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; 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.