About Medication

by Dr. Mark Edelstein

This article is an introduction to psychotropic medicines prescribed to children and youth.  Every child is unique, and this information is not intended to recommend specific treatment or to substitute for medical advice from your doctor.

UACF encourages you to share information from this article.  You may quote or copy any portion of it provided that you identify UACF as your source.

Topics addressed in this article are:

What is psychotropic medicine?
The evaluation
When does it make sense to take medicine?
What disorders are treated with medicine?
How do medicines work?
Commonly prescribed medicines (including a table of medications)
Pills and prescriptions
How long does medicine take to work?
Side effects
How long should a person take medicine?
Parent and youth responsibilities
Lab tests and psychological testing
FDA approved
Suicide risk
Medicines and self-control

What is psychotropic medicine?
All of us have our ups and downs, but when difficulties with mood, behavior or the thought process interfere with a person’s well-being or ability to function, treatment may be needed.   For children and youth, treatment may include individual therapy, family therapy, parent counseling, skills training, behavior therapy, or other interventions.  In most cases, medicine is not needed, but for certain mental health conditions, medicine is necessary and can be very helpful.

Just as some disorders involve the lungs or heart, there are disorders that affect the brain.  Symptoms of a brain disorder may be neurological (such as seizures and migraines) or psychiatric – for example, inattention, anxiety, depressed mood, hallucinations and confused thinking.  “Psychotropic medications” are medicines prescribed to reduce behavioral, mood and cognitive (thought) symptoms of brain disorders.

Managing medication includes decisions about the type of medicine, decisions about when to increase or decrease the dose, monitoring and addressing side effects, etc. Parents and children/youth are partners with the doctor in the medication management process.  Becoming educated about psychotropic medicines allows you to be a more effective partner.

You may have noticed that I use the words “medicine” and “medication” interchangeably.  In fact, I prefer “medicine.”  To my ear,  being “on medication” gives the sense that someone is doing something to you that is supposed to fix you, while “taking medicine” speaks to what the whole process should really be about: you yourself taking action to treat something that is a problem for you.  Language can be subtle but powerful.  For instance, we pick up medicine at the drug store, I avoid calling medicines “drugs,” because this confuses two different groups of psychoactive chemicals: those that are prescribed in order to reduce problematic symptoms, and those such as alcohol, nicotine and illicit substances that are taken recreationally. 

The evaluation
The most important meeting you will have with the doctor is the first one: the evaluation.  An evaluation is all about collecting and analyzing information on order to arrive at an understanding of the reasons behind the child/youth is having difficulties.  A solid evaluation is the foundation of good medication management. 

In the evaluation, the doctor meets with the parents and child/youth to learn about them and their concerns.  The doctor asks about the child’s medical history, how the child is doing in school and with friends, past mental health services, and more.  Unless it has been done recently, a physical exam, usually by the primary care physician, is recommended.  The doctor may also request reports or rating scales completed by teachers, reports from other doctors, lab tests to check for medical conditions, etc.  

Parents and youth can help by having information and being prepared to answer questions.  Know the name of your pharmacy, type of insurance and insurance ID number, the name of the child’s therapist or counselor if there is one, and the name of the pediatrician or family doctor.  If you have relevant documents – for instance, the results of psychological testing, reports from the teacher, or hospital discharge summaries – it is helpful to bring them to the appointment.  Questions you can expect include:

• What medicines does the child currently take?  What are the doses?  (If you want, you can bring the bottles to the appointment.)
• What psychotropic medicines has the child taken in the past?  When were they taken?  Were they helpful?  Did they cause any side effects?
• How is the child doing at school?
• Does the child have any relatives with mental health difficulties?  If so, what are the diagnoses?

When does it make sense to take medicine?
Once the evaluation is complete, the doctor explains his or her conclusions to the parents and child/youth.  Treatment options are discussed, and the doctor may or may not recommend medicine as part of the treatment. 

In my opinion, it makes sense for a child or youth to take psychotropic medicine when all five of the following conditions apply:

From the doctor’s perspective, prescribing medicine for a child requires more care and consideration than prescribing for most adults.  The starting dose is usually low, and any dosage increases are usually gradual (as we say, “start low, go slow”).  The goal is to use the least amount of medicine that works (the “lowest effective dose”) and the fewest number of medicines that work.  The younger the child, the more cautious doctors are about prescribing medicine.  There are definitely children younger than five years of age who need psychotropic medicine, but this is uncommon.  

What disorders are treated with medicine?
Medicine is nearly always part of the treatment of moderate to severe ADHD, psychotic disorders, severe depression, and bipolar disorder.  Then there are other conditions where medicine may or may not be used as part of the treatment. This group includes most anxiety disorders, moderate depression, agitated or aggressive behavior, and sleep difficulties.   As a rule, medicine is not indicated for rude or defiant attitude, planned aggression, or the intentional breaking of rules.  However, medicine may be helpful if an underlying brain disorder (such as a mood disorder or ADHD) is contributing to the problem.

How do medicines work?
Neurons are the most important cells in your brain.  You have about 100 billion of them and they are incredibly interconnected, using chemicals called neurotransmitters to communicate with one another.  Psychotropic medicines affect this communication, and I encourage you to visit web sites that will tell you more than you ever wanted to know about serotonin, dopamine, GABA and other neurotransmitters.  As you visit those sites, keep two things in mind.  First, although we know some of the ways that medicines affect the brain, we do not yet know for sure how they reduce psychiatric symptoms.  Second, thanks to all the researchers out there, we will know this in a few years.

Commonly prescribed medicines
The following table includes psychotropic medications that doctors typically prescribe to children and youth.  However, it does not include every medication that could be used, it does not include every last medicine that a doctor might recommend for a given disorder, and it is in no way a substitute for your doctor’s judgment and advice.

Every prescription medicine has a generic name and at least one brand name.  The names used for medication classes (the first column on the table) can be confusing.  SSRI “antidepressants” are also used to treat anxiety and some antipsychotics are also effective mood stabilizers.

Attention Deficit Hyperactivity Disorder (ADHD)

DEPRESSION

ANXIETY

OBSESSIVE COMPLULSIVE DISORDER

PSYCHOTIC SYMPTOMS
(includes hallucinations, delusions, and very disorganized thinking)

BIPOLAR DISORDER & MOOD LABILITY
 (“mood lability” means to sudden mood changes)

INSOMNIA (difficulty sleeping)

Pills and prescriptions
Except for very young children, just about anybody can learn to swallow a pill: place it on the back of your tongue, tip your head back a little, and drink something to wash it down.  A child taking a capsule (which, unlike a tablet, floats) may have more success with the following technique: put the capsule on the back of your tongue, drink fluid so that it stays in your mouth, tilt your head forward little (the capsule will float toward the back of the mouth), then swallow. 

Some medicines are available in liquid preparations.  Others come in capsules that can be opened and sprinkled on a spoonful of applesauce, yogurt or pudding, but check with your doctor before you do this with because not every medicine works correctly if sprinkled.  Do not sprinkle capsules into a glass of liquid, bowl of cereal, etc. because too much of the medicine may be left behind.  Do not sprinkle medicine into hot liquid. 

A number of medicines are available in slow-release forms.  These versions tend to have brand names ending in letters such as –XR (extended release), –ER (extended release), –CR (controlled release) or –LA (long-acting). 

Will a pill still work properly if you cut it in half?  It depends on the pill.  Capsules and most slow-release medicines (including Concerta) should not be cut.  Check with your doctor about your specific medicine.

You don’t have to understand the abbreviations used in prescriptions, but if you want to, here are some common abbreviations.  QD means daily, BID twice daily, TID three times daily, and QID four times a day.  PO is “by mouth.”  QAM means “ach morning” and q HS means “at bedtime.” Milligrams are “mg” and milliliters of liquid are “ml.”  PRN means “as needed for.”  NTE is “not to exceed.”  A horizontal line with one or more vertical lines under it and the same number of dots above it stands for a number: one line and one dot means “1,” two lines and two dots mean “2,” etc. 

How long does medicine take to work?
Most psychotropic medicines build up gradually in the bloodstream and take days or even weeks to be effective.  However, some medicines take effect quickly – within 15-45 minutes – and wear off in a matter of hours, or at least by the end of the day.  This group includes stimulants for ADHD (some of which last up to 12 hours), as well as Clonidine and certain benzodiazepines.

Side effects
“Side effects” are the unwanted effects of medicine.  They are different for each medicine and vary from person to person.  Usually, if a medicine causes any side effects at all, they are mild and/or temporary, but all medicines have the potential to cause serious and even dangerous side effects.  Sometime side effects (mild drowsiness, for instance) occur when a medicine is started and disappear on their own within a few days or a week.  Your doctor can give you written information about possible side effects of your medicine.  Tell the doctor if any side effects do occur so he or she can advise you about your options.

How long should a person take medicine?
This varies so much from one situation to another that the best thing I can tell you is to ask your doctor. The answer depends on the individual person, the severity and persistence of the disorder, and the responsiveness of the disorder to psychosocial interventions and to medication.

Parent & youth responsibilities

As partners with the doctor in the medication management process, parents and youth have some responsibilities.  Parents may need to remind their child to take the medicine.  Parents or youth should tell the doctor about any side effects.  Medicine should not be increased without consulting the doctor.  Similarly, medicine should not be discontinued without consulting the doctor, since suddenly discontinuing certain medicines that have been taken on a regular basis may cause side effects and can even be medically dangerous. 

Good medication management requires meeting regularly with the doctor, so it is important to keep your follow-up appointments.  Be prepared to give the doctor the following information:

People sometimes feel shy or intimidated at doctor’s appointments, but do your best to speak up.  Express your concerns, ask questions, share your ideas, and indicate your preferences.

Educate yourself about mental health and medication.  It is easy to locate web sites about specific medicines and specific disorders, such as http://www.chadd.org/ for ADHD and http://www.bpkids.org for bipolar disorder.  Here are some reliable web sites about psychotropic medicines for children and youth:

Lab tests and psychological testing
For purposes of evaluation, depending on the situation the doctor may recommend blood tests to look for medical problems, an EEG (electroencephalogram), psychological testing, neurological examination or a CT or MRI brain scan.  Scientists use advance brain scans (FMRI, PET, SPECT, etc.) to study the brain, but most experts agree that these are not reliable for clinical use.

Blood tests and/or an EKG (electrocardiogram) are checked prior to prescribing medicines that may reduce blood cells or platelets or that may affect the functioning of the heart, liver, kidneys or pancreas.  A few medicines – including Lithium and Depakote – require blood tests on a regular basis for as long as they are being taken.

FDA approved
Most psychotropic medicines prescribed for kids are not “FDA approved” for that age group.  This is because FDA approval depends more on the business decisions of pharmaceutical companies than on the results of research.

When scientists at a pharmaceutical company develop a new medicine or identify a new use for an existing medicine, the company submits its research for review by the Federal Drug Administration (FDA).  “FDA approved” means the FDA has determined that the company can market the medicine as safe and effective for certain disorders among people in a certain age group.  FDA approval does not restrict how doctors can prescribe the medicine.

Since most pharmaceutical company research is done with adults, most medicines are initially FDA approved for adults.  But researchers at universities continue to study the medicine – including its use in younger patients.  They publish their findings in professional journals.  If their research shows the medicine to be safe and effective in children and youth, doctors in practice will start prescribing the medicine to that age group.  In the end, if no pharmaceutical company decides to undertake the expensive process of seeking FDA approval in kids, the medicine will never be FDA approved for that age group.  If research and clinical experience support the use of a medicine as safe and effective, the fact that it is not FDA approved is not – and should not be – an obstacle to doctors prescribing it.

Suicide Risk
A lot has been written about the possibility that certain medicines – especially antidepressants – might cause some people to feel suicidal.  Research demonstrates clearly that the most commonly used antidepressants (SSRI’s) are effective for serious depression in adolescents and that they reduce the incidence of suicide in this age group.  However, as of mid-2008, it is still not clear whether a small number of children, adolescents and young adults experience new suicidal thoughts when they start taking an antidepressant.

As a practical matter, precautions against suicide and self-harm are necessary for any depressed child or adolescent, whether or not they take an antidepressant.  This includes (a) the parent, child/youth and doctor discussing the risk of suicidal feelings; (b) parents and mental health professionals “checking in” with the child/youth about this during the first month or two of treatment with medicine (or as long as significant depressive symptoms persist); and (c) the child or youth agreeing to tell a responsible adult if they experience any suicidal feelings. 

What about kids who take an antidepressant medicine for a condition other than depression, e.g., for an anxiety disorder?  Given the current research, it is wise to take the precautions listed above with any child or youth taking an antidepressant medication, regardless of the diagnosis.

The possibility of suicide is of course frightening to any parent.  Every situation is different and research continues to be done on this issue, so if you have any questions about it, talk with your doctor.

Medicines and self-control
People sometimes have the notion that psychotropic medicine is prescribed to “control” a person’s behavior.  In my experience, medicines simply cannot do this – except for making someone fall asleep, which, except for sleeping pills, is never a good reason to take medicine on a regular basis.

Serious mental illness is an obstacle that limits a person’s options. A person simply has less choice over his actions if he is impulsive because of ADHD, compelled to wash his hands repeatedly due to Obsessive-Compulsive Disorder, unable to think rationally due to psychosis, weighed down with hopelessness due to depression, or quick to become aggressive due to a disorder of mood regulation.  The point of taking medicine is not to control your behavior but to reduce symptoms that get in your way.  When a medicine is doing what it is supposed to do, a person should find more options available to them.  They should experience not less but more control over themselves and their lives. 

This article was prepared in July 2008 for UACF by Mark Edelstein MD, Board Certified Child and Adolescent Psychiatrist and member of the UACF Board of Directors.  Dr. Edelstein is a past president of the California Academy of Child and Adolescent Psychiatry.  He has three children.