• The symptoms are severe enough to cause the child/youth distress or dysfunction, to interfere with his or her physical health, or to interfere with healthy psychological and social development.
• A doctor has done an adequate evaluation and has concluded that:

1. At least some of the symptoms are likely due to a brain-based disorder, that is, not due only to psychological and social difficulties.
2. Any realistic treatment plan that did not include medicine would be unlikely to reduce the symptoms in a timely fashion.
3. The medicine being considered would be likely to reduce the symptoms and unlikely to cause serious side effects.

• The parents and child or youth:

1. Understand the reasons for taking medicine (for children, this should be explained in terms they can understand).
2. Are aware of the common side effects as well as any uncommon but potentially serious side effects.
3. Agree to try the medicine.

• Medicine is one part of an overall treatment plan, which may include therapy, skills training, parent counseling, special education services, learning about the disorder, etc.
• The prescribing doctor will order any necessary labs and the doctor, parent and child/youth will meet regularly to monitor progress, adjust the medicine and watch for any side effects.

What disorders are treated with medicine? Medicine is nearly always part of the treatment of moderate to severe ADHD, psychotic disorders, severe depression, and bipolar disorder.  Then there are other conditions where medicine may or may not be used as part of the treatment. This group includes most anxiety disorders, moderate depression, agitated or aggressive behavior, and sleep difficulties.   As a rule, medicine is not indicated for rude or defiant attitude, planned aggression, or the intentional breaking of rules.  However, medicine may be helpful if an underlying brain disorder (such as a mood disorder or ADHD) is contributing to the problem. How do medicines work? Neurons are the most important cells in your brain.  You have about 100 billion of them and they are incredibly interconnected, using chemicals called neurotransmitters to communicate with one another.  Psychotropic medicines affect this communication, and I encourage you to visit web sites that will tell you more than you ever wanted to know about serotonin, dopamine, GABA and other neurotransmitters.  As you visit those sites, keep two things in mind.  First, although we know some of the ways that medicines affect the brain, we do not yet know for sure how they reduce psychiatric symptoms.  Second, thanks to all the researchers out there, we will know this in a few years.

Commonly prescribed medicines
The following table includes psychotropic medications that doctors typically prescribe to children and youth.  However, it does not include every medication that could be used, it does not include every last medicine that a doctor might recommend for a given disorder, and it is in no way a substitute for your doctor’s judgment and advice.

Every prescription medicine has a generic name and at least one brand name.  The names used for medication classes (the first column on the table) can be confusing.  SSRI “antidepressants” are also used to treat anxiety and some antipsychotics are also effective mood stabilize

 

 

Attention Deficit Hyperactivity Disorder (ADHD)

 

DEPRESSION

 

ANXIETY

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OBSESSIVE COMPLULSIVE DISORDER

PSYCHOTIC SYMPTOMS
(includes hallucinations, delusions, and very disorganized thinking)

Medication class	Generic name	Brand name
“Atypical” or “second generation” antipsychotics	Risperidone	Risperdal
	Quetiapine	Seroquel
	Olanzapine	Zyprexa
	Ziprasidone	Geodon
	Aripiprazole	Abilify
	Clozapine	Clozaril
	Paliperidone	Invega
“Typical” or “first generation” antipsychotics	Chlorpromazine	Thorazine
	Thioridazine	Mellaril
	Trifluoperazine	Stelazine
	Perphenazine	Trilafon
	Haloperidol	Haldol

 

BIPOLAR DISORDER & MOOD LABILITY
 (“mood lability” means to sudden mood changes)

Medication class	Generic name	Brand name
Atypical antipsychotics	See Psychotic Symptoms, above	See Psychotic Symptoms, above
Lithium	Lithium	Lithobid, Eskalith
Anticonvulsants (seizure medicines)	Valproic acid or Divalproate	Depakene, Depakote
	Carbamazepine	Tegretol
	Oxcarbazepine	Trileptal
	Topiramate	Topamax
	Lamotrigine	Lamictal
	Gabapentin	Neurontin
Atypical antipsychotic + antidepressant	Olanzapine + Fluoxetine	Symbyax

 

INSOMNIA (difficulty sleeping)

Medication class	Generic name	Brand name
Antihistamines	Diphenhydramine	Benadryl
Melatonin	Melatonin	Melatonin
Antidepressants	Trazodone	Desyrel
	Imipramine	Tofranil
Zolpidem	Zolpidem	Ambien
Adrenergic agonists	Guanfacine	Tenex
	Clonidine	Catapres

 

Pills and prescriptions Except for very young children, just about anybody can learn to swallow a pill: place it on the back of your tongue, tip your head back a little, and drink something to wash it down.  A child taking a capsule (which, unlike a tablet, floats) may have more success with the following technique: put the capsule on the back of your tongue, drink fluid so that it stays in your mouth, tilt your head forward little (the capsule will float toward the back of the mouth), then swallow.  Some medicines are available in liquid preparations.  Others come in capsules that can be opened and sprinkled on a spoonful of applesauce, yogurt or pudding, but check with your doctor before you do this with because not every medicine works correctly if sprinkled.  Do not sprinkle capsules into a glass of liquid, bowl of cereal, etc. because too much of the medicine may be left behind.  Do not sprinkle medicine into hot liquid.

Will a pillA number of medicines are available in slow-release forms.  These versions tend to have brand names ending in letters such as –XR (extended release), –ER (extended release), –CR (controlled release) or –LA (long-acting). 

 still work properly if you cut it in half?  It depends on the pill.  Capsules and most slow-release medicines (including Concerta) should not be cut.  Check with your doctor about your specific medicine.

You don’t have to understand the abbreviations used in prescriptions, but if you want to, here are some common abbreviations.  QD means daily, BID twice daily, TID three times daily, and QID four times a day.  PO is “by mouth.”  QAM means “ach morning” and q HS means “at bedtime.” Milligrams are “mg” and milliliters of liquid are “ml.”  PRN means “as needed for.”  NTE is “not to exceed.”  A horizontal line with one or more vertical lines under it and the same number of dots above it stands for a number: one line and one dot means “1,” two lines and two dots mean “2,” etc. 

How long does medicine take to work?
Most psychotropic medicines build up gradually in the bloodstream and take days or even weeks to be effective.  However, some medicines take effect quickly – within 15-45 minutes – and wear off in a matter of hours, or at least by the end of the day.  This group includes stimulants for ADHD (some of which last up to 12 hours), as well as Clonidine and certain benzodiazepines.

Side effects
“Side effects” are the unwanted effects of medicine.  They are different for each medicine and vary from person to person.  Usually, if a medicine causes any side effects at all, they are mild and/or temporary, but all medicines have the potential to cause serious and even dangerous side effects.  Sometime side effects (mild drowsiness, for instance) occur when a medicine is started and disappear on their own within a few days or a week.  Your doctor can give you written information about possible side effects of your medicine.  Tell the doctor if any side effects do occur so he or she can advise you about your options.

How long should a person take medicine?
This varies so much from one situation to another that the best thing I can tell you is to ask your doctor. The answer depends on the individual person, the severity and persistence of the disorder, and the responsiveness of the disorder to psychosocial interventions and to medication.

Parent & youth responsibilities

As partners with the doctor in the medication management process, parents and youth have some responsibilities.  Parents may need to remind their child to take the medicine.  Parents or youth should tell the doctor about any side effects.  Medicine should not be increased without consulting the doctor.  Similarly, medicine should not be discontinued without consulting the doctor, since suddenly discontinuing certain medicines that have been taken on a regular basis may cause side effects and can even be medically dangerous. 

Good medication management requires meeting regularly with the doctor, so it is important to keep your follow-up appointments.  Be prepared to give the doctor the following information:

People sometimes feel shy or intimidated at doctor’s appointments, but do your best to speak up.  Express your concerns, ask questions, share your ideas, and indicate your preferences.

Educate yourself about mental health and medication.  It is easy to locate web sites about specific medicines and specific disorders, such as http://www.chadd.org/ for ADHD and http://www.bpkids.org for bipolar disorder.  Here are some reliable web sites about psychotropic medicines for children and youth:

Lab tests and psychological testing
For purposes of evaluation, depending on the situation the doctor may recommend blood tests to look for medical problems, an EEG (electroencephalogram), psychological testing, neurological examination or a CT or MRI brain scan.  Scientists use advance brain scans (FMRI, PET, SPECT, etc.) to study the brain, but most experts agree that these are not reliable for clinical use.

Blood tests and/or an EKG (electrocardiogram) are checked prior to prescribing medicines that may reduce blood cells or platelets or that may affect the functioning of the heart, liver, kidneys or pancreas.  A few medicines – including Lithium and Depakote – require blood tests on a regular basis for as long as they are being taken.

FDA approved Most psychotropic medicines prescribed for kids are not “FDA approved” for that age group.  This is because FDA approval depends more on the business decisions of pharmaceutical companies than on the results of research. When scientists at a pharmaceutical company develop a new medicine or identify a new use for an existing medicine, the company submits its research for review by the Federal Drug Administration (FDA).  “FDA approved” means the FDA has determined that the company can market the medicine as safe and effective for certain disorders among people in a certain age group.  FDA approval does not restrict how doctors can prescribe the medicine.

Since most pharmaceutical company research is done with adults, most medicines are initially FDA approved for adults.  But researchers at universities continue to study the medicine – including its use in younger patients.  They publish their findings in professional journals.  If their research shows the medicine to be safe and effective in children and youth, doctors in practice will start prescribing the medicine to that age group.  In the end, if no pharmaceutical company decides to undertake the expensive process of seeking FDA approval in kids, the medicine will never be FDA approved for that age group.  If research and clinical experience support the use of a medicine as safe and effective, the fact that it is not FDA approved is not – and should not be – an obstacle to doctors prescribing it.

Suicide Risk
A lot has been written about the possibility that certain medicines – especially antidepressants – might cause some people to feel suicidal.  Research demonstrates clearly that the most commonly used antidepressants (SSRI’s) are effective for serious depression in adolescents and that they reduce the incidence of suicide in this age group.  However, as of mid-2008, it is still not clear whether a small number of children, adolescents and young adults experience new suicidal thoughts when they start taking an antidepressant.

As a practical matter, precautions against suicide and self-harm are necessary for any depressed child or adolescent, whether or not they take an antidepressant.  This includes (a) the parent, child/youth and doctor discussing the risk of suicidal feelings; (b) parents and mental health professionals “checking in” with the child/youth about this during the first month or two of treatment with medicine (or as long as significant depressive symptoms persist); and (c) the child or youth agreeing to tell a responsible adult if they experience any suicidal feelings. 

What about kids who take an antidepressant medicine for a condition other than depression, e.g., for an anxiety disorder?  Given the current research, it is wise to take the precautions listed above with any child or youth taking an antidepressant medication, regardless of the diagnosis.

The possibility of suicide is of course frightening to any parent.  Every situation is different and research continues to be done on this issue, so if you have any questions about it, talk with your doctor.

Medicines and self-control
People sometimes have the notion that psychotropic medicine is prescribed to “control” a person’s behavior.  In my experience, medicines simply cannot do this – except for making someone fall asleep, which, except for sleeping pills, is never a good reason to take medicine on a regular basis.

Serious mental illness is an obstacle that limits a person’s options. A person simply has less choice over his actions if he is impulsive because of ADHD, compelled to wash his hands repeatedly due to Obsessive-Compulsive Disorder, unable to think rationally due to psychosis, weighed down with hopelessness due to depression, or quick to become aggressive due to a disorder of mood regulation.  The point of taking medicine is not to control your behavior but to reduce symptoms that get in your way.  When a medicine is doing what it is supposed to do, a person should find more options available to them.  They should experience not less but more control over themselves and their lives. 

This article was prepared in July 2008 for UACF by Mark Edelstein MD, Board Certified Child and Adolescent Psychiatrist and member of the UACF Board of Directors.  Dr. Edelstein is a past president of the California Academy of Child and Adolescent Psychiatry.  He has three children.

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