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.