Microsoft word - 09-07_psychoactive medication for children and adolescents_final.doc
Massachusetts Department of Mental Health
Barbara A. Leadholm, M.S., M.B.A., Commissioner
Psychoactive Medication for Children and Adolescents:
Orientation for Parents, Guardians, and Others
Division of Child and Adolescent Services
Office of Clinical and Professional Services
PREFACE TO 2005 REVISION
This revision reflects new scientific data, policy developments, and feedback from
users of the first version. Appreciation is expressed to Manuela da Costa, of DSS,
PREFACE TO THE 2007 REVISION
The revision has been updated to reflect new information about treatments and current controversies. Contributions from Mary Ellen Foti, MD, and Sean Palfrey,
This booklet presents principles for the use of psychoactive medication in children
and adolescents. It offers information about medication treatment. It does not recommend specific medications or doses. The booklet was developed by a group
convened by the Division of Child and Adolescent Services of the Massachusetts Department of Mental Health. The group included representatives of the
Department of Social Services (DSS), the Division of Medical Assistance, the
Juvenile Court Clinic, the Massachusetts Behavioral Health Partnership, the New England Council of Child Psychiatry, the Parent Professional Advocacy League, and
representative hospitals and health care organizations. Participants are listed in Appendix VII, Members of Working Group.
The Working Group expresses appreciation for review of the document and helpful suggestions from other colleagues, notably Drs. Joseph Biederman, Ronald
Steingard, Ed Wang, and Linda Zamvil, and Bernadette Drum, BSN, JD.
Chairman Children and Adolescents’ Psychoactive Medication Workgroup
TABLE OF CONTENTS
B. Psychoactive Medication for Children and Adolescents: Recent changes
C. Psychoactive Medication for Children and Adolescents: How do we know what to recommend?
D. The FDA, “approved” and “off-label” uses, black box warnings, and clinical
E. Personal Representatives: Their responsibilities
F. New Knowledge, New Ways to Help Children and Adolescents
G. Promoting Access
H. This Booklet II. CHILDHOOD AND ADOLESCENT MENTAL HEALTH – AN OVERVIEW
A. How children grow: Differences in development
B. When do “differences” amount to “disorders?”
III. PRINCIPLES OF PRACTICE
1. Comprehensive assessment: What does that mean?
2. Family, Peers and School, Pediatric Liaison, Psychological Testing
3. Interviews, Rating Scales: Using both
B. Planning and Contracting for Treatment
1. Articulating Problems, Target Symptoms, and Goals
2. Selecting Medications 3. Planning Treatment and Monitoring: Monitoring, Anticipating Problems,
4. Informed Consent: Who, What, How, When, Where, To Whom?
C. Integration of Treatment D. Communication and Record Keeping
IV. MEDICATIONS USED TODAY
C. Mood Stabilizers D. Antipsychotics E. Other Medications
V. AREAS OF CONTROVERSY
A. Antidepressants in Children and Adolescents
B. Attention Deficit-Hyperactivity Disorder
D. Use of Antipsychotics (also called Neuroleptics) E. Post-Traumatic States
F. Children and Adolescents with Developmental Disabilities G. Extreme Behavioral Loss of Control (Aggressive and Self-Injurious) H. Involuntary Treatment
VII. MEMBERS OF WORKING GROUP
A. Childhood Disorders: How common?
Eleven percent of children and adolescents in the United States ages 9 to 17 are
estimated to have a diagnosable mental or addictive disorder with significant
functional impairment (Surgeon General’s Report on Mental Health, 2000). Consistent with this estimate, 4 million youths may suffer from a major mental
illness and have significant impairments at home, at school, and with peers. Those with impaired development are at greater risk. Abuse or neglect, suffered by
three million children and adolescents each year in the United States, is a major
risk factor for later mental disorder.
B. Psychoactive Medication for Children and Adolescents: Recent
Children and adolescents with serious emotional disturbance are receiving
psychoactive medication more often than in the past. Several factors have contributed to this increase. One factor is scientific
progress; another is changing attitudes towards children and adolescents’ mental health, such as:
advances in our understanding of how the brain works. We now recognize
that the brain functions differently in children and adolescents with mental
evidence that many children with symptoms grow up to have disorders as
greater recognition of child and adolescent mental health needs and increasing
readiness to define those needs in terms of brain functioning; and
the availability of a wider range of psychoactive medications.
In addition, child and adolescent mental health services have changed: • Children and adolescents with serious emotional disturbance are no longer
treated only in hospitals, but often in foster homes and community residences, facilities that have not historically treated children and adolescents with serious
behavioral symptoms. Children and adolescents are hospitalized for shorter lengths of stay, resulting in pressure to use interventions that are likely to have
C. Psychoactive Medication for Children and Adolescents: How do we
know what to recommend?
Medication practice in children and adolescents, like other areas of medical practice, is based on clinical experience and controlled clinical trials. “Evidence-
based medicine” includes both kinds of evidence. While controlled clinical trials in children and adolescents are becoming more
common, most medication practice in children—in general medicine as well as in mental health—is based on clinical experience and individual clinicians’ judgment.
This is because drug development for children and controlled clinical trials to evaluate those drugs are much more difficult to do than for adults. Therefore,
most pharmacological research is done with adults.
D. The FDA, “approved” and “off-label” uses, black box warnings, and
The Food and Drug Administration (FDA) relies on information from controlled clinical trials to approve new medications. Because there are very few controlled
clinical trials with children, the FDA has not approved the vast majority of medications for use with children. When medications are used for indications or
populations (such as children and adolescents) that the FDA has not approved,
such use is called “off-label.” In addition to approving medications, the FDA sometimes requires that warnings (so-called “black box warnings”) be printed along with medication information that
is included when a prescription is filled. (See sections IV.B. and V.A., for
discussion of the “black box warning” regarding antidepressant medications.) Clinicians prescribing for children and adolescents must exercise caution, considering the physical and emotional development of the child, any neurological
or developmental deficits, possible interactions with other medications, and the
risk that children or adolescents may try other drugs or alcohol. Children’s and adolescents’ responses to medication are difficult to predict. A child may not respond to a medicine that has been helpful to others, or may require a
higher or lower dose than usual. Another child may have side effects at a dose
that most can tolerate well. Genetic differences may account for much of this variability.
E. Personal Representatives: Their responsibilities
Whenever a medication is recommended for a child or adolescent, those with
responsibility for them, called Personal Representatives,1 should raise questions like these:
• How do I assess medication recommendations made by a clinician?
• With limited data about possible benefits and risks, particularly in growing
children and adolescents, on what basis do clinicians make recommendations?
• How should I decide to authorize treatment?
• How can clinicians inform me of my choices? • How can I get the best information?
This booklet responds to these questions. In doing so, we hope to contribute to one of the goals in the Surgeon General’s Action Plan for Children’s Mental Health:
to “make available information on effective prevention and treatment interventions.”
F. New Knowledge, New Ways to Help Children and Adolescents
New developments in pediatric psychopharmacology give us new opportunities to
help children and adolescents. Child psychiatrists and other clinicians are learning
more from organized clinical trials and from clinical experience. G. Promoting Access
Children and adolescents are referred for pharmacological treatment from many
places. They come from schools and pediatricians’ offices; special education; child
welfare and child protection (including DSS); court, probation, or the Department of Youth Services (DYS) (where 50 percent of youths have been exposed to abuse
or neglect); and mental health settings. Referral is more likely when symptoms
persist or are thought unlikely to respond to psychosocial interventions alone.
But most children with serious emotional disorders are not getting the help they
need. Youth from ethnic and racial minorities encounter barriers in seeking and
receiving good treatment, as the Surgeon General has reported. Barriers include
stigma (that is, prejudice against those with mental illness), mistrust, cost, clinical bias, and cultural suspicion of people with mental illness.
1 The US Health Insurance Portability and Accountability Act (HIPAA) defines the person who is
legally authorized to make health care decisions as a "Personal Representative." The Personal Representative may be the minor's parent, a court-appointed guardian (with scope to cover health
care decisions) or an entity (e.g. DSS or DYS).
We hope information in this booklet will promote access to care for children who are challenged by emotional and mental troubles.
H. This Booklet
• acknowledges that the field of pharmacotherapy for children and adolescents is
• provides general information about psychoactive medication for children and
• offers principles of good care; and • describes areas of ongoing controversy.
This document does not indicate which medication should be used for a given kind
of mental trouble; that information is provided in available resources like Connor
and Meltzer (see references, at VI below). Nor does it recommend particular medications or doses.
CHILDHOOD AND ADOLESCENT MENTAL HEALTH – AN OVERVIEW
A. How children grow: Differences in development
Children and adolescents vary in many ways as they grow up. Some are taller,
some shorter. Some eat voraciously and with pleasure; others just eat. Some read early on their own, others later and with effort. For some, puberty comes
early, for others, later. Though everything changes with time, some children “take to” a developmental
stage early or easily, others later or with difficulty.
Similarly, differences also occur in behavioral and emotional development. For
instance, some children are calmer, some more restless. Some are more clingy,
others more independent. For some, mood varies little; others have periods when
they feel down or frankly depressed. Some are barely ruffled by upsets and challenges; others “lose their temper,” as we say, sometimes for extended times.
Diagnostic statements about children are always made against the background of
normal development and the spectrum of abnormal development.
In addition, some diagnoses refer to conditions that are long-lasting (chronic
conditions) and those that are short-lived or acute.
B. When do “differences” amount to “disorders?”
Children at the extreme of any continuum are said to have “conditions” or
“disorders.” Doctors and other students of child development have to define how
many symptoms it takes to “make” a “condition” or “disorder.”
Psychiatrists have written a manual, the American Psychiatric Association’s
Diagnostic and Statistical Manual, 4th edition (DSM-IV), with the criteria for all of the so-called “mental disorders.” These diagnoses are used for classifying the
mental disorders that adults, children, and adolescents have. Most of the
“disorders” fall in categories (Anxiety Disorders, Mood Disorders, Psychotic Disorders, etc.) derived from adult psychiatry; these disorders do not always fit
neatly with the troubles children have. Some of the “disorders” (like Attention-Deficit/ Hyperactivity Disorder, Tic Disorders, Conduct Disorders, Developmental
Disorders, and Learning Disorders) usually arise in childhood or adolescence.
Talking about “disorders” may sound odd to parents, teachers, and others who
are accustomed to describe children’s troubles in terms of differences in development.
Children who do not have all the features of a disorder, as defined by the DSM-IV, are called “subthreshold.” They may still need help, even if they do not meet “all
the criteria.” And defining any child’s trouble usually requires more than a DSM diagnosis (see below, III-A).
Children and adolescents with an emotional and behavioral trouble need a careful assessment. Appropriate help usually includes several kinds of intervention, not
just medication. Such help is called multimodal treatment.
C. What can medication help with?
Medication may help with many problems, but not with everything. Medication
may help with disturbances of mood (depressed, elevated mood [hypomania or mania] or unstable mood), disturbances of attention (attention deficit-
hyperactivity disorder), anxiety symptoms including compulsions and flashbacks
and other consequences of trauma, some impulse control problems, and confused thinking and perceptions.
Medication will not “bring up to age” a child or adolescent with delayed
development. Medication might, however, help with specified symptoms.
Medications will not take away the disturbed language and ways of relating seen in children and adolescents with autism or other pervasive developmental
disorders. But medication might help with associated problems like aggression,
obsessive-compulsive behavior or scattered attention. Medication will not help a
child or adolescent who has a problem telling the truth. But if lying is a symptom of a major depression, antidepressant medication might help with the depression.
Medication will not help with “normal” childhood sadness but may help with clinical depression.
Are we treating “symptoms” (specific problem behaviors) or “disorders” (diagnoses)? This question can be puzzling; the difference between symptoms
and disorders can be confusing. Parents bring their children and adolescents for help with symptoms, such as poor school performance, irritability, tics, and
depressed mood. But the same symptoms may come from many different
disorders, each pointing to differences in brain chemistry and requiring different
medication. Because choice of medicine should be guided by a diagnosis, doctors
usually diagnose a disorder before recommending a trial of medication. For instance, a child or adolescent’s poor attention may be associated with
attention deficit-hyperactivity disorder (ADHD), major depression, psychosis, metabolic disorder, or traumatic brain injury. The indicated medicine will be
different with each disorder. Irritability may occur in children and adolescents with brain injury or metabolic disorder, as well as ADHD, depression, Tourette
But while a specific diagnosis may point to disorder-specific treatment, it is not
always possible to base clinical practice on diagnosis alone. Psychiatric diagnoses are “conventions,” that is, agreements among physicians about ways to classify
people’s troubles. These conventions, though shared by doctors and endorsed by
insurance companies, differ from the ways that families, and whole cultures, talk about their children’s behavior. Professionals must respect a family's ways of
telling the story of a child's trouble, in addition to using the “scientific” tools of diagnoses from the Diagnostic and Statistical Manual of the American Psychiatric
In addition, DSM diagnoses “fit the patient” less well in child psychiatry than with
adults; to adequately describe their adaptive troubles, many children and adolescents are given multiple DSM diagnoses. Future research may refine our
present diagnoses, add new ones, or encourage use of different approaches to
assessment of children and adolescents (e.g., dimensional diagnosis). In the meantime, clinicians are trying to help children and adolescents with specific
symptoms, the targets of prescribed medications. Parents, guardians and professionals must keep in mind both symptoms and
diagnoses and the languages that parents, children and adolescents use to talk about their troubles.
III. PRINCIPLES OF PRACTICE
1. A comprehensive assessment: What does it mean?
Any pharmacotherapy should be preceded by assessment that is individualized, careful, and as comprehensive as necessary.
Assessment of children and adolescents is complicated by:
• the variety of symptoms in childhood. Categorical diagnoses (like those in
DSM-IV) may not fully capture the variety of symptoms in children and
adolescents. As a result, children and adolescents often receive multiple diagnoses. Even so, families may still feel that the doctor’s “language” doesn’t
fit their own ways of thinking and talking about the troubles of their child or
• the way symptoms in children and adolescents change over time. In some
conditions, symptoms remain stable for years. In other conditions, symptoms
continually change. In still others, there are periods of good functioning
interrupted by intervals of symptoms, even serious symptoms.
Medication treatment must be part of a comprehensive plan based on a comprehensive assessment which must include the child or adolescent, the family,
and relevant aspects of their world. Data should be gathered in interviews with
the child or adolescent and parents (or, absent parents, other caretakers) and from collateral sources (e.g., teachers, protective service workers). In many
situations, collateral data (from teachers or protective service workers) are
essential. Previous medical records should be reviewed. Discussion with the child’s or adolescent's primary care physician is indicated.
Assessment of the child or adolescent should identify:
• presenting symptoms, including the child’s or adolescent’s own words for
• current level of functioning;
• medical history, including history of substance use, previous treatment history,
• any history of neglect, abuse, molestation, or other trauma.
2. Family, Peers and School, Pediatric Liaison, Psychological Testing
Assessment of the family should include:
• family history of mental illness;
• assessment of current functioning and stressors;
• assessment of attitudes toward the child or adolescent’s symptoms and needs,
including the family’s or their culture’s ways of describing the child or
• any current or past protective needs.
Assessment of the child’s world should describe how the child or adolescent
functions with peers and at school. Assessment should identify, for child or
adolescent and family, strengths as well as weaknesses. Assessment of children
and adolescents should include description of their attitudes to their symptoms and readiness to participate in treatment.
Medical assessment of the child or adolescent should assess:
• general health and development, • well-child care, and
• possible contributing medical factors. Medical assessment should include a physical examination.
A call to the primary care physician will provide much of this information and
establish connections between physicians. A more detailed assessment should be offered to children and adolescents with
severe symptoms, chronic symptoms, or potential for harm to self or others, and to those for whom ordinary treatment—including treatment with several
medications or repeated hospitalizations—have not brought relief. More intensive assessment includes more extensive history from the child or adolescent, family
members, and other treating professionals current or past. More intensive
assessment may include consultation from specialists in child psychiatry, neurology, neuropsychology, pediatrics, child development, child abuse and
neglect, and treatment systems. Psychological testing should be considered for some children and adolescents to
further clarify the child’s or adolescent’s thoughts and feelings, intellectual capacity, and possible learning problems.
3. Interviews, Rating Scales: Using both
Assessment relies on clinical interviews. In addition, structured methods (like rating scales, questionnaires, and tests) may be used. Commonly used rating
scales include the Child Behavior Check List (CBCL), also known as the Achenbach
Rating Scale, and the Beck Depression Inventory (BDI), or its pediatric version,
the Child Depression Inventory (CDI). All data from rating scales must be interpreted by a clinician. All assessments must recognize the culture of the child
or adolescent and family. Assessment and treatment must be appropriately documented and monitored.
4. Providing more than a DSM diagnosis
Assessment should provide more than a categorical (DSM) diagnosis. Those
assessing children and adolescents should:
• consider the adaptive perspective, meaning that the child’s or adolescent’s
symptoms represent his or her best efforts to cope;
• use a developmental perspective, locating symptoms in the context of longer-
• balance accurate description of problems with the identification of strengths
• balance early detection to facilitate intervention with the risk of inaccurate
diagnosis and adverse effects of labeling.
5. Cultural assessment
Clinicians should assess the culture of the child or adolescent relative to their own.
Clinicians should acknowledge differences in experience or cultural background
and consider what knowledge, skills and attitudes they need in order to provide
care. The clinician should understand how values, beliefs, customs, language and communication style influence the perception and expression of mental distress,
how they shape help-seeking behavior and how their own backgrounds affect the way they hear and respond to children’s troubles. The goal is make a partnership
Planning and Contracting for Treatment
Contracting for treatment requires time, attention and discussion.
Assessment precedes treatment planning. In assessment process, the clinician
specifies target symptoms and goals, selects a medication for initial use and
schedules visits for evaluating progress. The clinician then recommends treatment, including medication, to the child or adolescent, parent or guardian.
Defining Problems, Target Symptoms, and Goals
Assessment identifies relevant diagnoses and treatable symptoms. Diagnoses may
help clarify the nature of the child’s or adolescent’s problems and predict their response to treatment.
Treatment is directed to target symptoms, such as anxiety, insomnia, poor
concentration, or impulsiveness. It is best to avoid using non-descriptive terms
like “acting out” or “behavioral issues.” The target symptoms selected should reflect the priorities of the child or adolescent, his or her family, and others (such
as teachers or residential staff), in terms of what symptoms are most in need of improvement. Target symptoms are not diagnoses; a given symptom might be
seen in a variety of disorders. Indeed, a single diagnosis or disorder may
contribute to a number of different symptoms. A diagnosis is one context for a symptom, to be taken into consideration along with other contexts, such as
presence of developmental disabilities, medical illness, history of abuse, or disruption of care-taking.
Stating target symptoms in child-friendly language helps the clinician develop a
treatment alliance with child or adolescent, family, and others. For instance, a child may prefer to say, "I get really down and feel like dying," rather than, "I
have depression with suicidal ideation." Each party to the treatment should state what he or she hopes medication will do. Each should be helped to understand
what changes may realistically be expected. Defining target symptoms provides a
basis for judging the success of the treatment.
Goals such as improved school performance or peer functioning are too broad to
be specific targets for pharmacotherapy. But such goals may help to clarify how medication can help—for example, by improving concentration or reducing social
anxiety. Distinguishing between improvement (or lack of it) in target symptoms
and progress towards overall goals (or lack of it) can help in defining how medication can contribute to overall progress.
Emergent side effects requiring treatment (like acute dystonias, activation on antidepressants (see section V.C.) or Parkinsonian symptoms) should be
anticipated in the treatment plan. When they occur, whether anticipated or not,
2. Selecting Medications
A medicine will be recommended to the parent or guardian (usually with the assent and participation of the child or adolescent, according to their
a) the class of medicines likely to be effective in treating the disorder;
b) the actions and side effects of individual medicines within that group;
c) the likely effects of the medicine on the target symptoms;
d) likely side effects or potential toxic effects; and
e) any available data regarding family members’ responses to this or similar
The recommendation should reflect the doctor’s judgment as to the best
medication in general and the preferences of child or adolescent and family as to
target symptoms and side effects. Physicians should mention medications other than the one recommended and discuss with all parties what alternatives might be
considered if the first agent is not effective.
It is best to begin treatment with a single medication. If a single medication
proves to be effective, the response can be attributed to that agent and the child
or adolescent will have been exposed to less risk of adverse effects. If treatment with a single agent is ineffective, then it is appropriate to try a different single
agent or to add an additional medication.
3. Planning Treatment and Monitoring
Having selected a specific medication, the doctor, child or adolescent, family, and others should share their expectations. Questions include the following:
• How soon should the child or adolescent (and other observers) expect to see benefits from taking the medicine?
• What side effects should be expected, and when? What are the most common
side effects? Which are potentially the most serious?
• What should the child or adolescent or family do if they notice side effects or
• Who should look for indicators of progress or adverse effects and how? Will
monitoring include any formal assessment such as checklists or rating scales?
• How will dosage adjustments be made and in response to which indicators of progress or lack of progress?
• Will laboratory or other medical tests be called for? If so, how and when should they be done?
• How frequently should follow-up visits take place? In response to which
circumstances should more frequent or urgent visits be scheduled?
• Which medical problems might affect the use of the medication?
• What symptoms might be expected when the medicine is stopped?
• Are interactions likely between this medication and others, including alcohol or
illegal substances, that the child or adolescent may be taking?
• How will compliance with taking the medication be assessed, monitored, and
• Is there a risk of abusing this medication or of developing dependence? How will this risk be managed?
In treatment planning one must anticipate a course of action if the medicine does
not seem or no longer seems to be effective. Acknowledging this possibility at the
start of treatment helps prevent disillusionment and increases the chances of continuing collaboration. If all have agreed on target symptoms, on how to
measure progress, and on the expected time course, then the doctor, the child or adolescent, the family and others will know when and how to consider
alternatives. Explicit planning also decreases the risk that an ineffective agent will
be continued longer than appropriate because of unreasonable initial optimism.
The use of expert consultation should be considered if treatment is ineffective. Especially when the prescribing clinician is not a specialist in the treatment of the
child's problems, it is useful to be prepared early on to seek consultation from
someone with more experience. The need for consultation may also arise when the child or adolescent or his or her family comes from a cultural background
markedly different from that of the clinician.
Obtaining informed consent completes treatment contracting. Consent should reflect the elements outlined above. The record should document who gives
consent; what information is provided; and how, when, where and to whom consent is given.
Typically, for children and adolescents under age 18, medical treatment, including psychoactive medication, must be authorized by the parent or guardian. Except
as noted below, there is no legal requirement that a minor child or adolescent give consent or “assent” (that is, implicitly consenting by taking the medicine) to
treatment. Nonetheless, good clinical practice requires that doctor, parent, and
others take account of the child’s or adolescent’s understanding of and attitude toward the treatment and that they gain as much assent as the child or
adolescent can give. The appropriate degree of autonomy to afford the minor varies with age, the type and degree of disability, the parent’s attitude, and the
urgency of the treatment. In some agencies, some minor children and
adolescents are explicitly authorized to refuse psychiatric medication. For example, the Department of Youth Services requires both parental consent and
child or adolescent assent to medication, as youths in the DYS take their own medicine when given it by a staff person.
An adolescent 18 or older must give consent to his or her own treatment. Certain
adolescents below 18 (emancipated minors and so-called mature minors) also may consent to their own treatment. “Emancipated minor” is defined by statute. The
designation of “mature” minor is a clinical decision based on two criteria: the ability of the minor to make an informed decision and the potential harm of
informing the minor’s parents or guardian of the decision. This concept is most
often used in sexual or reproductive health care but may also be relevant when a parent and or adolescent disagree on a recommended medication treatment.
Court endorsement of clinicians’ designation of the minor as emancipated may be sought but is not required.
Some children and adolescents require special consent. DSS caseworkers consent
to “routine treatment” for children and adolescents in the custody of DSS, but not those in voluntary DSS care or committed to the department on a “Child in Need
of Services,” or CHINS, petition. But by DSS regulation, the prescription of antipsychotic medication is considered to be “extraordinary treatment,” requiring
explicit court authorization (following a “Rogers petition”). Children and
adolescents in the joint legal custody of parents who disagree about treatment may require court assistance to establish authority to treat.
What Informed consent should specify the child’s or adolescent’s condition and the
proposed treatment. A DMH policy (96-3R) provides relevant language: Clinicians must “disclose (to the patient and/or their legal guardian)… the significant medical
information (as of 2003, “protected health information”)… that is material to an informed decision by the patient as to whether or not to undergo a proposed
treatment.” The required information includes:
• risks of the recommended medication (including significant, common, and
possibly serious or life-threatening side effects);
• reasonably expectable benefits of treatment;
• expectations of the course of illness without treatment;
• reasonable alternatives to treatment;
• expectations about results of interruptions in treatment; and
• expectations concerning the monitoring of treatment.
How To consent to medical care, a person (or his or her parent/guardian in the case of a minor) must be competent. Individuals are presumed competent to make
informed decisions unless they are “legally” incompetent (as are children and
adolescents under 18), or unless a judge has found them to be incompetent, for instance in a guardianship proceeding. The decision for or against treatment must
be a voluntary one, made without undue influence from others; it must be based
on a rational ability to understand facts as presented. A decision to forego
treatment may or may not be in the person’s best interests, as seen by an
outsider. Although such decisions are sometimes called “irrational,” they are valid
as long as the person is competent to make the choice. For instance, a refusal of
treatment based on religious beliefs may not be rational to another person but may still be competent. The decision must also be adequately informed, as
The medical record needs to document the consent process, including who
participates, what information has been conveyed, any concerns that may have arisen, and the final giving of consent for the treatment itself. Standardized
signature forms may help in documentation, especially if such forms specify the
elements noted above. Generic consent forms are neither necessary nor sufficient documentation for the giving of informed consent.
Consent for treatment must be obtained before treatment is begun, unless the
treatment is considered to be an emergency (see below). If treatment is
undertaken as an emergency, consent must be obtained as soon as possible; treatment cannot continue beyond the emergency without consent. New consent
must also be obtained whenever a different medication is introduced and whenever there is any material change in the circumstances of treatment. Such
changes include the emergence of side effects, the development of a relevant
medical problem, or other developments affecting risk and benefits. Consent for treatment is not a one-time event but rather a process of ongoing discussion with
a parent or parents, consenting child or adolescent, or other consenter.
A parent should ideally give consent in a face-to-face interview with the treating clinician. Such contact will provide the best opportunity for careful consideration
of the questions needing attention. It is less desirable, but sometimes necessary, to discuss treatment recommendations and obtain consent by telephone, as when
treatment is being provided in a residential setting and when it is difficult for
Consent should be given to the clinician prescribing medication. When the prescribing clinician cannot meet personally with the person providing consent,
consent may be given by telephone and written note made of it, signed by the
Integration of Treatment
Pharmacotherapy should be coordinated with other interventions. All
interventions should comprise an integrated treatment plan. Massachusetts DMH regulations require providers to obtain authorizations to receive and/or release
protected health information (except for emergencies). Authorizations must be signed by the person legally authorized to make health care decisions.
Physicians prescribing medications for children and adolescents should speak to the primary care physician. In addition, clinicians providing psychological services,
(for instance, those helping the child or adolescent with self-understanding and self-management) should be aware of the psychiatric diagnoses and
pharmacotherapy. They should help the child or adolescent talk with the
prescribing child psychiatrist. Similarly, the child psychiatrist should be aware of psychological interventions and use other clinicians’ data in assessment and
treatment planning. Treatment summaries should reflect each clinician’s awareness of the rest of the treatment.
When clinicians share information and use the same language, it helps the child or adolescent make sense of his or her strengths and weaknesses and feel like a
whole person. All members of the team should use the same model for understanding the child or adolescent and for bringing about therapeutic change.
Multiple autonomous practitioners working in isolation are unlikely to achieve an
integrated view of the child or adolescent. Treatment summaries should be written so that they are understandable to parents and guardians and can be shared with other clinicians, including primary
care clinicians and educators, as appropriate.
Communication and Record Keeping
Treatment needs to be summarized in a concise record that is easily shared from
one treatment setting to another, consistent with the requirements of confidentiality. Authorization for the release of protected health information
should be obtained routinely as children and adolescents enter services.
A summary of a child's medication treatment must be more than a list of
medications. It must state whether the trial of each medicine was adequate, whether each medicine helped with specific symptoms, and whether the
impression of effectiveness was clear or, as often happens, ambiguous.
The parent or legal guardian of a child or adolescent, including custodial agency,
should keep copies of all assessments and treatment summaries so that each new provider can review the treatment history. Accordingly, the parent or legal
guardian should receive all treatment records from providers promptly. Treating
clinicians should not prescribe new treatments until they have reviewed summaries of previous assessments and treatment or spoken to prior treaters
while awaiting receipt of the records.
Continuity of Care
Although the problems for which a child or adolescent is prescribed medication are
not short-term, many children and adolescents are cared for in multiple short-term placements. Frequent movement requires that assessment and treatment
information be efficiently transmitted from one setting to another. The possibility
that frequent changes of residence and caregivers may make symptoms worse should be considered as a factor contributing to the child’s or adolescent’s
problems. As the child or adolescent recovers, the goal should be to provide continuity of treatment, including medication, and relationships.
Discontinuity of care may be a special problem for children and adolescents
entering the custody of the Department of Social Services (DSS) or detained in a
Department of Youth Services facility. Clinicians prescribing psychoactive medications for children and adolescents should be familiar with different
agencies’ regulations regarding the use of antipsychotic medications. Specifically,
if a child or adolescent is taking an antipsychotic medication without judicial review at the time he or she comes under DSS custody, clinicians and others
should be alert to the risks of abruptly stopping psychoactive medication and appropriately advise those with responsibility for the child’s or adolescent’s care.
The same considerations apply when children and adolescents on psychoactive
medication enter a DYS facility. Interruption or discontinuation of that treatment might cause psychological deterioration and might violate the individual’s legal
III. MEDICATIONS IN CURRENT USE
This section lists medications in current use and their indications. A more
extensive discussion of the effectiveness and safety of medications commonly
prescribed to children and adolescents has been published in the journal Child and
Adolescent Psychiatric Clinics of North America (Pappadopulos EA, Tate Guelzow
B, Wong C, Ortega M, Jensen PS, 2004). That review is organized according to
class of medications; separate articles review stimulants, antidepressants, mood stabilizers, antipsychotics, anti-anxiety medicines, a class of medicines called
adrenergics and a drug that blocks the effects of opiates, called naltrexone.
This section lists names only; some important information, like dose ranges, is
excluded. Parents and Personal Representatives should be aware of differences in what is called potency, that is, the therapeutic power of a medication per
milligram. A few milligrams of one medication may be more "potent" than
hundreds of milligrams of another, even within the same class. Needless to say, parents should not change doses on their own, hoping for a different effect, but
must work with the prescribing clinician.
Stimulants (or Psychostimulants)
Stimulants have been used for decades to treat children who are hyperactive and
inattentive. These medications reduce hyperactivity and inattention and improve behavioral control and cognitive performance. (These effects are similar to those
of caffeine, another stimulant.) Research indicates that stimulants are effective long-term. Children and adolescents vary considerably in their responses to
stimulants; many children and adolescents experience only partial symptom relief.
(Also see atomoxetine (Strattera) below at III.E. and Attention Deficit-Hyperactivity Disorder in section V. B.)
Sustained-release methylphenidate. Concerta
Sustained-release dexmethylphenidate Focalin XR
Dextroamphetamine and Amphetamine Adderal
Antidepressant medications treat depression (and some kinds of anxiety). They have been prescribed to adults for several decades and to children more recently
(see below, in Section V. A.). There are several classes of antidepressants, named for their chemical structure or for the way they are thought to work in the brain.
The first antidepressants were called “tricyclic antidepressants.” Medications
introduced more recently are called “selective serotonin reuptake inhibitors (SSRIs)” because they are thought to act principally by changing the way the
Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) have been widely prescribed for
depression and anxiety for children and adolescents. Fluoxetine (Prozac and others), especially when combined when cognitive-behavioral therapy, has been
shown to be the most effective (Vitiello, et al, 2006). While the possibility of suicidal ideas or impulses, called “suicidality,” led the Food and Drug
Administration to require a “black box” warning when antidepressants are
prescribed for children and adolescents, there is a greater risk of suicide if depression goes untreated. (The latest FDA recommendation, extending this
warning to young adults, is at http://www.fda.gov/cder/drug/antidepressants/default.htm.)
Such warnings are a reminder that all psychoactive medications should be prescribed only after a careful assessment, analysis of possible benefit and risk
with and without treatment, fully informed consent (see below), and monitoring of
Tricyclic Antidepressants (TCAs)
Tricyclic antidepressants (TCAs), long the most commonly prescribed antidepressants in adults, have repeatedly been shown to be effective in treating
depression and anxiety in adults but not in children and adolescents. Some TCAs are effective in treating other symptoms in children and adolescents, including
Attention Deficit Hyperactivity Disorder (ADHD) symptoms and bedwetting. Side
effects, especially potential cardiac effects and sudden death in a few children and adolescents on desipramine, make TCAs no longer “first-line” treatment for
Monoamine Oxidase Inhibitors (MAOIs)
Among the other antidepressants, a class of drugs called monoamine oxidase inhibitors (MAOIs) which block the action of an enzyme by that name. They are
not considered “first-line” medications for children and adolescents. Newer MAOIs
do not have the same side effect risks and may be used in the future to treat depression.
Bupropion (Wellbutrin) is an antidepressant that is effective for symptoms of
Research with other antidepressants in children and adolescents has not
Mood stabilizers have been shown to be effective in the treatment of bipolar
disorder (also called manic-depressive disorder) in adults. Their use in children
and adolescents is controversial (see Section VI., Areas of Controversy). Some studies have suggested an association of weight gain and endocrine side effects
(polycystic ovary syndrome) with valproate use in women.
Another class of mood stabilizers, omega-3 fatty acids, is beginning to be used together with other mood stabilizers in adults. They may be used in the future in
Antipsychotic medications reduce psychotic symptoms in children and adolescents
with schizophrenia and other psychotic disorders, reduce verbal and motor tics in children and adolescents with Tourette Syndrome, and reduce manic symptoms in
adults and children and adolescents. They may also have a role in reducing certain abnormal behaviors in children and adolescents with autism and mental
There are two classes of antipsychotic medications. The older medications
(chlorpromazine and others) are called “first-generation antipsychotics” (FGAs). The newer medications, like risperidone, are called “second-generation
antipsychotics.” (They are also called “atypicals,” because they came later.)
First-generation antipsychotics (like chlorpromazine) carry significant risk of
movement disorders in both the short and long term. Second-generation medications (like risperidone) cause movement disorders but probably with less
frequency; of more concern is their association with serious metabolic risks,
including serious weight gain, development of diabetes mellitus, and abnormal secretion of a hormone called prolactin. Weight gain is especially pronounced
with olanzapine (Zyprexa) and clozapine (Clozaril). The most effective second-generation medication, clozapine (Clozaril), also carries a small but definite risk of
bone marrow suppression. Patients on clozapine must have a blood test every
other week. Quetiapine (Seroquel) can cause cataracts in adults; children and adolescents on this medication should have regular ophthalmologic exams. All
antipsychotics can be sedating, sometimes to a degree that interferes with optimal functioning.
Second-generation Antipsychotics (
also known as “atypical”
In Massachusetts, the prescription of antipsychotic medication is considered
“extraordinary treatment.” Parents can authorize such treatments, but the Department of Social Services does not authorize such treatment for children and
adolescents in its custody. For such children and adolescents, a court order (in
response to a Rogers petition) is required (see “Informed Consent,” in section IV.B.4).
A few other medications are currently used in children and adolescents, primarily for the treatment of anxiety and/or impulse control problems. They include the
Benzodiazepines are used to treat anxiety symptoms and sleep problems in adults;
research has provided some support for their use in children and adolescents. People taking these medicines long-term may develop problems with tolerance,
dependence, and habituation. These medicines are also subject to non-medical
use, which can cause undue sleepiness or intoxication, especially when combined with alcohol. Some people taking benzodiazepines develop disinhibited behavior
or hallucinations. Withdrawal from benzodiazepines can be difficult.
Buspirone can be effective in treating anxiety in adults, with relatively few side
effects. There are no controlled studies with children and adolescents. Clonidine has long been used to treat high blood pressure in adults. It has been used
extensively with children and adolescents for treating tics, ADHD, aggressive behavior, and sleep problems. Research support for its use in these disorders is
mixed. Guanfacine (Tenex) is a newer medication, similar to clonidine but longer-
acting, less sedating, and possibly more effective in improving attention. It is used in treating impulsiveness and hyperactivity associated with ADHD and other
disorders. Research has not demonstrated its effectiveness. Atomoxetine (Strattera) is a non-stimulant medication for treatment of ADHD.
Naltrexone (Revia), an opiate antagonist, is used to treat self-injurious behavior.
Beta-blockers like propanolol (Inderal) are used to treat anxiety, especially performance anxiety, and aggressive behavior.
AREAS OF CONTROVERSY
In some areas, child psychiatrists are still working to achieve consensus. In other areas, public opinion is divided. Parents, guardians, and children and adolescents
should be aware that different practitioners may approach the same problem
Use of Antidepressants in Children and Adolescents
The treatment of depression in children and adolescents is changing. Depression
is a serious problem in children and adolescents, as emphasized in the Surgeon General's report. Depression causes suffering, prevents children from
participating in school, and puts children at risk of suicide. More depressed
children are getting help, as parents and professionals have recognized that young
people get depression and, when depressed, can benefit from treatment. However, most depressed children and adolescents, like most adults with
depression, still do not receive help. Help begins with adults letting a child know they recognize his or her distress and that they do not blame him or her.
What help to offer is increasingly clear. Evidence now indicates that antidepressant medication, the so-called SSRIs, can help depressed adolescents,
especially when combined with a psychological treatment, cognitive-behavior therapy. While a few depressed children develop suicidal ideas or impulses while
taking SSRIs (mentioned in the “black box warning” from the FDA), it seems that
suicides may have increased after the FDA posted a warning and SSRI use decreased. Others point out the great variability in responses to these medicines;
even if the many do not respond, many individuals may benefit. The use of antidepressants in children and adolescents, even more than with
other medications, requires careful weighing of potential risks and benefits with and without treatment. Prescription of antidepressants requires careful
assessment of these risks and informed decision-making. The Department of Mental Health urges families and caregivers with young people
taking or considering taking antidepressant medication to keep in mind the following good practices:
• Monitoring of the patient by physicians, families and caregivers
• Not abruptly stopping medications without medical advice
• Positive and ongoing communication with the prescribing physician
• Careful risk/benefit analysis when considering antidepressants for young
people, including providing information and allowing time for questions and answers from the patient, family and caregivers
• Review of the patient information sheet (“Medication Guide”) from the FDA
Also see discussion of "antidepressant activation" in Section C, below.
B. Attention Deficit-Hyperactivity Disorder
Attention Deficit-Hyperactivity Disorder, although one of the most studied disorders in child psychiatry, is often misunderstood. Typical ADHD symptoms in
school-age children and adolescents (restlessness, distractibility, poor attention) resemble the normal behavior of younger children. Controversy exists as to the
diagnosis of ADHD and the use of stimulants in children under five years of age.
Moreover, considerable misleading and inaccurate information about ADHD and stimulant therapy has been distributed, some of it coming from groups opposed to
all treatments in psychiatry. Nonetheless, ADHD is different from normal
behavior. Children and adolescents with ADHD are at increased risk for academic,
social, and legal problems. A consensus statement developed by the National Institutes of Health concluded that ADHD is a valid disorder with considerable
costs to individuals and society. Effective treatments exist for ADHD, stimulants being more effective than psychosocial treatments. There is no known prevention
Stimulant medication helps children and adolescents with ADHD to concentrate
and focus better. Stimulant medication is as good as or better than behavioral treatment alone. Options in treating ADHD have increased with the demonstration
that clonidine (Catapres) and guanfacine (Tenex), alpha-adrenergic agonists, in
addition to the stimulants, can be effective, especially for hyperactivity, and with the introduction of a non-stimulant medication (atomoxetine (Strattera)).
Despite this evidence, many children and adolescents with ADHD get no
treatment. The Surgeon General (1999) reports that, while ADHD occurs in three
to five percent of school-age children, only two to three percent of school-aged children are being treated for ADHD.
MEDICATIONS USED IN ATTENTION DEFICIT-HYPERACTIVITY DISORDER
STIMULANTS Short-acting: Methylphenidate (Ritalin)
Desxmethylphenidate (Focalin) Dextroamphetamine (Dexedrine)
Sustained-Release Methylphenidate (Metadate ER)
Sustained-Release Methylphenidate (Metadate CD) Dexedrine Spansules
ALPHA-ADRENERGIC MEDICATIONS Clonidine (Catapres) Guanfacine (Tenex)
ANTIDEPRESSANTS SSRIs, TCAs, Bupropion (Wellbutrin) OTHER
Several points bear emphasis. First, children and adolescents with ADHD tend to
have other problems as well. Accordingly, those treating children and adolescents
with ADHD may make several diagnoses and recommend more than one medicine. Second, several factors other than ADHD may make it hard to
concentrate. The child or adolescent who is hungry, or who is worried about his or her safety, or who has flashbacks or thought disorganization, or whose school
program does not match his or her needs, will have difficult attending to
schoolwork. Amid such possibilities, the possibility of ADHD must be considered in the context of an overall assessment of the child and his or her life situation.
Third, the benefit of stimulant medication may only become apparent when external and internal turmoil has subsided. That is, a child or adolescent may
benefit from stimulants, but not while being abused or neglected or while
struggling to learn in when no one knows he has a learning disability, or while in an acute psychotic state. The child or adolescent who does not appear to benefit
from stimulants at such a time may, when the other problems improve, benefit. Medication treatment for ADHD should not be undertaken as if the other problems
did not exist. Fourth, in a child or adolescent receiving multiple medications, the
interaction between the medications must be carefully monitored. With ADHD as with other disorders, different clinicians, even with the same data, may make different treatment recommendations.
C. Bipolar Disorder
Recent research indicates that bipolar disorder occurs in children and adolescents.
Its features include emotional lability, especially tantruming, as well as
hypersexuality and suicidal behavior. Treatment with mood stabilizers may be
helpful. Clinicians disagree about the criteria for this diagnosis in children and adolescents and whether to recommend treatment with mood stabilizers. A family
history of bipolar disorder in a child or adolescent presenting with serious
problems with mood or temper regulation warrants close monitoring of any
antidepressant use and a possible trial of a mood stabilizer. Inappropriate diagnosis of bipolar disorder, on the other hand, may expose the child or
adolescent to unwarranted medication and undercut the child or adolescent’s efforts at self-understanding and self-management. When a child or adolescent,
or the family, say, “I’m (he’s) bipolar-” they may stop thinking about the course,
meaning, and management of mood changes or emotional dysregulation. Related to bipolar symptoms is so-called “antidepressant activation.” This term is used when the child or adolescent taking an antidepressant develops increased
activity, irritability, insomnia, hypersexuality, grandiosity, hallucinations or rapid
talking. Such activation does not make the diagnosis of bipolar disorder nor predict its emergence later; it may just be a medication side effect unrelated to
bipolar disorder. Some children and adolescents may benefit from antidepressant medication but only when also taking a mood stabilizer. For such children and
adolescents, a mood stabilizer may be prescribed along with an antidepressant.
D. Use of Antipsychotics (also known as Neuroleptics)
Some clinicians prescribe antipsychotic medications only for frank psychotic
thought disorder. Others argue for a broader range of use in children and
adolescents, helping those with severe, confusion or uncontrollable emotional flooding. Both first- and second-generation antipsychotics have serious effects.
Their prescription is not to be undertaken lightly. Antipsychotic medications should not be prescribed for children and adolescents as
a substitute for acknowledging and treating their other challenges. Many challenges—such as unrecognized abuse or molestation, post-traumatic states,
severe caretaking deficits, unrecognized visual or hearing impairment or other learning disability, or unacknowledged family conflict—can make children and
adolescents feel overwhelmed and disorganized. Too hasty assessment of such
children and adolescents can result in injudicious prescription of possibly unwarranted medication, as well as delay in recognizing and addressing other
adversities in the life of the child or adolescent. On the other hand, when the efforts of the child or adolescent to cope with
adversity are compounded by inner disorganization, environmental interventions may still leave them too disorganized to take advantage of the opportunities
available. A trial of antipsychotic medication may dramatically enhance such individuals’ ability to cope.
A comprehensive plan must ascertain that antipsychotic medication, if offered, has indeed made a difference in the child’s or adolescent’s coping and that such use is
E. Post-Traumatic States
While we know much about post-traumatic symptoms in children and adolescents,
researchers are still evaluating what are the best treatments for traumatized
children and adolescents. It is important to differentiate between “simple PTSD”
which follows a discrete traumatic event, and “complex PTSD,” which follows multiple traumas, over time, often not acknowledged, and associated with a wide
variety of symptoms. Treatment options include psychotherapy, especially cognitive-behavior therapies (CBT), pharmacotherapy and the newer physical
therapies such as eye-movement desensitization and reprocessing (EMDR).
Medications like clonidine and the SSRIs (fluoxetine, etc) help children and adolescents cope with the symptoms that come from trauma. The use of such
medications in children and adolescents rests on clinical experience, not on controlled clinical research trials.
Abused and neglected children and adolescents often present with extreme fragility, withdrawal, aggression and mood instability that do not meet full criteria
for PTSD but that require intervention. Treatment for such children and adolescents should include protective intervention, protective acknowledgement,
and psychological support by experienced therapists. Interventions should not be
limited to the use of medications, nor should diagnoses with lasting significance be made while the trauma-surviving child is just emerging from an unprotective
traumatic environment. Symptoms such as “hearing voices” are often present in traumatized children and
adolescents. Such hallucinosis is not in itself an indicator of psychotic illness and may not require anti-psychotic medications, with the attendant risks. Children and
adolescents with a history of trauma may also respond to subtle reminders of the trauma with behavioral outbursts and emotional instability resembling that seen in
affective disorders. Mood stabilizers, which are accompanied by fewer risks than
antipsychotics, may be helpful in treating such children and adolescents. A thorough assessment of the child or adolescent, noting current and past trauma, is necessary to identify factors that may respond to medications, as well as those
that require psychotherapy and environmental interventions.
Children and Adolescents with Developmental Disabilities
Psychiatric symptoms in children and adolescents with developmental disabilities present many clinical challenges, including whether to use medication.2 It is
2 Identifying sources of help for children with developmental disorders, including autism and
Asperger’s syndrome, can be confusing. Federal regulations locate responsibility for such children,
including their mental health problems, in the public schools (the so-called Local Education
unclear which diagnostic criteria should be used in this population, especially in
children and adolescents with IQ’s below 50. Diagnostic uncertainty notwithstanding, children and adolescents with developmental disabilities are
more likely to have multiple disorders. Developmentally delayed children and adolescents with psychiatric symptoms
should have a thorough assessment in a multidisciplinary setting and should be offered comprehensive therapy with emphasis on specialized behavioral
interventions. We do not know enough about the safety and effectiveness of psychoactive
medications in children and adolescents with developmental disabilities; there are only a small number of sound studies. Many medications have been
recommended; few have been shown to be effective in controlled trials. Nevertheless, depending on the circumstances of the individual child or adolescent
(and possible associated psychiatric comorbidity), antipsychotics or mood
stabilizers may be recommended. A recent well-designed study demonstrated a positive response to risperidone (Risperdal) in children with developmental
disorders. Pharmacological intervention is often recommended when aggressive or self-
injuring behavior is so intense, frequent or persistent as to threaten the child or adolescent or those nearby. It may also be recommended when behavior is so
disruptive that the child or adolescent cannot use school or occupational, physical, speech, or interactional therapies. Except in emergencies (see below, Section G),
clinicians should not prescribe something immediately “to take the edge off” the
challenging behaviors in lieu of a diagnostic assessment that will complete the overall picture of the child or adolescent, including delineation of the factors that
contribute to the behavior. Parents, teachers, and other caregivers may need considerable support during this phase, in order to ensure their cooperation with
It is advisable to treat each case on an individual basis, “as a single case study,
starting with the safest and most commonly used medications in low doses and increasing the dose gradually” (Santosh & Baird, 1999). In deciding to continue
treatment or revise the plan, adults should use reports of behavioral changes,
including the child's own assessment, the child’s tolerance for side effects, and any idiosyncratic reactions to the medication.
Authority). In Massachusetts, developmentally disabled people over age 22 are served by the Department of Mental Retardation. In this booklet, we address the principles that guide their
medication treatment, not where services are to be found.
Extreme Behavioral Loss of Control (Aggressive and
As mentioned above, medication treatment in children and adolescents is based
more on clinical experience than on controlled clinical trials—especially when
dealing with children and adolescents with aggressive or self-harming behavior.
For many such children and adolescents, the need for urgent intervention is often clearer than the diagnosis. With or without diagnostic clarity, medication is often
an important part of their treatment. Such treatment must, like any treatment, be part of a carefully developed plan based on comprehensive assessment. When
the diagnosis is uncertain, specifying the factors that contribute to the problem
may help to summarize a formulation and guide treatment. Target symptoms should be identified, as in any other treatment, and medications judiciously
introduced, with the results monitored according to an agreed-upon plan. It is essential to examine the context in which aggressive or self-harm behavior is
occurring. Medication should never be prescribed for a child or adolescent with extreme behavioral loss of control without an inquiry into context and interactions.
Assessment should also be alert to the possibility of undiagnosed medical disorder (endocrine-metabolic or toxic), of substance use including caffeine or withdrawal
from nicotine, and of unrecognized psychiatric disorder, such as post-traumatic or
other anxiety disorder, depression or bipolar disorder, or unrecognized psychosis. In prescribing any agent for extreme behavioral loss of control, the clinician should balance the urgency of the situation against the desirability of acquiring
more understanding before taking action. The clinician should also consider
whether the treatment will constitute an emergency, and, if so, whether treatment will be voluntary or involuntary (see Section H, below).
In general, pharmacological treatment of extreme behavioral loss of control starts
with less toxic, shorter-acting medications: sedatives (like diphenhydramine
[Benadryl and others]), alpha-agonists and beta-blockers. Longer-acting medications and those with more side effects (mood stabilizers, antidepressants,
naltrexone [Revia], antipsychotics) are recommended either when a specific disorder is diagnosed (e.g., depression, bipolar disorder, or psychosis) or as an
empirical trial when shorter-acting or less toxic medications have failed or are
deemed unlikely to be effective. H. Involuntary Treatment
This guideline may give the impression that medication treatment is always
voluntary, but involuntary treatment also occurs.
A competent child or adolescent or parent/guardian has the right to refuse
treatment. Therefore, involuntary treatment may be given only when a court has found the parent/guardian to be incompetent to provide informed consent or that
the parent/guardian is endangering the child or adolescent, as in a life-threatening situation.
When a parent/guardian gives informed consent for treatment and the minor child refuses treatment, it is incumbent upon the treating clinician to attempt to gain
the minor’s assent (although there is no legal obligation to do so). If a parent or legal guardian refuses to consent to treatment and a clinician judges that this
refusal places the well-being of the child or adolescent in jeopardy, the clinician
should consider seeking assistance from the Department of Social Services or asking the court to appoint a new guardian.
Emergency involuntary medication treatment may be given in two contexts. In
one setting, chemical restraint medication is given involuntarily to assist in
containing a child with immediately threatening behavior. At other times,
emergency involuntary medication may be given to prevent immediate, substantial
and irreversible deterioration of serious mental illness. Chemical restraint, like all forms of restraint, may only be used in emergencies,
when extreme violence, personal injury, or attempted suicide has occurred or been threatened. Such measures can be used only when there is a substantial
risk of serious self-destructive behavior or of serious physical assault or when a serious physical assault has occurred. A child or adolescent may be given
chemical restraint only on the order of an authorized physician. This physician
must have determined that such chemical restraint is the least restrictive, most appropriate alternative available. The physician can make this determination while
present in person or after telephone consultation with a physician, registered nurse or certified physician assistant who was present at the time of the
emergency and who personally examined the child or adolescent (See DMH
Regulations 104 CMR 27.12). [In schools, the Department of Education regulates the use of restraint and requires authorization by a physician and parent.]
Apart from situations requiring use of restraint, emergency treatment occurs very
infrequently. It may occur only when the physician believes that delaying
treatment in order to obtain a court order for the treatment poses the risk of the substantial and irreversible deterioration of the child or adolescent’s serious
mental illness. There are very few instances in which this threshold is met. I. Adverse Side Effects
All prescribing child psychiatrists and other clinicians are concerned about possible
adverse side effects of medication. Opinions differ as to how to weigh the
advantages and disadvantages of a course of treatment in a given child or
adolescent. The final decision, of course, rests with the parent or guardian, with the advice of clinicians. Once treatment is underway, vigilance is indicated for
emergent side effects, including unusual or idiosyncratic reactions. For instance, mood stabilizers/anticonvulsants like valproate (Depakote and others), which help
most children to manage emotional lability, may cause increased irritability and
Of particular concern are the metabolic side effects of second-generation antipsychotics (see above, II. D.). The American Psychiatric Association and
American Diabetes Association (2004) have made recommendations for the use
and monitoring of these medications.
VI. CLIENT/PARENT EDUCATION
Parents, full of questions as they seek the best care for their children, confront an unprecedented volume of information, including on the internet, of varying
quality. There is no substitute, in this flood of information, for personal relationships with trusted providers (primary care physicians, social workers, or
child psychiatrists). In addition to those personal resources, the following books,
articles, and websites are recommended: Connor DF, Meltzer BM. Pediatric Psychopharmacology: Fast Facts. New York: WW Norton, 2006.
Dulcan MK ed. Helping Parents, Youth, and Teachers Understand Medications for Behavioral and Emotional Problems. A Resource Book of Medication Information
Handouts. Washington DC: American Psychiatric Press, 1999. Findling RL, Steiner H, Weller EB. Use of antipsychotics in children and
adolescents. J Clin Psychiatry 2005; 66 Suppl 7:29-40. Review. Greene RW. The Explosive Child: A new approach for understanding and parenting easily frustrated, “chronically inflexible” children. New York: Harper Collins, 1998
McClellan J, Kowatch R, Findling RL; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents
with bipolar disorder. J Am Acad Child Adolesc Psychiatry 2007; 46:107-125. National Institute of Mental Health – Health Information
US Public Health Service. Report of the Surgeon General’s Conference on
Children’s Mental Health: A National Action Agenda. Washington DC: Department of Health and Human Services, 2000. Also available at
http://surgeongeneral.gov/cmh/childreport.htm Vitiello B, Rohde P, Silva S, Wells K, Casat C, Waslick B, Simons A, Reinecke M,
Weller E, Kratochvil C, Walkup J, Pathak S, Robins M, March J; TADS Team. Functioning and quality of life in the Treatment for Adolescents with Depression
Study (TADS). J Am Acad Child Adolesc Psychiatry 2006; 45:1419-26. Wilens TE. Straight Talk about Psychiatric Medications for Kids. New York:
Guilford Press, 1999. www.aacap.org – American Academy of Child and Adolescent Psychiatry – Facts for Families
Other References of interest
American Diabetes Association, American Psychiatric Association, et al. Consensus
development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27:596-601.
Levine MD, Carey WB, Crocker AC, eds. Developmental-Behavioral Pediatrics.
Philadelphia: Saunders, 1999.
Martin A, Scahill L. (eds.) Psychopharmacology. Child and Adolescent Psychiatric
Clinics of North America 2000. Vol 9, No.1.
NIH Consensus Statement, Vol 16, No. 2, Nov 16-18, 1998. Diagnosis and
Treatment of Attention Deficit Hyperactivity Disorder (ADHD). Bethesda, MD: National Institutes of Health, 1998.
Pappadopulos EA, Tate Guelzow B, Wong C, Ortega M, Jensen PS. A review of the
growing evidence base for pediatric psychopharmacology. Child Adolesc Psychiatr
Clin N Am. 2004;13:817-55, vi.
Riddle MA, Kastelic EA, Frosch E. Pediatric psychopharmacology. J Child Psychol
Roberts RE, Attkisson CC, Rosenblatt A. Prevalence of psychopathology among
children and adolescents. American Journal of Psychiatry 1998; 155:715-725.
Santosh PJ, Baird G. Psychopharmacotherapy in children and adults with
intellectual disability. The Lancet 1999; 354:233-42.
US Department of Health and Human Services. Mental Health: A Report of the
Surgeon General. Rockville, MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health,
Vitiello B, Bhatara VS, Jensen, PS, eds. Current Knowledge and Unmet Needs in
Pediatric Psychopharmacology. Special Section. Journal of the American Academy of Child and Adolescent Psychiatry 1999; 38. 501-565.
Zarin D, Suarez AP, Pincus HA, Kupersamin A, Zito JM. Clinical and treatment
characteristics of children with attention deficit/hyperactivity disorder in psychiatric
practice. J Am Acad Child Adolesc Psychiatry 1998;37:1262-70.
Zito JM, Safer DJ, dos Reis S, Gardner JF, Boles M, Lunch F. Trends in the
prescribing of psychotropic medications to preschoolers. JAMA 2000;283:1025-1030.
VII. Members of Working Group (identifications as of 2001)
Child and Adolescent Psychiatrist Central Area Office
Massachusetts Department of Mental Health
Child and Adolescent Services Massachusetts General Hospital
Mary Ellen Foti, MD Department of Mental Health Deputy Commissioner of Medical Services
Massachusetts Behavioral Health Partnership
Child and Adolescent Services Massachusetts Department of Mental Health
Lisa Lambert Parent Professional Advocacy League
Massachusetts Department of Social Services Bruce Meltzer, MD UMMC Continuing Care Inpatient Unit
Child and Adolescent Services Massachusetts Department of Mental Health
(affiliations as of 2001)
Richard Barnum, MD
Boston Juvenile Court Clinic
Shay Beauregard, RN Health and Education Services
Harvard Community Health Plan Cindy Nichols
Parent Professional Advocacy League Susan Pederzoli Massachusetts DSS
Tina Render, MD UMMC Continuing Care Unit
Massachusetts Division of Medical Assistance
Staatskanzlei GEVER Geschäftsverwaltung für Luzern Glossar und Literatur Version 1.0 vom 23. Februar 2010 Status: Verabschiedet 1. Glossar . 3 2. Literatur. 8 Diese Vorgaben entsprechen der Weisung des Staatsarchivs über Mindestanforderungen an Geschäftsverwaltungssysteme vom 1. September 2009, gestützt auf das Luzerner Archivgesetz (SRL Nr
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