Medicating children for behaviors: antidepressants and anticonvulsants

(This is entry #7 in a series of posts regarding medicating children for behaviors)
In my previous posts, I have lead you down the winding road of medications currently being used to treat ADD/ADHD. It is no longer a disorder for which the child receives a stimulant medication and everyone is satisfied. In an alarming new treatment trend, additional medications such as antipsychotics, blood pressure medications, anticonvulsant (seizure) medications and antidepressants are now being added to the daily medication schedule.

Ritalin, Adderal and Concerta are the stimulant medications most commonly prescribed for ADD/ADHD. Today, they are available in a long-acting form initially intended to allow the child to fore go a lunchtime dose and still receive the calming effects of the medication for the entire day. The frightening new trend I am seeing regularly is the long-acting medication is prescribed for both morning and lunchtime, resulting in an overlap of medication in the latter part of the day. Predictably, when this higher dose of stimulant takes effect, the child becomes nervous, agitated, refuses to eat, shows mood swings and explosiveness. When this behavior is demonstrated, parents seek additional medical help, and the child is often diagnosed "bipolar."

According to the National Institute of Mental Health, youth with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode.

Antidepressant medications often prescribed for "bipolar" are Trasadone, Tofranil, Zoloft, Prozac, Paxil, Remeron, and Sinequan. According to manufacturers' labels, many of these medications come with their own risks of side effects, including: irritability, acne, headaches, sleep disorders, and emotional side effects. You should know that the FDA has issued a "black box warning" for worsening depression and suicidal thoughts in adolescents using antidepressants. Further, some antidepressant medications change the liver's ability to break down other medications, potentially causing a dangerously high level of some medications in the bloodstream.

Doctors who prescribe antidepressants for bipolar disorder usually prescribe an anticonvulsant medication to be used as a mood stabilizer at the same time. The anticonvulsant medications most commonly prescribed are Tegretol, Trileptal, Depakote, Neurontin, Lamictal and Topamax. Again, according to manufacturers' labels, many of these medications come with their own risks of side effects, including: drowsiness, headache, constipation and diarrhea. However, Depakote may cause a reduction in blood count levels, or an inflammation of the liver. The risk of liver damage is increased when Depakote is used with other anticonvulsant medications in children under the age of 10 years. Now combine this risk of liver damage with the liver problems associated with antidepressants; these drugs are routinely being prescribed together!

Please take the time to read all of my previous posts discussing this subject; my hope is that this information will help you to wade through all of the advice, recommendations, expectations, and fears which will inevitably come with parenting a child with behavior difficulties.

Medicating children for behaviors: antipsychotics

(This is entry #6 in a series of posts regarding medicating children for behaviors)
Today, I would like to address the new treatment approach for ADD/ADHD that includes the use of antipsychotic medications along with the stimulants. Antipsychotics are medications developed to treat psychoses such as schizophrenia; most have black box warnings against the use in children under the age of 6. As I have previously discussed, I am now seeing these medications used routinely in the treatment of ADD/ADHD. The most frequently prescribed antipsychotics are: Risperdal, Zyprexa, Seroquel, Geodon, and Abilify. It is most important that you, the parent know as much as possible about these medications before allowing treatment of this type for your child.

Side effects of the antipsychotics can be two-fold: temporary but annoying side effects; and permanent, irreversible, crippling side effects for which another type of medication must be prescribed to combat.

Common temporary side effects of antipsychotics are drowsiness, constipation, blurred vision, increased appetite, and weight gain. I have witnessed adolescents gain as much as 20 pounds after 6 months on Risperdal; night time eating is the most common complaint.

Side effects to be particularly aware of are those showing uncontrollable movements of various muscle groups. These are called extra pyramidal symptoms, and may lead to a permanent condition called Tardive Dyskinesia. Observable effects that need to be reported to the doctor immediately are:

1. Muscle tightness or spasms, especially in the face

2. Head tilt or repeatedly turning the head to one side

3. Mouth and tongue movements; such as puckering lips, smacking lips, grimacing, sticking out tongue

4. Finger movements

5. Feet and leg movements; such as tapping toes, twisting ankles, or hip movements while seated

If these side effects are noted in the child receiving antipsychotic medications, you and the doctor need to weigh the risks versus the benefits of the medication. These movements may become permanent; so the treatment for tardive dyskinesia is usually removing the medication. Immediate discontinuation may lead to even more severe symptoms for a short time, so the medication should be slowly weaned. If you and the physician agree to continue with the antipsychotic medication, the next step is to mask the involuntary movements with medications commonly used for Parkinson's Disease. These medications could include Benedryl, Cogentin, Klonopin, and Inderal. Keep in mind, adding medications to combat side effects of other medications can bring a host of additional concerns. ADD/ADHD can suddenly be something for which the child is now taking one or two stimulants, an antipsychotic, and then a Parkinson's medication as well. Again, please weigh the benefit versus the risk of this medication regime.

In my next post, I will discuss the antidepressant medications.

Medicating children for behaviors: stimulants

(This entry is #5 in a series of posts regarding medicating children for behaviors)
My intention today was to write about the antidepressant medications, but I needed to address an FDA communication which you may have read about since my last post.

On June 15, 2009 the FDA issued Communication about an Ongoing Safety Review of Stimulant Medications used in Children with Attention-Deficit/Hyperactivity Disorder (ADHD)

Essentially, this study compared the sudden deaths of U. S. children by two means: 564 children who died suddenly in motor vehicle accidents, and 564 children who died suddenly with no known health problems.

The conclusion of the study:

1. Out of 564 healthy children who died suddenly with no known health problems, 10 were reported to be taking a stimulant medication at the time of death.
2. Out of 564 healthy children who died suddenly in motor vehicle accidents, 2 were reported to be taking a stimulant medication at the time of death.
3. The study authors concluded that there may be an association between the use of stimulant medications and sudden death in healthy children.

While there are limitations to this study, including a significant lag time between the deaths and the data collection, the FDA reports that it is continuing to study the risks of stimulant medications used to treat children with ADD/ADHD. Data collection for a new study should be complete by the end of 2009.

The FDA recommendation issued on June 15, 2009:

Follow all the current prescribing information for use of these medications, including:
1. Take a medical history for cardiovascular disease in the child and his or her family.
2. Perform a physical exam with special focus on the cardiovascular system (including examination for the signs of Marfan syndrome).
3. Consider obtaining further tests such as a screening electrocardiogram and echocardiogram if the history or examination suggests underlying risk for or the presence of heart disease.
4. Any child who develops cardiovascular symptoms (such as chest pain, shortness of breath or fainting) during stimulant medication treatment should immediately be seen by a doctor.

The FDA contends that this study does not mean that they are advising health care providers to discontinue prescribing these medications. However, the FDA does state that they are considering whether this information warrants further regulatory action.

Please note the FDA is continuing to study the stimulant medications . This is quite frightening alone, but review my earlier posts and my observation that stimulants and long-acting stimulants are often prescribed together, perhaps along with blood-pressure medications, antipsychotics, and antidepressants. It certainly bears a closer look in weighing the benefits versus the risks of these medications. Please take some time to do so.

Medicating children for behaviors; the basics

(This entry is #4 in a series of posts regarding medicating children for behaviors)
What exactly makes up a "disorder" that needs to be treated with medication? ADD/ADHD is the most common psychiatric disorder that doctors treat in children. The symptoms that characterize ADD/ADHD are impulsiveness, easily distracted, inability to maintain attention, and often hyperactivity. If this sounds to you like the average preschooler or school-age child, you're not alone. It is my observation that every child comes with his or her own personality traits; some are calm, sensitive to others, stay on task, easily soothed, and accept change with rational behavior. Others are more reactive, easily frustrated, have difficulty accepting changes in schedule, strong-willed, give up easily if unsuccessful. These differences are really the fabric of our society; each person is different with skills and abilities that are unique to them.

So how does a physician identify ADD/ADHD? The DSM IV Handbook is the tool accepted by the American Psychiatric Association for diagnosing mental disorders. It's intent is to provide clear descriptions of behaviors in order to properly diagnose and effectively treat the disorder.

Please read the DSM IV diagnostic criteria for ADD:

http://edschool.csuhayward.edu/departments/ted/instruction/howe/5500/ADD-DSM-IV.html

Couldn't these criteria apply to any average 4-10 year-old? Some of my own children have displayed most, if not all, of these behaviors from age 4 until today! I think the difficulty here is in #1 and #2 :
"a degree that is maladaptive and inconsistent with developmental level."

With these descriptions in mind, could the following criteria not apply to any preschooler or teenager today:
Inattention
1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
Hyperactivity
1. often fidgets with hands or feet or squirms in seat
6. often talks excessively
Impulsivity
7. often blurts out answers before questions have been completed
8. often has difficulty awaiting turn
9. often interrupts or intrudes on others (e.g., butts into conversations or games)

Do you understand where I am going with this? Treatment options are divided into two categories, family counseling and medication. Medication is not the accepted first line treatment for ADD; it is generally accepted as a treatment option after counseling has not been successful.
The question for you as parents would be: Is this a medication issue, one that has symptoms so unique that it must be classified as a disorder? If this is the case, I would suggest treatment by a very experienced physician to identify the medical component of the child's behavior difficulties.

Or is this a parenting issue, one that needs your full commitment to discipline and consistency, not just today and tomorrow, but for the long-haul; consistency even when you have corrected the child on the same behavior 10 times today, and 10 times per day for the last 5 years? Consistency when it would be much easier to look away "just this once" so you don't have to deal with it again when you are "burned out" for today. You and your doctor are the only ones who know the situation well enough to identify the difference. Many people may try to direct you one way or the other; since the choice to medicate or not is a very important one, only you and your doctor should decide what is best for your child.

Spend some time thinking these questions over until my next post. We will look at medication side effects in greater detail.

Medicating children for behaviors; underlying dangers

(This entry is #3 in a series of posts regarding medicating children for behaviors)
In my first two posts I discussed the frightening new approach for ADD/ADHD treatment which often includes an added diagnosis of "bipolar" (the former name for this was "manic-depressive"). The source of this additional diagnosis, I believe, is very predictable. Stimulant medications such as Ritalin, Concerta or Adderal are prescribed for the initial diagnosis of ADD/ADHD. When side effects of increased dosages of stimulants lead to agitated, combative or explosive behavior in the child, the new method of treatment adds antidepressant or antipsychotic medications in attempt to quell this predictable behavior and label it with a new diagnosis of "bipolar". Unfortunately, most of these medications contain a black box warning against the use in children or teenagers.

A black box warning means that medical studies indicate that the drug carries a significant risk of serious or even life-threatening side effects. Black box warnings on medications frequently prescribed for bipolar include: Desyrel (trazadone), Paxil, Prozac, Remeron, Seroquel, Tofranil (imipramine), and Zoloft. In 2006, the FDA recommended a black box warning for Ritalin due to adverse affects on the heart ; a month later the warning was removed by an FDA advisory panel.

What should this mean to the average parent struggling for answers about the treatment of their child? Education about every medication that is prescribed is necessary: What is the medication? What classification is this medication (such as stimulant, antipsychotic, antidepressant, blood pressure medication, antihistamine)? What is it being prescribed for? Are additional medications being prescribed to combat predictable side effects from others? What are the long-term benefits of the medication versus the risks?

This is a very complicated issue. Only in the past decade have I witnessed medications of this nature prescribed to our youngest school age children; 5 year-olds are receiving long acting stimulants along with the antidepressants, antipsychotics and blood pressure medications I've just named all in the same "hand full" at lunchtime! I am concerned about how their immature bodies can process this assault to their systems.

In my next post, I will try to simplify this. We will start with understanding the basics, then move into more detailed descriptions about medications--risks and benefits.

Medicating children for behaviors; a harsh new reality

(This entry is #2 in a series of posts regarding medicating children for behaviors)
In the 1970s and 80s, children who were deemed "attention deficit" or "attention deficit hyperactive" were started on a new wonder drug, Ritalin. This stimulant medication is thought to have a calming effect on children diagnosed with ADD or ADHD by increasing activity in the brain thereby improving attention. Long term affect on the brain is still unknown as it has been used only for the time span of one generation. It remains unapproved for children under the age of 6. This was the medication that I was handing out to the school children in the 1980s (see post from June 1, 2009).

Today, Ritalin, Adderal and Concerta are the medications most commonly prescribed for ADD/ADHD. They are available in a long acting dose, initially intended to be given in the morning and providing therapeutic calming for the entire day. What I have found to be a frightening new trend is the long acting forms of these medications are now being prescribed for both morning and lunchtime administration. So as the long acting morning medication is continuing to release its prescribed dosage, a second dose is now being started at lunchtime; in effect, two long-acting dosages are being released into the body at the same time, overlapping each other. The child is then receiving more than the prescribed dose during the overlap time.

General side effects of stimulants such as these are loss of appetite, growth retardation, weight loss, heart palpitations, and headache. When the long-acting forms are prescribed for both morning and lunchtime, these side effects are even more pronounced. Keep in mind these are stimulants, medications often sold on the black market, stronger than the caffeine in coffee or today's energy drinks. The child becomes nervous, agitated, refuses to eat lunch, shows mood swings and often becomes explosive (similar to our response when we have had too much coffee on an empty stomach). When this response occurs, the parents seek additional medical help; too often, the youngster is then diagnosed "Bipolar".

With the secondary diagnosis of Bipolar, the current method of treatment now seems to be prescribing psychotropic medications. These are the medications I discussed yesterday:
Abilify, Seroquel, Risperdal are antipsychotics (intended for schizophrenia but used "off label" for bipolar disorder); Trasodone, Tofranil, Zoloft, Prozac and Remeron are antidepressants; Clonidine and Tenex are blood pressure medications (used here to treat the insomnia brought on by the stimulants); and Tegretol, Trileptal, Depakote, Topamax and Lamictal are seizure medications (used here to treat mood instability or "explosiveness" brought on by stimulants). Each of these medications have powerful and permanent side effects. They all have warnings against use in children less than age 6; many have "black box warnings", citing extreme caution if using. I will discuss those in my next post.

Medicating children for behaviors

There is an interesting story in the Miami Herald today; interesting because this is my first post and the story discusses the most pressing issue I have found with children's health in the past 15 years. The disturbing trend of medicating children for behavioral difficulties, whether identified by the parents or the teacher, began in the 1970's with medications such as Ritalin for ADD or ADHD. I experienced this first hand as a Public School Health Nurse in 1985. At lunchtime, a line of small children started at my office (located in the main school office) and ran out the door, down the hall and around the corner. What were the children lined up for? In the words of several students I remember clearly, "I need my bad boy medicine", "I need my medicine so I can be good today", "I need you to call my mom to see if I had my bad girl medicine this morning". The recollection of these statements make me shudder even today, almost 25 years later. These youth of my memory are now adults, most likely with children of their own today. Each day, they lined up in front of the rest of the student body to receive the medication which, to their young minds, would make them be "good."

Today's Miami Herald story brings behavioral treatment into present day. The story reports a finding that 31% of all children in the Florida foster care system are being prescribed behavioral drugs. Today, however, those drugs are not limited to Ritalin. Today, as reported in the Herald and witnessed in my own practice, powerful antipsychotic drugs are prescribed for identified behavioral difficulties. Such medications include Risperdal, Seroquel, and Abilify. Even more alarming, these medications are being prescribed for children under the age of 6!

Please read the article in the Miami Herald today: http://www.miamiherald.com/news/southflorida/story/1086735.html

In my next post, I will discuss these medications in more detail, the black box warnings, and the permanent side effects of these medications.