In Support of Psychiatric Medications for Children

Many families find it very helpful to learn more about psychiatric medications for kids

Source: "Straight Talk about Psychiatric Medications for Kids", Timothy E wilens, Paul G Hammerness, Copyright year 2016, Copyright Guilford Press. Reprinted with premission of The Guilford Press

In 2022, a New York Times article raised concerns about the use of multiple psychiatric medications in children. They interviewed Renae Smith, a young woman who was prescribed seven different psychotropic medications at the time she graduated high school. “This is a generation of guinea pigs,” says Lisa Cosgrove, a clinical psychologist, and a clinician who does not prescribe medication.

Renae Smith struggled with inattention in fourth grade, and she received medication treatment for Attention Deficit Hyperactivity Disorder (ADHD). By eight grade, she showed signs of anxiety and depression, and noted intense pressure to get into a “big name university… the only path to security and happiness”. In ninth grade, she had suicidal ideation and was started on a small dose of Prozac at a local counseling center. These interventions are consistent with the standard of care. ADHD diagnoses often occur with anxiety, mood or conduct disorders. (Mohammad-Reza M, 2021)

Renae’s psychiatric difficulties do not improve during high school. I agree that the seven psychiatric medications listed at the time of her graduation don’t clearly form a coherent medication regimen. But the article highlights Renae’s experience and one additional anecdote to lambast the use of multiple medications in child psychiatry. From their perspective, pediatric psychopharmacology is a specialty out of control. They don’t discuss the hundreds of controlled clinical trials researching the use of psychiatric medications in children; they don’t document any patient stories that share how multiple medication trials led to remission and relief. These exist.

In 2022, the Boston Globe Spotlight investigation uncovered 21 malpractice settlements associated with Dr. Yvon Baribeau, a New Hampshire cardiac surgeon. How bizarre it would have been if the Globe concluded that cardiac surgery was a specialty out of control? Of course, the poor clinical care provided by one doctor does not reflect on the specialty as a whole, yet, in child psychiatry, inferior care by a few clinicians seems to reflect on the entire field. The bias against medications for mental health treatment is so ingrained in our society, it is ofte not even noticed.

How might I treat an adolescent patient like Renae? Treating ADHD can be life-changing. Research shows that if you can only choose one treatment for ADHD, medications are the most efficacious. (Catalá-López, 2017) “Now the lights are on” my patients have told me, when we find the right medication and dosage, and they can attend to their world, and feel productive. Self-esteem rises as capacity increases.

Renae reports getting caught up in the intense academic pressure that is so common in many high schools. Using the approach outlined in my previous post, I would work closely with the family to help Renae create an academic schedule that was stimulating but not overwhelming. If necessary, I might also talk to the high school guidance counselor.

If Renae’s symptoms of anxiety and depression make it difficult for her to function, I would discuss additional medications with the family. How am I sure that a child needs medications in the first place? As an experienced therapist and author of Becoming a Therapist: What Do I Say and Why?, a text used by psychotherapy trainees across the country, I am well-versed in the power of psychotherapy. Yet, when a child’s development is careening off course or they are actively self-harming or suicidal, medications, (and sometimes multiple medications) may make the greatest therapeutic difference in the shortest amount of time.

In my extended evaluation, I ask specifically about a family history of debilitating anxiety and mood disorders; intervening early can positively change the child’s developmental trajectory. I recommend the family read Straight Talk about Psychiatric Medications for Kids by my colleagues, Drs. Tim Wilens and Paul Hammerness. Throughout treatment, I am available to discuss any concerns about diagnosis, treatment, or side effects.

It isn’t unusual for children to need multiple trials to find the medication that works best for them. Child psychiatrists use medications that hit specific neurotransmitter targets; complex presentations (ADHD with mood issues and/or anxiety and/or eating issues) may require complex medication regimens to obtain remission. Coordinated care with a therapist is always helpful but sometimes there is no therapist available, or the child isn’t willing to attend psychotherapy.

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If the child’s depression doesn’t respond to multiple psychopharmacologic trials, or if they react with agitation or increased suicidality, I consider whether the child may have a bipolar spectrum disorder. In a study of adults with bipolar disorder, greater than 50% reported onset of mood symptoms before 18 years of age. (Leverich GS, 2007) Child psychiatrists evaluating children with treatment-resistant depression are highly likely to treat a subset of patients who will eventually be diagnosed with a bipolar spectrum disorder; these patients may require a mix of medications, including mood stabilizers, for remission to occur. No one would bat an eye at the use of multiple prescriptions to combat debilitating complicated physical illness. Why is this any different?

We are in the midst of a pediatric mental health crisis. Psychopharmacotherapy is one tool in our toolbox to combat severe symptoms and terrible suffering. Rather than adding to the stigma of accessing care, the Times could have recognized that we are still learning, and called for more research and investment in neuroscience. Instead, stable patients on multiple medications read the article and reported feeling anxious about continuing them. Parents of suicidal teens may balk at starting life-saving medications.

Good clinicians don’t have one approach (therapy) that we like and another that we disparage. Our job is to prescribe the appropriate therapies, and/or academic supports, and/or medications. A subset of patients may require multiple interventions to feel better, one of which may be combined pharmacotherapeutic strategies. Our goal is the healing of the child. A true understanding of child psychiatry includes a recognition that some children have a complex illness that requires complex care.

Note: This post was written in honor and in memory of Dr. Joe Biederman, a former teacher who is often considered the father of pediatric psychopharmacology.