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The physician should inform the guardian of the most frequent expected side-effects and the likelihood of the most untoward effects (Tables 2-4). The discussion of benefits and risks should be noted in the patient record.

Serious side-effects are usually related to dosage and duration of psychotropic medication. Intelligence and learning ability are affected when dosage exceeds optimum levels, usually associated with sedation or toxic effects. Behavioural changes, including irritability, temper tantrums, hyperactivity, or hypoactivity, however, may occur at lower dosages than those that produce even mild somatic complaints. These may be so irksome and so long-lasting that the particular drug must be discontinued.

The most dangerous effects of the major tranquilizer drugs (neuroleptics) are the central nervous system effects. Most effects will subside dramatically if the dose is reduced or if anticholinergic medication is added immediately (anticholinergic medication should not be given preventively, however, before symptoms occur). Neurological symptoms may include acute dystonic reactions, dykinesias, parkinsonian reactions, akathesia, and the “rabbit” syndrome (perioral chewing).

The most malignant of these conditions, tardive dyskinesia, involves involuntary movements of the face, eyelids, upper and lower extremities, fingers, toes, torso, and neck, and can occur as early as within three months of cumulative drug usage. The effect can occur during drug administration or after dose reduction or drug withdrawal. This condition is resistant to treatment with anticholinergic or other medication. It is difficult to differentiate tardive dyskinesia from withdrawal dyskinesia, in which the symptoms may abate within six months. It is worth noting that the poor responders to neuroleptics are the most likely to develop the dyskinesias. This emphasizes the importance of the physician’s evaluating the response to a psychotropic drug within the first month and preferably within a week of the first dose of some medications.

In general, prescription should begin at the lowest dosage. Give an adequate trial at each succeeding dosage level. Recognize that stimulants show an effect within hours, tranquilizers within days, and antidepressants sometimes not for weeks. Therapeutic blood levels for some psychotropic drugs may not be obtained routinely in clinical laboratories. Dosage for children and adolescents is more idiosyncratic than adults. Failure of one drug in a class of psychotropic drugs does not rule out using another drug in that same class. A general rule is not to use two or more drugs from the same class at once to guard against synergism. Usually dosage is increased until effective, which may sometimes be close to the level at which toxic signs appear.

Psychotropic drugs should not be discontinued quickly to minimize the occurrence of seizures or other withdrawal symptoms. “Drug holidays” should be discussed far in advance in order to assess the best opportunity for discontinuation.

Effectiveness should be judged on a weekly basis, with renewal of prescription on a monthly basis. Discontinuation of medication should be considered every three months. The responsibility of monitoring the risk-benefit ratio of long-term psychotropic drug use (for more than three months) must be shared with the guardians.

The physician should choose the one most appropriate medication.

Current indications for the use of psychotropic medications in children and adolescents can be summarized briefly (Table l). The listing in Table 1 is by no means an exhaustive review of this rapidly emerging field. In two situations, autism and obsessive-compulsive disorders, there is only recent evidence of the possible usefulness of psychotropic medication.

Certain psychotropic medications, such as lithium salts for manic-depressive disorders in children and adolescents, are best left in the hands of psychopharmacological specialists. The use of antihistamines, such as diphenhydramine, and benzodiazepines in treating anxiety disorders of children has not been clearly substantiated. These medications should be used in consultation with a child psychiatrist. They are, however, relatively safe in comparison to the major tranquilizers.

The physician should therefore become thoroughly familiar with a small number of psychotropic drugs in order to respond to parental questions. Three drugs, which are commonly used in pediatric psychiatry, are methylphenidate, imipramine, and thioridazine. The physician should have a certain range of knowledge about these drugs in order to provide appropriate care, although one may choose to use other drugs. One should know the indications, proper assessment procedures, optimum dosage, price, side-effects, drug interactions, contraintfications, common withdrawal effects, alternative therapy, and concurrent treatment recommended for the drug (Tables 2-4).

Freeman recommends that the physician should be prepared for a potential barrage of questions by the enlightened parent consumer. Such questions may include any or all of the following:
• How do drugs change behaviour?
• My child has brain damage. Will he react differently?
• Should something else be tried first?
• Which behaviour should be treated first?
• How quickly will the drug take effect?
• Are drugs abused by teachers? Institutions?
• What are the different kinds of drugs?
• What changes can I expect at adolescence?
• Are all brands the same?
• How long will she have to take the drug?
• How many drugs can he take at the same time?
• How many times a day does she need to take it?
• How do the drug doses differ from adults’?
• What time does he take them in relation to meals?
• Are drug samples ok?
• Should parents adjust dosage?
• Should drugs be discontinued suddenly?
• Why do stimulants slow down hyperactivity?
• Will she become addicted to this or other drugs?
• What side-effects can I expect?
• Do other drugs interact with this one?
• What side-effects mean that we should stop giving the drug?
• What examinations or blood tests will he have to take? How often?
• Will she become dazed or “out of it”?
• Will it slow down his learning?
• When will you want to change dosage?
• Will it affect her nutrition?

A simple time-saving technique that may anticipate most questions is to provide the family with a drug information pamphlet. The parents should be advised to read the pamphlet and then to ask questions.

Psychotropic drugs should be neither the first choice nor the last choice in treatment for the behavioural and emotional disorders in children. The physician needs to keep in mind that the child is a developing individual, whose subjective symptoms may not indicate mental illness as clearly as adults’ symptoms may. As a result, the physician’s decisions about treatment are usually based on the assessment of the ecological system of the child (home, school, neighbourhood).

Taking the History

Behaviour data, either in narrative form or using numerically validated scales (e.g., Conner’s scales), can be obtained from parents, guardians, siblings, peers, and teachers. The physician must be wary that medication may be sought as a simple solution for complex problems, such as family stress or parental emotional illness, inappropriate teaching situations, or inadequate child care. The physician must therefore explore the psychosocial history and educational background adequately and should also determine the availability of psychotherapy, behavioural therapy, family therapy, and remedial education.

Before initiating treatment the physician needs to determine any history of physical problems, especially drug hypersensitivity; previous history of seizures (which is not necessarily a contra-indication); and liver, kidney, or visual dysfunction. Any gross neurological abnormalities, especially incoordination, gait disturbance, tremors, or tics, should be noted.

Certain drugs may require additional tests. A complete blood cell and differential count is required before prescribing methylphenidate or thioridazine; a platelet count is also necessary before prescribing methylphenidate. Patients treated with imipramine should have dexamethasone testing, an electrocardiogram before and during treatment, frequent blood samples to assess the serum level of imipramine, and reassessment after a two-week withdrawal period when treatment is discontinued. Thioridazine therapy requires liver function tests at least once every month.

Attitude Toward Drugs

The attitude of the child, family, or guardians to medication should also be carefully assessed. Do they regard the child as unco-operative or manipulative and the medication as a means of control? Does the child or guardian expect the medication to cure the disorder? Is there undue pressure or resistance to the use of medication? The physician must also be aware of his or her own desire to offer a “quick fix,” for the sake of time or lack of awareness of other therapeutic interventions.

Klaus Minde has encapsulated, in two doctor-patient exchanges, the major communication required about the role of psychotropic medications in a child’s ecological system:

Doctor A. (to the parents):

I would like John to stay with these pills and take them twice daily, seven days a week at exactly 8 a.m. and 12 noon. Don’t let him forget them. Watch that he really takes them and don’t leave it up to him to remember. He is obviously doing much better and we want to keep it that way.

Doctor B. (to the child):

Paul, don’t forget that these tablets are simply some kind of crutch-like a crutch you need when you break a leg. Always remember, however, that a crutch can only help you with your walking, but can never do the walking for you, because that you have to do yourself.

Dr. B. has avoided enhancing powerlessness in the child and has stressed the importance of Paul’s effecting change. Minde stresses the “demedicalization” of this transaction. Although it is tempting to use the placebo effect of any medication, particularly in suggestible children or parents, Minde cautions against the resulting loss of autonomy and responsibility for the patient’s own actions.

Physicians have been using psychotropic drugs in children increasingly, probably because of the successful results of methylphenidate (Ritalin®) with hyperactive children who have an associated attention deficit disorder.

Parents and child advocates have been simultaneously concerned, however, about accuracy of diagnosis, over-labelling of the child, long-term side-effects, and providing a quick “fix” while neglecting other therapies that require long-term commitment. Consumer complaints in Ontario resulted in unique legislation, the Child and Family Services Act (CFSA) of 1985, which defines psychotropic drugs; formally states the physician’s responsibility to obtain informed consent; defines informed consent to include drug dosage and risks; requires caretakers other than the parents to be informed about the medication; and sets limitations on the emergency use of psychotropic drugs with adolescents older than 16.

This article will address common questions from parents and guardians about the use of psychotropic drugs, will provide a brief guide to use of three common psychotropic drugs used with children, and will list the common conditions in children and adolescents for which psychotropic drugs might be considered.

Legal and Ethical Issues

Although the CFSA applies only to children and adolescents in programs of the Ontario Ministry of Community and Social Services, the principles of obtaining informed consent have been endorsed by the Ontario College of Physicians and Surgeons and the Canadian Medical Protective Association. There have been myriad articles aimed at physicians following the 1980 Supreme Court of Canada “Reibl versus Hughes” case, which established the precedent of a physician’s obtaining informed consent.

Assessment of the case’s impact, however, has shown that it has been ignored for the most part by physicians, much to the dismay of the Ontario Hospital Association (and likely the Canadian Medical Protective Association). All that is legally required now, even under the Ontario CFSA, is a note in the doctor’s record that he or she has discussed the purpose of drug treatment and the risks associated with this treatment. The Ministry of Community and Social Services has, however, recently considered requiring formal, written consent forms signed by children receiving their services. The Ontario Medical Association will be asked to participate in developing potential regulations.

The Biomedical Ethics Committee of the Royal College of Physicians and Surgeons of Canada has urged a higher standard of informed consent than the law requires and has recommended the concept of shared responsibility. This recommendation entails good communication with the patient or surrogate, provision of reasonable data, noting and discussing any indecision on the part of the patient or surrogate, consulting legal authority if the physician believes that serious harm may befall the patient without treatment, and finally, avoiding delegation of this important medical act to others.