Doctors increasingly use psychiatric medications to treat children and adolescents who have psycho-social difficulties, but the practice is controversial. Critics point out that we know little about how these psychiatric agents work, that prescribing psychiatric medications to children may ignore possible social and environmental causes of childhood problems, and that the U.S. Federal Drug Administration has not approved many of the drugs to treat the disorders for which they are commonly prescribed.
Nonetheless, treatments for children and adolescents have relieved enormous suffering among young people with psychiatric difficulties. We can directly connect the effective use of psychiatric medications with the decreasing rate of adolescent suicides and the increasing rate of high school completion by students with severe psychiatric problems.
Schools find themselves on the front line of this controversy. Students who take psychiatric medications may display both negative side effects and positive benefits in school, and teachers often feel frustrated in trying to understand whether or not a student's behavior is the result of medication. Is a student tired in class because the medications are too sedating, or are there other reasons for the student's fatigue and inattention? The side effects of some medications often result in problem behaviors that mimic the very behaviors for which the medications are intended. For example, a student who is inattentive and hyperactive as a result of anxiety may become even more anxious and agitated if given a stimulant for suspected Attention Deficit/Hyperactivity Disorder (ADHD). And sometimes teachers are unaware that a student is taking medication, which makes determining the medication's usefulness more difficult.
But because children spend a great deal of time in the classroom, schools represent a valuable resource in assessing the efficacy of any psychiatric intervention.
When to Treat
Knowing when to prescribe medications for young people presents special challenges. Some clinicians lean heavily on medications, whereas others are considerably more wary. Similarly, some parents may prohibit medication regardless of the severity of their child's condition, whereas others may demand medication as a quick fix for their child's problems. The clinician must take a careful, balanced approach to each individual's situation.
The first rule for all psychiatric interventions is to carefully assess the child's development. Subjecting a child to any psychiatric treatment is a serious step. If the child is doing relatively well and would be bothered more by the treatment than by the condition, little more than vigilance is necessary. If the child or adolescent is not moving forward developmentally, however, intervention is essential.
Another rule for psychiatric intervention is to accommodate the concerns of the children and their parents as much as possible. After the children and parents have a clear understanding of the situation, they should decide together how to proceed. If they are adamant that medications are not an option, then forcing medication treatment will likely have little benefit. But if a family is seeking medications appropriately, then embarking on a medication trial makes sense, as long as the child and his or her parents are aware that these problems are complex and that medications usually work best when combined with some form of psychosocial intervention, such as psychotherapy or school consultation.
Commonly Prescribed Medications
A brief description of the most commonly prescribed medications for school-aged children and adolescents can help educators better understand how they may affect the student in the classroom.
For inattention, hyperactivity, and impulsivity. The most common psychiatric medications prescribed for school-aged children are designed to treat problems associated with symptoms of ADHD. Psychostimulants—such as Ritalin, Adderal, Concerta, and Dexedrine—have all had some success. Potential classroom problems related to these medications include increased agitation or anxiety for those children who are misdiagnosed or who have additional problems with mood changes or anxiety. Some children will appear to be emotionally nonresponsive once stimulant treatment is started and may require alternative interventions.
Other effective medications include the atypical antidepressant Wellbutrin, such tricyclic antidepressants as desipramine, and a new medication called Strattera, which is similar to a tricyclic antidepressant. Some medications, such as Clonidine, have been useful in controlling impulsivity but do little to treat inattention and may even be sedating during the school day. Whether or not students take medications, a number of school-based interventions are crucial for helping children with ADHD (see “Chaos in the Classroom,” Nov. 2000).
For depression, obsessions, and anxiety. Selective Serotonin Reuptake Inhibitors (SSRIs) are the most common medications for depression, obsessions, compulsions, and anxiety in pediatric populations. These medications include Prozac, Paxil, Zoloft, Celexa, Luvox, and Lexapro. All of these medications increase levels of serotonin, a brain neurotransmitter. Antidepressants such as Wellbutrin and Effexor and older tricyclic antidepressants, such as desipramine, are also useful. These medications rarely work immediately and need to be taken every day to be effective. If they are successful, symptoms start to get better around 2–6 weeks after starting treatment. Potentially troublesome classroom side effects include possible sedation or agitation, as well as a small chance of hugely increased agitation for those children afflicted with bipolar disorder rather than simple depression or anxiety. Neurontin has also helped with anxiety and agitation. Ativan or Klonipin are among the quick-acting antianxiety medications that are also potentially very sedating, although in some children these can lead to greater agitation.
For severe aggression and out-of-control behavior. Problems involving severely aggressive behavior are potentially the result of psychiatric disorders, such as pediatric bipolar illness, or, in rare cases, psychotic disorders that involve hallucinations and delusions. Clinicians have increasingly prescribed atypical antipsychotic agents, such as Seroquel, Zyprexa, Risperdal, and Geodon. In the classroom, all of these medications can control mood changes and intense aggression but may sometimes have a severe sedative side effect. More typical mood-stabilizing medications—such as Lithium, Depakote, and Tegretol—can also be sedating in the classroom without careful management, as can Neurontin, which is sometimes used as an adjunct to other mood stabilizers for children and adolescents with severe mood changes.
Only Connect
Medication interventions can be enormously beneficial to students who are struggling to maintain their academic and social standing in the face of serious psychosocial difficulties. Without careful management, however, the effects of these medications can have negative repercussions for classroom performance. Only through vigilant communication among clinicians, parents, educators, and students can we realize the full benefits of these interventions.
