IN CHILDREN AND ADOLESCENTS
Thanks to David Behar, MD for wise editing.
Copyright 2000 by James L. Schaller, MD, MAR. One copy per visit please. No more than 30 by any one person.
Written to Parents Who Love Their Struggling Children &
The Child and Adolescent Psychiatrists Who Want to Help Them
Working as a child and adolescent psychiatrist requires immense sensitivity to the side effects of medications and the uniqueness of each child. In this article we will describe:
- the titanic seriousness of medications to children
- the uselessness of simplistic common drug dosing protocols
- the fact most children do not have one problem. If this is ignored, the other problem(s) ruin treatment and alienate the child and parent(s).
- I offer practical solutions so youth have a positive experience with treating psychiatrists.
Developmental writers have proposed that the first self a person experiences is a body self. Meaning, the first "me" is my body, not "Dr. Schaller." A major side effect is experienced as a narcissistic bodily insult to a child--chemical battery. Some physicians hate hearing this and some of my Ivy tower researcher colleagues get annoyed when I say it. But they recall their first needle. I say it because I listen to kids and their parents take about the uncomfortable ways medications make them feel.
This bodily misery or dysphoria contrasts with the childs expectation of being soothed by things that are swallowedice cream, candy or your favorite food soothes and is a pleasure. Food rewards, it does not hurt. A swallowed pill is not expected to hurt or make you feel worse.
In terms of defenses and coping styles, children who experience a side effect of a drug get upset easily because by definition, they are only children, without the maturity to cope. Children are already inclined to feel emotional problems in their body. Specifically, a child may already be prone to somatization e.g., a headache or stomach pain when sad or afraid. Further, a legitimate side effect may cause primitive cognitive distortions, e.g., "I am dying" or "This pain from the medicine will never go away."
Youth either no nothing about medications, or may have failed under previous care. We do not want to alienate a child who might need medication for decades by an adverse reaction. Many children who experience nausea from food poisoning or viral gastritis can take years (or a lifetime) to retry food associated with pain. I once got a bad hotdog at 5 years of age and still dislike them. Children given maple walnut ice cream just before nauseating chemotherapy developed and maintained an aversion to the flavor.
Some child patients are treated by overwhelmed primary care physicians or other specialists. They give the child a few rushed minutes. Lawsuit abuse and HMO/PPO pay-cuts limit the time a physician can spend. These past doctors, despite their best efforts, have caused a patient to fear medications, any doctor or psychiatric medication. Causing a new patient to experience a side effect will not work to regain their trust.
Trust is hard to gain if children already do not trust their parents as competent caretakers. I am a parent so I do not want to pick on us. But we need to be aware of some common things that make it harder for treatment of a child
- Depressed children can have a parent(s) with chronic depression, which makes deep attachment hard for both parent and child. A child who is not connected with a parent will be less able to promptly click with a doctor.
- A stressful divorce can leave the caretaker parent grieving. The caretaker may be so stunned by the events that they are unable to realize or help the childs grief. If this occurs the child may assume the doctor is just one more uninterested and worn out parent.
- Parents with attention deficit hyperactivity disorder (ADHD) may be vulnerable to yelling, reactivity or rages. Their distractibility may appear as if they do not care.
- Children withdrawal from a parent with untreated substance abuse, schizophrenia, bipolar disorder and major anxiety disorders--they want the parents love, but flinch from the untreated mental illness. As treating physicians we need the parent as a team mate and do not want the child to flinch from us.
Why Do These Points Matter?
Child psychiatrists follow in the footsteps of past doctors, hospitals, therapists and even the childs parents. If any of these have been poor experiences we start with some alienation. So if the medication experience is poor we are in deep trouble with the child. Simply, if the child experiences unpleasant side effects, we become "bad" like past people. We are seen as uncaring or failing caretakers, and compliance may plummet.
Poor connection to a doctor can also be affected by the child. Distrust, fear, shame and poor interpersonal connection are typical in major depression, bipolar disorder, anxiety disorders, oppositional defiant disorder, anorexia/bulimia, schizophrenia, enuresis/encopresis and obsessive compulsive disorder. Interpersonal symptoms are hurdles to compliance. We will need a unique way to relate to children with each of these problems. Since each is unique it will require a stretch.
Deferring to the Physicians Desk Reference (PDR) or other simplistic drug dosing schemes is certain to cause problems. At times, the PDR only recommends 1-2 dosages with easy to remember guidelines to assist in increased sales. Many of these dosage guidelines stem from pre-market adult studies biased toward high doses. Low dose therapy is rarely emphasized. Further, sideeffect frequency is not necessarily updated after the initial pre-marketing studies.
Some patients have gone to the emergency room with markedly increased agitation and serotonin side effects. Common starting doses causing these unnecessary trips to the ER can be as low as a daily dose of Risperdal 1mg, Prozac 10 mg, Zoloft 50 mg. or Paxil 10 mg.
Neglect of Low Dose Therapy puts Patients at Risk.
Rushing to high doses of medication can increase school suspensions, car accidents, seizures, and cardiac arrhythmia. For example, some children who have mild trouble with aggression and have ADHD, are often merely given more stimulant. In four cases, the reduction of Adderall by 20-30% caused a decrease in school fights, impulsivity and conflict with caretakers. In three of these cases there were no signs of stimulant toxicity, e.g., insomnia, mental status changes or decreased appetite.
Some of my patients need very high medication dosing. Most patient dosages fall into the broad center of the bell curve. But some youth need extremely low dosesespecially at first!
For example, three patients with Obsessive Compulsive Disorder had clear long-term significant remission of their extensive symptoms on a mere 25 mg. of Anafranil. Two patients have responded to Adderall 2.5 mg. at breakfast with 80%-90% remission of their ADHD symptoms for over a year-with a benefit till approximately diner time. Indeed, one ADHD patient was so sensitive to stimulants he needed only the tiny stimulant metabolites of 2.5 mg. of selegiline. He was toxic and "zombie-like" on only 5 mg. of Ritalin.
Other Problems and Medication Sensitivity
It is easy to miss a sad child who also has an anxiety problem or an ADHD child who is also faintly depressed. We call having multiple problems "comorbidity."
One way to be aware of other problems is to consider the family blood line and the childs past response to medications. In thirty-eight in-patient and outpatient youth, over 75% of the intakes had significantly inadequate genetic family histories. No one looked for the blood history. If "Johnny acts like Uncle Ed did when he was a child" that is important. Family trees are possible warnings.
ADHD often has comorbid conditions, including depression and anxiety disorders. Missing a biological depression in ADHD treatment causes a small disaster. For example, if a patient has been stable on doses of 10 mg. of Ritalin, and becomes depressed what happens? Often the stimulant stops working, and their treating physician "adjusts the stimulant upward to keep pace with the childs new metabolism." Since stimulants can have antidepressant properties, this may work temporarily. Eventually, however, the stimulant needs to be raised to experimental doses because no anti-depressant is being used. Finally, the patient has ADHD that is poorly responsive to stimulants, because the child was burned out on them. And now they also have a severe depression.
If an ADHD child has an anxiety disorder, or a comorbid bipolar disorder, these are serious. Even moderate stimulant doses can induce a panic attack, mania or psychosis in an anxious child or bipolar child.
Sample Solutions for the Pharmacologically Sensitive
- Have pre-typed dosing schedules. You can then dose your most common medications slowly and fast. Have at least two options. If you have a patient with anxiety or somatic sensitivity you can follow the slow protocol. A youth who reports he once took Prozac and reported, "It was like water," could follow the faster protocol.
- On typed protocols list the ten most common disturbing symptoms and what to do if they are experienced. For example, patients on selective serotonin reuptake inhibitors (SSRIs) with a common side effect should hold their dosage increase until their side effect is gone three days.
- Give at least a half a day trial on a small dose of anything you prescribe, e.g., a fourth of a 25 mg. Zoloft or a fourth of a Wellbutrin.
- Have your protocols include intermediate smooth dose increases and recommend pill cutters for your intermediate dosages.
- Consider liquid medications for careful dosing. Depakote, Risperdal, Prozac come in liquid forms and Adderall liquid may also soon be available. But as we have published before, any medication can be made into a liquid, by National Compounding Pharmacy Association (1-800-927-4227).
- Reward oppositional defiant children for taking their medication until they see the benefit themselves in school and interpersonally. When their friends tell them they are no longer a "pain" you can decrease the reward.
- Do not ignore protests of weight loss or gain. For significant weight loss, e.g., associated with successful stimulant treatment consider Remeron. For weight gain in conditions which require mood stabilization, consider Tegretol or newer versions, Neurontin, both together, Lithium, molindone, Seroquel and many other newer options. Extremes in weight in female patients will cause extremes in estrogen which causes bloating and other problems
- Educate children as to the possible common transient side effects they may experience. For ADHD youth this will need to be written boldly and repeated--they do not attend. Telling any youth that there are "no major side effects" sets up potential betrayal. Anxious youths and anxious parents should know common side effects--a huge list will induce agitation. Ideally you will dose so gently they will have no side effects!
- Assertive and/or intelligent adolescents should not be treated as "flawed" youths dragged in for repair, but educated as collaborators. It is stunning how few adolescents have been educated about their illness--diagnostic criteria, epidemiology, synapse pictures, and brain scans. Their family tree may be useful and interesting to some patients. Without it, they have less cognitive resources and are marginalized from the treatment of their own brain chemistry.
Why is My Child Sensitive to a Low Dose?
First, assume that a low dose is a PDR simple dose, not a low dose. Most psychiatrists give initial doses on the first two days that are too high in my opinion. Of course, that is my clear bias. I hate side effects.
However, some youth have livers with fewer enzymes to remove the medication quickly.
Other youth may have many brain receptors sensitive to the unique medication being tried
Finally, other children do not have enough detoxifying agents in their liver to remove synthetic substances, e.g., medications or other more serious environmental pollution. We all have these toxins in our body as members on the third millennium world. In our research we offer many ways to help the liver function better and more efficiently. Our goal is not merely to have the liver look "normal" on a basic blood test, but to be able to provide it with the special detoxification nutrients it needs to remove waste.
In conclusion, one of the joys of child and adolescent psychiatry is that we can intervene early in a childs life to meaningfully heal. Some of my colleagues have joined our guild just because someone made such a helpful intervention with them. However, in this article we have explained the seriousness of casual interventions, which undermine child trust by serious side effects and missed comorbidities. If our treatment is experienced as "traumatic" in the small world of the child, it could ruin their view of our profession. They will understandably reject our care. They will be left with problems from psychiatric challenges in school, work and key relationships for decades.
My hope is for a comfortable experience for your child. Consider only a child and adolescent psychiatrist, a psychiatrist who has taken 2 additional years full time to learn the unique ways to treat children and adolescents. I hope your experience with a child psychiatrist will be pleasant and not rushed.
Dr. James S.
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- Cohen J, Insel P (1996), The Physicians Desk Reference: problems and possible improvements. Archives of Internal Medicine 156:1375-1380
- Schaller J, Behar D (1997), Selegiline for the delivery of small doses of Amphetamine. J of Neuropsychiatry 9:301-302.
- Jensen P, Shervette R, Xenakis S et al. (1993), Anxiety and depressive disorders in attention deficit disorder with hyperactivity: new findings. Am J Psychiatry 150:1203-1209
- Schaller J, Behar D (1998) Liquid medication preparations. J Am Acad Child Adolesc Psychiatry 37:136-137