Psychotropic Medications and Their Use with Children A Web-based Educational Program for Children’s Medical Services Care Coordination Daniel Armstrong,

Psychotropic Medications and Their Use with Children

A Web-based Educational Program for Children’s Medical Services Care

Coordination

Daniel Armstrong, Ph.D.Mailman Center for Child DevelopmentBatchelor Children’s Research Institute

Department of PediatricsUniversity of Miami School of Medicine

Psychotropic Medications for Children: What are the Issues?

• Lack of access to child mental health services• Inadequate numbers of mental health

practitioners with training and experience with children

• Underserved populations (Location, Culture)• Poor/non-existent empirical data on safety or

efficacy of most psychotropic medications with children

Psychotropic Medications for Children: What are the Issues?

• Inadequate attention to risks associated with selected sub-groups of children

• Absence of guidelines for prescribing, monitoring

• Role of the pediatrician in addressing these problems: AAP (2001): The new morbidity revisited.

Lack of Access to Mental Health Services

• Estimated 13 million children in the U.S. have diagnosable mental, emotional, or behavioral disorders

• Two thirds have no mental/behavioral health treatment

Lack of Access to Mental Health Services

• These numbers do not include:–Children under 4–Children with primary medical problems

where behavioral problems are secondary (e.g. cancer, HIV)–Children with behavioral problems that do

not meet disorder diagnostic criteria

Children’s Access to Mental and Behavioral Health Services

Types of Problems

• Serious Mental Illness• Developmental Disorders• Problems associated with environmental risk– Maternal risk factors: Depression, social isolation– Exposure to violence – Poverty and homelessness

• Physical or Chronic Illness

Inadequate Number of Child Mental Health Providers

• Estimates:– Child & Adolescent Psychiatrists: 6,000– Child Clinical/Pediatric Psychologists: 3,000– School Psychologists: 3,000– Developmental and Behavioral Pediatricians:

<1000– Clinical Social Work, Psychiatric Nurse Specialists:

2,000• Total: 15,000 or 1/866 children in need

Underserved Populations

• Lack of access to mental health services is highest among children of:– Poverty– Non-majority culture– Rural communities

• Underserved populations rarely have access to child mental health professional with cultural competence

What are “psychotropic” medications?

• Medications administered for the purpose of maintaining or improving behavior, emotions, mood, or thinking

• Other medications may have effects on behavior, emotions, mood, or thinking, but are not prescribed for that purpose

Psychotropic Medications Used with Children

• Psycho-Stimulants– Most often used in treatment of Attention Deficit

Hyperactivity Disorder– Also used in treatment of behavior disabilities in

children with autism and other developmental disabilities

– May have some benefits to children with long-term, late consequences of chronic illnesses (e.g., brain tumors, leukemia, stroke, neurotrauma)


• Stimulants (Schedule II Medications)– Methylphenidate • Commercial names: Ritalin, Concerta, Focalin,

Methylin, Metadate - methylphenidate in various forms of admistration

– Amphetamine & dextroamphetamine• Commercial names: Adderall, Dexedrine

– Pemoline• Commercial Name: Cylert


• Stimulants•Most Common Side Effects–Nervousness & Jitteriness–Insomnia–Decreased Appetite & Weight Loss–Headaches or Stomachaches–Skin Rash–Social Withdrawal


• Stimulants• Rare adverse events–Tachycardia, changes in blood pressure,

nausea, dizziness, and palpitations• Overdose symptoms–Vomiting, agitation, tremors, muscle

twitching, convulsions, hallucinations, delirium, sweating, and cardiac arrhythmias–Contact Poison Control Center


• Non-Stimulants (Not Schedule II)– Atomoxetine (norepinephrine reuptake inhibitor)

• Commercial Name: Strattera– Common Side Effects

• Excessive tiredness, insomnia• Increase in heart rate & blood pressure• Sexual side effects• Enlarged Pupils• Weight fluctuations• Headache, dizziness• Nausea, vomiting, stomach pain• Mood swings and irritability


• There is a lot of controversy about the use of stimulants with children– Recent AAP, AACAP reviews provide evidence of

benefits for children with significant behavior problems/ADHD

– Some children do experience side effects, some significant

– Stimulants are the most studied medications used with children, so safety and efficacy information is available


• Anti-depressants– Used in the treatment of• Depression• Anxiety/Panic Disorders• Obsessive-Compulsive Disorder (OCD)

– One class of anti-depressants (SSRIs) are under FDA black-box warning because of increased suicide risk


• Anti-Depressants– Selective Serotonin Reuptake Inhibitors (SSRIs)

• Fluoxetine (Commercial Name: Prozac)-only drug currently approved for use in children by FDA)

• Paroxetine (Commercial Name: Paxil)• Sertraline (Commercial Name: Zoloft)• Citalopram (Commercial Name: Celexa)• Fluvoxamine Maleate (Commercial Name: Luvox)-

approved for with Obsessive Compulsive Disorder• Clomipramine (Commercial Name: Anafranil) approved

for use with OCD


• Side Effects of SSRIs– Common• Anxiety & nervousness• Insomnia• Mania and agitation• Decreased appetite• Rash or hives

– Rare but significant Events• Thoughts of suicide, attempted suicide• Seizure


• Other non-SSRI anti-depressants–Buproprion (Commercial Names:

Wellbutrin, Zyban)• Side effects: Agitation, anxiety, insomnia,

hypertension, possible hallucinations, weight loss, dose related risk of seizure

–Propranolol (Commercial Name: Inderal)• Side effects: Dizziness, insomnia, tiredness,

stomach pain, vomiting, diarrhea; difficulty breathing, sore throat, unusual bleeding, swelling of feet or hands, slow heartbeat, chest pain)


–Other non-SSRI anti-depressants • Venlafaxine (Commercial Name: Effexor)–Side effects: Dizziness, drowsiness, sleep

problems, difficulty breathing, cold hands or feet, hallucinations, irregular heartbeat, hypertension; In rare cases, fever or increased depression.


• Atypical Anti-psychotics– Used in treatment of childhood schizophrenia,

bipolar disorder – Beginning to be used in treatment of children with

developmental disabilities, particularly autism


• Atypical Anti-psychotics– Risperidone (Commercial Name: Risperdal)– Clozapine (Commercial Name: Clozaril)– Olanzapine (Commercial Name: Zyprexa)– Quetiapine (Commercial Name: Seroquel)

– White blood cells checked weekly


• Atypical Anti-psychotics– Common Side Effects• Hyperglycemia• Diabetes Mellitus• Hypotension• Cognitive and Motor Impairments

– Rare Side Effects• Serious cardiac abnormalities• Serious neuromuscular effects

Current Prescription Patterns

• Approximately 80% of psychotropic medications are prescribed by primary care physicians (internal medicine, family medicine, & pediatrics)

• Primary pediatric patterns– Overwhelmingly stimulant medications– Some anti-depressants, anxiolytics

Concerns

• Empirical support for use with children– Extensive literature supporting use of

stimulants for ADHD • Primarily dexedrine & methylphenidate• Limited literature on newer stimulants

(long-lasting, methylphenidate/dexedrine combinations, methylphenidate patch, etc.)

Concerns

–Despite increasing use trends, and availability of new “atypical” psychotropic medications, almost no empirical support for use of other psychotropics with children, particularly those under age 6• Efficacy• Safety

Concerns• FDA Black Box Warnings (2004)-SSRIs– Elevated risk for suicide in children• At start of medication trial, at discontinuation• Specific concerns for adolescents

– Risk/Benefit Balance• In randomized, double-blind, placebo-

controlled clinical trials, SSRIs did not offer a significant benefit over placebo

Concerns

• Some concerns raised recently about several stimulants: long QT syndrome, etc.– Cardiovascular monitoring recommended for

children on a number of psychotropic medications

Concerns

• External Pressure to Prescribe– Parents– Schools & Agencies– Insurance Providers

• External Pressure to Not Prescribe– Parents– Advocacy Groups

Things to Consider Before Prescribing

• Training & experience (Competence)?• Collaborative relationship with mental

health specialist?

Other Things to Consider

• Is the diagnosis accurate?• What treatments are available for this problem?• What is the relative effectiveness of each?• Are combinations of approaches most

appropriate?


– Empirical support for psychotropics– Empirical support for behavioral interventions • Recent publications on empirically supported

treatments:, Society of Clinical Child Psychology, Society of Pediatric Psychology

– Empirical support for combined approaches• AAP (2001) Statement on ADHD


• What resources are available to the family?• What are the risks of using a psychotropic

medication compared with the risks of not using it?


• What educational information is available for parents, teachers about the medication?

• What consent process is used?– Understanding of risks and benefits– Understanding of monitoring plan, as well as plan

for adjusting or discontinuing meds or other concurrent treatments


• Special Considerations– Use of multiple psychotropic medications– Use of psychotropics with other medications (e.g.,

in chronic illness)– Medication and dose sensitivity in children with CNS

disease, treatment• Increased toxicity• Interference with other drug mechanisms

Suggestions for Use of Psychotropics with Children

• Establish plan for monitoring effectiveness • Obtain accurate medication history– Current medications (including OTCs)– Previous medications

• Establish plan for monitoring adherence• Establish plan for monitoring drug toxicity

Pitfalls to Avoid

• Avoid pressure to prescribe when inappropriate, or to not prescribe when appropriate

• Avoid pressure to use psychotropics to the exclusion of other effective and available interventions

Pitfalls to Avoid

• Avoid non-standard dosing, dose-escalation, or poly-pharmacy approaches without consultation

• Avoid practicing outside competence, experience, or comfort

Other Roles for Pediatric Care Providers

• Serve as a source of information about psychotropic medications for parents, schools, and communities

• Identify IRB approved clinical trials and make participation available to parents

• Advocate at community, state, and national level for increased access to child-competent mental health services

Acknowledgements

• This session is part of an ongoing training collaboration between the Florida Department of Health, Children’s Medical Services, and the Mailman Center for Child Development at the University of Miami Miller School of Medicine.

References and Resources

• NIMH. Treatment of Children with Mental Disorders. http://www.nimh.nih.gov/publicat/childqa.cfm

• Florida Department of Children and Families. 2005. Ensuring informed and appropriate use of psychotropic medications with children in department custody. http://www.dcf.state.fl.us/mentalhealth/psychpres0111.ppt#407,2,Ensuring Appropriate and Informed Use of Psychotropic Medications With Children in Department Custody

• The Center for Health and Health Care in the Schools. 2004. Psychotropic drugs and children: Use, trends, and implications for school. http://www.healthinschools.org/press/psych.asp

http://www.nimh.nih.gov/publicat/childqa.cfm

Documents

Psychotropic Medications and Their Use with Children A Web-based Educational Program for Children’s Medical Services Care Coordination Daniel Armstrong,