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by Louis Allen, M.D.
I. A BRIEF PSYCHOPHARMACOLOGY
COURSE
It is increasingly important for people who care for children
with special needs to be knowledgeable about the behavioral, cognitive,
social and physiological effects of various medications these children
may be taking.
A. Prevalence. An estimated
40 to 60 percent of children with particular diagnosed conditions,
such as mental retardation, seizures and autism, are taking medications.
Reportedly, 15 to 30 percent of children in special education
classes are taking various psychotropic medications. More than
half the children attending the ABLE clinic are taking some medicinal
substance for such conditions as ADHD, asthma, allergies, enuresis,
seizures, and mood and anxiety disorders. Up to five percent of
those patients take multiple prescription drugs risking drus interactions
and increased side effects.
B. Best Practices. Decisions about medication
use must always weigh benefits versus side effects. Making wise
pharmacological decisions and monitoring medication effectiveness
and side effects are important because of the high prescription
drug-use rates of children with special health care needs. Teachers,
parents and care providers working with this population must stay
informed and work as a team.
- It is beneficial to gather all available opinions on the
child’s functioning from such helpers as regular teachers,
school psychologists, resource teachers and other community
personnel working with the child.
- Coordinated team feedback provides ongoing information on
drug effects and side effects allowing a medical provider to
make appropriate drug management choices.
- Targeted behavior and quality-of-life outcomes may be monitored.
The well-researched Youth Outcome Questionnaire, or YOQ is an
appropriate rating scale:
- Behavior measurements include recordings of observed
frequency, duration, time samples and intervals between
the behaviors.
- Important records include such permanent products as
grades, citizenship ratings, and a tracking of “pink
slips.”
- Best practices suggest that a medication assessment consider
the following child bio-psycho-social contexts:
- Diagnostic information about organic and medical issues.
- Family history.
- Psychosocial and environmental conditions.
- Health status.
- A defined medical neuropsychiatric diagnosis, with current
prescribed medica-tion(s) and clear indications for their
use.
- A record of problematic behavior before medication and
a specific record of after medication.
- Best practices also suggest enabling the family to keep
an updated list of all medications and treatments at each
provider visit to facilitate possible modifications.
C. Behavior Baselines. The
change between pre- and post-medication behavior must be clearly
assessed. Baseline data of present target behavior is required
to compare with post-medication data, once enough time has passed
for the drug and associated interventions to take effect. We must
evaluate both the antecedents and consequences of the target behavior.
This way, caretakers can decide whether better self-control and
self-management is gained by the child, and through what means.
A web site providing a taxonomy or information on most drugs
is available to parents and helpers at Medline
Plus.
An analysis of the content and setting of the maladaptive behavior
substantiates whether it represents a deficit or excess, and whether
it is environmentally appropriate (in the healthy range—for
at-risk and semi-abusive environments). It is critically important
to determine whether the inappropriate occurs in different situations,
and whether this behavior is being reinforced.
All psychiatric diagnoses should be based on DSM IV criteria.
However, sometimes, because of organically-precipitated aggression
or impulse-control problems, behaviors may be targeted for medication
without meeting DSM IV criteria. In such cases the criteria needs
to be based on the function of the behavior along with
known positive effects of a particular medication on the behavior.
For example, administration of a Serotonin medication such as
one of the SSRIs may increase a child’s reactivity threshold
while lowering his aggression threshold. This in turn would also
make it more possible to teach him appropriate social coping skills
to better handle a problematic situation. In this case, a stimulant
in combination with behavioral management may result in decreased
impulsivity and improved restraint, as well as more openness to
conversation, listening and reflection. Thus, multi-modal treatments
combining medication, behavior control, social-skills training
and cognitive modification can achieve synergetic effects. Theoretically,
then, the “chemical or medication restraints” or impacts
beyond the individual’s personal control may be lessened
or withdrawn.
D. Multidisciplinary Teams.
A multidisciplinary team can serve as an external system of review
to monitor medication outcomes. A team may be composed of parents,
the child, teachers, counselors, health providers, psychiatric
and psychological consultants who are all disposed to work together
to integrate information. The more severe the case, the more issues
that are involved. And the more issues involved, the more medication
prescribed, and thus is indicated the even greater need for a
team approach.
The problems of children with multiple developmental disorders
and associated secondary behaviors are so complex and express
such incalculable variables, that teamwork is needed to promote
positive outcomes. The multiple perspectives of a team guard against
probabilities of high drug dosages and overmedication; in addition,
various viewpoints better monitor behavior and cognitive side
effects. Most importantly, varied perspectives insure the use
of multiple therapies, rather than focusing solely on medication.
An over emphasis on medication prematurely judges the situation
from a biological or “drug” viewpoint, rather than
a comprehensive whole-person perspective. The multiple perspectives
that a team brings help assess the symptoms seeing them in context,
and evaluate the social functions generally resulting from chemical
imbalances. A team evaluates problems not only from a genetic
and constitutional-risk basis, but also in the context of social,
school, and family goodness-of-fit. Possible political, economic,
as well as overt and covert sources of distress can also more
likely be observed in a team approach.
E. Basics. It would be helpful for each multi-disciplinary
team member to learn some basic psychopharmacology to intelligently
answer questions from medication providers and to share in the
query about the effects of drugs on a child’s physiology,
behavior, learning and quality of life.
A fancy word, pharmacokinetics, describes the process by which
a drug is absorbed, distributed, metabolized and eliminated by
the body. Pharmacokinetics helps evaluate positive and negative
medication side effects and the effects of drug interactions.
Given the current knowledge of enzyme inducers and inhibitors
(pharmaceuticals that inhibit or stimulate various liver enzymes,
affect the concentration of a drug, or that interact in other
ways), a drug interaction profile should be completed
for any child taking two or more drugs. Pharmacies and medical
center drug information services, which are available most everywhere,
and computer software programs for health care providers can furnish
information for this purpose. Learning the half-life of a drug,
which is the time it takes to reduce it to a 50 percent concentration
in the body, is important. The half-life can explain rebound and
withdrawal effects, especially with short-acting drugs that have
a brief half-life. A drug with a longer half-life may take more
time to arrive at a desirable steady-state concentration, and
long half-life drugs may lead to accumulation effects if prescriptions
change quickly. With dehydration, drugs that bind to proteins
in the body and have high lipid solubility may either decrease
or increase blood concentrations. Such information is available
from printed inserts that accompany drugs at any pharmacy. One
is cautioned to make sure to read a drug information handout and
have sufficient knowledge of side effects before taking any medication.
Some side effects to note include: Behavior
and such factors that affect learning, changes in mood, personality,
cognition, memory, alertness, confusion, agitation, insomnia and
a decrease or increase in activity. Possible physical effects
may include headache, nausea, blurred vision, dizziness, constipation,
diarrhea, tremors, dry mouth, sweating, heart irregularities,
decreased appetite, or changes in blood pressure, weight or skin.
Drug levels should be measured in the serum using daily trough
and peak times (a trough level is drawn at least eight hours after
the last dose; for example, a morning draw reflects the serum
level since the last p.m. dose). It may sometimes be necessary
to measure liver, bone marrow indices, heart, kidney, and lab
values for possible toxicity. Other parameters to note include
titration schedules (low starting), dosage range, and dose responses.
For children, this is based on weight (both linear and non-linear
drug response leads to more potent effects with increasing drug
amounts). Other parameters to note are duration of the drug response,
drug alternatives, the side effect profile and adverse interactions.
A good site for management of several common behavioral conditions
in children and adults is Medline
Plus - Health Topics. A second web site called
www.cehl.org offers a pediatric psychosocial perspective,
with an introduction to pediatric psychopharmacology by Sandra
DeJong which includes such topics as ADHD, anxiety, depression,
and sleep disorders. Once entered on this site, click on Physicians
and scroll down to Guest Articles, and find Dr. DeJong’s
article entitled “Introduction To Pediatric Psychopharmacology.”
II. MAKING Whole-child SENSE
OF THE FACTS
Changes in medication regimens are almost inevitable, and it
is essential that they be communicated to all team members and
be integrated with other interventions and activities. ABLE’s
experience has proved that multiple team-member input adds safety
and knowledge. Additionally, this collaborative model will likely
significantly increase the skill base of the involved family members.
Medication management has traditionally taken an approach focused
on its physiological effect to the body and the brain. However,
ABLE’s clinical experience shows that combining a focus
on social-cultural understanding along with a psychotropic drug
intervention greatly assists in stabilizing a person’s mental-bodily
states. A drug intervention may quiet the body’s noisy alarm
system so that the child can better hear his or her own voice
and the support of others around him. This whole-child approach
assists an individual in acting on his or her own and in gaining
wisdom with new behavior. The physical foundation is reorganized
and paves the way so that social-cultural relationships can be
supported and stabilized. This approach promotes a therapeutic
conversation that generates and elicits new and helpful ideas
from the team.
A. Chemicals Again. The neuro-chemical
activity at nerve endings, or synapses, is well researched. Much
is known about neurotransmitters, other hormonal agents, amino
acids and neuro-peptides. Some of these chemicals include norepinephrine,
glutamate histamine, dopamine and cortisol, which result in down-regulation
and activation associated with novelty, stress and especially
trauma. Others, like GABA, dopamine and serotonin, up-regulate,
or inhibit resulting in calming and soothing experiences. Some
new drugs selectively block or potentiate subtypes of noradrenergic,
serotonergic, dopaminergic and cholinergic receptors in the brain
and promote novel postural-emotional states of tranquility and
controlled mobilization.
B. Ethological Pharmacology.
Ethology is the study of the connection between physiology and
adaptive social behavior in animals, and has been a useful tool
in establishing a knowledge of fundamental relationships between
environmental factors and physiology across species, including
humans. It has also helped in understanding the formation of human
character. Because of the model ABLE supports, it is also interested
in ethological pharmacology. Cooperation, attachment and connection,
nesting, as well as assertiveness and defense are mechanisms studied
by ethology.
Some medications influence the brain system by regulating performance
during social interactions, including social approach, escape,
dominance and hierarchy. We know how to increase affiliation or
how to diminish sensitivity or irritability by resetting the brain
system with medication that elicits other possibilities for relationship.
Conjointly, we facilitate information flow with therapeutic conversation,
seeking ways to use our language as a complex way of gesturing
and touching the body from a distance. Language can reconfigure
the body’s physiological states and vice versa possibly
explaining the mechanism for body-mind influences and many other
unique characteristics in human language.
C. Emotional Postural States Mediate
Physiology and Embody Narratives. Emotion triggers a
bodily disposition or readiness for action, and the resulting
emotional postural state develops potent and synergistic language-embodied
narratives. Emotional postures include physiology, sensory reactivity
and the “story” held within the body. These bodily
expressions related to stories are clues for ways to practice
ethological pharmacology with appropriate medications.
D. Psychoactive Medications and Mental
States. Optimal treatment with appropriate medication
produce coherent brain-mind states where sensitivities can likely
be eased and where forward-feeding systems moderate the senses.
By recruiting alternative pathways and modes of information processing,
a calming effect can be strategically influenced. A primary effect
of the communication system is soothing of sensory emotional responses.
For example, nonverbal language, such as the use of gaze, attunement,
listening, reflecting, mutuality, and seeking of meaning and understanding
is all part of developed conversation. Communication, where sources
of knowledge and problem-solving are found, makes possible the
desired posture of tranquility.
Family members are essential to the team, and strategic conversations
with the family need to include such things as determining how
much credit for any resulting positive effects needs to be attributed
to the effects of medication.
E. Authenticity and Transparency. Sometimes
families are not interested in a chemical solution to their child’s
problem. The professional team needs to honor such a decision.
Professionals must always be mindful that specialized approaches
and technological language can be oppressive and may overwhelm
a family’s own language.
Important Questions to Ask:
- What is the family’s story about drugs?
- Did someone have an adverse effect?
- Was there a relative with a chronic illness on long-term
drug treatment? If so, did he or she become addicted?
- Does taking a drug suggest weakness, vulnerability, loss
of self-control?
- Is there a family taboo about taking medication, is it considered
“being on drugs”?
- Does subjecting one to a chemical cure override personal
agency and ability to respond?
Generally, the more the team members match their conversational
language and style with the family, the more likely repair and
recovery will take place. When properly attuned, a team’s
dialogue of ideas and thoughts may help the family members own
their problems and discover new solutions. Finally, a family may
choose to make an informed decision resulting in a medication
trial.
F. Motivational Interviewing.
Motivational interviewing can provide a technology for the aforementioned
family/drug discussion. Much depends on the parents’ predisposed
and overall readiness to change. The team needs to ask how important
to the family a positive outcome either with or without medication.
Further exploration is needed to determine reasons for and against
using medication. Education and information may ultimately assist
families with ambivalence concerning medication use. Such information
can lead to a process of considering other alternatives, including
non-medicinal practices. Nutraceutical ideas include nutritional
supplements and herbal preparations used in conjunction with behavioral
supports. Results of this type of conversation may lead to confidence
in family decisions as well as understanding about what parents
anticipate for positive and progressive outcomes.
The direction and momentum in the client’s change process
can be measured. The YOQ, or Youth Outcome Questionnaire, is a
research-standardized outcome measure of symptomatic distress,
change in behavioral process and possible improving social relations.
The parents and the team can collaborate to determine goals using
such questions as: What will be different next month if medication
has helped in all possible ways discussed? or Who would
notice the difference most? Then ask, What would they
see? and What is one small step that could possibly enable
other things to happen?
G. Give Plenty of Hope. It
is important to be optimistic about the results of medication,
but the team cannot make promises. A medical team will assume
that most children with ADHD, as a solitary diagnosis without
co-morbidity, will have some benefit from a stimulant. Two-thirds
will benefit from medication alone, but many of the children who
come in with ADHD, have “ADHD plus”, and the use of
a stimulant alone would be unsatisfactory. On the average, one-third
to one-half of children will have some reduction in suffering;
but only a few percent will have their condition totally managed.
It is likely that the teams and families who invest solely in
the “chemical cure” will be disappointed and may never
be completely satisfied. Alternatives to drugs must always be
available, and hopefully the gradual elimination of medication
will be a goal from the beginning.
H. Reductionism Caution. The danger of reductionism
is seeking an answer in one over-invested area, such as biological,
social or psychological determinism or reducing a set of complex
problems to one simplistic explanation. Living systems are made
up of many parts; and efforts to completely control any one part
may destabilize others. Therefore, if medical-physical solutions
alleviate suffering by one-half, what other healing interventions
need to be called forth?
I. Drug Attributions. Even in very successful
outcomes, the team, to include the parents, should be cautious
about attributing cure wholly to a drug. In ABLE Clinic, the child
is asked such questions as: What did the pills do for you?
and What did you do? A pie is drawn, and the child is
asked to show what slice is attributable to the pill, and what
slice was due to the child’s efforts. It is important to
deconstruct cures, because the pills may be over-objectified.
Making a plan, acting on choices, achieving a goal and deriving
meaning are all a part of one’s own agency and self-determination
and thus promote health. Most of the conditions that are treated
have multiple causes with complex interacting variables. Subsequently,
outcomes are difficult to predict.
III. REFERENCES
Web Sites:
Medication administration:
www.nimh.nih.gov/publicat/medicate/cfm
This is a very good web site especially for parents, with sound
advice on medication administration. It was conceived in 2002
and is easy to access.
Bipolar and mood disorders:
www.moodykids.org
www.bpkids.org
Seasonal depression:
www.cet.org
Post traumatic stress (Baldwin’s):
www.Trauma-pages.com
Asperger’s:
ww
w.asperger.org
Attention disorders:
ww w.chadd.org
Enuresis:
http://familydoctor.org/366.xml
Facts for Families:
www.aacap.org (these
are good handouts)
- Ideas about the connection with the body and mind come from
The Body Speaks, by James and Melissa Griffith. This
is a Basic Book, 1994.
- Clinical Handbook of Psychotropic Drugs For Children
and Adolescents, by K. Bezchlibmyk-Butler and is published
by Hografe & Huber, 2004. This is a current, up-to-date
manual for anyone, but especially physicians.
- Medication For School-Age Children, Gilford Press,
by Ron Brown and Michael Sawyer, 1998, is a very good compendium
for teachers, parents and other helpers involved with children’s
learning and behavior.
- Motivational Interviewing and other ideas for adherence from
Health Behavior Change, A Guide for Practitioners,
by Stephen Rollnick, et al., a Churchill-Livingstone Book, 1999.
- Psychotropic Medication and Developmental Disabilities–The
International Consensus For Health Behaviors, by Steven
Reiss and Michael Aman, published by the Ohio State University
Nisonger Center, 1998. It is a wonderful book on delivering
humane care to developmental disability populations, and is
a resource for much of this section Making the Most of Medication.
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