February 23, 2004

Whether, when, and under what conditions to medicate children for depression has never been easy to determine. But in the past few years, medical professionals treating children and adolescents have been writing more and more prescriptions for a group of medicines called selective serotonin reuptake inhibitors, or SSRIs. Recent research indicates that over 1 million individuals aged 18 or younger in the U.S. are currently taking SSRIs, which include Paxil and Zoloft among other drugs.

In February, 2004, the Food and Drug Administration held a hearing on concerns that the drugs might increase the risk of suicide among some children and adolescents. The hearing included passionate testimony from parents who blame the pills for their children’s suicides—as well as from others who argued the same medications had saved their children’s lives.

With so much at stake, and with a definitive assessment of the risks impossible given the shortage of research, parents are anxious for clear guidance on how to do right by their children. One important point: children and teens currently taking the drugs should not abruptly stop—any change in medication, including stopping, needs to be carefully monitored for the patient’s safety.

Connect for Kids decided to call Dr. Stanley Greenspan, M.D. the author of The Challenging Child and a clinical professor of psychiatry, behavioral sciences and pediatrics at George Washington University Medical School, and Dr. Lawrence Diller, M.D., the author of Should I Medicate My Child?, who has practiced behavioral/developmental pediatrics for almost three decades.

Both Greenspan and Diller were adamant about the need to see medication as just one potential tool in a treatment approach that should encompass the entire family, as well as a child’s school and social environments. Both doctors also said a shortage of clinicians trained to work with children, along with economic pressures, make it difficult for families to get the services they need. “Parents need to clamor for more insurance coverage, for increasing the supply of qualified child-treatment professionals,” said Greenspan. “Everything else is just Band-Aids.”

Parents who are concerned that their child is suffering from depression or another mental disorder are often advised to “consult a qualified health professional.” In practical terms, what does that mean? A pediatrician, psychologist, family counselor, psychiatrist, social worker?

Greenspan: It could be a psychologist, a psychiatrist, or any other mental health professional trained in the evaluation of children.

Diller: As an entry-point, I recommend that you go first to someone who is not an M.D. That’s because if you do go to an M.D. such as a child psychiatrist, you have only a one in ten chance of leaving without a prescription.

Describe the types of evaluation that should be carried out in the process of determining a treatment plan for a child, and whether medication fits into the treatment.

Diller: If your pediatrician recommends medication, step back. Ask yourself, what else has been tried, and what kind of evaluation has been used? If it’s been 20 minutes talking to the mother alone, or 10 minutes talking to the kid, that’s probably not adequate. Parents want to consider, what kind of information has the doctor gotten, how quickly has he or she made a decision?

There are no biological tests for depression. There should be a clinical interview, and a full medical and family history. That’s usually taken from one parent, but I would try to include both parents. There should be at least one family visit, including siblings. You learn an enormous amount about a child when you meet with the family. The person should make a phone call to the school, especially if there are school behavioral or performance issues.

Greenspan: There should be a full clinical evaluation, which involves interviewing parents, going over a history, observing the parents interacting with the child, and the clinician working directly with the child. Talking with the parents and assessing family functioning, talking with school personnel and other adults the child interacts with, reviewing any reports…The key is the evaluation of the family. The family evaluation has to be for at least one session or more – that’s 45 minutes. Then observations of the child directly and interacting with parents, at least one or two sessions.

When might it be appropriate to include medication in the treatment plan from the very beginning?

Greenspan: If medication is being considered it most often should be in terms of a comprehensive program, considered as one factor…A useful rule of thumb is that a comprehensive program, that may include psychotherapy and family counseling, should already be in place. When you consider medication in the sequence depends on the child. It might be six months or a year into treatment, but in an acute situation, you might have to move sooner. It is often good practice to see how a child responds to a comprehensive program before making a decision about medication.

Diller: If someone is thinking about suicide, that gets my attention. I don’t worry about side effects or long-term effects so much. To distinguish, thinking about suicide is very common, and my first reaction would be to spend time with the kid and figure out what’s going on. If the thinking is about specific ways to go about it, that’s an arena where I begin to weigh the possible advantages of SSRIs against the known risks and the uncertainties.

(Diller and Greenspan also both noted that hospitalization should also be considered in acute cases where suicide is a concern.)

There’s been a lot said about the need to follow up with children once they start taking medications. What is an appropriate level of follow-up?

Diller: The first couple of days and weeks are critical. Sending a kid out with a month’s supply and no follow-up is very close to malpractice. In the first couple of days, and then for the first two or three weeks, there has to be at least phone contact between doctor and parent…That way, if the kid is getting worse, you can act quickly. You can no longer presume that it is the disorder making things worse. (In that case) you would want to bring the kid in to talk, and potentially stop the drug.

Greenspan: You’re really asking the wrong question when you talk about follow-up for medications. The key is that you should not implement any kind of treatment, with a medication or otherwise, unless there is a comprehensive program, based on a comprehensive evaluation. If there is a comprehensive program in place, then the child is being monitored as part of that.

Dr. Lawrence H. Diller has practiced behavioral/developmental pediatrics for 28 years. He is the author of “Should I Medicate My Child?”(Basic Books, 2002) and “Running on Ritalin” (Bantam, 1998).

Dr. Stanley Greenspan is a clinical professor of psychiatry, behavioral sciences and pediatrics at George Washington University Medical School, and the author of “The Challenging Child” (Addison Wesley, 1995), among many other books.

Resources:

• The latest FAQs from the Food and Drug Administration on Paxil and adolescents and children has practical advice for parents whose children are already taking the drug, one of the most commonly prescribed SSRIs.
• Children’s Hospital in Boston has an on-line “journal” in a clear and engaging format, designed to help children and adolescents cope with depression.
• The NYU Child Study Center web site AboutOurKids.org, offers a screening checklist of questions to help parents determine if their child may be suffering a depressive disorder.

Talk Back

If you’ve got comments or questions about this story, we’d like to hear them. Send your response to Susan Phillips (susan@connectforkids.org).

Susan Phillips is the executive editor for Connect for Kids.