This document addresses ten common questions parents ask about prescribing medication to children. It summarizes the appropriate evaluations prior to medication, professionals who can prescribe, conditions where non-medical interventions are preferable, effectiveness of medications for conditions like ADHD, depression and bipolar disorder, safety and side effects of commonly used medications, expected duration of treatment, and signs that a child may not be receiving the right treatment.

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Ten Questions Parents Often
Ask About Kids and
Medication
Stephen Grcevich, MD
President and Founder, Family Center by the Falls
Chairman, Board of Directors, Key Ministry
June 15, 2013

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Our 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 child's 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?

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How would I know if my child
could benefit from medication?
• They have a mental health condition for
which medication is demonstrably
effective
• The condition causes significant
functional impairment in one or more
major life domains (school, friends, family,
community)
• Evidence-based non-medical treatment is
unavailable, has been unsuccessful, less
effective than medical treatment
• Severity of child’s condition requires
more rapid response than non-medical
treatment
Photos courtesy of http://www.freedigitalphotos.net

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What type of evaluation is
appropriate prior to kids receiving
medication?
• 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, psychoeducational
testing (if available)
• Rating scales from parents, teachers, along with information
from other corroborating sources when appropriate
• Evaluation of child’s mental status

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What type of professional is qualified to
prescribe medication for my child?
• Child and Adolescent Psychiatrist
• Pediatric Neurologist
• Developmental Pediatrician
• Pediatrician
• Family physician
• Nurse practitioner, physician
assistant (can’t prescribe
stimulants in Ohio)

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When might it more appropriate to
consider non-medical interventions first?
• Depression (mild to moderate severity,
without suicidal thinking)
• Obsessive-Compulsive Disorder
(although concomitant medication may
be necessary in severe cases)
• Anxiety Disorders (especially phobias)
• PTSD
• Preschoolers with ADHD
• Kids with autism spectrum disorders
with aggressive behavior

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How well does medication work for my child's condition?

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Effect sizes of
medications for ADHD...
• Effect size of Omega-3s...0.36
• Effect size of restricted
diets...0.19

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How well does medication work
for my child’s condition (SSRIs)?
• Comparable response rate to CBT in CAMS
study
• 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 in
more severe illness

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How well does medication work
for pediatric bipolar disorder?
• SGAs-all RCTs published in 2007 or later,
Response rates in acute RCTs 45-89%,
remission achieved in 25-72%...effect sizes
larger than mood stabilizers
• Lithium Carbonate: One acute RCT: Li>PBO
(46% response rate vs. 8%)...very toxic if
taken in overdose
• Divalproex sodium: open-label studies have
demonstrated response rates of 56-92%, but
two RCTs have failed to demonstrate efficacy
• Lamotrigine:Three open-label studies suggest
50-60% remission rates, helpful with bipolar
depression results confounded by adjunct meds
• Topiramate, oxcarbazepine: Negative RCTs

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How safe are the medications commonly
prescribed to kids and
teens?

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Short-term weight gain in youth treated with second-
generation antipsychotics for the first time

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Metabolic effects of second-generation antipsychotics in
pediatric patients

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Suicidal ideation following
treatment with SSRIs
• Major Depression: Number
Needed to Treat (NNT)=10
Number Needed to Harm
(NNH)=112
• OCD: NNT=6 NNH=200
• Non-OCD Anxiety: NNT=4
NNH=143

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Long-term side effects of medication in
kids
• Very difficult to do long-term studies with kids
• FDA doesn’t typically require trials longer than one
year
• ADHD medications...statistically, but not clinically
significant effect on growth (1-2 cm)
• Antipsychotics: Risk of tardive dyskinesia 0.4%/year
with risperidone
• Little known about long-term effects of
antidepressants

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For how long will my child need
medication?
• ADHD-environmentally dependent, greatest need
often in middle, high school, about half will still
meet criteria for ADHD as adults
• Depression...most clinicians typically treat for a
year
• Anxiety...more chronic than depression (especially
OCD)
• Bipolar disorder...lifelong condition if accurately
diagnosed

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Adherence on ADHD
medications:
• Less than 20% of patients started on
ADHD medication are still being treated
pharmacologically within one year
• More than 50% of ADHD patients
started on medication discontinue within
three months
• Adherence to ADHD medication lower
after seven months than adherence to
statins
• No difference in discontinuation rates
between the four most commonly
prescribed ADHD medications

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When should we question if our child is
getting the right treatment?
• Your professional can’t explainWHY your child is
experiencing the difficulties that led you to treatment.
• Your professional is unwilling or unable to discuss the
range of evidence-based treatments for your child’s
condition
• Your professional is unable to share the intended goals
of their treatment
• Your professional can’t offer a reasonable estimate of
the time required to see significant progress, alternatives
if your child doesn’t respond
• Your professional is unwilling to meet with you to
discuss your child’s progress
• Your professional is reluctant to seek another opinion
when your child’s behavior/condition is getting worse

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Warning signs...
• The prescriber is reluctant to
simplify the medication regimen
when medication(s) produce
unacceptable side effects or are
ineffective
• The prescriber wants to add on
additional medications without a
very good reason.
• Your child’s therapist is
recommending medication, but
lacks a close, working relationship
with a physician who can prescribe

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Why does it seem so many
kids are getting prescriptions
for psychotropic medication?

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Most kids with significant mental health disorders DON’T get medication

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Are expectations, our learning
environments driving increases in
use of prescription medication?

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Questions?

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Stay in touch!

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Resources...
• American Academy of Child and Adolescent
Psychiatry Resource Centers
http://www.aacap.org/cs/resource.centers
• National Institute of Mental Health
http://www.nimh.nih.gov/health/topics/child-
and-adolescent-mental-health/index.shtml