Whenever I write about children getting medications for anxiety, for depression, or especially for attention deficit hyperactivity disorder, a certain number of readers respond with anger and suspicion, accusing me of being part of a conspiracy to medicate children for behaviors that are either part of the normal range of childhood or else the direct result of bad schools, bad environments or bad parenting.
Others suggest that doctors who prescribe such medications are in the corrupt grip of the drug companies. And there are parents with stories of unexpected side effects and doctors who didn’t listen. (Of course, there are also parents who write to say that the right medication at the right moment really helped, or adults regretting that no one offered them something that might have helped back when they were struggling.)
Putting children, especially young children, on psychotropic medications is scary for parents, sometimes scary for children and also, often, scary for the doctors who do the prescribing. As a pediatrician, I have often had occasion to be grateful to colleagues with more experience and training who could help a family figure out the right medication, dosing and follow-up.
It is a big deal, and there are side effects to worry about and doctors should listen to families’ concerns. But when a child is suffering and struggling, families need help, and medications are often part of the discussion. And so, without presuming to judge what should be done for any specific child, I want to talk about the discussion that needs to take place around medicating a child in distress, and how the doctor and the family should monitor medications when they are prescribed.
Parents worry that medications will affect their children’s personalities, said Dr. Doris Greenberg, a developmental pediatrician in Savannah, Ga., who is associate clinical professor of pediatrics at Mercer University School of Medicine. She can see the message in their faces: “my child has a spirit and a sparkle, and we don’t want this taken away.” She faces this directly: “I ask them, what are you worried about, what horror stories have you heard?”
The family probably has been dealing with a very symptomatic child for a while before they get to her, and “when they come in, they’re kind of wounded.” Before talking about medication, she said, it’s important to understand — and to be sure the family understands — how the diagnosis is being made, and why medicine is even being considered. “We don’t treat people who aren’t impaired — just because the kid wiggles,” she said.
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Dr. Timothy Wilens, the chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, said, “The issue of medicine itself stamps that your kid has a behavioral health issue — they have a disorder that’s requiring treatment.” Dr. Wilens, the author of the standard recommended book on psychiatric medications for children, has faced criticism in the past about ties to pharmaceutical companies; he regards it as an academic obligation to work with the industry, he said, and discloses that directly to parents.
Dr. Wilens said that at that first visit, it’s especially important to discuss the diagnosis with parents, and be sure that they are in agreement about what the problem is. “I stop and say to the parents, Is this what you’re seeing? Does this make sense to you?” he said. “And I talk to the kid. This is what I think it is, does this feel like this is what you have?”
Medication isn’t always appropriate. For anxiety, he said, “I’m probably not going to recommend you go right on medication, I’m going to talk to you about cognitive behavioral therapy.”
When medication is indicated, Dr. Wilens said, parents need a little space and time to think about it, and it may take more than one visit to get to the point of actually writing a prescription.
What parents are most worried about, of course, is safety. “I go right to their worst fears,” Dr. Wilens said. “Is this going to hurt my kid, what are the side effects, what are the worst things that can happen?”
Dr. Greenberg said that she sometimes talks about the Milwaukee studythat followed children with A.D.H.D. as they grew up, and suggested that those whose A.D.H.D. was treated when young had fewer problems with drug and alcohol abuse. “I emphasize that this isn’t just a school problem, it’s a life problem,” Dr. Greenberg said. Dr. Wilens cited a 2017 study that also found that A.D.H.D. treatment was associated with less substance abuse later on.
The doctor should also talk directly to the child, even if the child is young, Dr. Greenberg said, explaining the plan, and answering questions, and getting the child’s assent to treatment. Don’t promise that medication will do the impossible: “It doesn’t cure anything, but it fixes the problem,” she said. “I explain, we’re going to make their brains work better — it won’t get you a girlfriend, you won’t dance.”
Prescribing psychotropic medicines for children involves close attention to the child’s rhythms and patterns. “I want to know about their eating habits,” Dr. Greenberg said, since some A.D.H.D. medicines can reduce appetite. It’s important to know whether they are night eaters or breakfast eaters and to time the dosing so that it interferes as little as possible — and then to monitor the child’s growth carefully.
And the doctor should check regularly on issues of sleep; sometimes a child can’t tolerate an afternoon dose of a stimulant without sleep problems. Good sleep hygiene is important, and it’s often helpful for children with A.D.H.D. to wake up at the same time consistently, weekdays and weekends, Dr. Wilens said.
Doctors should explain how the dosing works, Dr. Greenberg said. “I always explain what the therapeutic range is — some people are fast metabolizers, some are not, and we always start low and work up.” Families need to understand the pharmacology, and what to do if you miss a dose.
“Side effects matter a lot,” Dr. Wilens said. “I tell parents it’s like the old radio dial of an analog tuner, you get to the station and have to tune it perfectly.”
And no one should start a child on any of these medications without follow-up — parents need a number to call immediately if they have any questions, and the child needs to come back at regular intervals. For A.D.H.D. medications, Dr. Greenberg said, she usually sees children every three or four months during the school year to check that they are doing well, to check growth, and then in the summer to plan for the next school year.
These medicines affect the mind, but the mind is very much part of the body. “We do a very complete physical just about every time they come in,” Dr. Greenberg said, to make sure the medicine is safe.
Follow-up also gives parents a chance to report on what they see. Parents can tell whether the medicines are working and they get very good at knowing when doses need to be adjusted. “When parents feel that they are really part of the treatment team,” Dr. Wilens said, “you lose that hopelessness and helplessness a lot of people come in with when their kids have a behavioral health issue,” and that helps everyone take better care of the child.