Straight Talk about Psychiatric Medications for Kids
342
Straight Talk about Psychiatric Medications for Kids
342eBookFourth Edition (Fourth Edition)
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Overview
New in the Fourth Edition:
Extensively revised to include the latest information about medications and their uses, the fourth edition is even more accessible, and includes pullouts, bulleted lists, and "take home points" highlighting critical facts.
Product Details
| ISBN-13: | 9781462525898 |
|---|---|
| Publisher: | Guilford Publications, Inc. |
| Publication date: | 03/14/2016 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 342 |
| Sales rank: | 1,018,660 |
| File size: | 1 MB |
About the Author
Paul G. Hammerness, MD, is Assistant Professor of Psychiatry at Harvard Medical School and Medical Director of Outpatient Psychiatry at Boston Children’s Hospital. Board certified in child and adolescent psychiatry, Dr. Hammerness is an experienced clinician, educator, and researcher.
Read an Excerpt
Straight Talk about Psychiatric Medications for Kids
By Timothy E. Wilens, Paul G. Hammerness
The Guilford Press
Copyright © 2016 Timothy E. Wilens and Paul G. HammernessAll rights reserved.
ISBN: 978-1-4625-2589-8
CHAPTER 1
The Preliminaries
Building a Foundation of Knowledge
It's never easy to face the fact that your child has symptoms of a mental health problem. A tough situation becomes harder when, like most parents, you know little about the subject of childhood psychiatric disorders and their treatment. It's even more difficult when misconceptions and myths 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 suspects your child has a mental health disorder, for which treatment, possibly medication, may be necessary. Or you may be wondering whether medication could help your child now that a long-standing problem is worsening and no longer manageable by other means, such as psychotherapy or school services. 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 alarmed.
Remember, regardless of how you have come to this point, you're not alone. More and more people — parents and professionals alike — are realizing the importance of seeking psychiatric treatment for children and the potential benefits of psychiatric medications. The field of child psychiatry is not as young as it was when this book's first edition came out, and every year brings greater awareness and progress.
One of the major challenges is that while doctors look for commonalities, every child's situation is unique, complex, and evolving. A child psychiatrist's foremost role is to conduct a thorough evaluation of the child's problems and to thoughtfully consider a range of available solutions. As we will reinforce throughout this book, you have the 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, medication or other. The entire evaluation, diagnosis, and treatment process should be a collaborative effort between you and your child's health care providers. Saying "I'm trying to understand how you came to that conclusion — can you walk me through it?" is one means of ensuring that the process remains collaborative.
In general, it's best to stay as open-minded as possible as you approach the issue of medications for your child. Objective information gathering will help you make the best possible decision. Try not to let fear of the unknown sway you before you tap all the sources of information available. Later in this chapter, we'll go into more detail about when medication generally benefits children and how it works. (For more specific information, consult the chapters in Parts II and III that cover your child's disorder, if it has already been diagnosed, and any medication that has already been recommended.) 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.
Why does the pediatrician think my child needs medication?
Let's talk first about the practical reality. The pediatrician is most likely recommending medication because of concern about your child. The recommendation is based on the degree of emotional suffering (sadness, anxiety) seen or described. The doctor might also be recommending medication because your child has not responded to supportive efforts at home or school or to therapy. These are both reasonable considerations as long as the threshold applied to your child is the same as would be applied to another child in the pediatrician's practice. For example, anxiety that is present all day, every day, and is keeping your child from attending school is an appropriate threshold for medication, versus anxiety that is present only once a week, in certain situations. If you're uncertain, ask the pediatrician what he or she considers a severe enough problem to warrant medication. And ask similar questions about the other treatments your child has tried: Was it the right therapy? Did we try it long enough before turning to medication?
Another rationale for recommending medication would be to treat an underlying biological deficiency or imbalance, such as a low level of a brain chemical needed for healthy energy and mood. We hope that as our knowledge of child emotional health matures we'll be able to identify the specific causes of emotional and behavioral disorders in youth. Unfortunately, while we suspect a biological deficiency underlies emotional illness for many children, at present there is no blood test or brain scan to prove a medical etiology for a child's psychiatric disorder. In the absence of such testing we look for other evidence, and one place to look is in the family. If many members of a child's extended family have similar problems, the condition may have a medical etiology due to a genetic abnormality — that is, it might be a disorder passed down along generations. From a medical standpoint you can consider this evidence of an inherited problem.
Let's say your 10-year-old daughter has developed some unusual repetitive hand-washing rituals. As you talk about your concerns at a family birthday party, you're surprised to hear about a grandparent, an uncle, and several cousins in your family with "OCD" (obsessive–compulsive disorder). This "family loading" of a psychiatric condition increases the chance that your daughter's rituals will continue and develop into a full disorder because of an inherited condition. Compare this to your neighbor's child, who had a similar period of heightened focus on hand washing, without any family history, and it just passed without concern.
Attention-deficit/hyperactivity disorder (ADHD) is another well-known example of a psychiatric disorder that runs in families. Scientists believe that the impulsivity, short attention span, and other symptoms associated with ADHD are caused by a specific, inherited problem in the brain. Ongoing research is investigating the very specific pathophysiology of childhood mental health disorders like ADHD. Much of the attention is on the processes by which chemical messages are passed between nerve cells (neurons) in the brain. Possibilities include abnormally low levels of brain chemicals being produced in a neuron, so the message needed to control focus or to ignore environmental distractions is not sent to the next neuron, or dysfunctional receptors in a receiving neuron so the message is not received.
Even if a disorder has a medical or biological cause, such as abnormal brain messaging, the onset as well as the degree of any given child's problems may depend on environmental factors. Factors in a child's environment typically involve home and/or school stressors. In the case of 7-year-old Molly — whose parents both suffered from depression — feelings of sadness, isolation, and withdrawal began after the death of her grandmother, continued for 8 months, and were accompanied by failing at school and social withdrawal. We suspected that the stress of losing her grandmother had triggered in Molly a major depressive episode stemming from a biological predisposition (i.e., genetic risk) toward mood disorders.
Similarly, 12-year-old Joy had become withdrawn, apathetic, and listless for many months following her dog's death. A tendency toward depression that she may have inherited from her mother appeared to be activated by the trauma of losing her beloved pet. Joy's withdrawal from family and friends only served to increase the environmental impact on her psychological health by removing needed support.
Fascinating research suggests that environmental factors such as the loss of a loved relative (or pet) can cause brain changes that may be similar to inborn abnormalities. Medications may help to correct abnormal brain functioning regardless of the cause, inherited or environmental or, most likely, a mixture of the two.
We hope to offer more certainty about the causes of psychiatric disorders in the years to come, but at present your child's pediatrician is most likely basing his recommendation for medication on the perceived degree of suffering and/or lack of response to other treatments. In the future doctors may be able to prescribe a medication specifically targeting the known medical cause of your child's disorder, perhaps based on a blood test or a certain type of brain imaging.
It's also possible, however, that increased knowledge about the causes of psychiatric problems in the future could support recommendations for nonmedical treatments. For example, a brain abnormality could be found that indicated a need for a treatment other than medication, such as a certain type of therapy or nutritional supplement.
Are there other options besides medication?
Yes, there is a wide range of nonmedical treatments. One primary form of nonmedication treatment is psychotherapy. Psychotherapy (informally called "therapy") is often an appropriate starting point for the treatment of mental health problems in children when the distress or impact on a child's day-to-day functioning is relatively mild. Many forms of therapy exist, so your child's practitioner should prescribe a specific type of therapy. Check the chapter in Part II that addresses your child's problem for more specific information on treatment choices.
These days, some child psychiatrists provide therapy alone or in combination with prescribing medication. This model of psychiatric care is typically found in "private practice." Commonly in private practice you pay the psychiatrist outside of insurance, meaning you pay the full cost of the session, not simply a copay. Some insurance plans may allow you to submit the bill, however, and you may be reimbursed for some portion of the session's cost. Appointments are typically 45–50 minutes long and can occur weekly, monthly, or less frequently.
In comparison, in a clinic setting, medications are usually prescribed by a psychiatrist and therapy is conducted separately by a psychologist, social worker, or other mental health professional. Appointments with the psychiatrist are typically 15–30 minutes long and occur monthly or less frequently. These appointments are billed to your insurance, with you being responsible only for copays.
The many varied forms of therapy available for children and families include:
• Interpersonal and dynamic-oriented therapies
• Social skills training
• Family therapy
• Cognitive-behavioral approaches
Regardless of the type, it's always important to understand and help to define the specific goals of therapy for your child. Therapies tackle the core issues of psychiatric disorders as well as the secondary effects.
For example, a therapy may aim to improve a depressed child's way of thinking about himself and his future, help a child with Tourette's disorder lessen disruptive shouting out (i.e., tics), or teach a teenage girl with an eating disorder to regain the proper perspective on the role of food in her life. Jason, a 13-year-old with ADHD, had very few friends at school and fought with his siblings at home. Over time Jason improved his ability to be patient and a better listener in a form of therapy called social skills training. While not "cured," his impulsivity became more under his control. Family therapy, involving a fair amount of education for Jason's siblings and attention to consistency in his parents' parenting approaches, led to a calmer, less reactive household. Therapy and medications together may have a very powerful additive, long-lasting effect as compared to either treatment alone, but success depends on using the right kind of therapy and medication for the disorder and the specific, unique needs of the child, and often the family too.
Working with children and families in therapy provides the opportunity to move back and forth between what may be the central, initial "cause" of the family strain (e.g., a rageful depressed teen) and the "effect" on the family (e.g., parents yelling back or avoiding the teen). Specific styles of parenting often develop partly in reaction to the hardwired personality (temperament) of a child, and those parenting styles may in turn affect the child's development. Therefore it's difficult to disentangle whether the child is acting a certain way based on a particular parenting style or whether the parent is reacting to the child's biologically based problem. In some cases, of course, the rageful depressed teen is reacting to parents who are highly conflicted and avoidant themselves.
A clear-cut case of confusion between cause and effect involved a 14-year-old girl whose severe OCD continued to keep the family awake at night despite 6 months of family therapy. Emily spent every night checking to be sure that doors were not left ajar and that all of the electrical plugs were pulled out of the outlets. The family felt frustrated and hopeless, and the therapist hypothesized that the family's anger was the cause of Emily's unusual behaviors. While her treaters were well intentioned, the problem began with a hasty discussion between parents and primary-care doctor and led to the wrong type of family referral. The inappropriate therapy referral led to the wrong therapeutic approach. Fortunately the therapist recognized this over time and referred the family to child psychiatry. After 1 month of medication, Emily's compulsive and ritualistic behaviors greatly diminished. Almost immediately, the family reported reduced conflict in the home, as well as improved relationships between the various family members and Emily. As is the case for many of the children we see, the child's emotional or behavioral state greatly disrupts the family, and positive interactions can become scarce. Education and therapy with parents and family members can significantly improve family relationships.
If you're not sure you understand why a certain type of therapy is prescribed, ask the practitioner to list your child's specific needs. Do you concur with the list? If not, review these needs with the doctor; don't hesitate to offer parental insight. Once you and the doctor agree on a list of needs, ask the doctor to outline the therapies that address each need before you agree to pursue one or more of them.
Could my child get better without treatment, medication or otherwise?
The good news is that a number of mental health disorders that affect children can improve with time. Separation anxiety can lessen with time. Children with oppositionality commonly outgrow their argumentative features as they mature. Another common example is ADHD, which is thought to lessen considerably into adulthood in roughly half of the children affected, particularly the hyperactive–impulsive symptoms of the disorder.
However, postponing treatment may lead to future problems born of years of demoralization and poor self-esteem. Justin, for example, had a social anxiety disorder and began avoiding social situations despite wanting friends at the age of 10. When he showed up at the office at age 17, he had so fully isolated himself that despite gains with medication and therapy, he remained socially disconnected and lonely.
In thinking about the natural course of psychiatric problems, the type of problem may be less important than the severity, in terms of predicting which child may get better over time without treatment. Children with more severe problems (or with more than one psychiatric disorder) are more likely to have continued problems without treatment.
(Continues...)
Excerpted from Straight Talk about Psychiatric Medications for Kids by Timothy E. Wilens, Paul G. Hammerness. Copyright © 2016 Timothy E. Wilens and Paul G. Hammerness. Excerpted by permission of The Guilford Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
IntroductionI. What Every Parent Should Know about Psychiatric Medications for Children
1. The Preliminaries: Building a Foundation of Knowledge
2. The Psychopharmacology 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. Anxiety-Related Disorders
7. Mood Disorders
8. Autism Spectrum Disorder
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 Alpha Agonists and Antihypertensives
17. The Antipsychotics
18. Medications for Sleep, Bedwetting, and Other Problems
Appendix A. Representative Medication Preparations and Sizes Used for the Treatment of Childhood Emotional and Behavioral Disorders
Appendix B. Medication Log
Resources
Bibliography
Interviews
For Parents and other caregivers seeking a reliable, accessible source of information; and mental health professionals, who may wish to recommend the book to clients.