Third of 3 part series

Why has the prescribing, type of medication and liberal use of medication including multiple medications at the same time become so widespread?

Answer:

The answer to this question is, at first glance, quite simple. The number of psychiatric medications available has increased as well as the number of psychiatric diagnoses applicable to children. This growth has coincided with increased acceptability of using psychiatric medications treating behavioral problems. Many disorders previously felt to be the result of poor parenting are now known to be biochemical in origin.

I talked in my first answer about the skills necessary to make psychiatric diagnoses in children. There is ongoing effort to standardize the way that these diagnoses are made. However, there remains variability in the way that psychiatrists reach their conclusions. Often time is limited and a rigorous examination of the child’s environment and cognitive capabilities cannot be done. Diagnoses are made based on an hour or less of contact with parent and child with little to no time spent interviewing or observing the child in the classroom and talking with teachers.

Usually the psychiatrist or psychologist is not familiar with the child and family. There is little time to assess the accuracy of parental reporting. Behavioral check lists from parent and teachers are economic tools. Many of the checklists have validity checks built in that will highlight contradictions. A comparison of behavioral scores from parent and teacher verify that at least two observers see the child similarly. Some checklists can be completed by the child to obtain a self-report. All of this increases the likelihood of more accuracy in diagnosis.

Valid, reproducible checklists have been developed to diagnose the spectrum of Attention Deficit diagnoses. These have age-related norms and therefore, give a more reliable comparison with behavior of peers. Similarly, standardized self-administered interviews are available for child and adolescent depression and anxiety disorders. These are not used as much as those for Attention Deficit. Other complex, computer generated and scored questionnaires intended to assess more complex childhood psychiatric diagnoses are available. These are time consuming and primarily used in clinical research.

Most of the newer psychiatric medications have not been clinically tested in children, partly because the more complex diagnoses such as psychosis and Bipolar disorder are relatively rare and it is difficult to collect a homogeneous group of children to treat. The group would have to be seen frequently and parents would have to sign off because of the experimental nature of the study. It is very complex and expensive, and consequently very few rigorous studies of psychiatric medications in childhood. The exceptions, of course, are those used for the treatment of Attention Deficit Hyperactivity Disorder. Even these are extremely expensive and complex and require years of follow up. Consequently, most of the newer psychiatric medications are not officially approved for use in children.

Unfortunately, we still have children with severe behavioral disorders whose parents and educators are desperate for a corrective treatment. I have discussed the difficulty of making an accurate diagnosis and the fact that doing this rigorously is expensive and time consuming. These children are being diagnosed in a variety of ways and often the diagnosis is treated as one would an adult with the same diagnosis. Consequently more and more children are on combinations of mood stabilizers, atypical anti-psychotics and stimulant medications.

Many psychiatric medications have emotional as well as physical side effects. Some may be more pronounced in childhood. These can include anxiety, sedation, slowing of cognitive processing, and inattentiveness. Some cause weight gain, some suppress appetite, some cause stomachache; others headache. Others can cause neurological side effects such as tics or muscular rigidity. I have seen times when the medication had the exact opposite effect and caused worsening of the behavior targeted for treatment.

Often medications are the only treatment option available other than hospitalization. It is understandable that medications are used first. Often if a child does not respond to a medication or responds poorly, another medication is added. Sometimes another medication is added because of the side effects of the original medication, i.e. sleeping medications to treat the insomnia caused by stimulants.

Fortunately, child psychiatrists and pediatricians are working to correct these difficulties. More standardized ways of making psychiatric diagnoses are being developed by expert consensus. More treatment “flow sheets” that describe the best way to intervene with medication are being publicized, again by expert consensus. More and more information is available to professionals diagnosing and treating childhood psychiatric disorders. There is much more research on treatment of these childhood disorders.