Did you know…

That mental disorders are surprisingly common in children and teenagers?

According to the National Institute of mental health, up to 50% of children and adolescents meet criteria for a mental disorder in the diagnostic and statistical manual (DSM) by age 18.

That means that up to half of children and adolescents are struggling significantly with emotional issues to the point that they are suffering and have impaired functioning. This statistic begs the question, how many children and adolescents experience emotional difficulties that don’t quite meet criteria?

It is commonly said that mental disorders are caused by chemical imbalances in the brain, and medication is often used to help relieve the suffering caused by mental illnesses and disorders.

Medication can have a life-altering effect, and it can sometimes be absolutely transformative.

However, medication can sometimes be over-prescribed.

Like anything in medicine and life, the question is not whether or not medication is helpful, but rather how to use it appropriately in the correct balance.

This issue is especially important when considering some of the psychiatric medications that can have more severe long–term side effects. Some psychiatric medications, such as antipsychotics and mood stabilizers can cause obesity, high cholesterol, and diabetes. These side effects, in turn, can lead to blockages in the arteries that increase the risk of heart disease and stroke.

In children, there is an added subtle risk to using medication. Though all of our medications are tested and proven to be generally safe, we are never exactly sure what subtle effects they may have on the developing brain of a child. We are not able to reliably determine exactly what kinds of subtle effects they may be having over, let’s say, twenty years on factors such as personality or cognitive development.

In all of medicine, the decision to prescribe a medication is based on an analysis of whether the benefits outweigh the risks. It is very often the case that the benefits do outweigh the risks, but it is important to keep the above considerations in mind.

Because I cannot be exactly sure how a medication could subtly effect a child’s developing brain, I am even more conservative with medications in children than I am in adults, and I only use medication when I think that it will have a positive effect on the child’s development.

The truth is, though, that untreated psychiatric symptoms often lead to all kinds of developmental problems, as I’ll discuss later on in this article, and these problems can cause neurodevelopmental issues as well.

It’s important to realize that when symptoms are above a certain threshold delaying or avoiding treatment is also not benign. At that point, it usually makes sense to accept the possible risks of medications to avoid the relatively certain negative outcomes ahead.

In general, psychiatric medications usually have one of three effects.

1. The symptom in question goes away entirely.

2. The symptom gets better but is still present.

3. There is no effect.

The truth is, most psychiatric medications for children are actually prescribed by pediatricians and not child psychiatrists. If a child happens to fall into the first category, and the symptoms go away entirely, that’s great, and that child often does not require any further or more complicated treatment.

By the time children have been referred to a child psychiatrist like me, they have often already tried one or more medications with minimal or no improvement. These children fall into the second or third category.

Unfortunately, what often happens with children in the second and third category is that they are prescribed medication after medication, in a search for a medication that will finally do the trick.

I wish that we had a magic bullet in pill form that would take away all mental suffering, but unfortunately we are far from that. The reality is that for most children struggling with emotional difficulties medication will take the edge off but not erase the symptoms.

With this background, let me tell you about how I approach prescribing psychiatric medications.

I prescribe medication for most of my patients, but I do so within a developmental framework. Child development is a very complex and important topic which I address in more depth in other articles. Here I will just give a brief summary. Children undergo massive developmental changes as they approach adulthood.

These include the development of:

  • Healthy self-esteem
  • A mature and appropriate sense of self
  • Healthy styles of forming and keeping relationships
  • The ability to delay gratification
  • Tolerance of uncertainty and imperfection
  • A healthy and flexible sense of morality and values

All of these psychological functions are acquired through a complex reciprocal interaction between the child and his or her parents and other authority figures, such as teachers and coaches.

The relationship between a child and these authority figures is paramount for development. Let me give you an example. A child with ADHD, who is so hyperactive and who has such problems with attention that he or she cannot follow directions and expectations of parents and teachers, may have very negative interactions with these authority figures.

It’s only natural that parents and teachers of such a child will enforce punishments, and such children often perceive the painful gap between their performance and that of their peers.

Unfortunately, these children often develop serious issues with self-esteem, concept of self, and style of relating to others.

In turn, these issues negatively influence a child’s overall social–emotional development. Since all of the developmental gains necessary for a healthy adult life require a secure and positive relationship with parents and authority figures, distortions in a sense of self and style of relating to others can snowball and lead to much more serious problems down the line.

Unhealthy ways of relating to peers snowballs as well. In order for children to develop appropriate and healthy social skills, a great deal of social experimentation is needed, with a long process of trial and error.

Children who struggle significantly with self-esteem and have inappropriate styles of relating to kids their age will not be able to engage in this process appropriately. Often, when these children hit puberty and their teenage years, they can run into difficulties in romantic relationships, drug use, and other problematic behaviors because they haven’t learned to navigate the social world in a stable and healthy way.

When I am considering prescribing a medication, I have my eye toward all of these social–emotional developmental issues.

Of course one of my goals is to reduce suffering in the moment, using medications to reduce symptoms.

However, though I am concerned with how a child is feeling in the moment at age five, I am much more concerned with how that individual will function at age twenty five.

That five-year-old boy or a girl playing in my office has an immense amount of development ahead, and if my assessment of their social–emotional development is that they are not on track to make the appropriate gains, that is a much larger problem than whether or not they feel angry or anxious today.

Because of the possible side-effects of medication and the fact that we never know exactly how medications will affect the developing brain, I try to be as conservative as possible when prescribing medication for children.

I try to assess how the current symptoms are affecting the child’s development. For instance, if levels of anxiety, depression, or attention problems are preventing the child from developing healthy relationships with parents and teachers, or if the symptoms are preventing appropriate social interactions with peers, I am much more likely to use medication.

On the other hand, even if a child is experiencing psychiatric symptoms, if their development seems to be on track, I would be less likely to use medication.

This view on prescribing, in my opinion, is different than how many psychiatrists prescribe medications today.

The Diagnostic and Statistical Manual (DSM) of the American psychiatric Association, the main diagnostic system in use today, is based on symptoms in the present. Diagnoses are formed from clusters of symptoms such as depression and anxiety, and if there are no symptoms present then there is usually no diagnosis made.

The problem with the application of this system in children, though, is that it does not give enough weight to developmental issues. A child could have no obvious symptoms and not meet criteria for any DSM diagnosis yet still have very significant developmental issues. Often we can see the storm brewing years in advance.

Another aspect of the developmental view of prescribing Psychiatric Medications involves one of the mechanisms of action.

Psychiatric medications work in many different ways, but one of the main ways that they work is by increasing the brain’s ability to change and adapt.

This ability of the brain to mold itself is called neuroplasticity, and studies have shown that individuals with depression, anxiety, and other psychiatric disorders have a reduced ability of their brain to mold and adapt to new situations.

Many psychiatric medications increase neuroplasticity and give the brain the needed flexibility to adapt to changing situations.

This mechanism fits perfectly into the developmental model.

A child with a brain that is less adaptable may have difficulty with the significant changes and psychological overhauls that occur throughout childhood and teenage years. Medications that increase that neurological flexibility may help a child engage in the necessary developmental processes.

Combining Psychotherapy with Medication
This view on psychiatry and prescribing medication is part of why I am such a proponent of psychotherapy. In addition to being a treatment, psychotherapy is also a tool for understanding the true nature of a child’s emotional difficulties.

In psychotherapy sessions, I gain a window into the child’s internal world, which gives me a much more complete view of the child’s social-emotional development and family relationships.

After the initial evaluation, medication management sessions with a psychiatrist are often between 15 and 30 minutes every 1 to 3 months. In my experience, it is very difficult or even impossible to truly appreciate the developmental and psychological status of a child with that level of frequency and length of appointments.

Since my decision to prescribe medication is based on a deep understanding of these social–emotional developmental issues, I strongly prefer combining medication with psychotherapy, not only because I know how helpful psychotherapy can be but also because ongoing psychotherapy allows me to develop a much more complete and nuanced understanding of what it is that I am treating.

It’s not always so easy to fully understand the presenting symptoms without understanding the underlying developmental status, especially since psychiatric symptoms can sometimes be normal and temporary in children. Whether symptoms require medication or can be monitored over time often requires a much deeper understanding.

The next best option is what is sometimes called “split treatment,” where a psychiatrist prescribes medication while a psychologist or social worker provides the psychotherapy. If I am able to collaborate closely with the therapist, then I am able to get a much better sense of what is going on developmentally, which informs my medical treatment.

However, I have routinely found that in the cases in which I provided the psychotherapy and medication together I develop a much deeper and accurate understanding of the child’s symptoms, which informs my use of medication.

Most psychiatrists today do not provide psychotherapy, and this trend has occurred for many reasons. Insurance companies often do not reimburse psychiatrists for psychotherapy as well as they do for shorter medication appointments.

Many psychiatrists have opted for shorter medication visits of 15-30 minutes, in part due to these external pressures. In addition, the field of psychiatry in general has shifted away from a developmental and psychological orientation to a more biological and medical model.

Don’t get me wrong – I am not advocating for some new-age holistic treatment outside of the mainstream medical model. As I mentioned before, I use medication in most of my patients, and I have a great appreciation for the biological and medical aspect of psychiatry.

However, I do think that the pendulum has swung a bit too far toward biological reductionism, where symptoms are treated with medication without a deeper appreciation of the personal and developmental perspective.

My goal is to strike a balance, taking what we have learned about the brain and medication and placing that knowledge in a developmental and psychological context. In my opinion, this more conservative approach leads to more reasonable prescribing that limits the over-prescription of medication while capitalizing on a child’s developmental capacity.

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Thanks for reading,

Jason Dean, MD