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: 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.