Children and Psychiatric Medications
Understanding best practices.
Posted Oct 10, 2019
Nearly half of children receiving treatment for mental health conditions never see a psychiatrist. Primary care providers prescribe more psychiatric drugs to children than psychiatrists, raising concerns about over-medication, proper dosing, and appropriate diagnosis of mental health conditions. Children are a vulnerable population, with specific developmental and social needs. Treatment must take into account these concerns. Here are 10 best practices for all providers who prescribe psychiatric drugs to children.
Use Evidence-Based Diagnostic Criteria
Using diagnostic criteria greatly enhances the reliability of psychiatric diagnoses. Yet many providers, especially pediatricians, do not use them. They instead assign the child a common diagnosis based on a few behavioral observations or insights from parents. Instead, clinicians should gather information from multiple sources, interview the child, and use relevant diagnostic criteria from the DAM or another diagnostic guide.
Follow Treatment Guidelines
The American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and other organizations have published treatment guidelines for most common childhood mental health disorders. For example, the American Academy of Pediatrics advises preschoolers with ADHD should receive behavioral interventions before trying medication. All children with ADHD should receive therapy as well as medication. Advise parents that following relevant treatment guidelines can greatly increase the efficacy of treatment, including medication.
Refer for Mental Health Care
Pediatricians and PCPs treating mental health conditions should offer the child a referral to a child psychologist and psychiatrist. They should also encourage the family to seek family therapy and counseling for the child. Changes to the family environment and parenting support can greatly improve outcomes in children.
Know Which Behaviors Are Developmentally Normal
A two-year-old who throws herself on the floor crying and hits herself in the face is behaving in developmentally typical ways. Yet parents may be alarmed by developmentally typical behavior. So it’s important for clinicians to know what’s normal, especially when they don't specialize in the treatment of children. Advise parents about normal behaviors, about when they can expect these behaviors to disappear, and the extent to which parenting and social environment may mediate these behaviors.
Involve the Child in Treatment
It’s tempting to partner only with the parent or caregiver, and to see children—especially young children—as incapable of participating in their treatment. This is a mistake that can decrease compliance and trigger conflict between parent and child. Even very young children can understand that medication helps them feel happier and calmer. So explain the diagnosis and medication to the child in an age-appropriate and comprehensible way.
Enlist Assistance from Caregivers
Caregivers are more than just medication dispensers. They must understand the child’s diagnosis and the need for the medication. It’s also important that they play a proactive and evolving role in treatment. That includes informing prescribers of side effects and continuing to monitor the child’s behavior. So encourage open two-way communication, and help caregivers understand that medication management is often a process of trial and error.
Discuss Side Effects and Contraindications
Parents who have little experience with psychiatric medications may view these drugs as a panacea. It’s important to give them a more nuanced perspective. Discuss common side effects, contraindications, and how side effects tend to evolve over time. Some medications may require lifestyle changes. For instance, some children have fewer side effects on stimulants when they eat regular meals. So discuss lifestyle factors that may play a role in side effects, and encourage parents to do their own research.
Many parents whose children take psychiatric drugs report continual behavior and psychiatric problems, in spite of the medication. While a single medication won’t fix all of a child’s problems, it’s important to continually follow up with the family. Set clear treatment goals and benchmarks and assess at regular intervals to see if the child and family are reaching those goals. If not, it may be necessary to change medication or increase the dosage.
Start With Lower Doses and Fewer Drugs
In almost all cases, it’s safest to start with the lowest potentially efficacious dose and to steadily increase from there. Begin with just one drug, and add other medications as necessary. Otherwise it’s difficult to assess whether treatment is working, which drug is working, and which drug is responsible for any side effects that appear. Remind families that treatment may take time, and that this is the safest way to initiate treatment.
Work With Schools
Many children receiving psychiatric treatment are also entitled to educational accommodations at school. The right educational environment can set students up for success, and may even reduce the need for long-term medication. So it’s important to inform parents of their right to an Individualized Education Plan (IEP) and to provide appropriate documentation to support the plan.
Perhaps most importantly, encourage caregivers to be proactive, to do their own research, and to ask as many questions as they want. The success of treatment is heavily dependent on a parent’s ability to monitor medication, report side effects, and critically assess the child’s progress. So treat the parent and child as partners in treatment—not as people upon whom treatment is imposed. Instruct them that the medication may need to shift or change over time, and help them understand that sometimes it takes a while to get the right drug or dosage.
By encouraging them to see treatment as a collaborative and evolving process, you support families to make intelligent treatment decisions and support children through a wide range of mental health challenges.