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The NYSPA Report: Medication for Children and Adolescents

A doctor’s recommendation to use psychotropic medication for a child can lead to many concerns and questions in both the child and their parent. This article is meant to help clarify these concerns and help families understand that they can get safe, effective treatment for their child.

The prevalence of Child and Adolescent Psychiatric disorders is substantial. Currently approximately 1 in every 4 to 5 youth in the U.S. meets criteria for a mental disorder with severe impairment across their lifetime. The prevalence of ADHD in school age children is approximately 8 %. Many mental disorders in adults first emerge in childhood and adolescence; this highlights the need for services early to avoid or minimize the impact of an illness on a developing child, including on home life, friendships, academic success and future productivity. If possible, focus should be on prevention and early detection.

Increasingly medications are used to help a child with emotional problems achieve remission or reduction in symptoms. The right kind of medication, along with other interventions can be an effective and important part of treatment. The NIMH, sponsored Multi Modal Treatment Study (MTA), has shown that stimulant medication works and should be a first line treatment for ADHD. Medication for ADHD not only aids in improving focusing, learning, academic performance but also helps a child achieve better relationships with parents and peers, decreased aggression and impulsivity.

In the past most medication studies were done on adults, not children. Due to this, many times child psychiatrists used adult studies to give them a direction on how to use these medications in children and adolescents. This was necessary then, as there were limited child studies, but unsatisfying as children are not mini adults, and medications do not necessarily work the same way as in adults.  Their brains are still developing and some of the neurotransmitter systems targeted by medications are not fully developed. In addition, metabolism of the drugs differ because of differences in functioning of the liver, kidney and differences in weight.

Most child psychiatrists often prescribed off- label because the medications used are only FDA approved for adults or if approved for children, are being used for a non-approved indication. This problem has begun to be rectified with more research, better empirical evidence and treatment algorithms.

In order to get adequate care, whether with medication or a non-medication treatment, it is important for a child to get a thorough assessment. As part of any assessment, the parent and child are usually seen together and individually, school records and information is requested and information about the child’s health is collected. Contact with the Pediatrician and lab work may be required. In addition, there are a variety of useful rating scales, questionnaires and structured or semi-structured interviews that may help assess your child’s issues. Children also often have more than one issue that they are coping with and will need to be addressed.

During the assessment and treatment process a parent needs to know they should have a dialogue with the person (s) who is doing the assessment and with the treating psychiatrist. In this discussion, the review should include:  a parent’s understanding of their child’s problem, the factors affecting it, the treatment approaches recommended, other options and the impact of not accepting the proposed treatment.

If medication is recommended, a parent should know the name of the medication, what it will help with, what target symptoms will be monitored, how the doctor and they will know whether it is working, what is a reasonable time frame to see a benefit and what else besides medication should be part of the treatment approaches. They need to know typical side effects and any special precautions. Parents sometimes feel they cannot ask questions, or the physician is too rushed to answer them, but doing it is an essential part of their child’s care and getting the best treatment possible.

This past summer, New York State Assembly Bill 5602 was vetoed by Governor David Patterson. The bill would have mandated the Department of Health and other agencies, to do research and study the effects of psychostimulants, selective serotonin reuptake inhibitors, antidepressants and other drugs prescribed for ADHD in school age children.  The focus of the study was to look at the efficacy and the harmful side effects of drugs.

In his veto, Governor Patterson said others are responsible for this research and that much of this research already exists.   Passing it would have diverted funds away from other important functions done by the Department of Health (DOH), Office of Mental Health (OMH) and Office for People with Developmental Disabilities (OPDD), including the funding for programs to help children and families who are dealing with emotional problems. The bill ignored that there is already a large body of evidence supporting the efficacy and safety of psychostimulants to treat ADHD.  The bill was prejudicial against the use of psychotropic medication in children and erroneously implied that they were being medicated in a reckless manner.

Since the mid-nineties, there has been increased research on medications used with children. In 1997, US Congress passed the Food and Drug Modernization Act which provided financial incentive for pharmaceutical companies to conduct research on pediatric use of their drugs. The Patent Exclusivity extension program provided for a 6-month extension of their patent if they conducted research on how their drug would work on children; this led to pharmacokinetic and clinical trials on children and adolescents. There are also limited funds to study the use of off patent medications. Other legislation allows the FDA to insist a pharmaceutical company do pediatric studies for a drug when it is likely to be prescribed to children, even if it is only being introduced for adult use. Such legislation has all helped with advancing the field of Pediatric psychopharmacology research.

Since then the NIMH has funded several important multisite studies, including the MTA, that looked at treatments for ADHD in a school age population, the PATS study, which looked at stimulant use in preschoolers, TADS, treatment of adolescent depression study, TORDIA , the treatment of resistant depression in adolescents, POTS, Pediatric OCD treatment study, and CAMS, Child and adolescent anxiety multimodal study. These studies looked at both medication and non-medication treatments for several key conditions seen in children including ADHD, Depression, OCD and anxiety disorders. These studies followed children for longer periods of time than most drug studies that only follow children or adults for weeks or months.  Hopefully studies like these will continue to help us better understand and treat psychiatric disorders in children and adolescents.
A child is referred to a Child Psychiatrist usually when he/she has been disruptive or the illness has affected many aspects of his/her life. In the future, we hope that children, adolescents can be identified and treated early, before an illness severely disrupts their life. Identifying and treating emotional problems in children have both short and long terms benefits. Reducing symptoms helps a child stay on track, functioning better at home, with peers, at school and helps keep a child on the right developmental path. It can reduce their emotional pain, avoid legal and drug problems, improve their self-esteem and confidence. It can reduce violence against themselves and others and reduce the impact on their adult development.

Dr Engel is Chairman of the NYPSA Child and Adolescent Psychiatry Committee, Director of Child Psychiatry Training at SUNY-Downstate Medical Center/ Kings County Hospital Center and former Director of Child and Adolescent Psychiatry at SUNY – Downstate/KCHC, Dr Bajpayi is a first-year child fellow at SUNY – Downstate Medical Center/ KCHC.

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