Ten Questions Parents Ask About Kids and Medication
1Ten Questions Parents OftenAsk About Kids andMedicationStephen Grcevich, MDPresident and Founder, Family Center by the FallsChairman, Board of Directors, Key MinistryJune 15, 2013
2Our Agenda For Today...• How would I know if my child needs medication?• What type of evaluation is appropriate prior to starting my child on medication?• What type of professional is qualified to prescribe medication for my child?• When is it more appropriate to consider non-medical interventions first?• How well does medication work for my childs condition?• How safe are the medications commonly prescribed to kids and teens?• What do we know about any long-term side effects of commonly used medications?• How long will my child have to take medication?• When should we question whether our child is getting the right treatment?• Why are so many kids getting prescriptions for medication?
3How would I know if my childcould benefit from medication?• They have a mental health condition forwhich medication is demonstrablyeffective• The condition causes significantfunctional impairment in one or moremajor life domains (school, friends, family,community)• Evidence-based non-medical treatment isunavailable, has been unsuccessful, lesseffective than medical treatment• Severity of child’s condition requiresmore rapid response than non-medicaltreatmentPhotos courtesy of http://www.freedigitalphotos.net
4What type of evaluation isappropriate prior to kids receivingmedication?• Thorough history of presenting problems from child/parent(s)• Screening for common comorbid conditions• Family history of mental health diagnosis, treatment• Review of previous treatment (including medication)• Review of child’s medical, developmental history• Review of educational progress/records, psychoeducationaltesting (if available)• Rating scales from parents, teachers, along with informationfrom other corroborating sources when appropriate• Evaluation of child’s mental status
5What type of professional is qualified toprescribe medication for my child?• Child and Adolescent Psychiatrist• Pediatric Neurologist• Developmental Pediatrician• Pediatrician• Family physician• Nurse practitioner, physicianassistant (can’t prescribestimulants in Ohio)
6When might it more appropriate toconsider non-medical interventions first?• Depression (mild to moderate severity,without suicidal thinking)• Obsessive-Compulsive Disorder(although concomitant medication maybe necessary in severe cases)• Anxiety Disorders (especially phobias)• PTSD• Preschoolers with ADHD• Kids with autism spectrum disorderswith aggressive behavior
7How well does medication work for my childs condition?
8Effect sizes ofmedications for ADHD...• Effect size of Omega-3s...0.36• Effect size of restricteddiets...0.19
9How well does medication workfor my child’s condition (SSRIs)?• Comparable response rate to CBT in CAMSstudy• Effect sizes in FDA-sanctioned clinical trials...• Anxiety...0.69• OCD...0.48• Depression...0.25• Adolescents respond better than school-age children for both MDD and Anxiety• Better response to antidepressants inmore severe illness
10How well does medication workfor pediatric bipolar disorder?• SGAs-all RCTs published in 2007 or later,Response rates in acute RCTs 45-89%,remission achieved in 25-72%...effect sizeslarger than mood stabilizers• Lithium Carbonate: One acute RCT: Li>PBO(46% response rate vs. 8%)...very toxic iftaken in overdose• Divalproex sodium: open-label studies havedemonstrated response rates of 56-92%, buttwo RCTs have failed to demonstrate efficacy• Lamotrigine:Three open-label studies suggest50-60% remission rates, helpful with bipolardepression results confounded by adjunct meds• Topiramate, oxcarbazepine: Negative RCTs
11How safe are the medications commonlyprescribed to kids andteens?
12Short-term weight gain in youth treated with second-generation antipsychotics for the first time
13Metabolic effects of second-generation antipsychotics inpediatric patients
14Suicidal ideation followingtreatment with SSRIs• Major Depression: NumberNeeded to Treat (NNT)=10 Number Needed to Harm(NNH)=112• OCD: NNT=6 NNH=200• Non-OCD Anxiety: NNT=4 NNH=143
15Long-term side effects of medication inkids• Very difficult to do long-term studies with kids• FDA doesn’t typically require trials longer than oneyear• ADHD medications...statistically, but not clinicallysignificant effect on growth (1-2 cm)• Antipsychotics: Risk of tardive dyskinesia 0.4%/yearwith risperidone• Little known about long-term effects ofantidepressants
16For how long will my child needmedication?• ADHD-environmentally dependent, greatest needoften in middle, high school, about half will stillmeet criteria for ADHD as adults• Depression...most clinicians typically treat for ayear• Anxiety...more chronic than depression (especiallyOCD)• Bipolar disorder...lifelong condition if accuratelydiagnosed
17Adherence on ADHDmedications:• Less than 20% of patients started onADHD medication are still being treatedpharmacologically within one year• More than 50% of ADHD patientsstarted on medication discontinue withinthree months• Adherence to ADHD medication lowerafter seven months than adherence tostatins• No difference in discontinuation ratesbetween the four most commonlyprescribed ADHD medications
18When should we question if our child isgetting the right treatment?• Your professional can’t explainWHY your child isexperiencing the difficulties that led you to treatment.• Your professional is unwilling or unable to discuss therange of evidence-based treatments for your child’scondition• Your professional is unable to share the intended goalsof their treatment• Your professional can’t offer a reasonable estimate ofthe time required to see significant progress, alternativesif your child doesn’t respond• Your professional is unwilling to meet with you todiscuss your child’s progress• Your professional is reluctant to seek another opinionwhen your child’s behavior/condition is getting worse
19Warning signs...• The prescriber is reluctant tosimplify the medication regimenwhen medication(s) produceunacceptable side effects or areineffective• The prescriber wants to add onadditional medications without avery good reason.• Your child’s therapist isrecommending medication, butlacks a close, working relationshipwith a physician who can prescribe
20Why does it seem so manykids are getting prescriptionsfor psychotropic medication?
21Most kids with significant mental health disorders DON’T get medication
25Resources...• American Academy of Child and AdolescentPsychiatry Resource Centershttp://www.aacap.org/cs/resource.centers• National Institute of Mental Healthhttp://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml