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Medication of Children with Behavioral Problems Debated

Monday December 3, 2007
<B>ADHD and ADD might be different expressions of the same disease. Girls tend to internalize and present with ADD, while boys tend to externalize and present with the hyperactivity typical of ADHD. </B>
ADHD and ADD might be different expressions of the same disease. Girls tend to internalize and present with ADD, while boys tend to externalize and present with the hyperactivity typical of ADHD.
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Almost anyone who has been around school-aged children is familiar with the scenario. There are quite a few 8-year-olds at a birthday party, and one is running around the table at top speed, shouting, "I'm Superman!" He isn't paying any attention to the other children and has gone into the bathroom to help himself to a towel, which is now draped around his neck. In this day and age, it is almost inevitable that someone at the party who is watching this young boy's exuberance will turn and say, only half joking, "Somebody didn't take his medication this morning!"

The facts speak for themselves

The benefit of medicating children for behavior and emotional problems is not as clear as conventional wisdom characterizes it. A study by the CDC published in the Sept. 7, 2007, issue of "Morbidity and Mortality Weekly Review" reported that suicide rates among people ages 10 to 24 increased by 8% from 2003 to 2004, the largest single increase in more than 10 years.

In fact, during 2004, suicide was the third largest cause of death in this age group, accounting for 4,599 deaths. The rise in the rates occurred during the same time the FDA began requiring "black box" warnings on widely prescribed type of antidepressants — selective serotonin reuptake inhibitors (SSRIs). The warning is associated with a decrease of 22% in pediatric prescriptions. There is some question as to whether this decrease in the use of the medication had an unintended and adverse effect on the suicide rate (www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a2.htm).

The controversy continues

It is little wonder that there is a debate among health care professionals, parents, and schools about the use of psychotropic medications in pediatric practice. At the eye of the storm are children like the exuberant young boy. Would we be giving him tools to learn by helping him to concentrate, or would we be medicating the enthusiasm out of him?

The confusion and controversy around the medication of children for behavioral and mental health problems becomes more powerful every year. It is not hard to understand why. More children are taking more medications than ever before. We medicate children to help them think more clearly, behave more acceptably and, hopefully, to make their lives better. It is not evident, however, that these medications improve the lives of children who struggle with problems of depression, attention deficit, and other psychological issues.

Medications used for children are not specifically formulated for pediatric use. In general, the same medications that are used for adults are given to children in smaller doses. The long-term effects from the use of these medications are uncertain, and the research regarding the long-term effects on children is scant.

A new vision of childhood

The ideal of a carefree, happy childhood is no longer accepted as the norm for 21st century children. The National Mental Health Center reports that at least one in five children or adolescents has a mental health disorder. There are many disorders, including depression, behavior disorders, emotional difficulties, substance abuse, attention deficit disorder (ADD), and attention deficit hyperactivity disorder (ADHD). Some of these children can benefit from medication, but for some, medication is inappropriate.

Wanda Mohr, RH, PHd, FAAN APN
Figuring out the best approach is best left to an expert health care provider, says Wanda Mohr, RN, PhD, FAAN, APN, professor of child psychiatric nursing and advanced psychopharmacology, School of Nursing, University of Medicine and Dentistry of New Jersey.

A multidisciplinary approach

"These medications should not be offered by primary health care providers," she says. "It is very difficult to determine the most appropriate treatment approach even when the clinician is expert and trained in pediatric psychology. When there is a question regarding the diagnosis and treatment of behavioral or psychological problems, the child should be seen by a specialist. Most people don't realize how complex and understudied these conditions are."

Furthermore, there is a critical shortage of pediatric psychiatrists, and Mohr points out that the advanced practice nurse who has had specialized training in the field can help by working in tandem with the psychiatrists. This is one way to broaden the availability of appropriate services to more children. When psychotropic medications are used, the APN can be a valuable asset by assessing the efficacy of, and the children's reactions to, the treatment.

Mohr says that there are many children who are overmedicated, undermedicated, and inappropriately medicated. One of the most important rules of prescribing any psychotropic medication for children is "Start low and go slow." That means starting with monotherapy — one medication — and giving the treatment ample time to work. A common error is increasing the dose or the number of medications too quickly before there is any effect. Mohr says that it can take as much as six weeks to see any effect from the medication.

"Adding medications too quickly can result in a medication 'cocktail' — a combination that isn't put together in an evidence-based way," says Mohr. "This is particularly dangerous in children."

It's a family affair

Parents are not entirely silent during the treatment process, and sometimes they pressure the clinician to "do something" to stop the chaos that may be caused by the child's behavior. There are often other children who need parental time and attention. In all cases, says Mohr, medication should be only one part of an overall treatment plan that includes talk therapy with an experienced pediatric specialist.

"Both parents should be included in the therapeutic process whenever possible," she says. "School should also be an integral part of any treatment."

Mohr notes that the school nurse and teachers are often the first sentinels in terms of identifying problems. She cautions that school staff must limit the kind of advice they offer to parents. Staff can appropriately recommend that parents investigate a given behavior or change in the child's behavior, but they should not tell parents that the child needs medication.

"Medications may be one answer, but there are non-medication interventions that should be tried," she adds. "Cognitive behavior therapy provided by a well-trained therapist may allow a child to avoid medication. This therapy helps the child learn different ways of coping."

Attend to a deficit

ADHD occurs more frequently in boys than in girls, and the National Institute of Mental Health estimates that from 3% to 5% of all children in the U.S. have this problem. These children are impulsive and hyperactive and can be difficult to manage in a traditional classroom setting. ADD, without the hyperactivity component, is sometimes characterized by an overall impression that the child is daydreaming.

Mohr notes that ADHD and ADD may be different expressions of the same disease, and that girls tend to internalize and present with ADD, while boys tend to externalize and present with the hyperactivity typical of ADHD. Diagnosis is never simple, and certainly not every active child nor every dreamer has this disorder. It is important that the child be evaluated by an expert (www.nlm.nih.gov/medlineplus/attentiondeficithyperactivitydisorder. html#cat3).

"We really have to look at the context of the behavior," says Mohr. "The behaviors of a bored child may look very much like a child with ADHD."

Medication can be helpful to the child with ADHD, and there is information regarding the long-term effects of these medications. According to information from the Mayo Clinic, psychostimulants are used most often, sometimes with dramatic improvement. Commonly used are methylphenidate (Ritalin, Concerta), dextroamphetamine/amphetamine (Adderall), and dextroamphetamine (Dexedrine). Atomoxetine (Strattera) is not a psychostimulant, but it works in a similar manner.

It is not clear why these medications work well, but they appear to boost and balance the neurotransmitters in the brain. Mohr says that the long-term outcomes for unmedicated children with ADHD are poor (http://mayoclinic.com/health/adhd/DS00275/DSECTION=7 ).

Children who have psychiatric or mental health problems begin life from a few steps behind the starting line. The lives they ultimately build for themselves as adults can be made happier and healthier if they have the correct interventions early in life. Identifying the child who needs this intervention and differentiating that child from the individual who is just "dancing to his own music" is best left to clinicians specially trained in the field.

Marylisa Kinsley, RN, BSN, is a frequent contributor to Nursing Spectrum. To comment, e-mail editorPA@nursingspectrum.com