Last month, I wrote a post about the use of psychiatric medication in children and adolescents. My emphasis was on the complexity of the decision parents face when a psychiatrist recommends medication for a child with a diagnosis of Attention Deficit-Hyperactivity Disorder, Panic Disorder, or Major Depressive Disorder, for example. In that post, I promised to provide parents with some questions to ask when faced with such a decision. It would be a good idea to read the original post, Psych Meds for Kids: Keeping the Conversation Complex, before proceeding.
Assuming you have now read the earlier post, you understand the circumstances under which it makes sense to consider psychiatric medication for a child or adolescent and how to weigh the risks of medication as well as the risks of leaving a condition untreated. Basically, you have considered the big questions and can turn now to the nitty-gritty. Here are some suggested questions to ask the prescribing psychiatrist if you have not already been provided the information:
1. Are you trained in child and adolescent psychiatry? Believe it or not, there is no requirement that physicians treating children and adolescents have specific training to do so. Working with this population, as opposed to working with adults, requires a different set of skills as well as knowledge of a different body of scientific literature. Unless there is a compelling reason to do otherwise (such as no access to a child-trained psychiatrist), work with a physician who has completed a fellowship in child psychiatry.
2. Are there additional treatment options to try before or with medication? Aside from therapy, there are other important avenues to explore. Nutrition, exercise, and sleep all have potential benefits that should be maximized whether or not medication is used. There are some (but not many!) dietary supplements that have good scientific research supporting their use (for example, omega-3 fatty acids in the treatment of depression and ADHD). Meditation and other mindfulness practices have demonstrated effectiveness in some psychiatric conditions such as anxiety disorders. Ideally, medication, when used, is just one part of a more holistic treatment plan.
3. Will you coordinate my child’s care with other treating professionals? In most instances, if a child needs psychiatric medication, therapy will also be recommended. It is essential that all treating professionals talk to one another periodically. Therapists typically see children on a more-frequent basis and for longer sessions, so they can provide invaluable information to the prescribing psychiatrist. Others who might be involved in a child’s care for a psychiatric condition are school counselors, pediatricians, nutritionists, occupational therapists, and other medical specialists, just to name a few.
4. Why did you choose the specific medication recommended? For any given condition, there are usually many different medications. For depression, for example, there are close to 50 anti-depressant drugs with approval from the Food and Drug Administration (FDA). Different medications work differently, have different side effect profiles, have different indications for use, and vary in terms of cost. Some have been around for many, many years; some are fairly new to the market. Some have been FDA-approved for use in children and adolescents; some are used with children and adolescents without such approval. Choosing a medication is a complex process that requires weighing many factors. You should know why the psychiatrist chose the medication he or she did.
5. What are the target symptoms? I often see children and adolescents, referred by a psychiatrist or pediatrician, who are already taking psychiatric medications when I meet them. I typically ask whether the medication is helping. Oftentimes, neither parents nor children can answer this question because they don’t really understand what the medication is supposed to do. When making the tough decision about putting a child on medication, it is essential that you understand how it is supposed to help. Otherwise, how will you know whether it is working or not? In the case of an anti-depressant, target symptoms might include appetite and sleep disturbance, depressed and irritable mood, and thoughts of suicide. The medication trial would be considered successful if the child’s sleep and appetite improved, he became less irritable and depressed, and he began to think less and less about hurting himself.
6. How will the effectiveness of the medication be evaluated? Once you know what symptoms the medication is targeting, find out how improvement will be monitored. Sometimes, it can be obvious that a medication is working such as when a teenager who has been refusing to get on the school bus due to panic attacks no longer attempts to avoid school. Other times, improvement can be much more subtle. For example, improvement in focus and self-control in a child with a mostly inattentive form of Attention Deficit-Hyperactivity Disorder (ADHD) may not be so apparent. Only by obtaining observational feedback from teachers may it become clear that a medication is working (or not). There are many ways to monitor progress: self-report, observations made by parents and teachers, questionnaire data, and structured interviews. Another important aspect of this question is how frequently the psychiatrist will see the child or adolescent once a medication trial is initiated. It is important that there be close follow-up in the early stages of a medication trial in order to make sure there are no serious side effects.
7. How long will my child stay on the medication? Assuming the medication works, it is important to talk about an exit strategy. Because the brains and bodies of children and adolescents are still undergoing significant developmental changes, it is important to evaluate the need for medication on an ongoing basis. For some conditions such as depression and anxiety disorders, it is reasonable to expect that successful treatment will involve an eventual taper off of the medication. Other conditions such as Bipolar Disorder and ADHD, for example, are likely to mean longer-term use of medication. Before committing to a medication trial, it is important to know how the decision to discontinue medication will be made.
These are the broad-brush questions you should be able to answer before consenting to a medication trial for your child or adolescent. You may have many others. Teenagers often ask excellent questions themselves. It is important to recognize that the psychiatrist has expertise about medication and mental illness that you do not have, but that you are an expert on your child. Ideally, you, your child, and the psychiatrist will work together to make sure that the use of psychiatric medication is safe and effective.