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Psychopharmacology for
Child Advocates, Clinicians
and Counselors
Joe Wegmann, PD, LCSW
504.587.9798
www.pharmatherapist.com
Are you receiving our free monthly e-
newsletter?
I’ll Address…
Describe the maturational and
developmental issues regarding response to
medication in youth
Discuss the mental disorders that typically
emerge during childhood and adolescence
Examine symptoms, how to differentiate
among disorders, and medications employed
in treatment
Special Aspects of Child
Psychopharmacology
In the U.S., any psychiatric medication
prescribed for adults can be prescribed for
children
Prescribers diagnose based on interviews,
checklists of symptoms and observations
Parents, school systems and other
environmental factors exert influence on
prescribers
Yet-to-be-developed neurotransmitter
systems
Mood Disturbances in Children
Symptoms of Pediatric
Depression
Persistent mood disturbance that is a
change from prior functioning
Lack of energy, motivation or enthusiasm
Changes in sleep or eating patterns
Irritability, agitation, unwarranted crying
Pervasive anhedonia
Sad or morbid play that concentrates on
harming themselves or others
Manifestations in Children
Demoralization;
Esteem and Image
Issues
Physiological
Demoralization Issues
I see many kids with disturbed mood and unhappiness
related to challenging life circumstances: bad schools,
problematic family or parents, poor peer
relationships, poverty, trauma, violence
All of the above can profoundly affect how these kids do in school, behave at home and in social settings
Public sector counseling services have been cut to the bone in Louisiana, leaving many affected children with few if any coping skills
The number of kids suffering from clinical depression is small compared to those who are demoralized
Case Example: Demoralization
During the past two months, 11 year old Kyle has appeared
distracted, agitated and irritable throughout the school
day. He’s often not paying attention, gets aggressive with
other students, getting him into trouble. His grades have
fallen off somewhat, but he’s in no danger of failing.
His teachers report he’s confident and assertive in class and
recreational activities, but seems “down.”
When you address these issues and ask him what’s been
going on, he responds, “my dad lost his job and he and my
mom are fighting all the time.” “It makes me mad and
unhappy to hear them fighting and I want it to stop, but I
don’t know what to do.”
What To Look For
Kyle is willing to express his concerns about how
difficult the situation between his mom and dad has
become
Kyle is coming to school every day and is engaged.
His grades have fallen off somewhat, but this is likely
a by-product of the frustration he’s feeling, which in
turn is affecting his concentration and desire to apply
himself.
How To Proceed
Demoralized youth will better respond to time-
honored problem-solving techniques. Let him tell
his story about the situation and what really
bothers him about the discord between his
mother and father
Use Kyle’s confidence and assertiveness as
strengths to help him confront his parents
Assist him with developing a script he can try out
– “mom and dad, it upsets me when you
constantly fight and I wish you would stop,
please don’t do it in front of me”
Mindfulness techniques work well with
demoralized kids
Informal Mindfulness Techniques Mindfulness is simply grounding oneself by focusing on and
becoming aware of thoughts, feelings and sensations happening in
the present with curiosity and interest.
Mindfulness can help any of us to shift our troublesome thoughts,
feelings and worries to something more positive, relaxing and
rewarding by keeping us in the here and now.
Have the child just notice his breathing. In and out…in and out, it
goes. No need to complicate this with specific breathing exercises,
and don’t have the child count the breaths. Give this about 10-15
seconds tops
Challenge the child to start looking around and hunt for things
they’ve never noticed, then let them share their findings and why
they think they haven’t seen them before
Remind them that all of these things are happening LIVE, in the
very moment in which they’re operating
Mix these up, create your own, or ask the kids to come up with
their own suggestions for staying in the present, BE IMAGINATIVE!
Clinical Depression Depression is very confusing and there is no general consensus as to
what’s going on or even what’s wrong with the brain
Psychomotor slowing
Acute attention and concentration problems – often report
struggles with absorbing material when studying, and reading in
particular
Usual onset age: 15-18
If I see an unhappy 6 or 7 year old, I’m going first to
demoralization or anxiety
Diurnal variation in mood – which is a worse mood in the morning,
but improving throughout the day. Involves “phase shifting” and
often sleep deprivation
Inability to experience pleasure – some will openly say “I’m
miserable”
Medical conditions (asthma); Drugs: (substance abuse, steroid
inhalers
Most Frequently Prescribed
Antidepressants
Prozac – FDA approved for kids 8 and older
Zoloft
Paxil
Celexa
Lexapro – FDA approved for kids 12 and older
Effexor
Wellbutrin
Children Taking
Antidepressants Antidepressant effectiveness today is no better than the
1950s
The journal Lancet recently: “Antidepressants provide small or modest efficacy in the majority of adult users
What does this translate to in youth with only growing and developing neurotransmitter systems?
Side effects can be persistent (anxiety, sedation, insomnia)
What about discontinuation? - withdrawal can be tough
Fix The Physiology First…Not The
Brain
We have been animals that move for a lot longer than we have been animals that talk and convey
It’s difficult for an animal operating in its natural habitat, with an acceptable status in its chosen group to be depressed
Scientific evidence is clear – exercise and nature significantly reduce depression and anxiety
Because…it returns us to our more natural and healthy animal state – where we are moving and our endorphins are rushing
Fixing the physiology comes first – not pills, not counseling not mindfulness
Kids (and adults) MUST get out and move!
Bipolar
(Disruptive Mood Dysregulation
Disorder)
Comments to Start
Diagnosing this disorder in youth is difficult
as well as controversial
Bipolar symptoms can easily be mistaken for symptoms of other disorders, such as ADHD, oppositional defiance, conduct problems and certain anxiety disorders
Genetics play a significant role
Diagnosis in youth and teens is complex and requires careful observation over a long period of time. Approximately 25-30 percent of cases first appear in late childhood or early adolescence
Definitely be on the lookout for substance abuse problems with this disorder
Symptoms of Early-onset
Mania Rage, sometimes intense – possibly lasting a few
hours
Pressured speech – displays as a quick, starting and stopping speech pattern without continuity or flow
Marked mood swings – rage and irritability switching to dissatisfaction and unhappiness
Mood swings are often rapid – cycling frequently throughout the day
Grandiosity – a display of inflated ego about self, accomplishments
Decreased need for sleep – demonstrates ability to function and manage well on little sleep, with much of the daytime energy coming from manic-like feelings
Increase in risk-taking behavior
Marked oppositional behavior – aggressive, bullying, fighting
Depressive Symptoms
Stomachaches and headaches
Sleeping too much or too little
Changes in appetite
Guilt, worthlessness
Extreme sadness
Decreased interest in school activities
Assessing a Child for Bipolar: The
3 Best Questions to Get Started
1. Has there been a time when you can
remember having lots of energy for getting
things done, where you needed little sleep,
and people noticed this and thought you
were acting strange or different?
2. Has there been a time when you felt sad
and down and isolated yourself, and people
noticed that you were absent?
3. Is there anyone in your family as far back as
you can remember who has been treated for
what I just asked you?
Medications for Bipolar
Disorder Lithium
Depakote
Lithium
Treats acute mania
Produces “normalizing” effect by smoothing
out manic highs and depressive lows
Most effective single agent for bipolar
disorder
Used to treat aggression or self-injury in
children and adolescents with conduct
disorder, autism and intellectual disability
FDA approved in children at least 12 years of
age
Side Effects of Lithium
Thirst
Excessive urination
Weight gain
Nausea, vomiting,
diarrhea
Depakote
Classified as an anticonvulsant
Effective for mania, but not as effective as lithium
Treats rage reactions and extreme mood instability
Depakote Side Effects
Weight gain
Sedation
Can cause birth defects – completely
contraindicated in pregnancy
Polycystic ovary syndrome – development of
ovarian cysts, decreased fertility, menstrual
irregularities
Anxiety
Overview Children and adolescents have their struggles with
nervousness, tension and that sense of something stirring
inside of them in ways similar to adults
Anxiety starts with a situation or circumstance that feels
uncomfortable or difficult to manage. Sometimes the
distressing thoughts precede the situation
This is known as “worrying in advance” of something that
may never happen, or won’t happen in the way it’s
perceived
The worry gives rise to threatening feelings followed by
fear – which is just waiting on the doorstep to pounce
The response to the fear is to fight back, flee or freeze
Generalized Anxiety
Chronic, low-level type of anxiety that tends
to be free-floating without any boundaries
Children with GAD engage in irrational worry about many things such as academic performance, athletic capability and peer relationships
Resolved worries are quickly replaced with new ones, consuming excessive amounts of time
Obsessive-Compulsive Disorder…
I Get Lots of Questions
“My 12-year-old son is
adamant about toilet
tissue being placed on the
roller so that the tissue
dispenses from the top of
the roll, not the bottom.
When other family place
it on the roller in reverse,
he becomes irritated and
immediately changes it
back. Does this mean he
has OCD?”
Obsessive-Compulsive Disorder
We all have eccentricities, oddities, habits
The full-time companion
A disorder of excessive carefulness accompanied by an exaggeration of possible danger
Persistent thoughts and compulsions accompanied by shame and guilt
Often incapacitating
Emerges in late childhood, prevalent in children and adolescents
If untreated, symptoms remain remarkable throughout life
OCD is no longer DSM-classified as an anxiety disorder, rather it is neurological in nature, generating obsessive thoughts and behaviors
What To Look For
Writing a sentence or phrase, erasing it or lining
through it, and then writing the same thing again
Slow to complete tests and other exercises
Checking work repeatedly before actually turning
it in
Becoming upset when rules aren’t followed by
other kids, as on the playground
Being precise, meticulous, demonstrates a need
for near perfect order; fastidious about
appearance; need for symmetry
Examining backpacks and gym bags for needed
items repeatedly, particularly when leaving school
for the day
Best Practices for Managing OCD
Use of logic results in abject failure
Expose and prevent; expose and prevent –
THIS IS HOW AFFECTED CHILDREN GET
BETTER
Example: A child with an excessive
“checking” type of OCD
Visual and audio confirmation
For those who stick with E&P and practice
regularly – 85% improve
Serotonin antidepressants so often impede
progress.
Medicating Anxiety Medication management
studies are virtually non-existent and inconclusive
Mood stabilizer and antipsychotics are often used “off-label” for the treatment of violent outbursts, severe aggression, tantrums, destructive behavior
Antihistamines (Benadryl) Not so much for anxiety, but more to initiate sleep
ADHD ADHD is definitively…a neurodevelopmental disorder with
onset in mid-childhood through early adolescence
Those with ADHD have racecar brains with bicycle brakes
CDC: Nearly 20 % of high school age boys in the U.S. and 11%
of school-age children have received a diagnosis of ADHD;
53% rise in diagnosis in those 4-17 this past decade alone
Some diagnosticians are hastily viewing any complaints of
inattention as ADHD – so the diagnosis is poorly established
Parents pressure doctors for pills, instead of challenging and
questioning this diagnosis
Once started on pills as a child, the now high school student
or college student “can’t be without them”
The 5 Ps (Stimulants)
The Pills:
Ritalin; Focalin; Adderall
The Pump:
Concerta
The Pellets:
Ritalin LA; Focalin XR; Adderall XR
The Patch:
Daytrana
The Pro-Drug
Vyvanse
Psychostimulant Side Effects
Appetite suppression in the beginning, but not
persistent
Insomnia can occur, but usually not a significant issue (sleep improves due to less bedtime rumination) or because of decreased blood levels of the drug
Irritability, particularly with amphetamines
Dry mouth
Curbing The Misuse of
Psychotropic Medication Children make excellent targets for psychiatric medications
Once started on drugs, many never discontinue them
Aging; Environmental and Developmental influences
Recommendations for Parents
Become fully informed consumers
Does the presenting problem conform to an approved indication for a particular drug
Safety; side effects
What might better explain the child’s behavior?
For Clinicians, Counselors, Child Advocates
Medication and psychotherapy are not mutually exclusive
Biology affects psychology and vice versa
We as therapists need to be attuned to reactions, side effects, results so as to have input on directing medicated youth going forward
Resources
Adapted from:
Wegmann, J. 2018. Behavior
Management Guide for the Classroom.
Eau Claire, WI: Premier Publishing &
Media
Thanks for Attending!
Joe Wegmann, PD, LCSW