ITS 835 enterprise risk management Chapter 15 Embedding ERM into Strategic Planning at the City of Edmonton University of Cumberlands 1 introduction Edmonton –Past and present ERM Links to strategic plan and to other strategic tools Selecting and testing tools and framework Recommended strategic ERM approach Lessons learned 2 University of Cumberlands Edmonton past and present erm Edmonton –Capital of Alberta, Canada Over 800,00 population ERM piloted in 2005 CORPORATE Business Risk Planning (CBRP) model Not fully implemented Based on COSO Adopted strategic plan The Way Ahead Strategic ERM 3 University of Cumberlands Links to strategic plan University of Cumberlands 4 Selecting and testing tools and framework 5 University of Cumberlands Selecting and testing tools and frameworks University of Cumberlands 6 Strategic goals and objectives University of Cumberlands 7 Risks and strategic objectives University of Cumberlands 8 Iso 31000 risk management University of Cumberlands 9 Pm2 versus iso 31000 University of Cumberlands 10 Proposed erm framework University of Cumberlands 11 Lessons learned Key success factors Senior management buy-in Culture of innovation Consistency of model across goals Resource requirements for department SMEs Department accountability for key risks Process of selecting and implementing framework Takes linger than expected No system is perfect Do not roll out all at once Clearly define all milestones and deliverables University of Cumberlands 12 CHAPTER NINE Medicating Children This chapter is divided into seven sections. Section One is an overview that discusses current trends in medicating children, problems the trends cause, and directions for the future. It also discusses developmental issues. Section Two focuses on stimulant medication and the diagnosis of attention deficit hyperactivity disorder (ADHD). Section Three focuses on research on combined interventions and particularly the Multimodal Treatment Study (MTA study) of Children with ADHD. Section Four focuses on children taking mood stabilizers. Section Five focuses on antipsychotics and children. Sections Six and Seven focus on anxiolytics and antidepressants in children, respectively. SECTION ONE: PERSPECTIVES, DILEMMAS, AND FUTURE PARADIGMS Learning Objectives • Understand the problematic increase in psychotropic medications for children despite a dearth of evidence of the effectiveness of these drugs. • Have a general understanding of the impact of the FDA Modernization Act and the Best Pharmaceuticals Act for Children. • Be able to state the “developmental unknowns” associated with giving kids psychotropic medications. Thus far, we have explored the medical model and psychological, cultural, and social perspectives as they relate to psychopharmacology. In this chapter, we demonstrate that using psychotropic medications with children and adolescents raises particular problems and concerns fro ...

1. ITS 835 enterprise risk management
Chapter 15
Embedding ERM into Strategic Planning at the City of
Edmonton
University of Cumberlands
1
introduction
Edmonton –Past and present ERM
Links to strategic plan and to other strategic tools
Selecting and testing tools and framework
Recommended strategic ERM approach
Lessons learned
2
University of Cumberlands
Edmonton past and present erm
Edmonton –Capital of Alberta, Canada
Over 800,00 population
ERM piloted in 2005
CORPORATE Business Risk Planning (CBRP) model
Not fully implemented
Based on COSO
Adopted strategic plan
The Way Ahead
Strategic ERM
3
University of Cumberlands

2. Links to strategic plan
University of Cumberlands
4
Selecting and testing tools and framework
5
University of Cumberlands
Selecting and testing tools and frameworks
University of Cumberlands
6
Strategic goals and objectives
University of Cumberlands
7
Risks and strategic objectives
University of Cumberlands
8

3. Iso 31000 risk management
University of Cumberlands
9
Pm2 versus iso 31000
University of Cumberlands
10
Proposed erm framework
University of Cumberlands
11
Lessons learned
Key success factors
Senior management buy-in
Culture of innovation
Consistency of model across goals
Resource requirements for department SMEs
Department accountability for key risks
Process of selecting and implementing framework
Takes linger than expected
No system is perfect
Do not roll out all at once
Clearly define all milestones and deliverables
University of Cumberlands
12

4. CHAPTER NINE
Medicating Children
This chapter is divided into seven sections. Section One is an
overview that discusses current trends in medicating children,
problems the trends cause, and directions for the future. It also
discusses developmental issues. Section Two focuses on
stimulant medication and the diagnosis of attention deficit
hyperactivity disorder (ADHD). Section Three focuses on
research on combined interventions and particularly the
Multimodal Treatment Study (MTA study) of Children with
ADHD. Section Four focuses on children taking mood
stabilizers. Section Five focuses on antipsychotics and children.
Sections Six and Seven focus on anxiolytics and antidepressants
in children, respectively.
SECTION ONE: PERSPECTIVES, DILEMMAS, AND FUTURE
PARADIGMS
Learning Objectives
• Understand the problematic increase in psychotropic
medications for children despite a dearth of evidence of the
effectiveness of these drugs.
• Have a general understanding of the impact of the FDA
Modernization Act and the Best Pharmaceuticals Act for
Children.
• Be able to state the “developmental unknowns” associated
with giving kids psychotropic medications.
Thus far, we have explored the medical model and
psychological, cultural, and social perspectives as they relate to
psychopharmacology. In this chapter, we demonstrate that using
psychotropic medications with children and adolescents raises
particular problems and concerns from several perspectives. As
discussed in Chapter Three, we frequently see explanations and
justifications from the medical model perspective used to
reduce childhood disorders to chemical and genetic problems,
excluding crucial consideration of environmental traumas,
developmental foreclosures, or life stressors.

5. We explore child and adolescent psychopharmacology primarily
from the medical model perspective but complement this
approach with information from the other perspectives
(psychological, cultural, and social). We set the stage by
exploring the current status of the treatment of children and
adolescents with mental and emotional disorders. This chapter
is structured differently from the others in this book. We begin
by discussing the context from the social and cultural
perspectives and the problems with prescribing psychotropic
medications to children. Then we cover an introduction to
stimulants used to treat symptoms of ADHD. Finally, we give
the status of their current use since the last edition of the book
if that is possible.
THE COMPLEX STATE OF THERAPY
Dr. Frank O'Dell, Professor Emeritus of Counseling in the
College of Education and Human Services at Cleveland State
University, has argued in all his lectures on counseling children
and adolescents that the United States is an “anti-kid” society
(Personal Communication, 2001). By that he means fewer and
fewer therapists and psychiatrists choose to treat or continue to
work with children in counseling. To support his argument,
O'Dell points out that resources for children, including the
number of hospital beds in mental health wards for children,
have been shrinking. He believes the rules of managed care
companies, dwindling personnel resources, and increasing
difficulty in working with parents or guardians and their
struggling children all contribute to the current trend. This has
been a problem for at least 45 years. The American Academy of
Child & Adolescent Psychiatry (AACAP) (2001) summarized
the following facts, which support O'Dell's assertion, indicating
little has changed:
• There is a dearth of child psychiatrists. Satcher (2001) stated
further that many barriers remain that prevent children,
teenagers, and their parents from seeking help from the small
number of specially trained professionals who are available and
that places a burden on pediatricians, family physicians, and

6. other gatekeepers to identify children for referral and treatment
decisions (U.S. Department of Health and Human Services,
2001).
• The AACAP's report projected that between 1995 and 2020,
the need for child and adolescent psychiatrists will increase by
120%, whereas the need for general psychiatry is projected to
increase at 22% for the adult population.
• McCarty, Russo, and Rossman (2011) demonstrated that only
13% of youth with suicidal behaviors and ideation receive
mental health services.
• In November 2010, the Coalition for Juvenile Justice
estimated that up to 75% of teenagers in the juvenile justice
system nationwide have a diagnosable mental disorder, and
these numbers continue.
• One in 10 children suffers from mental illnesses severe
enough to impair development. Fewer than 1 in 5 children get
treatment for mental illness.
The U.S. Department of Health and Human Services (2001)
concluded that burgeoning numbers of children are suffering
needlessly because their emotional, behavioral, and
developmental needs are not being met by the institutions and
systems created to care for them. As the number of children and
adolescents needing psychological treatment rises and the
number of service providers falls, the primary treatment
modality becomes psychotropic medications rather than therapy.
Imagine if you were a parent of one of these children.
Debner (2001a) reported that in a one-year period, 350 children
needing hospitalization were turned away from hospitals in the
Boston area. This phenomenon is occurring in most major U.S.
cities and is exacerbated by hospitals holding onto children who
are ready to be discharged, because there is no suitable
placement for them. In another article, Debner (2001b) noted
that the chief pediatricians from the five major academic health
centers in Massachusetts indicated there is a serious crisis in
psychiatric services for youth in the state. The doctors said they
and their staffs could not find appropriate therapy and other

7. mental health services for mentally ill children. As a result,
many such children deteriorate to the point of crisis. Thomas
and Holzer (2006) reported that America suffers from a serious
long-term shortage of child psychiatrists that is taking a toll on
young people, their parents, and their doctors. It is further
recognized that the demand for psychotropic drugs is intense in
spite of dangerous side effects.
The Washington Post (2002) published an article about a woman
who desperately needed a psychiatric evaluation for her teenage
daughter and who left 36 phone messages for various
psychiatrists. She received only four replies. All the replies
were from practitioners who refused to take the case because
they did not treat adolescents. The article further detailed how,
more and more, in-network providers (clinicians) prefer not to
take patients covered by managed care plans, because
reimbursements are so low and restrictions so numerous. The
article also highlighted the disparity and arguments between the
treating professionals and spokespeople from managed care
companies. It is more than fair to say that desperate parents and
anguished children are caught in the political policy dilemma
over the cost and reimbursement of mental health treatment for
children and adolescents.
Since the first edition of this book, there has been a movement
to train more primary care physicians in pediatric mental health
services to try to address the shortage of pediatric mental health
professionals. Aupont et al. (2013) describe a model called
Targeted Child Psychiatric Services designed for primary care
physicians as well as child psychiatrists. This was associated
with improved access to the child psychiatric services that exist,
helped identify optimal care settings for patients and helped
pediatricians be more likely to accept a patient back after that
patient had been under psychiatric care.
Another problematic topic is who dispenses medications in
schools. Most states have a policy on this and many states have
a Nurse Delegated Medication Administration program (Ryan,
Katsiyannis, Losinski, Reid, & Ellis, 2014). Most standardized

8. curricula include trainings of approximately 30 hours with 8-
hour updates every two years or so. These are by and large
directed by professional nurses (Spector & Doherty, 2007).
Nationwide lists of states and their programs can be found
at http://www.nasbe.org/healthy_schools/hs/bytopics.php?topici
d=4110&catExpand=acdnbtm_catD and http://www.healthinscho
ols.org/health-in-schools/health-services/school-health-
services/school-health-issues/medication-management/state-
policies-on-administration-of-medication-in-schools.aspx.
THE EXPLOSION OF PSYCHOTROPIC MEDICATION
PRESCRIPTIONS FOR CHILDREN AND ADOLESCENTS
With diminishing psychological supports for children and
adolescents, using psychotropic medications with them has
become the treatment of choice, even though the majority of
medications used with them lack FDA “on-label” approval for
them (Werry, 1999). Researchers currently estimate that
between 7.5 and 14 million children in the United States
experience significant mental health problems (Riddle, Kastelic,
& Frosch, 2001; Wozniak, Biederman, Spencer, & Wilens,
1997). These statistics vary a little from Satcher (2001), cited
earlier; clearly, millions of children in this country require
mental health services. Children are increasingly prescribed
psychotropic medications as part of their treatment; in many
cases, the medications replace the therapy (Jensen et al., 1999;
Phelps, Brown, & Power, 2002). Given the explosion in the use
of psychotropic medication with children, it is important also to
note that this population has been excluded from clinical trials
of these drugs. Hence, decisions about juvenile medication
obviously rest more on extrapolation of adult data to children
and adolescents than on direct research and evaluation of the
safety and efficacy of psychotropic medication with children
(Riddle et al., 2001; Vitiello & Jensen, 1997).
Coyle (2000) indicated that 80% of all medications prescribed
to children and adolescents in the United States have not been
studied for the safety and benefit of these populations. As of
2011, The National Institutes of Health indicated that

9. methylphenidate, lithium, all atypical antipsychotics,
lorazepam, and amitriptyline were still on the highest priority
list of needs in Pediatric Therapeutics of drugs to be studied in
pediatric populations.
Even though there is a black box warning related to the risk of
increased suicidality in children and adolescents prescribed
SSRIs and SNRIs, the use of these psychotropic agents has
increased with children and adolescents (Markowitz & Cuellar,
2007). The trend in treating children and adolescents with off-
label psychotropic medications, mostly in lieu of counseling and
psychotherapy, has triggered concern both in the general public
and the mental health community. Coyle (2000), Furman (1993),
and Zito (Zito et al., 2000, 2003) argue that there is little or no
evidence to support psychotropic drug use with very young
children and conclude that such treatment could have harmful
psychological, developmental, and physical effects. In a
multinational study, American youths were three times more
likely to be on an antidepressant medication than their peers in
Denmark, Germany, and the Netherlands (Zito et al., 2006). In
2010, the pharmaceutical companies research protocols were
really challenged when uncovered pharmaceutical studies on
many highly utilized psychotropics were found to be no more
efficacious than the placebo. In fact, the second author has
personal communications with several psychiatrists in their
fourth or fifth decade of practice who question the overall
effectiveness of psychopharmacology with patients, especially
children (Ramirez, Personal Communication, 2014).
In another multinational study, Zito et al. (2008) found that the
annual prevalence of youth taking psychotropic medication was
threefold greater in the United States than in the Netherlands
and Germany. The atypical antipsychotics represented 5% of
antipsychotic use in Germany but 66% in the United States.
Interestingly, though, anxiolytics were twice as common in
Dutch youth than as in U.S. or German youth.
With proper research, mental health professionals may be able
to head off disasters such as aspirin precipitating Reye's

10. syndrome or valproate leading to sudden death in infants
(Riddle et al., 2001). Given the lack of knowledge about the
long-term and adverse effects of psychotropic medication on
children, it is crucial that mental health clinicians be alert to the
impact of these drugs on children and advocate for youth when
the evidence that such drugs would be helpful is questionable
(Ingersoll, Bauer, & Burns, 2004). At this point, we would like
to introduce a case that highlights many of the treatment and
medication dilemmas children and adolescents encounter.
THE CASE OF PHILLIP
Phillip is a 7-year-old first-grader from a single-parent home.
His mother is on public assistance, and he is the oldest of four
boys. Although some of the details of his developmental history
are sparse, Phillip began to exhibit impulse control problems at
the age of 2 years and 4 months, shortly after his father moved
out of the house. He was hyper-vigilant, easily distractible,
aggressive with his younger sibling, and frequently irritable.
Initially, his mother believed he was going through a stage of
rebelliousness, but after several months she became concerned
about his behavior and mentioned this to the pediatrician. After
a brief examination, the pediatrician indicated that Phillip was
likely suffering from ADHD and recommended against
medication unless his behavior got too out of control at home.
However, she felt he would need a course of
methylphenidate/Ritalin, a prescription stimulant, once he
began preschool. Phillip's mother accepted this recommendation
and planned to have him evaluated when he began preschool.
Phillip's behavior improved slightly over the next several
months, without therapy or psychotropic medication.
When he began preschool, it took only a few days before all his
active symptoms returned. After observing him for several
weeks, the teacher recommended to Phillip's mother that he see
a physician to be assessed for a stimulant medication. After the
evaluation, the physician prescribed 10 mg of
methylphenidate/Ritalin daily for Phillip.
Methylphenidate/Ritlain is one of the most common stimulants

11. used for symptoms of ADHD in children. It is intended to
reduce inattentiveness, distractibility, impulsivity, and motor
hyperactivity, with a goal of improved academic productivity.
Phillip's symptoms slightly improved over the next eight weeks,
but his aggressive behavior toward other children increased.
Phillip's mother noticed more unpredictable behavior at home,
as well as sleeplessness and restlessness followed by long
periods of lethargy. She took him back to his physician, who
referred them to a psychiatrist. The psychiatrist, after a three-
session assessment, diagnosed Bipolar I (BPI) Disorder, took
him off the methylphenidate/Ritalin, and prescribed 50 mg of
carbamazepine/Tegretol daily and 0.01 mg of
clonazepam/Klonopin. The carbamazepine/Tegretol was used to
reduce his manic symptoms. This antiseizure medication has
over time been found very effective with Bipolar Disorder
(Phelps et al., 2002).
The clonazepam/Klonopin was used to address Phillip's anxious
and agitated symptoms. This anti-anxiety medication often
relaxes children and reduces anxiety without inducing sleep.
Many of Phillip's symptoms diminished, but his mother noticed
both a sluggishness and apathy in him that were new. Over the
course of the next year, Phillip's teacher addressed several of
his learning and cognitive processing problems. Up to
this point, the focus of Phillip's treatment had been
psychopharmacologic. No psychosocial interventions were
given to Phillip, as is often the case (Phelps et al., 2002). No
one seemed to have any awareness or discussion about the
optimal level of medication for Phillip, and there was no
referral for a psychosocial assessment. As his symptoms
worsened, he was evaluated by a psychiatrist schooled in
prescribing adult psychotropic medications off label to children.
Finally, Phillip's mother took him to see a therapist, who
focused on Phillip's attachment issues, his phobic anxiety
triggered by sudden loss or the anticipation of sudden loss, and
his physiologic symptoms, which the therapist considered
powerful side effects of the pharmacologic therapy.

12. Analysis of Phillip's Case
Analyzing the case, Phillip was treated by pharmacology in the
medical model method and rational thinking centered on
pharmacology dominated the case. The combination of
methylphenidate/Ritalin and carbamazepine/Tegretol on
Phillip's system was supposed to reduce some of his
externalizing symptoms in the constellation of ADHD or
Bipolar I disorders, but the psychological aspects of his
personality were ignored. Not until much later in the course of
his illness did Phillip get some assistance in those domains.
Culturally, Phillip's mother had little power in society and was
torn between accepting the opinion of the medical experts, and
watching the negative impact the medications were having on
her son. As mental health professionals, we need to understand
the medical psychiatry's rapid efforts to address most disorders
of childhood and adolescents with psychotropic medication. Far
too often, medicating professionals view talk therapy and other
psychosocial interventions as ineffective and second rate.
Because medical professionals hold more power in our society
than mental health professionals, their medical opinions are
frequently given more weight. Today, psychiatrists burdened by
enormous caseloads are open to what is known as split-
treatment, a joint effort by the mental health professional and
psychiatrist to plan and integrate treatment and be vigilant for
client manipulation. We must integrate care into a larger model
of treatment that addresses each of the four perspectives equally
and where mental health professionals' opinions on mental
health treatment are given more weight. In addition, the power
of pharmaceutical companies must be monitored. Bodenheimer
(2000) has documented numerous cases where companies
prevented important research findings from being published
because they were not favorable regarding the compounds being
tested. To what extent may such situations affect clients like
Phillip? This will be discussed later in the chapter.
Remember, Phillip was in the 4 to 7 age range when he began
treatment. Coyle (2000) comments that there is “no empirical

13. evidence to support psychotropic drug treatment in very young
children and that such treatment could have deleterious effects
on the developing brain” (p. 1060). Furman (1993) posited that
psychiatrists in the United States are recklessly “out of control”
in prescribing methylphenidate/Ritalin and other stimulants for
children, in contrast to the extreme caution that physicians in
almost all European countries use in recommending this
treatment approach. With the increasing trend to medicate a
younger and younger population (Zito et al., 2000), mental
health professionals not only need to understand the impact and
therapeutic effectiveness of these medications, but also their
limitations and potential for harming children.
THE MEDICATION OF CHILDREN AND THE FEDERAL
LAWS
As we have noted in previous chapters, the laws of the land hold
great influence over cultural and social paradigms. To a large
extent, laws are the result of a dynamic interaction of forces
that influence other areas such as socioeconomic status and the
fiscal systems of a society. Socioeconomic status and fiscal
systems shape laws in very powerful ways, and people with
financial resources are able to buy influence with lawmakers.
This is nothing new, but bears stating in this chapter. Although
recent legislation has been introduced to address the many
problems of prescribing psychotropic medications for children,
most such laws require only voluntary testing of psychotropic
drugs, diminishing any real impact. In this section, we
summarize recent laws and comment on them, beginning with a
summary in Table 9.1.
TABLE 9.1 Major Emphases of Recent Legislation on Pediatric
Pharmacology
Law/Rule
Summary
FDA Modernization Act
Recognizes rights of children as patients
(Public Law Number 105–115, 1997)
Sets specific standards for research of pediatric drugs

14. Encourages pediatric labeling
Best Pharmaceuticals for Children Act
Voluntary pediatric studies of currently marketed drugs
(Public Law Number 107–109, 2002)
Created list of all pediatric drugs needing documentation
Requires timely labeling of pediatric drugs
Establishes a mandate to include children of all cultures in
studies
Voluntary studies of new drugs
Pediatric Rule Bill of 2002a
Required timely pediatric studies and adequate labeling
aChild & Family Services Improvement Act: Language on how
the use of medications is to be monitored.
© Cengage Learning®
FDA Modernization Act
Buck (2000) traced the unfolding need for greater specific
labeling of drugs used with patients less than 18 years of age.
The burgeoning use of almost all drugs approved for children by
the FDA compelled pediatric health care providers to use these
drugs off label without a clear knowledge of dosing,
administration, or adverse-effect information. In 1992, the FDA
took steps to improve both pediatric labeling and research,
which resulted in support for building a network of
pharmacologic research by the National Institutes of Health
(NIH). These efforts began to address the problem, and passage
of the FDA Modernization Act (1997) for the first time set
specific requirements to tighten regulations relating to pediatric
pharmacology. This law encouraged pediatric labeling on drugs
used widely with children and adolescents where the lack of
labeling might lead to serious misuse. However, the FDA
website (2013) warns that users of methylphenidate/Ritalin may
have an erection lasting many hours. This from an agency that

15. still cannot conduct pediatric studies that evaluate the full
impact of the drug on that population.
This law goes a long way toward recognizing the rights of
children as patients, protecting their health, and assisting
pediatric providers with essential information. Unfortunately,
the law did not go far enough. Many practitioners and
lawmakers felt the need for a comprehensive law to mandate
pharmacologic research, monitor it, and further protect children.
The Best Pharmaceuticals for Children Act
On January 4, 2002, President George W. Bush signed Public
Law Number 107–109, the Best Pharmaceuticals for Children
Act (Dodd, 2001), with the anticipation that it would address
many of the dilemmas and controversies surrounding the
eruption in use of pharmaceuticals for children. This law aims
to initiate critical studies with pharmaceuticals already
prescribed to a population for whom there exists little research,
and it tightens the monitoring and development of new drugs
released for children and adolescents. The law seeks to integrate
viewpoints on medicating children with the medical, cultural,
and social perspectives. Unfortunately, its most powerful
provisions regarding the conduct of pharmaceutical companies
are voluntary.
The Best Pharmaceuticals for Children Act (BPCA) has 19
sections that can be viewed
at http://www.fda.gov/RegulatoryInformation/Legislation/Feder
alFoodDrugandCosmeticActFDCAct/SignificantAmendmentstot
heFDCAct/ucm148011.htm). This law encourages voluntary
pediatric studies of already marketed drugs, the so-called off-
label psychotropic drugs in widespread use with children, and it
creates a research fund for studying these drugs
(see http://blogs.fda.gov/fdavoice/index.php/tag/best-
pharmaceuticals-for-children-act-bpca/). Both efforts are
critical to understanding the effectiveness and efficacy of
psychotropic medications for children and adolescents. Further,
the law establishes an ongoing program for the pediatric study
of drugs, including a list of all drugs for which documentation

16. is needed. This aspect of the law is monitored by the
commissioner of the FDA and the director of the National
Institutes of Health, who have the power to make written
requests to pharmaceutical companies for pediatric studies. The
law requires timely labeling changes for pediatric drugs under
study.
As of this edition, the status of most pharmaceuticals for
children and adolescents remains similar to what it was in 2006.
There was the black-box effort with SSRIs and SNRIs, but they
are prescribed at rates higher than in 2006 (Cummings &
Fristad, 2007) and most other psychotropics are used with
children and adolescents to quiet anxiety, agitation, and rage.
However, the pharmaceutical companies continue to challenge
the Pediatric Rule on all fronts and now it is 2014 and most
important drugs for children have not been studied with a
pediatric group. So goes the Pediatric Rule. On October 17,
2002, the U.S. District Court for the District of Columbia ruled
that the FDA did not have the authority to issue the Pediatric
Rule and has barred the FDA from enforcing it. The Pediatric
Rule would have required timely pediatric studies and adequate
labeling of all human drugs.
Child and Family Services Improvement Act
The Child and Family Services Improvement Act of 2011
(Public Law 112–34) includes new language that addresses the
social-emotional and mental health of children who have been
traumatized by maltreatment. State Child and Family Services
Plans now have to include details about how emotional trauma
associated with maltreatment and removal is addressed. They
also have to describe how the use of psychotropic medications
is monitored.
A WORD ON CROSS-CULTURAL PERSPECTIVES
Tseng (2003) proposed many variables and differences in
prescribing psychotropic medications to children and
adolescents from various cultures. He stressed that one must
consider not only the physician's attitudes about treating people
from different cultures, but also the patients' perspectives on

17. how they feel about psychotropic medications. Thus, the giving
and receiving of medications has many implications. This factor
is greatly enhanced for children and adolescents, because the
physician must not only communicate with the parents about the
diagnosis and the psychotropic medications (neither of which
may make sense in the parents' worldview) but must also weigh
carefully the cultural issues that the family brings to treatment.
Tseng (2003) also addresses the enculturation issues of
children. His research has described how not every culture
emphasizes the fast-paced and often accelerated approach to
growing up that characterizes the United States. Enculturation is
defined as a process through which an individual, starting in
early childhood, acquires a cultural system through the
environment, particularly from parents, school, and so on. Some
cultures, such as many Asian cultures, have a laid-back attitude
toward babies and toddlers that is more indulgent. Yet later,
they show a dramatic shift for these children, who, when they
arrive at latency, the developmental period between the ages of
6 and 11 or 12, experience enormous pressure to be diligent and
to achieve. Thus, as clinicians treat children and adolescents
from all cultures, they need to reconsider cross-cultural
adjustment and revise the psychosocial stages of Erikson
(1968), which depended on developmental understandings in a
particular culture.
With the upsurge in the use of psychotropic medications, it is
impossible to monitor the expected and unexpected adverse
effects. Given the expanding knowledge of the varying
developmental trajectories of children from other cultures,
mental health practitioners and psychiatrists need to exercise
further caution when prescribing psychotropic medications for
these children. Lin and Poland (1995) described in detail the
remarkably large interindividual variability in drug responses
and side effect profiles. This can be partially accounted for in
differences of ethnicity and/or culture apart from physiological
pace. Some cultures are very suspicious of medication and may
delay the decision for more than a year.

18. Lin and Poland (1995) have made significant contributions to
the understanding of cultural psychiatry and to the fact that
genetic factors associated with individual and ethnic
backgrounds contribute greatly to responses to medication in
children, adolescents, and adults. Kirmayer and Ban (2013) note
that cultural differences in self and personhood are equally
important. All researchers we reviewed point to variations
within the same ethnic group and variations among ethnic
groups. This further complicates the integrative dilemma, which
is how to view psychopharmacology and cases from the four
perspectives outlined in Chapter One as well as consider
important developmental lines and levels. Mental health
professionals recognize that researchers have much to learn
about psychopharmacology with children and adolescents, as
shown by the research cited in this chapter. We need to
integrate our growing understanding of cultural psychiatry with
our limited understanding of how psychotropic medications
work in children. The Best Pharmaceutical Act for Children
(2002) provided …
Week 5 Discussions - Normal Behavior
Respond to one of the following in a minimum of 175 words:
1. Medication can be an important part of treatment for some
psychiatric disorders in children and adolescents. Psychiatric
medication should only be used as one part of a comprehensive
treatment plan. Parents and guardians should be provided with
complete information when psychiatric medication is
recommended. Children and adolescents should also be included
in the discussion, using words they understand. Please select a
psychotropic medication commonly prescribed to children
and/or adolescents and answer the questions below.
How will the medication help the child? When will it start to
work?

19. What side effects commonly occur with this medication?
Is this medication addictive? Is it likely to be abused?
2. The population of elderly individuals is growing with
extraordinary rapidity. Although, the majority enjoy good
health, many older people suffer from multiple illnesses and
significant disability. They tend to exhibit great medical
complexity and vulnerability; have illnesses with atypical and
obscure presentations; suffer major cognitive, affective, and
functional problems; are especially vulnerable to iatrogenesis;
are often socially isolated and economically deprived; and are at
high risk for premature or inappropriate institutionalization.
How do these factors impact treatment?