Mark Chenven, MD
Private practice child and adolescent psychiatrist, San Diego, CA
Dr. Chenven has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Good practice using psychotropic medications with children and adolescents requires a psychiatrist to pay attention to a number of elements. The following are some recommendations from child psychiatrist Mark Chenven, MD, of the things you should observe and the rules you might want to follow while prescribing medications:
Start low, go slow: Most side effects are dose-related, so gradual up-titration is simple common sense. This allows for the body’s homeostatic and regulatory mechanisms to respond gradually and reduces the severity of emerging side effects. With this approach, a favorable clinical response may also be achieved for some patients at lower than standard dosing.
One step at a time: Making one change at a time is another sound practice, as this allows you to monitor the impact of each changed variable. An exception to this rule would be a situation where you are cross-titrating between two agents and/or dealing with a clinically complex problematic situation. But overall, the math of “less is more” applies to the medication change agenda.
Consider weekend trials: Starting a new medication or making a significant dosage adjustment over the weekend affords parents and the child or teen the opportunity to monitor for both efficacy and side effects.
Seek feedback: Requesting parents or the older adolescent/young adult patient to call with any emerging concerns and scheduling timely follow-up visits further enhances our ability to understand and respond to medication impacts.
Longitudinal follow-through is key: Ongoing routine inquiry about side effects and monitoring relevant vital signs is a core practice expectation. Also, routine should be recognition of co-occurring health conditions and coordination of care with the youth’s pediatric physician.
Focus on med compliance: Compliance and noncompliance should be reviewed periodically. Use longer-acting agents (eg, fluoxetine) when appropriate, and work with kids and parents on developing more consistent medication use habits.
Review and reconsider: Recognizing the failure of a medication to achieve desired results needs to be considered, and it should trigger a reassessment of the diagnosis and treatment plan. A medication without appreciable and definable benefit probably needs to be set aside.
Reject fads: With newly marketed agents, it’s better to be the tortoise than the hare. It is safer for patients to be a late adopter than to pursue the cutting edge.
Beware of polypharmacy: Multiple agents raise the risk of side effects. Combinations can have therapeutic benefits, but it is important to reassess the efficacy of all agents monitored for side effects, interactions, and other challenges.
Pay heed to second thoughts: When in doubt, get a second opinion—either from a trusted colleague or through a more formal request for patient-centered consultation.
Monitor sleep patterns: Disturbances of sleep should be addressed behaviorally when possible, and pharmacologically when warranted. Ask about them.
Inquire about herbals and OTC agents: Many patients and parents think that herbals, supplements, and “natural” remedies are benign. Ask, or you may never be told. Learn more about these agents, and work with families and youth to make mutual decisions on whether to continue them.
Ask about cannabis use: Whether the teen (or younger child!) is using it on the sly or the parent is administering it, inquiring about cannabis is increasingly important. Research will catch up eventually, but absence of evidence does not mean absence of efficacy. Dialog with your patients and their families and, for now, recommend against cannabis use.
Check for other substances: These include alcohol, methamphetamine, psychedelics, heroin, or use of grandma’s codeine, sleeping pills, SSRIs, etc. These substances may be misused, so ask, discuss, and intervene wisely.
Learn about life changes: Inquire about other changes in the child’s life—parental discord, changes in the family structure (eg, siblings off to college), new or lost friends, changes in school, illnesses, accidents, bullying, or all the other things that can upset the apple cart. Any of them may impact our patients’ functioning.