Guide Addresses Psychotropic Drug Use in Kids

Although strides have been made in use of psychotropic medications in children and adolescents, concerns remain over whether these medications are prescribed appropriately.

That's one reason that the American Academy of Child & Adolescent Psychiatry gives for issuing a new practice parameter on psychotropic medication use.

“Strategies to address the overuse or inappropriate use of medications (e.g., the Food and Drug Administration advisory 'black box' warning for antidepressants) may actually create barriers to care and may result in unintended negative consequences,” according to Dr. John Walkup and his colleagues at the academy's Work Group on Quality Issues. “Rather than advocating for restricting access to medication treatment, this parameter advocates for high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated.”

The parameter lists 13 principles that should be followed in prescribing psychotropic medications to children, beginning with the need for a medical history and a psychiatric evaluation—and, when needed, a medical evaluation—before beginning pharmacotherapy (J. Am. Acad. Child Adolesc. Psychiatry 2009;48:961-73). Other principles included:

▸ Communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial. “Early communication elicits the support of key professionals for the treatment plan … and may reduce the chance of misunderstandings during treatment,” the authors noted. “Follow-up among professionals during treatment enables all professionals who are involved to be up to date with the treatment plan and that treatment is well coordinated.”

▸ Develop a psychosocial and psychopharmacological treatment plan based on the best available evidence. Traditionally, psychosocial treatment is recommended before pharmacological treatment, but there are some exceptions to this principle, according to the authors. For instance, “randomized controlled trials suggest that medication management for attention-deficit hyperactivity disorder (ADHD) is the first-line treatment, and that medication combined with behavioral treatment may be required for optimal outcome in children with more complex problems.”

▸ Develop a plan to monitor the patient, short and long term. Although there are few data to help determine how long to monitor a child after medication is discontinued, “the duration of follow-up reflects the risk for relapse in the short term and risk for recurrence of illness over the longer term,” the authors wrote.

▸ Provide feedback about the diagnosis, and educate the patient and family regarding the child's disorder and the treatment and monitoring plan. The authors noted that in some families, “extended psychoeducation to address specific attitudinal or psychological issues regarding medication and/or specific psychosocial interventions to stabilize the home environment may be necessary” for successful treatment.

▸ Complete and document the assent of the child and consent of the parents before initiating medication treatment and at important points during treatment. The parameter states that assent/consent is an ongoing process. “It is recommended that before initiation of any additional psychotropic medications, at the transition to the maintenance phase, and before a discontinuation trial, the prescriber, patient, and family review the rationale for treatment; the past treatment experience; and the benefits, risks, and alternative treatments for each additional medication or the next phase of treatment.”

Dr. Walkup has received research support from Eli Lilly & Co., Pfizer Inc., and Abbott Laboratories, and his spouse is a consultant to Abbott. Another parameter author, Dr. Oscar Bukstein, has received research support or consulting or speaking fees from McNeil Pediatrics and Novartis Pharmaceuticals.

Although strides have been made in use of psychotropic medications in children and adolescents, concerns remain over whether these medications are prescribed appropriately.

That's one reason that the American Academy of Child & Adolescent Psychiatry gives for issuing a new practice parameter on psychotropic medication use.

“Strategies to address the overuse or inappropriate use of medications (e.g., the Food and Drug Administration advisory 'black box' warning for antidepressants) may actually create barriers to care and may result in unintended negative consequences,” according to Dr. John Walkup and his colleagues at the academy's Work Group on Quality Issues. “Rather than advocating for restricting access to medication treatment, this parameter advocates for high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated.”

The parameter lists 13 principles that should be followed in prescribing psychotropic medications to children, beginning with the need for a medical history and a psychiatric evaluation—and, when needed, a medical evaluation—before beginning pharmacotherapy (J. Am. Acad. Child Adolesc. Psychiatry 2009;48:961-73). Other principles included:

▸ Communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial. “Early communication elicits the support of key professionals for the treatment plan … and may reduce the chance of misunderstandings during treatment,” the authors noted. “Follow-up among professionals during treatment enables all professionals who are involved to be up to date with the treatment plan and that treatment is well coordinated.”

▸ Develop a psychosocial and psychopharmacological treatment plan based on the best available evidence. Traditionally, psychosocial treatment is recommended before pharmacological treatment, but there are some exceptions to this principle, according to the authors. For instance, “randomized controlled trials suggest that medication management for attention-deficit hyperactivity disorder (ADHD) is the first-line treatment, and that medication combined with behavioral treatment may be required for optimal outcome in children with more complex problems.”

▸ Develop a plan to monitor the patient, short and long term. Although there are few data to help determine how long to monitor a child after medication is discontinued, “the duration of follow-up reflects the risk for relapse in the short term and risk for recurrence of illness over the longer term,” the authors wrote.

▸ Provide feedback about the diagnosis, and educate the patient and family regarding the child's disorder and the treatment and monitoring plan. The authors noted that in some families, “extended psychoeducation to address specific attitudinal or psychological issues regarding medication and/or specific psychosocial interventions to stabilize the home environment may be necessary” for successful treatment.

▸ Complete and document the assent of the child and consent of the parents before initiating medication treatment and at important points during treatment. The parameter states that assent/consent is an ongoing process. “It is recommended that before initiation of any additional psychotropic medications, at the transition to the maintenance phase, and before a discontinuation trial, the prescriber, patient, and family review the rationale for treatment; the past treatment experience; and the benefits, risks, and alternative treatments for each additional medication or the next phase of treatment.”

Dr. Walkup has received research support from Eli Lilly & Co., Pfizer Inc., and Abbott Laboratories, and his spouse is a consultant to Abbott. Another parameter author, Dr. Oscar Bukstein, has received research support or consulting or speaking fees from McNeil Pediatrics and Novartis Pharmaceuticals.

Although strides have been made in use of psychotropic medications in children and adolescents, concerns remain over whether these medications are prescribed appropriately.

That's one reason that the American Academy of Child & Adolescent Psychiatry gives for issuing a new practice parameter on psychotropic medication use.

“Strategies to address the overuse or inappropriate use of medications (e.g., the Food and Drug Administration advisory 'black box' warning for antidepressants) may actually create barriers to care and may result in unintended negative consequences,” according to Dr. John Walkup and his colleagues at the academy's Work Group on Quality Issues. “Rather than advocating for restricting access to medication treatment, this parameter advocates for high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated.”

The parameter lists 13 principles that should be followed in prescribing psychotropic medications to children, beginning with the need for a medical history and a psychiatric evaluation—and, when needed, a medical evaluation—before beginning pharmacotherapy (J. Am. Acad. Child Adolesc. Psychiatry 2009;48:961-73). Other principles included:

▸ Communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial. “Early communication elicits the support of key professionals for the treatment plan … and may reduce the chance of misunderstandings during treatment,” the authors noted. “Follow-up among professionals during treatment enables all professionals who are involved to be up to date with the treatment plan and that treatment is well coordinated.”

▸ Develop a psychosocial and psychopharmacological treatment plan based on the best available evidence. Traditionally, psychosocial treatment is recommended before pharmacological treatment, but there are some exceptions to this principle, according to the authors. For instance, “randomized controlled trials suggest that medication management for attention-deficit hyperactivity disorder (ADHD) is the first-line treatment, and that medication combined with behavioral treatment may be required for optimal outcome in children with more complex problems.”

▸ Develop a plan to monitor the patient, short and long term. Although there are few data to help determine how long to monitor a child after medication is discontinued, “the duration of follow-up reflects the risk for relapse in the short term and risk for recurrence of illness over the longer term,” the authors wrote.

▸ Provide feedback about the diagnosis, and educate the patient and family regarding the child's disorder and the treatment and monitoring plan. The authors noted that in some families, “extended psychoeducation to address specific attitudinal or psychological issues regarding medication and/or specific psychosocial interventions to stabilize the home environment may be necessary” for successful treatment.

▸ Complete and document the assent of the child and consent of the parents before initiating medication treatment and at important points during treatment. The parameter states that assent/consent is an ongoing process. “It is recommended that before initiation of any additional psychotropic medications, at the transition to the maintenance phase, and before a discontinuation trial, the prescriber, patient, and family review the rationale for treatment; the past treatment experience; and the benefits, risks, and alternative treatments for each additional medication or the next phase of treatment.”

Dr. Walkup has received research support from Eli Lilly & Co., Pfizer Inc., and Abbott Laboratories, and his spouse is a consultant to Abbott. Another parameter author, Dr. Oscar Bukstein, has received research support or consulting or speaking fees from McNeil Pediatrics and Novartis Pharmaceuticals.