Making the Most of Medication

Making the Most of Medication
—or—
Muses on Medication

by Louis Allen, M.D.

I. A Brief Psychopharmacology Course II. Making Whole-child Sense of the Facts III. References

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.

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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.

1. 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.
2. Coordinated team feedback provides ongoing information on drug effects and side effects allowing a medical provider to make appropriate drug management choices.
3. 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.”
4. 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.
     

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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.

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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.

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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.”

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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.

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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.

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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.

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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?

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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.

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III. REFERENCES

Web Sites:

Medication:

Mental Health Medications
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:
www.asperger.org

Attention disorders:
www.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.