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PRESCRIBING PSYCHIATRIC MEDICATIONS FOR CHILDREN AND ADOLESCENTS
Introduction
Fifty percent of all adult psychiatric disorders have manifested by age 14, with 75% manifesting by age 24.Two thirds of pediatric-onset psychiatric disorders are moderate or severe and most continue into adulthood. This pattern clearly indicates the importance of identifying and appropriately treating psychiatric disorders as early as possible to preserve healthy development. Approximately 75% of youth with psychiatric disorders are seen for initial assessment in the primary care provider’s office. When needed, PCPs can seek consultation with a child and adolescent psychiatrist to address issues related to the usage of psychotropic medication while continuing to treat the youth themselves. At other times, the family and the PCP may decide that a referral to a child and adolescent psychiatrist is indicated. Factors to Consider When Deciding to Treat or to Refer to a Mental Health Specialist
Psychotropic medications are taken for the purpose of improving the emotional and behavioral health of a child or adolescent diagnosed with a mental health condition There is evidence that psychotropic medications are both over and under prescribed for children and adolescents. Medication can be overprescribed when there is insufficient attention paid to other supports and services that may benefit the youth. Medications can be under or overprescribed particularly when practicing in underserved areas where access to expertise is limited. Prescribing psychotropic medications for children and adolescents requires a competent prescriber, who is trained and qualified in treating this population, and should be utilized when indicated. Psychotropic medications are only one component of a comprehensive biopsychosocial treatment plan. This takes into account physical health, genetic factors, psychological factors, that contribute to emotional and behavioral functioning and environmental factors that influence a youth’s functioning. This can include family circumstances and relationships, trauma, and school related issues. The benefit from the medication must be evaluated against the potential unwanted side effects, when considering whether a medication should be prescribed. Parents and guardians and the youth must be informed about the potential risks as well as the benefits when giving consent for initiation of a trial of psychotropic medication. 1 Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62L593-602 2 Kesser RC, Avenevoli S, Costel o J, et al. Severity of 12 month DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2012;69:381-9 3 American Academy of Child and Adolescent Psychiatry. Practice parameter on child and adolescent mental health care in community systems of care. J Am Acad Child Adolesc Psychiatry, 2007;46:284-299 PRESCRIBING PSYCHIATRIC MEDICATIONS FOR CHILDREN AND ADOLESCENTS
The treatment of an adolescent or child with a trial of medication is something that requires coordination of care among the PCP, other behavioral health practitioners and others involved in the care of the child or adolescent; i.e. DCF, Jail system, schools. An express written and informed consent is required, in accordance with HIPAA regulations. Informed consent and assent for the use of medication is necessary. AHCA has implemented a form which must be completed prior to a medication prescription is filled. The form can be found at Http://www.fdhc.state.fl.us/medicaid/prescribed_drug/med_resource.shtml, and a copy of the form is attached. Once there has been a decision to treat, appropriate follow up is critical. Follow up in person should occur within two weeks and at least monthly until symptoms stabilizes. According to the HEDIS measures for the treatment of Attention-Deficit-Hyperactivity Disorder, Children aged 6-12 with newly prescribed ADHD medication should have at least three follow up care visits within a 10 month period, one of which is within 30 days of the first prescription. The measure looks at the initiation phase, which should include a fol ow up visit within 30 days of the initial prescription, and the continuation and maintenance phase, which measures the percentage of members who remained on medication for at least 210 days and had at least two additional visits with a practitioner within 270 days, after the initiation phase ended.
Other Medication Considerations
There are few medications, which are FDA approved for the treatment in children and adolescents. • For the antidepressants only fluoxetine (Prozac), is approved for the treatment of depression. • Fluoxetine (Prozac), Sertraline (Zoloft), Fluvoxamine (Luvox), and Clomimpramine (Anafranil) are approved for the treatment of Obsessive Compulsive Disorder • There are four atypical antipsychotics approved for the use in children and adolescents (age 13- 17), for the treatment of Schizophrenia and Bipolar Disorder, manic and mixed type:  Aripiprazole (Abilify)  Olanzapine (Zyprexa)  Quetiapine (Seroquel)  Risperidone (Risperdal) • Paliperidone (Invega) is approved for use in Schizophrenia • Aripiprazole and Risperidone are approved for the use of irritability in Autistic Children ages 5- • There are no atypical antipsychotics approved for use in children under the age of five. • There are a number of stimulant medications approved for the use in ADHD in Children and Adolescents  Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)  Dexmethylphenidate (Focalin)  Amphetamine-dextroamphetamine (Dexedrine, Dextrostat) PRESCRIBING PSYCHIATRIC MEDICATIONS FOR CHILDREN AND ADOLESCENTS
• Atomoxetine (Strattera) is the first non-stimulant approved for ADHD in Children These medications are not without risk. The antidepressants and the atypical antipsychotics both carry warnings associated with their use and a careful risk/benefit analysis must be completed before Although there were no completed suicides among the 22,000 cases studied, there appeared to be an increased risk of suicidal thinking, so the FDA issued a black box warning indicating that antidepressants may increase the risk of suicidal thinking and behavior in children and adolescents with MDD. These children should be closely monitored for any worsening of depression, emergence of suicidal thinking or behavior or unusual changes in behavior especially during the first four weeks of treatment. More recently, results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders. The study, partially funded by NIMH, was published in the April 18, 2007, issue of the Journal of the American Medical Association. The atypical antipsychotics carry an increased risk of metabolic syndrome and diabetes, and Children and adolescents need to be routinely monitored for signs and symptoms, including routine lipid profiles, The FDA has directed manufactures of ADHD medication to warn of increased cardiovascular risk and should not be prescribed in children with structural heart problems or congenital heart disease. If there is any concern a youth should have a consultation with a pediatric cardiologist. At the time the American Academy of Child and Adolescent Psychiatry does not routinely recommend a baseline EKG for all patients prescribed stimulants, but clinical judgment should always take precedence. Importance of Education Regarding Compliance and Expectations When making a decision to treat a child or adolescent with medication, both parents and children need to be aware of the risks and benefits associated with taking the medication, the importance of compliance with treatment recommendations and reasonable expectations with regards to treatment. 4 Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA, MD. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment: A Meta-analysis of Randomized Controlled Trials. JAMA. 2007;297:1683-1696. PRESCRIBING PSYCHIATRIC MEDICATIONS FOR CHILDREN AND ADOLESCENTS

Making a Referral

If assistance is required in making a routine referral to a child psychiatrist, Psychcare can facilitate the
referral process. Simply call 1-800-221-5487 and ask for assistance in making an outpatient referral. The Encompass program can also assist in getting routine appointments as well as closer monitoring for those who require more intensive services, or a higher degree of coordination among specialties. An Encompass referral can be made by completing the referral form, which can be found on
REFERENCES
American Academy of Child and Adolescent Psychiatry. Practice parameter on child and adolescent mental health care in community systems of care. J Am Acad Child Adolesc Psychiatry, 2007;46:284-299 American Academy of Child and Adolescent Psychiatry. A Guide for Public Child Serving Agencies on Psychotropic Medications for Children and Adolescents Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA, MD. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment: A Meta-analysis of Randomized Controlled Trials. JAMA. 2007;297:1683-1696 Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62L593-602 Kesser RC, Avenevoli S, Costello J, et al. Severity of 12 month DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2012;69:381-9 Http://www.nimh.nih.gov/health topics/schild-and-adolescent-mental-health/antidepressants

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