School Nurse funding

I met with the Grants Liaison at the office of U.S. Congressman Dale Kildee today to discuss the House bill 2730: Student-to-School Nurse Ratio Improvement Act of 2009. This was an informative meeting where I was able to educate the Congressman's office of our current situation in the school district where I serve; there are two nurses for 9,000 students. Mr. Bennett, the Liaison, was very interested and helpful in advising how bills go through Committees and how they ultimately become tabled or passed. Today, Congress had reconvened from recess specifically to address emergency funding for states to retain teachers and provide support staff. The Liaison did note that while this bill is in its early stages, it will need more support to move through the process. Please take a look at the school districts your children attend; do it have nursing services? Do you have health needs that must be addressed while your child is at school? If you are concerned about the health and safety of our youngsters while they are at school, please notify your Representative in Congress that you ask for support of House Bill 2730, and it's corresponding Senate Bill 2750.

Student-to-School Nurse Ratio Improvement Legislation

Did you know there is a bill introduced by Representative McCarthy of New York that would legislate the improvement of the number of students per school nurse in public elementary and secondary schools? H.R. 2730, the "Student-to-School Nurse Ratio Improvement Act of 2009" has 32 co-sponsors and currently is in committee. This bill would offer grants through the Centers for Disease Control to reduce the numbers of students that school nurses now serve. The recommended ratio of nurse to student in this act is 1:750; this number seems far more manageable than the current number of students I and fellow Michigan nurses currently serve, 1:4274! Michigan is at the bottom of the list in school nurse to student ratios, and this is detrimental for the increasingly complicated health care issues that nurses deal with on a daily basis in the public school system. I am scheduled to meet with the Constituent Liaison for the U.S. Congressman for my district here in Michigan tomorrow; I will be posting more on this subject in the future. In the meantime, please study this bill. H.R.2730. I will post the supporters of this bill in my next entry, and ask that you consider writing or calling your Representative in support of this critical piece of legislation. It may be one answer for continuing to provide life-saving care in the Public Schools in the face of drastic budget cuts.

Psychiatric Drugs: Deadly Reaction

I am sorry it has been so long since my last post, but there is a serious situation I witnessed the past two weeks that parents of children on Psychiatric medications need to be aware of.

I know a 6 year old youngster who is currently on a regime of medications that frightens me: Focalin XR, Risperdal, Lamictal, Clonidine, and Benzotropine all at lunchtime! Focalin is an ADD medication, Risperdal is an antipsychotic, Lamictal is a seizure medication (used here for mood stabilization), Clonidine is a blood pressure medication (used here for calming effects), and Benzotropine has antihistamine properties. This little boy just turned six!

Two weeks ago, he had a small, dime-sized pinpoint rash on his lower cheek. I was aware that Lamictal is a medication that can have a deadly rash side-effect if the body can not process this medication; however this resembled a small "whisker burn", as if he had hugged his dad before school. In fact, I called home and dad did confirm a big hug and kiss before school that morning.

Later in the day, a dime-sized raised area appeared on the opposite cheek. Again, a call home and the parents reported this to the psychiatrist who ordered to stop the Lamictal immediately. Three days later, the child appeared at school with a pinpoint rash over his stomach and back, and he was listless and sleepy. He was running a fever of 102. The parents took him to the Emergency Room, where tests showed nothing abnormal, he was given IV fluids and sent home.

Three days later, he returned back to school with a full body rash that is dark red to purple in color, with large spots that have filled in to create a skin color in many areas that is red/purple. His face is swollen, his eyes are swollen, and he has a blank facial expression. My thoughts were that this child is now in the process of experiencing Stevens-Johnson Syndrome, a rare serious disorder in which the skin and mucous membranes react severely to a medication. This can be deadly, because the skin affected can slough and die, large areas of skin can become infected, and the person may need treatment similar to having had a severe burn.

Parents, please be very aware of the medications your child is taking, and the side effects or warnings that might accompany that medication. I will keep you posted on the status of this young child.

Thyroid Disorders: ADHD/Bipolar Copycat

In my first several posts I explored the new treatment regimes for ADD/ADHD and Bipolar diagnoses in children. If you haven't read those posts, please take a moment to read posts named
"Medicating Children for Behaviors" of June, 2009. In those posts, I discussed the new multi-medication treatments for ADD/ADHD and how this diagnosis is frequently evolving into a new diagnosis of Bipolar Disorder. Today, powerful antidepressant medications and antipsychotic medications seem to be regularly added to the prescribed stimulant medications in effort to combat symptoms of ADD/ADHD and Bipolar. All these medications I have seen prescribed regularly in children under the age of 6!

Something that you as parents should be aware of before any medications are prescribed is that the thyroid hormone plays a powerful role in emotions, thought and behavior. The thyroid gland is located in the front of the neck at the "adams apple". Every cell in the body depends upon thyroid hormones for regulation of their metabolism. Too much thyroid hormone is called hyperthyroidism; too little thyroid hormone is called hypothyroidism.

According to the Thyroid Foundation of Canada, hyperthyroidism and hypothyroidism have symptoms that appear to look like mental illness. People with too much thyroid hormone may be anxious, impatient and irritable, and emotionally explosive. They may also be easily distracted, over active, sensitive to noise, have problems with sleep and appetite. In extreme cases,
they may appear schizophrenic, losing touch with reality and becoming delirious or hallucinating.

The Thyroid Foundation of Canada states that people with too little thyroid show slowing of mental processes, poor memory, loss of interest in activity, depression and paranoia, and eventually, if not treated, dementia and permanent harmful effects on the brain.

For each condition, people have been wrongly diagnosed and treated unsuccessfully for mental illness. Please review these symptoms again; note that symptoms of hyperthyroidism are very close if not exactly the symptoms of ADD/ADHD. Note also that the symptoms of hypothyroidism could easily be the symptoms of depression, and depending upon the activity level or effects on the brain, the symptoms of Bipolar Disorder.

Imagine the young child treated with a multitude of stimulants, antipsychotics and antidepressants when the undiagnosed problem is actually Thyroid disorder. Please keep this in mind if you are seeking medical help for a child with behavior difficulties.

Source: http://www.cchr.org/media/pdfs/The_Thyroid_and_the_Mind_and_Emotions_by_Awad_Professor_of_psychiatry.pdf

Chicken Pox: What's going on?

During the 2007-2008 school year, something very interesting happened with our elementary school aged students. We had a chickenpox epidemic, affecting approximately 33% of the student population in our 500-student elementary school.

It started in October 2007 with one kindergarten student was sent to me showing 7 raised blisters on his head and face. I thought it resembled chickenpox; admittedly I was rusty on this childhood illness as it had become more rare since the introduction of the chickenpox vaccine. The student had all of the symptoms of chickenpox:

He had a sore throat, had a slight fever, his parents reported that he had been sick over the previous weekend with an upset stomach and a cough. Now, the raised blisters on his face were itching to the point that he could not stop scratching.

Reviewing the vaccination history, this child had received the chickenpox vaccine when he was about 12 months old, as recommended by the CDC. In fact, in 2005, the chickenpox vaccine was required for every child in Michigan before entering school.

It was first thing in the morning, so to be more comfortable with assuming a chickenpox possibility, I counted the blisters and logged them on a diagram. My next step was to recheck in one hour while contacting the local Public Health Department. One hour later, the blister count had increased to 16, with new blisters in the scalp and abdomen. The child was sent home with the presumption of chickenpox. He was taken to his pediatrician, and unfortunately, the chickenpox diagnosis was denied. The reason--he had had the vaccine as an infant.

Within 2 weeks, similar symptoms were showing up in our elementary school students across the board; attempts to contain the illness to grade-level, or geographic location in the school building was impossible. I was reporting to the Public Health Department 5-15 students weekly with chickenpox. By Christmas, pediatricians in the city were confirming the diagnosis. By Easter, the chickenpox had affected approximately 180 students, all of whom had had the vaccine as an infant.

But here is another interesting question that remains unanswered: This epidemic was limited to elementary school students only. No older siblings in the Middle School or High School were affected. While this question continued to be raised by myself and the local Public Health Department, by the end of the school year letters were sent by the Health Department to all school age children in our district encouraging a chickenpox booster shot as recommended by the CDC.

In 2007, the new CDC guidelines for chickenpox vaccination:

1. All healthy children 12 months through 12 years of age should have two doses of chickenpox vaccine, administered at least 3 months apart. Children who have evidence of immunity to varicella do not need the vaccine.
2. People 13 years of age and older who do not have evidence of immunity should get two doses of the vaccine 4 to 8 weeks apart.
3. Chickenpox vaccination is especially important for certain groups of susceptible adults.

**An interesting side note for further discussion; my own child erupted in chickenpox on the last day of school in 2005 at the age of 7. He had had the vaccine at age 18 months along with his older brother and sister, who were vaccinated at age 4 1/2 and 6 years old. Neither of the older children showed any signs of chickenpox during or after his illness.

While the CDC denies any change in effectiveness of the vaccine based on the age of the person receiving the dose (see http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm "Risk factors for Vaccine Failure"), why is it that in these two incidents, children who received the vaccine at an older age did not develop the chickenpox when exposed to their siblings with active chickenpox who had received the vaccine as infants?

Atopic Dermatitis: Uncontrollable Scratching

Over the years, I have had elementary school children sent to me with a red, raised itchy rash on the inside creases of their elbows and behind their knees. Sometimes, the rash is also noted on the back of the neck, in the armpits, and along the jawline. Frequently, the student is also known to have asthma, with an inhaler or nebulizer used at school. Often, the teacher is concerned about something contagious, such as chickenpox or scabies.

These signs and symptoms usually result in a diagnosis of atopic dermatitis. This is a noncontagious skin condition that starts in infancy and is most notable by about the age of 3 months. It is a form of excema. The child will show bright red, raised and bumpy skin on the cheeks and chin. Soon, the red patches appear in the creases of the elbows and behind the knees. The child will rub the itchy areas until the skin is raw and weepy. Some respiratory problems might be noticed at this time, such as coughing or runny nose.

As the child develops into a toddler and preschooler, it is obvious that something occurs with the skin in a course that has flare-ups and total remission. I have dealt with this condition affecting my own child for 14 years. With my child, the flare-ups would occur on the first warm day of spring. Instantly, her cheeks would become swollen with reddened hives, she would begin scratching her arms in the elbow creases, her legs behind the knees, and the skin folds under her eyes would become visible. She would scratch until the skin was scraped raw, and the areas would become weepy. Attempts to cover the itching skin was futile; the area was too great and any covering would stick to the weepy skin. Asthma symptoms would then start, with coughing and wheezing evolving into need for a nebulizer. Interestingly, by the fall and winter, the skin condition that had once defined our summers was a distant memory.

By the time the child is school-aged, the itch-scratch cycle is evident if not predictable. The rash location is very predictable: behind the knees, in the creases of the elbows, the armpits, behind the ears, at the neck and the jawbone. Scratching is uncontrollable, especially while the child is sleeping. The skin in the creases becomes thick and leather-like. Asthma or other breathing problems usually accompany the rash.

Criteria used to diagnose atopic dermatitis include: itching skin in a cycle that is preceded by some type of irritation (for my child, we believe it is warm weather and sweating); remissions; early onset, such as in infancy; changes in the skin as time passes (such as leathery or discolored skin).

Treatment is designed to combat three problems:
1. Avoiding the irritant if it can be identified
2. Preventing the itch-scratch cycle
3. Treating the rash if it develops

Avoiding the irritant is easier once you are able to identify the problem. For my child, we believe it is triggered by heat. Therefore, we attempt to keep her indoors on hot days and have air conditioning to keep her cool at night. Air conditioning helps in two ways: it improves the asthma symptoms and keeps night time scratching to a minimum.

Preventing the itch-scratch cycle starts with keeping other irritants to a minimum by using mild soap only, such as unscented Dove; unscented laundry detergent; and mild shampoo. Use an unscented moisturizer such as Cetaphil to keep the skin from becoming dry and leathery. Have the child wear cotton gloves to bed to prevent nighttime scratching ( a pair of cotton socks on the hands at night works well also). The doctor may prescribe an antihistamine at night to keep the itching under control.

Treating the rash will depend on the prescribing physician. A steroid cream is often effective, and the physician will recommend using it only during flare-ups to avoid side effects from long term use.

Research shows that this condition may be hereditary, and usually lessens in intensity by puberty and early adulthood. In the meantime, vigilance in watching for triggers, preventing the itch-scratch cycle, treatment during flare-ups; and remaining aware of respiratory complications should help the child remain more comfortable until the condition lessens with age.

Over-the-Counter Multi Symptom Medications: Overdose Risk!

This week the FDA released a report that it is considering warnings on over-the-counter multi symptom cold and flu products. The problem is one that I have had concerns about for years: many of these products contain acetaminophen, the pain reliever found in brands such as Tylenol and Exedrine. That alone is not a problem; however, when acetaminophen is an ingredient in many products that might be used together to treat such illnesses as a cold or flu, the potential for overdose is great. According to the FDA report, from 1998 to 2003, acetaminophen was the leading cause of liver failure in the United States. 48% of those cases were from accidental overdose.

Consider the average parent going to the drugstore hoping to find medication to help their child's cold symptoms. The child is coughing; has a stuffy, runny nose; is running a slight fever; and has a headache. He picks up some cough medicine, a decongestant, and some children's pain reliever for the headache and fever. Unless the parent is knowledgeable about the generic names for medications, what he did not see when he stared at the shelves and shelves of cold and flu products is that many of the medications he picked up were combination medications. These may have been labeled to address one of his child's symptoms, but had other ingredients in the formula.

Examples of generic names for symptom-relieving medications include: acetaminophen, a pain reliever; phenylephrine HCL, a nasal decongestant; guaifenesin, a medication to liquify thick mucus; diphenhydramine, an allergy medication; and dextromethorphan, a cough suppressant.

In my own medicine cabinet, I have found a children's cough medicine that has an additional label in small print "and nasal congestion". I also have a cough medicine that has in an additional label in small print "chest congestion, sore throat". So, liquid medication was purchased intending to control a cough, and in addition, expectorant, nasal decongestant, and acetaminophen were also included in these medications.

If I had not known the purpose of these additional medications, (or didn't have my reading glasses on), I probably would have treated my child with a pain reliever for the sore throat and maybe even a dose of nasal decongestant as well if the child was too stuffy to breathe! My child would have been double-dosed on both acetaminophen and decongestant.

The examples of these multi symptom medications are too numerous to list all here. Watch for labeling such as "cough and cold" (which could have all of the medications I listed above), "nighttime" (which might have an antihistamine product as well as a pain reliever), "daytime" (which may have a number of ingredients), "cold and flu" (which may have all the medications I listed above).

My recommendation would be to study the generic names of all the over-the-counter medications you purchase; know what they are and their intended purpose. Know the side- effects of each medication, and the dosage recommended for your child (or yourself for that matter). Consider purchasing only single-symptom medications, and give only those medications that address the symptoms that your child is experiencing.

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.