Psychotropic medications are confusing for most of us who aren’t trained in psychiatric medicine. We get lots of conflicting messages in the media about medications for children. The medications come in confusing names and seem to be used for reasons that aren’t always clear. We are going to try to answer some of the most common questions about the use of prescribed medications for children with emotional or behavioral problems. Click on a question below to go directly to it.
There are lots of medications that are prescribed for the behavioral and emotional problems for children and adolescents. We used a variety of sources and the expertise of Dr. Sylvester to prepare a chart that can be found here to introduce you to these drugs. It includes drugs that are commonly prescribed for certain psychiatric disorders, and some information on how quickly these medications start working and some of the more common side effects for the medication. This chart is not for decision-making purposes and should not be used by medical professionals for prescribing advice. It is for introductory purposes and may help you ask the psychiatrist good questions.
There are some terrific books that are available to provide information to professionals that work with the children and the adults that provide care for them. One we recommend is Child and adolescent clinical psychopharmacology made simple, written by a psychologist, a psychiatrist and a nurse. It provides information on psychotropic medications in general, on psychiatric disorders that children may have, the medications that are often prescribed for them, and the side effects of the different types of drugs. Other useful information can be found on our Additional Resources Page.
There are lots of ways to categorize these drugs. Drugs for treatment of ADHD are stimulants. They would make most people more active. Antidepressants are usually categorized by the neurotransmitters they target. You may hear the term SSRIs. This stands for selective serotonin reuptake inhibitors and this class of drugs includes many often prescribed medications like Prozac (Fluoxetine) and Zoloft (Sertraline). There are several other types of antidepressants, such as SNRIs (serotonin and norepenephrine inhibitors) and NDRIs, (norepenephrine and dopamine reuptake inhibitors). Some drugs used to treat depression are called MAO inhibitors. The doctor will usually make a big deal about someone prescribed with an MAO inhibitor, because people who take them must have specialized diets.
Bipolar disorders are usually treated with mood stabilizers like lithium or medications with anticonvulsive properties like Depakote (Divalproex). Psychotic disorders are treated with two classes of drugs: traditional antipsychotics (also called neuroleptics) and newer atypical antipsychotics. Risperdal (Risperidone) and Seroquel (Quetiapine) are two of these newer drugs.
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It depends on the drug. The bodies of research on different types of psychiatric medications used in children vary considerably. For a long time, research was not conducted on children because of the risks inherent in this research. No one wanted a child to be hurt in the development of a drug. But, by the late 1990s, the arithmetic changed, and federal officials decided that it was more risky to continue to use these drugs on children in practice without knowing the risks that are often determined through scientific trials on the drug with children. The federal government now requires research on children for medication that will be used with children, so the science is growing much more quickly.
There are a few medications with long, established records of clinical use supported by dozens of high-quality research studies, such as amphetamines in the treatment of ADHD. There is quickly accumulating evidence for medications for other psychiatric problems, such as juvenile depression and bipolar disorder.
Approval of a medicine for use with children by the Food and Drug Administration (FDA) might be considered the “gold standard” assurance that a drug is effective and safe, at least in a relative sense. You should not, however, immediately discount a drug simply because it has not been FDA approved in use for children in any age group or diagnostic category. Gaining approval is a protracted, cumbersome process and it often lags far behind the latest research and other clinical knowledge. Responsible clinicians who are up-to-date on these recent advances, (which may come in the form of clinical trials, placebo-controlled research studies, case examples or another form), may have excellent reasons to believe that a child would benefit from a certain type of treatment, even though the FDA has not yet recognized its utility.
The best way to ensure a child’s safety while taking these medications is to be informed. The prescribing doctor knows the risks associated with these medications and has a responsibility to make you aware of them. If you have any questions or concerns, the doctor or your pharmacist is a great place to start. But an informed child welfare professional should probably also have a reference available to him or her that explains different psychotropic medications or know where to find this information on the internet. It would also be wise to make use of information that is already available, such as the package insert that comes with each prescription medication (when the drug comes from Walgreens Pharmacies, for example, this information is usually on a folded sheet of paper that is stapled to the bag containing the medicine).
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Physicians often discover that a drug that is approved for one medical condition may offer therapeutic benefit to people with another medical condition. When it is prescribed for this second condition, the use of the medication is said to be “off label.” Because not enough has yet been learned about the use of these medications with children, much of the medication prescribed for children with behavior or emotional problems is off label.
The use of off label medication doesn’t mean there is no evidence that the medication works for that condition. The FDA approval process is very long. Sometimes, there is ample evidence of a drug’s effectiveness long before approval. Sometimes, there is little research evidence of effectiveness before a drug starts being used off label for a new condition. But, the physician is basing the prescription on some kind of information. Feel free to ask the physician about the level of evidence for use of an off label prescription.
Some types of drugs are now prescribed for many different problems. For example, SSRI antidepressants like Prozac and also other new anti-depressants such as Effexor, Remeron and Cymbalta are now used for things well beyond depression, such as obsessive compulsive disorder, panic disorder, eating disorders, and premenstrual changes in mood.
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No one thinks this is right, but one dirty truth about the medical business today is that physicians often learn about a new medication or a new use of a medication from a pharmaceutical sales representative. Doctors must rely on that information and their own clinical experience when deciding whether or not to use this drug right when it comes out. Doctors also have to rely on the package inserts to gain insight into both the side effects and the pharmacokinetic and pharmacodynamic properties of new drugs. After a few years, independent studies of drugs that are methodologically sound and not influenced by financial interest become available both in peer-reviewed journals and at professional conferences. Some doctors elect to wait until they can review these studies before using new medications.
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If you think that important pieces of the child’s life were not taken into consideration before medications or other treatments were prescribed, there’s a good chance that you’re right. Very often, the doctor has received incomplete information from the child, their parents, other responsible adults and their prior records. This is not anyone’s fault per se, but it may mean that the doctor does not know something he or she might need to in order to effectively treat the child. Speak with the doctor and let them know your concerns in a frank but non-combative way. If something has been missed, they may ask to schedule a longer conversation with you so that they can get all of the information they need.
It’s important to remember that psychiatrists and primary care physicians usually genuinely want to help the child and family in the best way they know how. Their training as medical doctors sometimes makes them most familiar and comfortable with medication as the primary tool for treatment. If you believe that the doctor has not considered other forms of treatment, (psychotherapy or behavioral/educational interventions), ask them about other treatments that are being used for children with similar problems. If you still have concerns, it may be wise to consider an evaluation by another doctor or other mental health professional (such as a clinical social worker or psychologist).
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This list of side effects is a brief introduction for individuals working with children: it is not comprehensive and is not intended to replace advice from a medical professional. When a child is prescribed a new medication, the responsible adults should have a conversation with the doctor about potential side effects of the specific medication and what should be done if they are experienced. Ask specifically what potential side effects should be reported immediately to a doctor.
As anyone who has watched TV commercials for medications knows, most drugs come with a long list of potential side effects. This does not mean that the drug is unsafe. It does mean that you should be familiar with the list and know what to do if the side effects are experienced.
Side effects of drugs used for ADHD (Attention Deficit-Hyperactivity Disorder)
Among common medicinal treatments for ADHD are stimulant and non-stimulant medications. Stimulant medications such as Dexedrine and Adderall (which contain amphetamine) and Ritalin, Concerta, Focalin, Metadate, and Methylin (which contain methylphenidate) have generally similar common side effects, including:
- Nervousness and insomnia
- Loss of appetite
- Nausea and vomiting/abdominal pain
- Weight loss and digestive problems
- Dizziness
- Headaches
- Withdrawal symptoms
Non-stimulant medications, including Strattera and Wellbutrin can often cause:
- Insomnia
- Irritability
- Dry mouth
- Headaches
- Upset stomach
- Agitation
- Muscle aches
- Appetite suppression and weight loss
- Constipation or diarrhea
Tri-cyclic Antidepressants such as Anafranil, Asendin, Aventil, Sinequan, Pamelor, Tofranil and others are gaining popularity among psychiatrists as a treatment of ADHD. Some of these drugs have also been FDA approved for use in children to treat depression, Obsessive-Compulsive Disorder, and bedwetting. These medications are known to commonly cause:
- Nervousness
- Sleep problems
- Sedation
- Upset stomach
- Dizziness, hypotension
- Dry mouth
- Heart palpitations
Side effects of drugs used for depression: Other than the Tri-cyclic Antidepressants (listed above), the other common class of drugs used to treat depression is the "SSRI’s" (Selective Serotonin Reuptake Inhibitors). Members of this group include Prozac, Luvox, Zoloft, Celexa, Lexapro, Paxil, Pexeva, and their respective generics. While the known side effects of these drugs do vary, common ones include:
- Nausea
- Diarrhea/loose stools
- Dyspepsia (vague abdominal discomfort, indigestion)
- Male sexual dysfunction
- Insomnia
- Somnolence (feeling abnormally sleepy or drowsy during the day)
- Tremor
- Increased sweating
- Dry mouth
- Dizziness
- Prozac is additionally known to cause rash, sinusitis, flu-like symptoms, weakness, anxiety, and other problems
Side effects for medications with antipsychotic action: Antipsychotic medications include two classes: atypical and typical. Atypical antipsychotics are a newer class of medication and include Risperdal, Zyprexa, Seroquel, and Geodon. Typical antipsychotics include Haldol, Mellaril, Loxitane, Moban, Orap, Prolixin, Thorazine, and others. These medications are known to commonly cause:
- Sedation or insomnia
- Stiffness
- Dry mouth
- Dizziness
- Increased appetite and weight gain
- Headache
- Anxiety
- Upset GI (stomach etc.)
- Diarrhea or constipation
Side effects for medications used as mood stabilizers: “Mood stabilizers,” which are commonly used in the treatment of bipolar disorder, include Cibalith (and other lithium concentrations), Tegretol, Topamax, Lamictal, Depakene, and Depakote. Common side effects associated with these drugs vary, but often include:
- Sedation
- Increased appetite and weight gain
- Hypercholesterolemia (excess cholesterol in the blood)
- Dry mouth and increased thirst
- Dizziness
- Upset GI (stomach etc.)
- Elevated liver enzymes
- Headache
- Hair loss
- Irritability
- Fine hand tremor
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This is information the prescribing doctor will want to know. Since you have more consistent contact with your child, doctors count on your observations about the effects drugs are having on them when they decide whether or not to change the treatment regimen. If you are concerned that the side effects the child is experiencing are more severe than expected, call the prescribing doctor. When you contact him or her, give behaviorally-specific descriptions of why you are concerned. An example of a behaviorally-specific description would be “s/he takes 30 minutes to wake up in the morning and often forgets to take her/his lunch to school.”
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Some side effects should be brought to the immediate attention of the prescribing physician. For other side effects, you can wait to tell the doctor about them at your next appointment, provided that the appointment is not far in the future.
As a general rule, if a side effect is severe enough that the child does not want to take their medication because of it, call the doctor.
One side effect which is both common to a number of psychiatric medications and potentially serious enough to warrant immediate medical attention is rash. If a child develops a rash after starting a medication, the child should be brought to their psychiatrist or an ER immediately. It may be just a minor annoyance, but it is sometimes indicative of the development of a serious complication which results in liver failure.
Another side effect that requires action is frequent headaches. Presence of frequent headaches is not a normal reaction to these medications.
Many stimulant medications have the potential to cause upset stomach or other stomach pain. While the medicine is likely not hurting the child, if the distress is severe enough that the child does not want to take the medication, the doctor should know.
Muscle cramps or increased temperature (“feverishness”) warrant a call to the doctor. If a child is having very serious reactions such as shortness of breath or heart palpitations, it is best to notify the child’s psychiatrist and take the child to the emergency room. Primary care providers are not as well equipped to deal with these issues as an ER doctor.
Akathisia is a common reaction which does not get enough attention from patients and doctors. It is a subjective feeling of restlessness which makes it extremely difficult for the individual to stand or sit still for any length of time. If a child begins having these types of reactions, it is best to call the doctor because there is anecdotal evidence supporting the notion that being this restless and not being able to sleep increases the risk of suicide.
Another time to call the doctor is when the child shows new problem behaviors or symptoms, particularly psychotic symptoms such as hearing voices or thoughts of suicide. Other changes that should be reported to the physician without waiting to the next appointment include an usual state of happiness, excitement or irritability.
Also, parents or caseworkers need to know when to call about other symptoms that are specific to the child’s drug or combination of drugs. The parent or caseworker should ask the doctor what to watch for with each drug the child is taking and report back to the doctor if they have concerns.
Some caregivers want to call when there are minor changes in the child’s behavior or when the medicine doesn’t begin to work right away. It is best to leave these questions for scheduled visits with the doctor or other care provider.
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The fact that the child is on a number of medications is not, by itself, cause for concern. The child’s psychiatric issues may be complex and require such treatment. There are ways to use multiple medications for children that are supported by clinical research and expert consensus.
How the child got that number of prescriptions is a better indicator of whether or not to be concerned. If the doctor has decided to prescribe these medications only after making a conscientious effort to try a number of different drugs on their own, there is probably no serious cause for concern. If the doctor appears to have added drugs to your child’s cocktail even when the first drugs were not helpful, ask them to explain what made them decide to do so. If there appears to be confusion about your child’s diagnosis, speak with your doctor and/or consider having him or her evaluated by another doctor. If your child is taking psychiatric medications prescribed by more than one doctor, speak with them to ensure that they know which and how much of each medication the child is taking.
A common path children go down toward multiple medications involves them being on one medication that helps them, but not enough. In these situations, many practitioners believe the best course of action is to discontinue that drug, reassess the child’s diagnosis, and start them on another drug which may be more beneficial. This process can take weeks or even months to complete, and doctors sometimes feel enormous pressure from parents, teachers, and caseworkers to “fix” a child’s problem more quickly, making them more likely to simply prescribe another medicine to alleviate the remaining symptoms. If you think any of these dynamics may be at work, talk with the doctor about what they believe the best course of treatment would be for your child.
Doctors rely on your judgment, so trust yourself when you begin to be concerned. Observing your child and his or her reactions to medications is your greatest ally. If your child is on a number of medications and does not appear to be getting any better, consult with the child’s doctor. If a new drug, being used in concert with other drugs, seems to be causing more severe side effects than your doctor anticipated, call the doctor.
Additionally, the Texas Department of State Health Services published a list of recommendations for when to review a child's psychotropic medications cocktail.
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After the doctor prescribes a medication, there are a number of things to ask that will increase both the child’s safety and the chances of successful treatment. The discussion with the doctor should include the child and be in language which s/he can understand.
Know the dosage and how often to give the medication to the child. Ask the doctor if the child’s school nurse will need to know about or manage the medication during the day.
One of the most important things to ask of a prescribing doctor is a list of possible side effects and directions for what to do if the child begins to exhibit signs of them. Knowing what reactions to watch out for is critical knowledge for both the parent/caseworker and the child themselves.
Ask the doctor if the drug is known by any other names (e.g. methylphenidate is also known as Ritalin) and whether there are any differences in cost between brand name and generic versions.
It is also important to get an idea of how the drug works in the child’s body. Know how long to expect before you will begin to see the drug’s intended effects. Ask the doctor how long the drug’s effects should last and what to expect when it wears off. Ask about potential for abuse so that you can be sure to administer the child’s medication properly (i.e. swallowing the pill whole instead of chewing, crushing or snorting it).
Some drugs require blood tests or other medical examinations to occur before a child starts on a medication or while they are taking it. Ask the doctor if tests are necessary. If they are, ask when they need to be done and by whom.
Help prevent chemical interactions by asking about what medicines or foods the child should avoid while on the medication. Also know what activities the child should be cautious of or avoid.
If you go to the doctor with problems or concerns about a drug’s side effects, ask them if there are any ways to address these issues without additional medications or dosage changes. For example, one common side effect for stimulants is irritability in the afternoon or evening. This irritability could be caused by a number of things, but it may be possible to address this issue with a behavioral plan or simply by having a large snack after school.
Be sure to ask the doctor what to do about missed doses or abrupt discontinuation. With many medicines, children cannot simply “pick back up” on the same amount of the drug after missing doses. If the doctor allows the child to take “drug holidays” over weekends or school breaks, (which is a common practice with some medications), be sure to know how to start back up on the medicines when the plan calls for it.
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Finding the right dosage of a medication is not always easy.
Adults often get alarmed if they see a child prescribed a medication at the same dosage that an adult may receive. These adults reason that because children are physically smaller than adults, they should be on much less medication. The truth is that children who have not yet hit puberty metabolize medications much differently than adults. In children, medications are vigorously metabolized and rapidly excreted. Less medication makes it into their bloodstream so they often need higher dosage than an adult, pound for pound. This can change quickly just before physical signs of puberty present themselves.
Doctors are taught when and how to prescribe medication based on present knowledge while in medical school and in residency. The creation of these practice standards, called “medicinal algorithms”, is a continually growing area of study. Two of the largest projects which construct algorithms for psychopharmacology are the Texas Medication Algorithm Project and the Psychopharmacology Algorithm Project at Harvard Medical School. The resulting algorithms are “decision-trees” which doctors can use to decide when to prescribe what medication, when to increase dosage, and when to switch to a different drug.
With regard to dosage of medication, guidelines are available to doctors in comprehensive directories such as the Physician’s Desk Reference and Epocrates, a database available to physicians on the web and for handheld devices. These references include age and dosage guidelines for many drugs.
Generally speaking, physicians will start a child (or anyone) on the lowest possible dose of a medicine and then observe the child to determine whether changes should be made. They will decide whether to increase or decrease the dose based upon a how the child has responded to the medication and the presence and severity of side effects. If a child’s symptoms have begun to ameliorate as the doctor expected, but the child is experiencing moderate or severe side effects, the doctor may consider lowering the dosage. On the other hand, if a child has partially responded to the drugs and there have been little or no observable side effects, the doctor may increase the dosage. Doctors may use blood or other medical tests to determine whether your child metabolizes drugs more quickly or slowly than average, whether they have appropriate amounts of the drug in their bodies, or whether other drugs may be affecting your child’s response to the medications.
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Only two classes of drugs used to treat emotional and behavioral problems with children are known to be potential drugs of abuse. These are stimulants (such as those used to treat ADHD) and some anti-anxiety drugs. Research suggests that children with true ADHD are much less likely to get a high of euphoria from stimulants as compared to other children, and are therefore less likely to use the drug recreationally.
Some people have also raised concerns about stunted growth or diabetes for children on long term regimens of some drugs. Unfortunately, not much is scientifically known yet about these phenomena.
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Generally, children age seven and older can understand some things about medications, such as why they are taking them and how often they should be taking them. In our research on children in the foster care system showed that many older youth had no clue what their medication was for. Including adolescents fully in the discussion about what the diagnosis is, how it was made, what the medication is for, how it works, the side effects and the consequences of premature or unmonitored discontinuation helps prepare the adolescent for the day in the near future when they will be responsible for their own health management. In addition, there is often other medical information of vital information to youth. For example, people taking an SSRI anti-depressant should not drink alcohol. Young people should not just be told that, but hear the full description of why from a doctor.
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