of conducting tests with children and adolescents (who cannot consent themselves to the studies the way that adults can).
Nonetheless, based on the information we do have (including the results of so-called open-label medication studies, our understanding in treating adults with the same medications, and an ever-growing body of knowledge in child psychiatry based on clinical experience as opposed to research experience), many of us believe that some of the “non-approved” medications are effective in treating a range of psychiatric disorders. Thus, many of the medications we prescribe are “off-label,” because there is either not yet an “approved” alternative for children and adolescents, or because we believe the “approved” alternative is less safe or more likely to cause side effects.
7. What happens if I decide not to try medication that has been recommended for my child?
(And this is certainly every parent’s prerogative.)
The short-term answer to this question is easy: nothing will happen. On the plus side, there is no risk of a child’s having an adverse reaction to a medicine he or she isn’t taking.
The long-term answer is harder. As mentioned earlier, some problems improve with time, some get worse, and some wax and wane. In a sense, this approach carries its own risks as well. A child or adolescent with poor attention and hyperactivity in school may continue to struggle in the classroom and with peer relationships. Kids with significant anxiety may be avoidant of things they are anxious about to the point they miss out experiences important to their growth and development. Kids with significant mood disorders may miss out on enjoyment of their childhood and teen years. Some find themselves getting into more trouble, and some are more likely to turn to alcohol and drugs in an attempt to feel better. Some feel unhappy enough that they think about killing themselves, and, unfortunately, some ultimately commit suicide. And so on.
The trick is to balance the risks of taking medication with risks involved in doing nothing, or relying exclusively on other treatment strategies. And that can be a hard call for all of us sometimes.
Ultimately, the decision to try medication with children and adolescents is one that is made by parents and their children. This decision can be a very difficult one for some families. Our job is to review with you all treatment options for your child, and, if medication appears to be one option that may be helpful, provide you with information to make this decision easier.