Teaching Health Care Providers About Psychopharmacology and Mental Health

I was fortunate to spend the past weekend continuing my work as Faculty-in-Training at the REACH Institute, a non-profit organization dedicated to transforming children’s health services by empowering their care providers – parents, doctors, teachers, counselors, and therapists – to know and use the most effective methods for identifying and assisting children with mental health conditions.

My involvement with this organization began in 2011 when I had the opportunity to participate in an intensive Mini-Fellowship, Patient-Centered Mental Health in Pediatric Primary Care.  The Mini-Fellowship was designed to address the growing shortage of pediatric psychiatrists by providing pediatricians, family physicians, nurse practitioners, physician’s assistants, psychiatrists and neurologists with up-to-date training in the use of psychiatric medications  for children and adolescents.  

Since 2011, The Yellin Center’s involvement in children’s mental health and psychopharmacology has grown steadily.  Therefore, I was thrilled when I was invited to apply and was subsequently accepted in the REACH Institute’s Faculty Training Program.  Having completed the first two phases of training, I am hopeful that I will complete the process of becoming a full-fledged member of the REACH Institute’s National Faculty within the next few months.  My work with them already has had a significant impact on my practice and I look forward to ongoing collaborations with experts to ensure that my knowledge and skills continue to grow and remain current.  I also am excited about the prospect of participating in the critical work of addressing the growing shortage of pediatric psychiatrists and increasing access to high quality mental health services for our nation’s children and families.

ADHD Treatments for Young Children - A New Study

A new study just released by the Centers for Disease Control and Prevention (CDC) finds that while more than 75% of young children (ages 2-5) with attention-deficit/hyperactivity disorder (ADHD) are prescribed medication, only about half receive behavior therapy* to address their attention difficulties.

 

This preference for medicating young children runs counter to the clinical guidelines established by the American Academy of Pediatrics, which in 2011 recommended:

"For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based … behavior therapy as the first line of treatment and may prescribe [medication] if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child's function."

The AAP guidelines go on to caution that, “…in areas where evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment.” The AAP noted that even students whose attention difficulties do not rise to the diagnostic criteria of ADHD may benefit from a behavioral approach to their attention issues.

The CDC study observed that approximately 6.4 million U.S. children ages 4-17 years had a diagnosis of ADHD in 2011-12, which was an increase of 42% increase compared to 2003. The study used insurance claims for psychological services (which includes behavior therapy) and ADHD medication from both Medicaid and private insurance to determine the frequency with which each approach was utilized. 

The CDC reported that the strength of evidence for behavior therapy exceeds that for ADHD medications. It noted that behavior therapy might require more time to impact child behavior and might require more resources but that the impact lasts longer relative to ADHD medication and does not have the side effects associated with these medications. Most of these side effects are minor but they are experienced by approximately 30% of children aged 3–5 years who take ADHD medications and more than 10 % of the children in this group stopped medication treatment because of such side effects.

Here at The Yellin Center we always recommend behavioral strategies for school and home when dealing with attention issues. When appropriate, we can also provide consultation and ongoing prescription management for medications, but we strongly believe that medication should only be considered in the context of a student's overall educational plan, and never thought of as a "quick fix" for school difficulties.

*Behavior therapy in this context includes any psychological interventions that are designed to change problem behaviors, including ADHD symptoms, by modifying the physical or social contexts in which the behavior occurs and can be delivered to the child by a therapist, teacher, parent, or other provider.

Heading to College? We've Got Lots of Advice

Now that summer is in full swing, high school graduates heading off to college in the fall should be thinking ahead to what they need to do to make their freshman year -- and their entire college career -- a success. This is even more important for students with learning and other challenges who have had access to accommodations and academic supports in high school. Over the five years we have been writing this blog, we have addressed a number of issues that college students need to think about and act on to ensure their success.

Students taking medication need to think about how they will refill their prescriptions. Incoming freshman also need to make sure they have contacted their college's Office of Disability Services and submitted documentation of their learning or other disability. Having an IEP or 504 Plan in high school is not sufficient for college accommodations; there is no IEP in college!

It is important to discuss the need to stay on top of academic challenges if they occur. Too often, students don't want to face the fact that they are in academic difficulty, or they want to keep the fact that they may be failing one or more courses from their parents. The problem is that once a student fails a course, this becomes part of their academic record and can have consequences such as suspension, dismissal, or even just a lower GPA. 

Students in STEM fields - science, technology, engineering, and mathematics -- who haven't already registered for  fall courses, might want to consider research that indicates that students perform better in courses that involve "active learning". And avoiding courses with frequent tests may not be the best decision, since research has found that frequent testing can actually boost learning in college classes.

There are lots of other resources in our blog posts that college bound students may find useful. Try our search feature (on the right hand side of the page) to look for tips for technology, writing, and organization. We hope you find these helpful!

Benefits of Demystification for Teens with ADHD

A small but interesting study from a team of Canadian researchers sheds light on the benefits of demystification -- "the act of putting into plain words what an individual's strengths and weaknesses are, without the use of judgment or labels" -- on teenagers with ADHD.

The researchers built on earlier studies that demonstrated that parents who participated in training programs that provided information about their children's ADHD had improved decision making and knowledge, and their children had improved adherence to both medication and non-medication interventions. Similarly, elementary school children with ADHD who attended demystification workshops gained both knowledge about ADHD and had more favorable opinions of medication and other methods of treating this condition.

The study's focus on teens was prompted by data showing that less than half of teens with diagnosed ADHD who have been prescribed medication stick to their medication regimes, even when their symptoms continue to cause distress. Furthermore, the decision to stop medication is most often made by the teens themselves, whether or not their parents support this decision. The researchers in the present study wanted to see what would result from having teens participate in a two-hour workshop which addressed the following topics: "characteristics of ADHD, evidence-based treatments, strengths and weaknesses associated with ADHD, the connection between ADHD and the brain, how ADHD in adolescence is different from childhood ADHD, what to expect in the future, and important steps to self-advocacy, such as knowing when, who, and how to ask for special accommodations in school."

The study results were strongest when looking at improved self-advocacy information; students who participated in the demystification workshop had a significant and lasting improvement in recognizing which adults could help them with their ADHD and in recognizing ways they could take steps on their own to manage their ADHD. The researchers found an unexpected level of concern among the participants as to the safety of ADHD medications, including questions about combining these medications with alcohol or "recreational" drugs. The researchers note that more investigation is needed to determine how to best transmit information to teens with ADHD, but concluded, "A key strength of the demystification workshop was the notable change in adolescents' individual self-advocacy knowledge." They note that this will "allow adolescents to take more initiative in recognizing when support is required, seeking support from others, and knowing what steps they might take to help manage their ADHD symptoms."

Thinking about ADHD

An article in last week’s New York Times, "A.D.H.D.Seen in 11% of U.S. Children as Diagnoses Rise," raises some important issues. The article concerns data from a CDC study which interviewed more than 76,000 parents between February 2011 and June 2012 as part of a wide-ranging look at children’s health issues. The CDC has not yet published its findings, but the Times used the raw data as the basis of the article.

According to the Times, diagnoses of ADHD in the U.S. have risen some 41% in the past decade, and 11% of school-age children have received a diagnosis of ADHD. It also reported that about two-thirds of those diagnosed received a prescription for stimulant medication. 

The article continued by noting that the criteria for ADHD -- a checklist of symptoms occurring across situations (for instance both at home and at school) over a period of time -- was due to be expanded in the new Fifth Edition of the DSM, due out this May. This is expected to add to the numbers of teens and adults who are diagnosed with ADHD. 

So, what does this mean for you, for your child, and for clinicians? 

First, parents need to understand that just because a child has difficulties with attention does not mean that he has ADHD. There can be many reasons for attention issues and children can fidget for many reasons. Thoughtful clinicians need to apply the time tested medical approach of “differential diagnosis” when they look at the symptoms commonly associated with ADHD. "Why," they should always ask, "are these behaviors present?" Does this student have a language difficulty, so that she has trouble understanding what is going on in class? It can be hard to pay attention when you can’t follow the classroom discourse. Does he have a problem with memory, so that he jumps and shouts out so that the teacher will call on him before he forgets what he wants to say? Or, perhaps, does she have a true deficit of attention which may or may not be accompanied by hyperactivity?

Even when children have ADHD, we must be thoughtful about what the best strategies may be to deal with this problem. There are many interventions that can and should be tried before using medication. In fact, medications are NEVER sufficient alone. They must always be prescribed in the context of a comprehensive educational plan that includes strategies students, educators, and parents can implement on a daily basis.

Building self-awareness must also be part of the treatment. A child can have ADHD without being ADHD. They must learn about their strengths, and understand that attention weakness exists within the context of their strengths, and perhaps other weaknesses. Attention is a multi-faceted function that appears to involve at least three different parts of a child’s brain. A child needs to know what parts of attention are the sources of their difficulty, and perhaps what parts of attention are working well for them. Attention problems rarely exist in isolation. We owe it to our children to ask, “What else might be contributing to their difficulty?” 

We understand that medication can be enormously helpful for many children for whom the benefits greatly exceed the risks. However, as is the case with every medical treatment, the risks and benefits must be considered on a case-by-case basis. I believe our role as clinicians is to provide parents with the best information that we can and with our best judgment. However, I worry when I hear that parents had their child “tested for ADHD.” I am not saying that the possibility of an ADHD diagnosis shouldn't be considered. What I am saying is that it must be considered in the context of thoughtful consideration of all of the possible causes of a child’s symptoms. And once a diagnosis has been made, medication must be examined in the context of all of the potential interventions.

Illustration: Life Mental Health

Use of Antipsychotic Medications by Children and Teens On the Rise

A new report on the increased use of antipsychotic medications by children and teens reveals some disturbing trends. The report, which appears in the Archives of General Psychiatry, analyzes data gleaned from the 1993-2009 National Ambulatory Medical Care Surveys compiled by the Centers for Disease Control.

The data revealed that from the early years of the survey until 2009 the number of doctor visits at which children received prescriptions for antipsychotic medications rose from .24 to 1.83 per 100 children. For teens, the increase was from .78 to 3.76 per 100 individuals. Antipsychotic medications include such drugs as Abilify and Risperdal. These medications have been approved -- and have been used effectively -- for such serious conditions as schizophrenia and bipolar disorder.

According to Dr. Mark Olfson, lead author of the report, the problem is that most of the time these medications are not being used for their approved purposes but, instead, are being prescribed for such conditions as ADHD and disruptive behavior. As noted in a release from Medline, a service of the National Institutes of Health, Dr. Olfson notes, "Only a small proportion of antipsychotic treatment of children (6 percent) and adolescents (13 percent) is for FDA-approved clinical indications ... These national trends focus attention on the substantial and growing extent to which children diagnosed with ADHD and other disruptive behavioral disorders are being treated with antipsychotic medications." Olfson further noted that most of the children and teenagers receiving the antipsychotic medications were not receiving psychotherapy. In addition, he noted that research has not yet determined what the long term impact of these medications may be on the developing brains of young people. Antipsychotic medications can have significant side effects.

Dr. Paul Yellin, the Director of The Yellin Center notes, "Antipsychotic medications can be an effective treatment for certain disorders and their thoughtful use by experienced physicians can be helpful. What is of concern is their use, particularly in young children, for conditions such as ADHD, where there are safer, better studied alternatives that work well."

Photo: cdedbdme / Creative Commons

Helpful Tips for College Freshmen

It may still be mid-summer, but it's only a couple of weeks until freshman orientation begins on many college campuses. Along with high tech electronics and extra long twin bedding, there are some items that students with learning or attention challenges need to bring with them to get off to a good start.

Students who take medications for ADHD or for medical or emotional issues need to consider the logistics involved in both taking and refilling their medications. How will they best remember to take their medications regularly when caught up in their busy academic and social schedule? Some helpful tools include a pill tray for those who take multiple medications (which can be set up once a week), a watch or phone with a reminder alarm that is set to go off at the time(s) medications need to be taken, and a designated location in the student's dorm room where medication is both accessible to the student and safe from roommates or visitors.

What about refills? Controlled substances -- which include most medications for attention and emotional issues -- require a new prescription for each month's supply. Families should check with the prescribing physican and speak to the campus health center for recommendations for local pharmacies. Another option is re-stocking during visits home.There is no single best arrangement, but it can take time to procure a refill and the day the student runs out of his or her medication is too late to create an effective plan.

Students with learning difficulties or ADHD who need academic accomodations, such as extended time on exams, should have already been in touch with the campus Office of Disability Services to provide required documentation of their disability and to obtain appropriate accommodations. If your student has not yet done so, make this your first priority, since it takes some time for this process to be completed. You do not want your student to face their first exam without the accommodations needed for success.

There are a number of tools that can benefit all students that are particularly helpful to college freshmen with learning or attention issues. These include: 

• A large white board to keep track of upcoming tasks and to break down extended assignments into workable segments 
• A device for recording lectures. This can be a Smartpen, which can allow the student to link their notes to the recording so they do not have to listen to the entire lecture to get the parts they missed, or a smartphone or other device with a recording feature. 
• A file box, set up with a separate folder for each course. Once a week, papers from each course should be filed and retained for studying for the final exam. 
• For those students who qualify, authorization for access to audio books through organizations like Bookshare or Learning Ally. Most textbook publishers are required to make their materials accessible to students in multiple formats. 
• An electronic or paper organizer. Electronic versions can provide reminders that help keep students on track. 

A little bit of planning can make a big difference for a new college student. Take some time now to smooth your student's start to college.

Photo: Matt Runkle / Creative Commons

ADHD Medications and Teenage Drivers

We are frequently asked whether it is really necessary to take attention medications every day. Some students feel that they only need their meds when they have a major project, important test, or heavy workload. Many parents like to give their children a “break” over the weekend or during vacations. I believe that deciding whether and how to take medications is a personal decision best made in consultation with the prescribing physician. But making a wise decision requires the best information so each of us can weigh the potential benefits and risks in the context of our own lives. With that in mind, I think it is important to share interesting research that was published in the April 2012 edition of the Journal of Clinical Psychopharmacology in a study called "Long-Acting Methylphenidate Reduces Collision Rates of Young Adult Drivers With Attention-Deficit/Hyperactivity Disorder" (by Cox, Daniel J. PhD; Davis, Margaret BA; Mikami, Amori Yee PhD; Singh, Harsimran PhD; Merkel, Richard L. MD, PhD; and Burket, Roger MD). 
    
The investigators studied adolescents diagnosed with ADHD who had previously responded to medication, were not routinely taking medication, and were active drivers with more than one collision or citation in the past two years. Half of the participants received long-acting stimulants; the other half did not. Their driving was monitored for three months with in-car video cameras. (You are probably wondering how you can get a hold of one for your own adolescent driver). Compared to the untreated group, the group receiving medications had fewer video-documented collisions and “problematic driving events.” So, when making decisions about risks and benefits of attention medications, bear in mind that academic performance may not be the highest priority.

Photo by Dominic Alves via Flickr/Creative Commons

Behavioral Therapy and ADHD

Scientific American has reported on findings from the recent Experimental Biology meeting in San Diego that look at the relative effectiveness of cognitive and behavioral therapies versus medications in helping children and young adults with Attention Deficit Hyperactivity Disorder (ADHD). 

Included in the research reported at the meeting were findings by Dr. Claire Advokat of Louisiana State University, who looked at college students with attention difficulties and found that it was not medication, but good study habits, that determined several parameters of college success, such as grades. Dr. Advokat noted, according to the Scientific American report, that this does not mean that medication had no effect for these students, but that it may help students develop good study habits, which then improves student performance. 

Other researchers at the Experimental Biology meeting included Dr. William Pelham of Florida International University, who noted improvement in children's ADHD behaviors, such as classroom disturbances, when their parents received training in behavioral tools and in managing their own stress. Dr. Pelham has also conducted studies suggesting that children with ADHD who receive low doses of medication combined with behavioral therapy do better than children receiving only medication or only therapy. 

While there is much work to be done, none of the researchers whose findings were discussed in this article by Scientific American suggested going back to the days before ADHD medications became available and only cognitive and behavioral therapies could be offered; they generally agreed that it is important to explore the relative uses of all available modes of treatment. While medications generally work more quickly and are more cost effective than longer term behavioral therapies, they can have side effects. The real question that remains is what works best for each individual child and young adult in the long run.

Study Shows No Link Between ADHD Medications and Cardiac Problems

A report in the November 1 edition of the New England Journal of Medicine included the results of a large study designed to clarify whether ADHD medications are associated with an increased risk of serious cardiac problems (the study was not designed to monitor minor side effects -- only significant heart complications). The authors sought to quantify the risks which these medications may pose for the 2.7 million children for whom they are prescribed each year. In particular, they wanted to determine if previous anecdotal reports of negative cardiac events were supported by a review of the data from a large number of patients.

The study did not find any association between ADHD medications and serious cardiac problems.

The researchers reviewed data compiled over the course of at least three years from four geographically diverse health plans (Tennessee Medicaid, Washington State Medicaid, Kaiser Permanente California, and OptumInsight Epidemiology) with more than 1.2 million members between 2 and 24 years of age.

While this is only one study, it is reassuring and is consistent with other studies and clinical experience indicating that these medications are safe and effective when clinically indicated, provided in appropriate dosages, and monitored for possible side effects. It is also important to bear in mind that medication decisions need to be individualized, must involve ongoing communication between parent, patient, and physician, and are only one part of a comprehensive treatment plan.