This discussion is designed to help you consider some of the issues you may want to address with a parent or guardian of a child or adolescent who is prescribed a psychotropic medication. To develop your response, review the readings and any other resources you have identified. 

• What are some of the main things you would want to include in a conversation with the parents or guardians of a child or adolescent who is prescribed a psychotropic medication?
• What is important for you to know about the medication itself?
• When might it be necessary to consult with the prescribing doctor? How would you reach out to the doctor?

Client, counselor
prescriber
Counselors can serve as an important link between clients and the medical
professionals who prescribe them antidepressants

R
oughly one in 10 Americans
over the age of 11 takes
.antidepressant medication,

according to data released this past fall
by the Centers for Disease Control

and

Prevention. Antidepressants are the
third most common prescription taken
by Americans of all ages and the most
common among Americans ages 18-44.
The rise in popularity of antidepressants
has been meteoric in recent decades.
Since 1988, the rate of antidepressant
use nationwide among all ages increased
almost 400 percent.

These data, collected as part of
the National Health and Nutrition
Examination Surveys between 2005 and
2008, don’t surprise Dixie Meyer. In fact,
they further support the message she
tries to share with counselors: You need
to know about the antidepressants your
clients are taking.

Antidepressants, which are prescribed
not just for depression but also for
anxiety disorders, pain disorders, learning
disabilities and more, are the medication
most requested by patients, says Meyer,
an assistant professor in the Department
of Counseling and Family Therapy at
St. Louis University and a member of
the American Counseling Association.
She notes that primary care physicians
prescribe the majority of antidepressants.
“This suggests that a large portion of
our clients on antidepressants sought out
the medication without knowledge of
why individuals need medications, and
in most cases, an expert on psychotropic
medications did not prescribe the
medications,” says Meyer, who teaches
psychopharmacology and has been
researching the topic since 2007.
“While counselors are not experts on
antidepressants either, counselors need

By Lynne Shailcross

to understand when their clients may
need to have the medication reassessed
or when the counselor may need to meet
with the medication prescriber.”

Elisabeth Bennett, chair of the
Department of Counselor Education
at Gonzaga University, says even
though counselors are not prescribing
the medications, they are in a prime
position to assist clients who are taking
antidepressants. “Medical professionals
see their psychiatric patients an average
of about eight minutes each … three
to four meetings per year. This is not
enough time to do all the tasks they
must do, let alone to build a relationship
[with the patient, which] is likely the
most critical element contributing to
successful compliance and treatment,”
says Bennett, an ACA member who
also works as a counselor in private
practice and has researched, taught
and presented on neuropsychology and
psychopharmacology.

Counselors, on the other hand, see
their clients two to four times per
month for an average of 50 minutes per
session, Bennett says. When counselors
understand what an antidepressant is
meant to do and what side effects it
may cause, they can better prepare their
clients to follow the regimen prescribed
by the medical professional, she says.
Counselors can also help prepare clients
to note negative side effects that might
need immediate attention, note when
the medication is effective or when there
are breakthrough symptoms, and to
otherwise gain the most benefit while
experiencing the least harm.

A second set of eyes
Meyer echoes Bennett, noting that

the regular interaction counselors have
with their clients positions them to help

38 I Counseling Today | July 2012

with management of antidepressant
medications and, in some cases, to act
as the liaison between clients and the
prescribing doctor. To play that role
effectively, however, Meyer emphasizes
that counselors must educate themselves
about antidepressants. “It is important
for counselors to be knowledgeable about
potential side effects of antidepressants,
the empirical support for antidepressants
and how antidepressants work, including
how they alter neurochemistry,” she says.
“Counselors also need to understand the
neurochemical differences of depressive
symptoms and how to monitor symptom
improvement when clients are taking
antidepressants. This is especially
important when clients think their
antidepressant is not working.”

Bennett points out that the liability and
authority for all elements of a medical
regimen remain with the prescribing
physician but says counselors can be of
great value to clients by educating them
about the medications and the regimens
that doctors prescribe. “Oft:en, the time
limitations of the doctor make such
educational sessions rushed, and the
counselor can supplement at a time when
the client is better able to understand, thus
increasing compliance,” she says. Among
the topics Bennett suggests that counselors
consider discussing with these clients:

• How antidepressant medications work

• Why complying with the regimen is
critical

• How long it takes to reach therapeutic
windows (when enough medication is
in the bloodstream to be effective)

• Potential side effects that might arise

• Which side effects to be concerned
about and which to endure

• How to talk with the prescribing
doctor about symptoms

Meyer encourages counselors to stay
alert to the side effects their clients are
experiencing. If the side effects appear
to be getting out of hand, Meyer
suggests talking with the client and
perhaps encouraging him or her to ask
the prescribing physician to reassess the
medication or dosage. Sometimes, too
many side effects mean the dosage of the
antidepressant is too high, Meyer says.
“Other side effects may lead a physician
to prescribe an additional medication
to alleviate the unwanted effect,” she
says. “For example, for individuals
experiencing sexual side effects [such as]
lack of desire, a physician may prescribe
Wellbutrin, which has been shown to
help with unwanted sexual side effects.”

The counselor’s role in medication
monitoring is to check in weekly with
the client, Meyer says. “It is important

for counselors to ask their chents if they
are noticing anything unusual physically
or mentally,” she says. “Counselors then
need to be knowledgeable about what
may be expected during the course of
treatment. For example, some individuals
report increased anxiety when they begin
taking an antidepressant, but the anxiety
subsides after a few weeks of treatment.
It is important for counselors to know if
certain side effects are transient.”

Sattaria Dilks, a licensed professional
counselor who teaches at McNeese State
University, says some antidepressants
can have serious or even life-threatening
side effects that counselors should be
aware of and educate clients about.
For instance, certain foods can have
life-threatening interactions with
monoamine oxidase inhibitors (MAOIs),
a class of antidepressants, Dilks says.
Other medications potentially can
produce a life-threatening rash. Being
knowledgeable of such side effects will
alert counselors that a client needs to
see a medical professional immediately,
says Dilks, an ACA member who works
in private practice as a psychiatric nurse
practitioner in Lake Charles, La.

All medications have side effects, but
there are two major concerns when it
comes to antidepressants, Meyer says.
One is increased risk for suicide among

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children and young adults, and the other
is serotonin syndrome, in which a person’s
serotonin level can increase to a potentially
lethal level. Among the symptoms
of serotonin syndrome are extreme
anxiety, cognitive disturbances, cardiac
disturbances, hyperthermia, seizures and
coma, Meyer says.

Although not life-threatening,
antidepressants can also have sexual
side effects. As Dilks points out, clients
might be more likely to disclose these
side effects during regular sessions with a
counselor than during a short visit with the
prescribing physician.

Engaging in a conversation with clients
about the relationship between physical
Wellness and mental Wellness as it relates
to antidepressants also can be worthwhile,
Meyer says. “Many clients expect their
antidepressant to be a ‘happy pill,'” she
says. “They are disappointed, then, when
they do not feel euphoric after taking the
medication or assume the medication
is not working because they don’t feel
euphoric. Oftentimes, though, when
working with these types of clients, it is
important to ask about what changes they
are noticing. In these situations, clients
may report they are sleeping better or
are not tired all the time. That is a great
opportunity to discuss how those changes
are positively affecting their lives. This
helps clients see the big picture with
how their medication may help them
feel better, even if it is not an instant
happy pill.”

Weighing the options
These experts also agree that counselors

should know when to refer clients who
aren’t taking antidepressants to a medical
professional for additional help. If the
client’s depression is mild to moderate and
is of short duration, oftentimes, no drugs
are needed, Dilks says. But if a client has
a family history of depression, anxiety or
bipolar disorder, has experienced mtiltiple
depressive episodes or has become suicidal,
the counselor needs to refer the client for
additional assistance, she says.

“Antidepressants are the most helpful
for individuals suffering with the somatic
symptoms of depression, anhedonia,
worsened mood in the morning or
concentration disturbances,” Meyer adds.
“For many individuals experiencing grief,
transient reactive depression or depression
related to early life traumas, they may

be better ofF processing the root of the
depression with a counselor.”

With those clients who are considering
antidepressant use, Meyer suggests
that counselors review both the risks of
taking an antidepressant and the risks
of not taking an antidepressant so these
individuals can make informed decisions.
Counselors might also talk with clients
about how diet, exercise, sleep and
counseling may alter neurochemistry in a
way that alleviates depressive symptoms
without medication, she says.

Also worth discussing, Dilks says, is the
fact that needing an antidepressant is not a
failure on the part of the person taking it.
“[Counselors can] help them work through
that this is not a weakness [and] it’s not
something they did or didn’t do,” she says.
“It’s the genetic deck they got dealt.”

Meyer and Bennett point to multiple
studies comparing the effectiveness of
antidepressants only, counseling only
and a combination of medication and
counseling in treating depression. Meyer
believes the results of these studies are
worth discussing with clients so they
will have the best information possible

for reaching a decision concerning
antidepressants. “Generally, the research
suggests that medication only is the least
helpfiil for treating depression,” Meyer
says. “[Regarding] the best options for
clients, some studies suggest counseling
only is just as effective as a combination
treatment. However, the majority of the
research indicates the combination of
counseling and medication as the best
practice for depression. If the client chooses
an antidepressant, it would be appropriate
to address when he or she could expect to
experience symptom relief, what type of
symptom relief, how the medication works,
the potential side effects and the expected
length of treatment.”

Counselors should also be aware that
antidepressants won’t work for every
person or for every type of depression,
Meyer says. “For example, one of the most
common types of antidepressants, selective
serotonin reuptake inhibitors (SSRIs),
focuses on serotonin,” she says. “Yet, not all
symptoms of depression are associated with
serotonin.”

Effects can also vary among different
populations of people, she adds. For

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July 2012 I Counseling Today | 41

Antídepressants and bipolar disorder
Wlien working with clients who are taking antidepressants,

Dixie Meyer, an assistant professor in the Department of
Counseling and Family Therapy at St. Louis University, is
carefijl to assess for Bipolar Disorder I and IL Many people
with bipolar disorder don’t seek counseling tor manic or
hypomanic episodes, Meyer explains, but they might seek
counseling or medication for depression. For that reason,
she advises counselors to be on the lookout for undiagnosed
bipolar disorder.

It is especially important to be cognizant of undiagnosed
bipolar disorder because the use of antidepressants may
precipitate a manic episode, says Meyer, who teaches
psychopharmacology at St. Louis University and has been

researching the subject for five years. “Caution should also
he utilized when working with individuals who have a family
history because they may be at risk for bipolar disorder,” Meyer
says. “When cotinseling clients who are on antidepressants, we
address how they are feeling aft:er using the antidepressants.
If clients report irritability, racing thoughts or distraction, I
also look for other indicators of mania or hypomania such
as increased motor behavior or rapid speech. If symptoms
of mania or hypomania are observed, I recommend the
client meet with a psychiatrist about treatment with a mood
stabilizer.”

— Lynne Shallcross

instance, Meyer says, individuals of East
Asian ethnicities typically respond better
to lower dosages of antidepressants than do
Caucasians. Age can also play a factor, she
says. “While many children and adolescents
take a variety of antidepressants, the only
FDA (Food and Drug Administration)-
approved antidepressant medication for use
with youth is Prozac.”

If a counselor thinks a client might
benefit from taking an antidepressant,
it is acceptable to recommend that the
client go to a doctor to be evaluated, Dilks
says. However, she warns, a counselor
shotild never tell the client to go to the
doctor expecting or seeking a specific
drug. It’s hest to let the doctor make any
recommendations, she says.

Teaming up for the ciient
Considering the amount of time typi-

cally spent with clients and the comparative
strength of the relationship, counselors
shouldn’t be shy about offering to collabo-
rate with their clients’ prescribing doctors.

In her work as a psychiatric nurse
practitioner, Dilks says she ofien
communicates with her patients’ counselors
to ensure more well-rounded care. “As a
prescriber [myself ,̂ I think the counselor
has a much closer relationship with the
patient,” Dilks says. “They see them for
a longer period of time — 50 minutes or
more at a time — and generally see them
more frequently. I find that if we touch
base with each other periodically, we offer
a more coordinated effort in providing the
patient with continuity of care.”

Dilks says she collaborates with many
counselors in her area, but to do so, clients
must first sign a release allowing the

counselor and prescriber to have ongoing
contact as treatment providers. It’s not
uncommon for Dilks to receive a text
message or voice mail from a counselor to
update her on a mutual client’s situation
or to report side efTects the client is
experiencing related to antidepressant use.

Of course, the reality is that the
counselor’s role in collaborating with thç
doctor, if at all, depends largely on the
doctor and the client, Meyer says. “Some
physicians or psychiatrists seek out the
counselor’s opinion. I have been asked
about client improvement and if I have
suggestions for what may be best for the
client. I have also discussed side effects.
Some physicians may specially ask the
counselor to monitor for certain side
eífécts. Physicians may also want to know
about compliance or complaints that the
client has,” she says. “I find that often the
role of the counselor is dependent upon the
prescribing physician. This may include a
meeting and then follow-up phone calls,
or it may mean discussing with the client
what he or she plans to share in his or her
meeting with the prescribing physician.”

A counselor’s thoughts and observations
can be especially helpfiil when the
prescribing physician is a general
practitioner, Bennett says. “Most general
practitioners have not had many psych
courses or extensive psych training. They
tend to do very brief rotations through
psychiatry during their third year of med
school, during which time they are only
briefiy exposed to psychopathology and
rarely exposed at all to what counselors can
and do facilitate. They usually know that
there is something ‘mental’ going on but

not what to do with it. They medicate the
symptoms as best they can and hope the
patient will feel better and/or complain
less. Counselors can be of great help to the
medical professional but need to be sure to
respect the professional and his or her role
as the medical expert.”

Taking a collaborative approach can
prove beneficial to both the counselor’s and
the doctor’s practice, Meyer says. “Many
physicians are looking for counselors for
referrals. Ofi:entimes, a referral base can
be created by counselors just through
those physicians who are seeking out the
counselor’s opinion. If asked to meet with a
physician, this could be a great opportunity
to leave some cards. The reverse is also true.
Many counselors are looking for physicians
for client referrals. From this, a mutually
beneficial relationship could be created.”

But even more important, Dilks says,
collaboration benefits clients. “All of us
want our patients/clients to have the best
care possible, and that is incredibly more
efficient when we all work together —
therapist, prescriber and patient.”

65===?

To contact Dixie Meyer, email
dmeyer40@slu. edu.

To contact Sattaria Dilks, email
tdilks@mcneese.edu. •

Lynne Shallcross is a senior writer
for Counseling Today. Contact her
at lshailcross@counseing.org.

Letters to the editor:
ct@counseiing.org

42 I Counseling Today | July 2012

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Joumal of Mental Health Counseling
Volume 33/Number 3/July 2011/Pages

196

-222

PROFESSIONAL EXCHANGE

Psychopharmacology and Mental Health Practice:
An Important Alliance

Kevin P. Kaut

Many mental health professionals are concerned about an increasingly “mediealized” society, driven in
part by significant growth in biomédical research and biological perspectives on psychological disor-
ders. The modern medical era, which has endorsed reductionism as the principal way of viewing many
health conditions, offers many options for treating psychiatric diagnoses. Pharmacology is a major
influence in psychiatric treatment decisions, and despite questions by mental health practitioners about
reliance on drugs (Murray, 2009), psychopharmaeology provides helpful alternatives. However, phar-
macological options for mental health concerns should not be considered in isolation, and the use of
drug treatments for cognitive, emotional, and behavioral disorders warrants careful contextual analy-
sis. Mental health practitioners are encouraged to view pharmacology within a comprehensive sociohis-
torical framework that recognizes the value of a reductionist perspective as part of psychology’s rich
cognitive and behavioral contributions to contemporary mental health assessment and intervention.

The past 40 years have produced remarkable medicines that can ameliorate much of the symp-
tomology and suffering that accompanies both acute episodes and chronic persistence of… cen-
tral nervous system disorders. (Julien, 1998, p. 430)

It would be difficult to overestimate the significance of pharmacology in our
lives today. Drugs are nearly ubiquitous in the modem medical and social land-
scape, from the ever-expanding selection of medications, prescription and non-
prescription, to the growing impact abused drugs are having on individuals,
families, and society (Fogarty & Lingford-Hughes, 2004). For better or worse.

Kevin p. Kaut is affiliated with The University of Akron. Correspondence concerning this article
should be directed to Dr. Kevin P. Kaut, Department of Psychology, Third Floor, College of Arts and
Sciences Building, The University of Akron, Akron, Ohio 44325-4301. E-mail: kpk@uakron.edu.

196

Kaut IPSYCHOPHARMACOLOGY AND MENTAL HEALTH 197

drugs will continue to play a major role in health care. One of the major chal-
lenges for mental health practitioners—^particularly given advances in medi-
cine, pharmacology, and managed care (Nys & Nys, 2006)—is the need to
continually update how they conceptualize client mental health needs and inter-
vention strategies within a rapidly changing environment (Cohen, 1993),

Despite the tremendous emphasis in health care on biomedicine, particularly
pharmacology, concerns have recently been raised about the role of drug ther-
apy in mental health (Jureidini & Tonkin, 2006; Murray, 2009; see also Peele,
1981), The criticism is not necessarily about the impact pharmacology has in
general, at least not with the application of pharmacological interventions to the
treatment of medical conditions for which there are known biological causes
and targeted drug mechanisms. Instead, concerns about the expansion of psy-
c//o-pharmacology seem to reflect fundamental questions about how we view
or understand mental health conditions, and the extent to which the biomédical
approach to treatment should be unquestioningly applied to all types of psychi-
atric diagnoses.

Naturally, such questions relate in part to how we as professionals view the
nature of mental and affective processes and the relative emphasis we place on
reductionism (i,e,, observable behavior reduced to neurobiological mecha-
nisms) versus more global socially and environmentally associated influences
on behavior (see Peele, 1981), Our definitions, typically constructed out of edu-
cational background, personal beliefs, and professional experience, infiuence
mental health delivery. Even in considering mental health assessment models
that advocate an appreciation of bio-psycho-social-spiritual facets of behavior
(Hoffinan, 2000; Kaut, 2005), most practitioners bring to a therapeutic relation-
ship or an applied client context biases that constrain how they view mental
health conditions and treatments. For instance, some professionals advocate for
pharmacological strategies in appropriate situations, while others might be
reluctant to consider drugs as a responsible aspect of therapy.

In addition to professional perspectives that can impact mental health deci-
sion-making, we must recognize the role of public perception itself: Clients
bring to mental health scenarios their own understandings—and misunder-
standings—of behavior, medicine, and treatment (Cohen, 1993; see also Kaut
& Dickinson, 2007), Client understanding of mental health issues likely reflects
socially biased attitudes and media-driven conceptualizations of psychological
conditions. Again, modem perspectives of biomedicine, including our under-
standing of the brain, drugs, and behavior (Cohen, 1993; Drevets, 2000) signif-
icantly affects how people approach mental health issues—most notably
whether they request treatments and comply with treatment recommendations.
Uptake of mental and behavioral health services is certainly influenced by a
growing awareness of modem medicine, but the extent to which the medical
model (that disorders are biological manifestations) determines the future of

198 JOURNAL OF MENTAL HEALTH COUNSELING

mental health treatment depends on careful consideration and a willingness to
accept the realities of today’s pharmacological milieu.

The principal goals of this article are to underscore the clinical utility of psy-
chopharmacology in mental health and to encourage mental health profession-
als to evaluate their own understanding of mental health conditions and
treatments as biomédical discoveries and potential clinical applications are
expanding. I view pharmacology as an essential component in mental health
treatment (see Kaut & Dickinson, 2007) and believe the advances of modem
neuroscience and psychopharmacology are creating new opportunities for treat-
ing a variety of psychological and behavioral issues. Naturally, some profes-
sionals might express concern about the appropriateness and efficacy of
psychoactive drug treatments amidst the growth of the pharmaceutical industry,
particularly where the financial cost (and gains) of drug research, development,
and implementation is so high. It is here that mental health professionals, espe-
cially those directly involved in client care, must analyze mental health
research and practice and consider ways to judiciously incorporate the results
of the growth of psychopharmacology into the services they provide.

This article will sequentially address the following:

1. The contextual basis of pharmacology and the need to identify a frame-
work for placing mental health within a much larger psychopharmaceuti-
cal industrial culture (Murray, 2009)

2. Modem reductionism as a philosophical perspective that guides belief in
the medical model; practitioners and researchers alike must be challenged
to critically evaluate the relationship between neural reductionism and
mental health

3. Recommendations for mental health counselors based on endorsement of
reductionism and the embrace of pharmacology within a more inclusive
bio-psycho-social context.

PSYCHOPHARMACOLOGY AND
THE MODERN MENTAL HEALTH CULTURE

A brief consideration of a relatively recent—^possibly watershed—historical
debate at the confluence of pharmacology and mental health practice may be
relevant here. Nearly two decades ago the American Psychological Association
(APA) undertook an extensive initiative to promote prescription privileges for
qualified psychologists (see DeLeon & Wiggins, 1996; DeNelsky, 1996;
Lorion, 1996). Although not directly relevant for most mental health care
providers, raising the issue helped shape a discussion about changes in how
mental health care was being delivered. The ensuing debate stimulated much

Kaut IPSYCHOPHARMACOLOGY AND MENTAL HEALTH 199

discourse about the qualifications of psychologists to write prescriptions (e.g.,
Gutierrez & Silk, 1998; Robiner et al., 2003; Sammons, Gomy, Zimmer, &
Allen, 2000). It also helped bring attention to pharmacology as a useful tool in
mental health treatment.

Whatever a counselor’s personal or professional position may be on the mer-
its of psychologists as prescribers, pharmacological treatment of psychiatric
conditions remains an important contemporary mental health issue (Bamett &
Neel, 2000). Looking hack, it would seem that advocacy for prescription priv-
ileges was predicated at least in part on a reductionist perspective (see
Sammons & Brown, 1997), thus substantiating a belief in the relevance and
effectiveness of pharmacology for the treatment of mental health concerns.
Moreover, and central to my position here, this debate underscored the ever-
growing influence of pharmacology in modem health care and reinforced the
link between psychoactive drugs and mental health interventions. Today,
because drugs are commonly recommended for a variety of mental health
clients in community mental health centers, public schools, university counsel-
ing centers, and medical facilities, their use often intersects with emotional and
behavioral issues.

Unequivocally, the prescription privilege debate affected relatively few pro-
fessionals and seems to have faded into relative obscurity. Nevertheless, its
essence still has implications for all types of mental health professionals.
Concern with the interface between drugs, the brain, and behavior is not lim-
ited just to psychiatrists or general medical practitioners. Biomédical research
is progressively deepening our appreciation of the biological foundations of
human cognition, emotion, and behavior (e.g., Drevets, 2000; Ochsner &
Gross, 2005; Steele, Currie, Lawrie, & Reid, 2007; see also Machamer &
Sytsma, 2007). Modem advances in areas like medical and behavioral genetics,
neuroscience, and pharmacology may impact how we understand behavior
(e.g.. Raine, 2008) and how we treat conditions ranging from attention deficit
disorder (Fone & Nutt, 2005; Mazei-Robison, Couch, Shelton, Stein, &
Blakely, 2005) to schizophrenia (Rhen & Rees, 2005). Scientific progress can
thus affect professionals at every level of human service (including educators)
where mental health may be at issue.

No matter how exciting advances in biomédical and pharmacological
research may be, there is always a need for caution along with optimism and
for a tempered approach to the acceptance of scientific applications.
Enthusiasm about the promise of biomédical science is not intended to suggest
that all treatments for psychological diagnoses should he approached first
through a biomédical lens. Indeed, it is here that the work of Murray (2009) can
be of particular value for mental health professionals—but with a measure of
scientific balance.

200 JOURNAL OF MENTAL HEALTH COUNSELING

Understanding the Pharmacological Context
Murray (2009) offers a unique perspective on what he terms the psychophar-

maceutical industrial complex (PPIC) and expresses considerable concem
about endorsement of the “disease model” as a way of understanding and treat-
ing psychiatric conditions. His description of the PPIC reflects skepticism
about the enormous influence the pharmaceutical industry has on mental health
practice; moreover, he questions the prevailing concept of mental health condi-
tions as “biological manifestations”—a perspective he suggests serves merely
to reinforce adoption of a restrictive biomédical lens through which we evalu-
ate (or potentially ww-evaluate) clients.

Although a complete review of Murray’s work is beyond the scope of this
paper, his concem about the potential for pharmacology to shape mental health
practice is particularly worth discussing. Logically, endorsement of a disease
model or a highly reductionist perspective of psychological disorders presup-
poses the need to link diagnosis (e.g., major depressive disorder [MDD]) with
underlying causes (e.g., serotonin, norepinephrine, or dopamine insufficiency)
and specific pharmaceutical interventions (e.g., Cymbalta®; Wellbutrin®).
This synergy between behavior, disease, and treatment reflects the very essence
of reductionism and is a driving force in the pharmaceutical industry’s
approach to psychiatric conditions. However, such synergy also requires care-
ñil evaluation if it is to be a primary explanation for, and approach to, the treat-
ment of psychological disorders.

In his contribution to the debate about the role of pharmacology in mental
health treatment, Murray (2009; see also Kaut & Dickenson, 2007) rightly
identifles a need for caution and an attitude of skepticism when evaluating
pharmaceutical claims. However, his notion that the PPIC operates according
to cult-like principles, somewhat insidiously biasing the perspective of con-
sumers and professionals alike and potentially maintaining them in a cycle of
pharmacological dependence, warrants further consideration that may suggest
a more measured approach.

Here I would emphasize that psychoactive medications, which are but a small
component of the pharmaceutical industry’s interest in health care, reflect less
what he termed a “cult” and much more a modem culture. The contemporary
medical context in which we live is pervaded by pharmacology. Rather than
criticizing the pharmaceutical industry, I suggest, there is more to be gained by
trying to understand the pharmacological context of mental health (see Figure
1), which can provide insight into how best pharmacology can influence men-
tal health practice.

Kaut / PSYCHOPHARMACOLOGY AND MENTAL HEALTH 201

Figure 1. The Pharmacology-Client Interface (PCI) in Context

Societal Needs and
Governmental Agenda

Provider Background, Education,
Training

Mental Health Providers

General Physician/ Psychiatrist Clinical and Community
Practitioner Specialist Counseling Mental Health

Psychologist Counselor

Client Entry Level

Presenting Symptoms
and

Client

Characteristics

Client Baciiground, Education,
and Understanding

Client

Advertising/Media

Pharmaceutical
~’–., Industry

Biomédical
Research . ‘ ‘

Psyciiology

TtttE –

Figure I. The time dimension (bottom) represents the sociohistorical context influencing develop-
ments in psychology, biomédical research, and pharmacology. In seeking mental health support
(i.e., client entry level), a client experiencing specific symptoms at a particular point in personal
and social history is influenced by intra-individual characteristics (e.g., cognitions, emotional sta-
bility, problem-solving style) and external moderators (e.g., background, education, understanding
of mental health issues). Background, education, and training subject mental health practitioners to
various influences (pressures) for treatment selection (e.g., drugs). The mental health context is
influenced by biomédical research, in hospitals, universities, and the pharmaceutical industry.
Societal and governmental priorities influence the research and development context (top); and
client awareness of disorders and treatments is shaped by his or her attitudes toward drug treatment
options (pharmaceutical advertisements, media, and “medicalization” of health issues) (bottom).

202 JOURNAL OF MENTAL HEALTH COUNSELING

An Ecological Framework
I find it helpful here to begin with an ecological framework, modeled in part

on the work of Bronfenbrenner and its application to various other issues in
human development (Campbell, Dworkin, & Cabrai, 2009; Swick & Williams,
2006), A key application borrowed from ecological theory is the notion of a
chronosystem level of analysis (Figure 1, bottom), which suggests the need to
understand human development—and the factors influencing behavior—
through the lens of both a person’s own developmental history and the larger
sociohistorical context. Applied here, this suggests to me that the multiple lev-
els and varied contexts illustrated in Figure 1 must be considered within our
contemporary historical era—an era marked by unique and significant
advances in our understanding of genetics, physiology, brain, and behavior
(e,g,. Raine, 2008), Through this context many individuals, each with their own
unique developmental histories, seek and receive mental health interventions.

Our sociohistorical context has changed markedly even in the last half cen-
tury, and the ways in which we can view psychological conditions continue to
change with advances in psychology, biomedicine, and pharmacology. Some 30
years ago Peele (1981) commented on this infiuence of reductionism in psy-
chology and identified the growing recognition of brain science as an influence
on mental health practice:

The area of psychology in which this shift is most apparent is that having to do with psy-
chopathologies and their treatment. The study of neurosciences is now often the one common
link in training programs for counseling, clinical, and educational psychology, as psychology
practitioners come to believe that such grounding is necessary for their work, (p. 810)

This influence of modem neuroscience and related instruction in the biolog-
ical bases of behavior is reflected in Figure 1, where medical professionals
(general practitioners, medical specialists, psychiatrists) and mental health
practitioners (clinical and counseling psychologists, community counselors,
social workers) represent the first line of client interface with mental health
treatment options. It is at this entry point, particularly with medical profession-
als, that individuals presenting with mental health concems (e,g,, anxiety,
depression, bipolar symptoms, thought disorder) are typically introduced to
pharmacology. Given the modem scientific and medical context that influences
the education, training, and professional perspectives of providers of health
care, particularly mental health care)—plus the impact modem medicine has on
patient/client understanding—it is reasonable to expect that medications would
be part of today’s discussions about treatment.

The Client in Context
Recognition of the modem medical context is not intended to advocate blind

Kaut I PSYCHOPHARMACOLOGY AND MENTAL HEALTH 203

acceptance of the disease model for mental health; rather, the objective is to
identify variables influencing the beliefs, expectations, and decisions associ-
ated with psychological conditions and treatments. Accordingly, mental health
providers must first think about how clients conceptualize health conditions in
general. For example, the use of prescription medications to treat physical con-
ditions or ailments is reasonably well accepted. Today’s patients, no matter
what their conditions, are accustomed to leaving a doctor’s offtce, hospital, or
medical center with prescriptions. The contemporary availability of drugs to
address a host of medical concerns—^infections, inflammatory conditions, pain,
cardiac issues, cholesterol problems, and blood pressure regulation, for
instance—would seem to support public acceptance of the broad role pharma-
cology has in managing virtually all health concerns. It is thus understandable
that clients might view the use of medications as sufficient for treating mental
health concerns (a perspective I do not endorse entirely).

Murray (2009), borrowing from Gosden & Beder (2001), places considerable
blame on pharmaceutical companies and their relationship with psychiatry,
research institutes, public media, and the federal government for public accep-
tance of, and reliance on, drug use in mental health practice. Essentially, he
argues that the relationship promotes a context that subverts client agency
(responsibility for health care independence) and undermines the breadth of
mental health interventions.

I see this differently. I would advocate that the elements in Figure 1 (each
represented to some degree in the model Murray uses) reflect productive
(though imperfect) components of an evolving mental health care system (see
below). As providers deal in many different contexts with client mental health
issues (e.g., childhood ADHD, adult major depression, drug abuse, workplace
or school-related anxiety), decisions to treat with medications, or the need to
monitor drug effects as part of treatment, can be construed as emerging under
the influence of selective pressures that influence the provider and similar pres-
sures that affect client willingness to accept pharmacotherapy (see Table 1 ; also
Kaut & Dickinson, 2007). Rather than criticizing the pharmaceutical industry,
it might be better to identify issues that shape the perspectives of mental health
providers o«(i clients as they consider treatment alternatives.

In this microcontext (client interacting with mental health provider), practi-
tioners should think careñally about factors that affect client beliefs about men-
tal health and associated interventions (see Table 1). Whether a client is taking,
seeking, or avoiding medications, it is helpful to understand what motivates or
influences that approach. More important, providers must be sensitive to how
their own training and background affect decision-making. Certainly, the phar-
maceutical industry as a major player in drug development, distribution, and
information dissemination exerts a significant influence on medicine and health
care delivery (Figure 1; Healy, 2009; see web review in endnote 1).’ However,

204 JOURNAL OF MENTAL HEALTH COUNSELING

Table 1. Considerations influencing Practitioner and Client Decision-Making in
Mentai Health Treatment

Treatment Issue Considerations for Mental Considerations for Client
Health Provider

Nature of condition or
symptoms

What is indicated by the pre- Does the client have any
sent symptoms or behav- insight into the symptoms or
iors? behaviors in question?

Pharmacology as a
treatment option

What variables might influ-
ence development of these
behaviors?

What drug approaches are
typically used?

What do I understand about
drug treatments for the con-
dition in question?

What is my personal bias
concerning drug therapy in
general?

How does pharmacology fit
within my model of human
behavior?

Does the client understand
the potential influences on
behavior?

What does the client know
about drug therapy?

What factors influence the
client’s knowledge of drug
therapy?

Does the client have specific
beliefs about medications for
psychological conditions?

What are the client’s expec-
tations about drug therapy?

Therapeutic drug and
behavior monitoring

How should this drug impact How is this drug likely to
behavior over time? affect client behavior?

Are there time limits to using Are there side effects or
this drug? interactions that should be

known?

the uptake of pharmacological resources is multidimensional; it is not necessar-
ily driven solely by an industrial objective. To extend the comments of Peele
(1981; see above), some practitioners will naturally be influenced by bioméd-
ical research that informs their current understanding of brain, behavior, and
pharmacology (see Drevets, 2000; Ehert, 2002; Nandham, Jhaveri, & Bartlett,
2007; Pile, Chaki, Nowak, & Witkin, 2008; Preskom, 2006). Such a context is
much broader, and deeper, than the pharmaceutical enterprise alone.

Essentially, the way we view mental health issues should reflect the synergy
in biological, psychological, and behavioral research (Hoffman, 2000; Kaut,
2005). Over the last half century, advances in our understanding of the biolog-
ical underpinnings of behavior seem to have somewhat exceeded the relative
contributions of disciplines, such as behavioral interventions or psychotherapy.^
The micro-context surrounding the client-practitioner interface may thus be

Kaut I PSYCHOPHARMACOLOGY AND MENTAL HEALTH 205

heavily influenced by the impact of neuroscience research and biological
reductionism in general. To me, this is an appropriate and logical consequence
of our research, development, and education.

The Evolution of Pharmacological Thinking
Unlike Murray (2009), I consider research and development by the pharma-

ceutical industry and allied health entities to be a positive driving force in
human health and Wellness (see Figure 1, top section). Without their investment
in basic and applied research for a great number of conditions—including psy-
chological disorders—advances in our understanding of how to treat such con-
ditions would be drastically limited. In some ways, the emergence of
pharmacological altematives for mental health disorders has been evolutionary,
with treatment options that have succeeded and failed throughout previous
decades analogous to functional adaptations and failures to environmental pres-
sures. Dmg therapies change (see Julien, 2008) as new medications “adapt” to
pressures for more efficacious treatments, fewer side effects, and more symp-
tom specificity (Preskom, 2006; Slattery, Hudson, & Nutt, 2004). Typically, the
dmgs reaching the market treat specific conditions more appropriately, safely,
and competitively than other dmgs. The pharmaceutical industry is under enor-
mous pressure to design, produce, and monitor pharmaceutical products, and
the product pipelines of the major pharmaceutical companies are impressive.’
Given the extensive research, development, and financial requirements for
bringing a dmg to market (Berkowitz & Katzung, 1998), I have confidence in
the integrity of the modem pharmacological enterprise and believe it con-
tributes in important ways to today’s biomédical context.

Understandably, part of this context is established and moderated by priori-
ties of govemment and other institutions that reflect our interest in science and
medical research (e.g., hospitals, universities, research foundations; see Figure
1). Such priorities influence how federal funds are allocated and to some extent
which issues are investigated. Few would question why conditions like
HIV/AIDS, cancer, spinal cord injury, genetic disorders, Parkinson’s disease,
and Alzheimer’s disease have high priority today. We tend to view these and
many other disorders through a biomédical lens, which magnifies the salience
of reductionism and certainly influences the way we educate and train profes-
sionals to evaluate, diagnose, treat, and monitor physical maladies. This perva-
sive philosophy of reductionism adds yet another contemporary pressure that
helps shape research priorities, methods, and ultimately knowledge.

When I also look at research to identify and clarify biological mechanisms
associated with various psychological conditions and dmg therapies (see Table
2 and the next section), I believe firmly that pharmacological thinking, predi-
cated on a bio-psycho-social base, can be beneficial in preparing future mental
health practitioners. By this, I mean a reasonable understanding of cognitive.

206 JOURNAL OE MENTAL HEALTH COUNSELING

affective, and behavioral neuroscience (or neuropsychology; see Banich, 2004;
Zillmer, Spiers, & Culbertson, 2008) and how pharmacology infiuences diverse
aspects of health and behavior (for an excellent and readable reference, see
Julien, Advokat, & Comaty, 2008). Appreciation for the way drugs are
researched and brought to the clinical market can also offer a helpful perspec-
tive on pharmacological research and dmg efficacy (e.g., Berkowitz &
Katzung, 1995).

Table 2. Biomédical Research and Psychological Disorders

Biological LeveM Putative Brain-Behavior Mechanismus

Systems-structures Limbic
Amygd
Nucleus
Hippoca
Prefrontal
Anterior ci
Striatum (basal ganglia)”DD

Cellular-physiological 5-HT transporters (SSRI/TCA)MDD
NE transporters (SSRI/TCA)MDD
DA transportersMDD

5-HTiA, 2c, 2A. 7
NK, receptorMDD

GABÁ receptorsANx
Glutamate (metabotropic
NMDA receptor (glutamate)MDD
Neurotrophins (growth factors)”°°

Intracellular-genomic Lithium
PAP phosphataseBo
Cyclic AMP response protein (CREB)MDD
BDNF (growth factor)
Neurogenesis (new cell growth)
Synaptic remodeling

‘Biological levels correspond to Figure 2.
^Superscripts: ANX: Anxiety disorders; BD: Bipolar disorder; MDD: Major depressive dis-
order; SCZ: Schizophrenia.
3BDNF: Brain-derived neurotrophic factor; CRH: Corticotropin-releasing hormone; DA:
Dopamine; GABA: Gamma aminobutyric acid; NE: Norepinephrine; NK: Neurokinin;
NMDA: N-methyl-D-aspartate; PAP: 3′(2′)-phosphoadenosine-5’-phosphate.

Kaut I PSYCHOPHARMACOLOGY AND MENTAL HEALTH 207

Insights into the science behind pharmacology can be of particular benefit,
especially when practitioners can extrapolate from them conceptual frame-
works (Figures 1 and 2) and practical considerations to help them better evalu-
ate medications that will inevitably be part of mental health interventions.
While I do not believe that recovery rates for psychological disorders will nec-
essarily parallel advances in biomedicine, I believe that as biomédical knowl-
edge of psychological disorders increases, so too will the potential to better
understand etiologies, appreciate person-environment interactions, and con-
sider new treatment strategies. Here again it is helpful to identify how a spirit
of reductionism—judiciously incorporated into approaches to research, educa-
tion, and professional training—affects the way we view mental health condi-
tions and how we evaluate the range of solutions available to promote best
practices in mental health care,”

Figure 2. The Biology-Environment Interface

–

Low

– Medium
T

Sleep
Disorder

– High
T

Parl

Systems

Structures

– Ceiluiar

Physioiogy

intraceiiular “”

Genomics

Reductionism

Major
Depression

Low

— Limbic

— Hippocampus

Neurotransmiller
transporters: NE
and 5-HT levels

Focal Region
ot

CREB
protein

Figure 2. Some conditions are conceptualized as having more treatment specificity when a drug
with a known mechanism of action is the most effective treatment for the behavior in question.
Other conditions might be viewed as positioned somewhere along a continuum of treatment speci-
ficity and the corresponding gradient of environmental influence. For many conditions, pharmaco-
logical specificity might be considered moderate to low, reflecting a greater influence of individual,
situational, or environmental factors.

208 JOURNAL OF MENTAL HEALTH COUNSELING

REDUCTIONISM AS A POSITIVE INFLUENCE IN MENTAL HEALTH

As a psychologist, I teach students to appreciate the complexities of human
behavior and respect the diverse influences on behavioral development over
time. Psychology enjoys a rich tradition of behaviorism in psychology (Bolles,
1993), not to mention the substantial influence of cognitive psychology in its
efforts to help scientists peer into what was known as the “black box.”
However, I caution students to anchor their models of human behavior in the
modem context of significant developments in the natural sciences. The black
box, formerly “mind,” is now “brain,” and (to extend the metaphor) it is filled
with smaller and more integrated mini-boxes that collectively yield what we
identify as the thinking, feeling, and behaving brain.

As a neuroscientist I expect students to understand the biological bases of
behavior, with particular attention to the systems level of analysis and the
genetic and molecular aspects of human experience.’ Reductionism can of
course be viewed with skepticism, and rightly so, as it tends to medicalize many
conditions and treats the complexity and richness of human behavior as
reducible to progressively smaller parts (Cohen, 1993). This emphasis on inter-
nal rather than external factors has naturally enjoyed the support of the pharma-
ceutical industry (see Cohen) and tends to reduce psychological conditions to
quantifiable, measurable, and natural components (Nys & Nys, 2006). Such an
approach “[detaches a] disease from a patient’s natural history”‘ (Nys & Nys,
p . I l l ) , which essentially minimizes clinical judgment and a holistic perspec-
tive of client health and illness (see also Murray, 2009).

Cartesian duality, which separates the natural (biological) components of
behavior from the more uniquely human dimensions of thought, feeling, and
memory (spirit, soul, transcendent aspects), must be viewed with skepticism.
On the one hand there is a need to recognize “mind” as a reflection of “brain,”
but on the other we must recognize the uniqueness of individual history, cul-
ture, environment, and even behavior on the development of adaptive and mal-
adaptive tendencies. A conceptual framework (see Kaut & Dickinson, 2007;
also Kaut, 2006) therefore serves to clarify the interface between biology and
environment in shaping behavior (see Figure 2).

Disorders as Diseases
The belief that behavioral and psychological disorders can be reduced to bio-

chemical disturbances is naturally linked to the expectation that treatments will
correct the biochemical dysfunction or imbalance (Nys & Nys, 2006). The fun-
damental premise (and criticism) of this medical or disease model is the
assumption that all conditions are reducible to specific biological mechanisms
(see Nys & Nys). The problem with this model is not the expectation that dis-
orders, or selected features of disorders, are manifestations of biological system

Kaut I PSYCHOPHARMACOLOGY AND MENTAL HEALTH 209

dysfunction (imbalances); it lies in the failure to identify the limits of reduction-
ism and the inherent opportunities for a holistic approach—even when pharma-
cology is part of the treatment algorithm.

The Biology-Environment Interface
When a disorder has a known biological mechanism, we might suppose a

highly specific relationship between the behavior of interest, a biological tar-
get, and the mechanism of treatment (Figure 2). For example, Parkinson’s dis-
ease follows from a drastic reduction in dopamine activity in cells making up a
specific structure (the suhstantia nigra) that regulates a particular system in the
brain (the basal ganglia). Dopamine-enhancing drugs (e.g., Sinemet®, Stalevo)
directly influence motor activity in a dose-dependent manner. In such cases, the
gradient of environmental influence would be fairly low insofar as treatment of
the condition per se is concemed. However, there may still be a need for
mental and behavioral health interventions to promote or enhance adaptive
behavior.**

In other conditions, such as sleep disorders, the relationship between known
biological elements and the behavior itself might be less specific. A number of
prescription medications are available to promote and sustain sleep; typically
they manipulate the GABAergic system in the arousal circuits of the brain
(Prosom®, Dalmane®, Restoril®, Lunesta®; see also Julien et al., 2008).
Nevertheless, sleep architecture is complex and is multiply determined by
various neurotransmitter systems and brain circuits. Moreover, stress, activity
levels, dietary habits, and other manageable environmental issues can be
targeted to help bring ahout sustainable change in sleep behaviors.

The point here is that a reductionist perspective alone is unlikely to offer sin-
gular solutions to the more complex conditions that afflict the cognitive and
affective integrity of the human brain. Nevertheless, for many psychological
disorders, including attention deficit disorder, major depression, anxiety, bipo-
lar disorder, obsessive-compulsive disorder, and schizophrenia (American
Psychiatric Association [DSM-IV-TR], 2000), a variety of genetic, structural,
and physiological issues might be addressed. Even when the relationship
between biological mechanisms and behavioral symptoms seems low to moder-
ate (e.g., MDD; Figure 2), the biomédical approach can offer significant
insights into the etiology and nature of such conditions (Drevets, 2000;
Fitzgerald, Laird, Mailer, & Daskalakis, 2008; Gupta, Elheis, & Pansari, 2004).’

Support for Reductionist Beliefs
My training as a psychologist emphasized the research, theories, and appli-

cations of cognitive and behavioral approaches to child development and dis-
orders. As a practicing school psychologist, I recognized environmental, social,
and behavioral contingencies that might influence manifestation of certain

210 JOURNAL OF MENTAL HEALTH COUNSELING

disorders in children. Nevertheless, somewhere during my formal education I
acquired an appreciation for the biological correlates of many cognitive, educa-
tional, and emotional disorders. In practice, this was reinforced by reading case
histories, having discussions with parents and with other professionals, and
dealing with use of medication to manage challenging behaviors.

As a neuroscientist, my training exposed me to the richness of neurobiology
and the intricate relationship between brain and behavior. Through coursework
with medical students, seminars, and my own research (Kaut & Bunsey, 2001;
Kaut, Bunsey, & Riccio, 2003) I glimpsed how modem education—driven by
biomedicine—influences the knowledge, beliefs, and values of professionals
(see Figure 1). Society at large may have been similarly influenced, affecting
the expectations of patients and clients dealing with health, including mental
health, issues.

Although I often expect students to appreciate the synergy between biologi-
cal and environmental factors in producing a given psychological outcome
(Kaut, 2005, 2006; Kaut & Dickinson, 2007), my proclivity is to consider the
weight of evidence conceming the biological foundations of behavior. Medical
and mental health professionals can understandably be influenced by their
experience in educational systems shaped by a growing biomédical research
agenda and an emphasis on the disease model as a way of understanding human
disorders.

The Value of the Modern Research Agenda
Critics of the medical or disease model so pervasive in mental health today

sometimes suggest that many medical treatments have questionable efficacy
(Murray, 2009). There is particular concem that clients seeking mental health
treatments are encouraged to suspend critical thinking about the reality of phar-
macological treatments:

Anecdotal evidence suggests that psychiatric consumers rarely criticize the chemical imbalance
theory despite not having their chemicals measured, as would be done with diabetes, to verify
that there is indeed a brain imbalance. (Murray, 2009, p. 297)

.. Certainly, there is always the need for caution when incorporating pharma-
cology into a mental health treatment program, and Murray’s concems are in
part well-founded. However, such criticisms might also lead to the erroneous
belief that research is not seriously looking for, or successfully identifying, the
biological mechanisms underlying many mental disorders. Table 2 (modeled
after the reductionist elements shown in Figure 2) offers a limited perspective
on research linking psychological disorders with biological mechanisms; it is
intended here to underscore the value of pharmacological interventions as treat-
ment strategies.

Kaut / PSYCHOPHARMACOLOGY AND MENTAL HEALTH 211

The Neurochemistry of Emotion. The complexities inherent in mental health
research and treatment are well-represented in the case of mood disorders, par-
ticularly MDD (see Figure 2). The notion of chemical imbalance is embodied
in the biogenic amine theory of depression that implicates the neurotransmitters
norepinephrine (NE), serotonin (5-HT), and dopamine (DA) (Ebert, 2002;
Julien, 2008); the theory has long been central to the development of tricyclic
antidepressants (TCAs); serotonin selective reuptake inhibitors (SSRIs);
monoamine oxidase inhibitors (MAOIs); and newer-generation serotonin and
norepinephrine reuptake inhibitors (SNRIs). Though their efficacy, selectivity,
and pattems of over-use have been questioned (Juereidini & Tonkin, 2006),
these dmgs are still widely marketed and are among the medications most fre-
quently prescribed (Abilify®, Cymbalta®, Effexor XR®, Lexapro®; see
rxlist.com).

Further research to expand understanding of antidepressant mechanisms is
therefore important (Table 2). Apart from clarifying the blockade of neurotrans-
mitter reuptake in TCAs, SSRIs, and SNRIs (e.g., Preskom, 2006; Slattery et
al., 2004), researchers have also identified new serotonergic receptor targets
(e.g., 5-HT variants) and have suggested as potential targets for antidepressant
activity receptors for glutamate (i.e., NMDA; Pétrie, Reid, & Stewart, 2000;
Pile, Chaki, Nowak, & Witkin, 2008); substance-P (neurokinin-l [NKl]; Adell
et al., 2005); and even stress-related hormones (corticotropin-releasing hor-
mone [CRH]; Taylor, Fricker, Devi, & Gomes, 2005).

This limited review is intended to underscore how contemporary research
continues to investigate the chemistry (e.g., “imbalance”) of psychological dis-
orders and offers support for the focal mechanisms of pharmacotherapy (neu-
rotransmitter activity; see Figure 2). Naturally, there are concems about the
potential for abuse by pharmaceutical companies in the way dmgs are clinically
evaluated and “proven” to be selective and effective for psychological condi-
tions (Healy, 2004). However, it is hoped that diverse lines of research across
the world will provide convergent support (or the lack thereof) for pharmaco-
logical claims. In this way, dmgs are subject to rigorous and incisive studies
conceming the many known, and potentially new, targets for therapeutic agents
(e.g., Adell et al., 2005).

In the tme spirit of reductionism (see Table 2), representative studies con-
tinue to test theories of depression (e.g., biogenic amine), yielding intriguing
insights into the cell-signaling pathways affected by psychoactive dmgs
(Slattery, Hudson, & Nutt, 2004; Taylor et al., 2005). Collectively, such efforts
have extended our understanding of how genetic activity (e.g., cyclic AMP
response element binding protein [CREB]; Blendy, 2006;.Yamada, Yamada, &
Higuchi, 2005; see also Adell et al., 2005) triggers intracellular cascades result-
ing in the neuronal growth factors (e.g., brain-derived neurotrophic factor
[BDNF]; Altar, 1999; Duman & Monteggia, 2006; Taylor et al., 2005), protein

212 JOURNAL OF MENTAL HEALTH COUNSELING

synthesis, and cellular changes associated with better behavior (Yamada et al,,
2005),

A Context for Reductionism. Clearly the precise causes of such psychologi-
cal disorders as depression, anxiety, bipolar disorder, and schizophrenia have
yet to be determined. And I would agree with Murray (2009) that there are no
tests of neurotransmitter levels or receptor-mediated effects that would confirm
a given diagnosis; diagnosis is not yet precise. Even with the tremendous
research advances suggesting neurological regions and systems affected by
psychological disorders (Table 2, Figure 2), there is no clinical utility in pre-
scribing MRI, CT, or PET scans to identify stmctural or ñinctional alterations
in limbic anatomy, hippocampal volume, or amygdala reactivity (Addell et al,,
2005; Drevets, 2000), And despite our understanding of the role served by the
prefrontal cortex in emotional behavior and mood in general, there is insuffi-
cient evidence to support evaluation of this and other regions of the brain (e,g,,
nucleus accumbens, basal ganglia) involved in affect and emotional regulation.
Here, in the midst of so many advances in biomédical knowledge, reductionism
(like the disease model) is limited and must be judiciously integrated into a
more holistic (e,g,, ecological) clinical perspective,

THE DISEASE MODEL IN CONTEXT: RECOMMENDATIONS
FOR MENTAL HEALTH PRACTICE

Formerly the magic was in the therapist; he or she might also give pills, but these were an exten-
sion of his or her impact on us.,., Therapists have forgotten how to manipulate their impact on
patients. With the focus both doctor and patient have on the pill, neither heeds the context in
which the patient has become distressed, (Healy, 2009, p, 24)

The disease model, buttressed by the influence of biomédical research, pro-
fessional education (e,g,, universities, hospitals, see Figure 1), the media, and
the health care industry itself (Cohen, 1993), will continue to be part of the
mental health system. And it should. But it need not be the primary perspective
with which individual providers render their services. It can be part of a larger
approach where well-informed clinicians draw from a variety of treatment
approaches to best serve each client. Graduate students in training need to
become knowledgeable in the range of treatment options available to a client
and carefully consider where pharmacotherapy might fit into the treatment plan.

Here clinical judgment is of paramount importance. Such judgment requires
an informed professional perspective balanced by openness to therapeutic alter-
natives. Toward this end, I offer recommendations for promoting eclecticism in
clinical practice, while emphasizing the need for mental health providers ulti-
mately to recognize the potential value of pharmacology in client care, (The

Kaut IPSYCHOPHARMACOLOG Y AND MENTAL HEALTH 213

conceptual models in Figures 1 and 2 and the suggestions in Table 1 can also
provide anchors for thinking about how biomedicine influences or might influ-
ence mental health care.)

1. Take a Position on Drugs in Mental Health.
My intent is to avoid another piece that merely advocates the need to inte-

grate pharmacology into practice (Kaut & Dickinson, 2007). What is necessary
is critical examination of one’s beliefs about the nature of human cognition and
emotion, coupled with a deeper examination of how reductionism fits within
this model (Cohen, 1993; Nys & Nys, 2006; Peele, 1981). I begin with the fun-
damental assumption that biology is the essence of our functional being, but as
we develop our biological inheritance interacts in complex ways with environ-
mental circumstances. Even in the womb the nervous system can be influenced
or otherwise shaped by the uterine environment and maternal physiology (e.g.,
stress, anxiety; DiPietro, 2004; Dipietro, Costigan, & Gurewitsch, 2003).
Beyond development, various conditions have differing levels of biological
specificify (see Figure 2) that always reflect the need to consider the “gradient
of environmental influence” resulting in behavioral manifestations.
Pharmacology should be part of an individual’s model somewhere, even if only
in a limited way.

2. Recognize the Benefits and Limitations of Pharmacology.
Building on the previous recommendation, it is important to recognize that

drug therapies can have tremendous benefits for some clients (Julien et al.,
2008), sometimes being central to the resolution of symptoms (high treatment
specificity. Figure 2), but for others the use of medications might address only
certain aspects of a disorder or be of clinical use for only a limited time.
Antidepressants or anxiolytics, for example, might help a client manage diffi-
cult affect-driven physiological manifestations, which might then facilitate
therapeutic work dealing with adaptive behaviors and cognitions (i.e., higher
gradient of environmental influence. Figure 2). The “magic” (Healy, 2009) is
neither in the drug nor the therapist; rather, the therapeutic process yields its
greatest proximal and long-term impact when multiple treatment pieces fit
together cooperatively. Therapeutic success is an emergent properfy, better
viewed as the unveiling of new adaptations as balance is restored to cognitive,
affective, environmental, and biological processes.

I have rarely if ever experienced a clinical situation where clients were pres-
sured to take medications or intentionally driven to dependence on pharmacol-
ogy (see Murray, 2009), but I recognize the potential for abuse and certainly
understand that some individuals might be more vulnerable to such abuses than
others. Clearly, the astute clinician must be aware of a client’s medication

214 JOURNAL OF MENTAL HEALTH COUNSELING

history and carefully consider how and why medications are used (see Table 1).
Awareness of a drug’s intended effects, side effects, and possible interactions
with other drugs is imperative (see www.RxList.com; www.drugs.com).’

3. Educate Practitioners.
Education of mental health providers that takes into account advancing

knowledge is particularly important. Frankly, better approaches to education
ahout mental health issues is needed for many professionals, including physi-
cians, psychologists, community mental health providers, and social workers.
Advocacy for mental health provider education and training in psychopharma-
cology was clearest during the APA endorsement of prescription privileges (see
Gutierrez & Silk, 1998; Kaut & Dickinson, 2007; Scovel, Christianson, &
England, 2002; see also Snibbe, 1975), but attention to training in pharmacol-
ogy has apparently subsided. Yet the need is growing.

Training for Psychologists and Counselors. Finding space in professional
training curricula is difftcult, but change must begin there. However, rather than
specific courses or course sequences (Fox, Schwelitz, & Barclay, 1992), what
might work better is a systematic attempt to integrate pharmacological knowl-
edge into the curriculum as a whole. The graduate program with which I am
afftliated has little freedom for additional coursework—or at least for course-
work not directly related to core faculty interests. In such cases psychopharma-
cology can become relegated to a position of minimal impact, despite anecdotal
evidence that students involved in clinical practica and internships often com-
ment that pharmacology is pervasive in their client contact hours (see Scovel et
al., 2002).

With a minimal amount of curricular time and carefiil consideration of topi-
cal areas of opportunity, biomédical principles and pharmacological issues can
be incorporated into a great many content areas, such as assessment, vocational
behavior, individual differences, ethics, and practicum experiences themselves.
What is required is coordination among faculty and a willingness to seriously
identify content that will have the greatest real-world influence. Again, regard-
less of one’s specific position on the use of medications in mental health prac-
tice, 1 strongly advocate for background in at least three areas: (a) reductionism
and the disease model (see Engel, 1977; Kaut & Dickinson, 2007); (b) the clin-
ical interface between psychological diagnoses and neural science (e.g.,
Drevets, 2000; see also APA, 2000); and (c) appropriate use, potential misuse,
and warnings associated with psychoactive medications.

Training for Medical Personnel. Unequivocally, one of the greatest needs in
mental health today is for education of primary care physicians. Patients with
mental health or related concems often tum first to their general practitioner
(Figure 1), who might prescribe any number of medications to treat symptoms
associated with sleep problems (Lunesta®), depression (Cymbalta®), anxiety

Kaut I PSYCHOPHARMACOLOGY AND MENTAL HEALTH 215

(Paxil®), or sexual dysñinction (Cialis®). Any of these conditions might have
an etiology for which psychological intervention might be indicated. While I
fully endorse the use of medications for any one of the conditions mentioned, I
also believe in the need to evaluate diagnoses according to the Figure 2 frame-
work. My concem is not necessarily with psychiatry (but see Nys & Nys,
2006); rather, the point of entry through general practitioners reflects a place
where education about disorders and referral networks can affect the greatest
number of patients and providers who deal with mental health issues.

4. Educate the Public.
Mental health practitioners are information providers (Ingersoll & Brennan,

2001; Kaut & Dickinson, 2007) who must educate the public about mental
health conditions. For most people the media significantly affect how psycho-
logical conditions are viewed. Television advertisements for such problems as
allergies (Claritin®), insomnia (Lunesta®), gastric reflux (Prilosec®), erectile
dysfunction (Cialis®, Viagra®), social anxiety (Paxil®), depression (Abilify®,
Cymbalta®, Wellbutrin®), and cholesterol (e.g., Crestor®, Lipitor®, Zocor®)
actually educate the public about physical and mental health while offering a
biomédical (pharmacological) perspective on preferred treatment options.

I support what to some seems to be a pharmacological intmsion into the pub-
lic’s living rooms. Normalizing certain disorders—even depicting individuals
suffering from them^-can help persons stmggling with similar issues. Such
advertisements, by reinforcing the disease model for virtually all health condi-
tions, essentially direct the public to the lower half of Figure 2 as a way of
understanding clinical disorders. This might be beneficial in helping them to
identify the nature of various conditions; however, the possibility for miscon-
ceptions can potentially undermine holistic mental health perspectives (Healy,
2009; Murray, 2009).

Informing the Consumer. Education will help the public to understand the
multiple dimensions surrounding mental health issues and treatments (Figure
2). The inability to identify a neurochemical imbalance (see Murray, 2009, p.
297) should in no way undermine consideration of pharmacological approaches
to mental health issues. Practitioners must exercise good judgment in facilitat-
ing client understanding and refrain from minimizing or criticizing a particular
treatment approach. The mental health disciplines have a rather unfortunate his-
tory of perpetuating untestable assumptions about human nature (e.g., psycho-
dynamic forces) and incorporating them into long-term investments in
treatment (e.g., psychotherapy). Nevertheless, there is value in some aspects of
such theoretical approaches to behavior (e.g., defense mechanisms; uncon-
scious activity), although there is considerably more support for pharmacolog-
ical perspectives on mental health treatment—even if chemical tests are
unavailable.’

216 JOURNAL OE MENTAL HEALTH COUNSELING

Certainly, members of the public do not need either a mental health degree or
an education in physiology or biology. Yet exposing them to certain principles
seems advantageous. The way to educate the public is not through newspapers
(e.g., letters to the editor; see Murray, 2009) or even the electronic media. Such
efforts must begin at the K-12 level, where young people can leam how to eval-
uate claims, ask questions, seek information, and make informed decisions. As
professionals and educators, we should be less concemed with telling individ-
uals what to think than with helping them understand how to think.

A model of human behavior, one that reinforces the interface between biol-
ogy and environment (Figure 2; see also Hoffman, 2000; Kaut, 2005, 2006;
Kaut et al., 2003; Kaut & Dickinson, 2007), is typical of my own instmctional
work and central to my work in behavioral health (e.g., end-of-life interven-
tion, genetic testing, head trauma/concussive head injury, pharmacology).
Models are excellent instmctional aids and can help students, and providers,
critically examine mental health treatments. Ultimately, a conceptual model
(see Figures 1 and 2 here) can be used to generate questions for both provider
and client that promote awareness, insight, and increased responsibility for
treatment adherence and compliance. Helping clients work through a series of
questions about both dmg and non-dmg therapies (see Table 1), while placing
their mental health issues within a biopsychosocial context (Figure 2) can be
educational. Most important, clarifying a client’s understanding of treatment
options—and the role of pharmacology in treatment—can be an adaptive
approach to developing an informed consumer and can have long-term
problem-solving advantages.

5. Contextualize Mental Health Treatments.
Above all, I encourage practitioners to view mental health interventions

within a larger context—one embedded in what Bronfenbrenner likened to a
sociohistorical developmental timeframe (e.g., Swick & Williams, 2006). The
pattem of development for each client intersects with a larger medical-health
context comprised of physicians, mental health professionals, social and cul-
tural influences, and a historical timeframe. One of the distinguishing charac-
teristics of our own period in history is the advanced pharmacological milieu
that pervades mental health treatment.

It is important to advocate assiduously for traditional mental health practice
(cognitive and behavioral therapies), which includes establishing relationships
with other mental health disciplines. Rather than undermining the approach of
professions like psychiatry (Cohen, 1993; Nys & Nys, 2006) it is most helpftil
to identify the strengths of different perspectives (e.g., general practitioner,
psychiatrist, community counselor) and seek to integrate their unique health
emphases into a unified framework for serving diverse client needs (see

Kaut I PSYCHOPHARMACOLOGY AND MENTAL HEALTH 217

Figure 1), One of the indicators for the ñiture success of mental health will be
the degree of synergy between psychological disciplines, in both research and
practice. Recognizing how various professions contribute to mental health
practice (see Figure 1) and understanding how modem pharmacology influ-
ences treatment perspectives and preferences can facilitate practitioner and
client awareness of the role dmgs and traditional psychotherapies have in treat-
ment options and the success of treatment.

The goal of mental health care is to provide the most effective and durable
treatment for clients. Depending on the etiology, intensity, and duration of
symptoms, pharmacology is likely to be part of a treatment approach for many
of today’s clients. Given the extensive research into the underpinnings of men-
tal disorders and into dmg treatments, pharmacology should he part of modem
therapies, and mental health practitioners should adapt accordingly. The phar-
maceutical industry is a major influence in modem health care. As Healy
(2009) noted, the failure is when practitioner and patient both become focused
on the pill (p, 24, emphasis added), Pharmaceutical companies will continue to
do what they are essentially intended to do—design, develop, produce, and
market dmgs. Accordingly, mental health practitioners (perhaps psychology
professionals in particular) should be vigilant about their focus on “the pill” and
help clients understand both the potential benefits and the limitations of dmg
therapy (as well as traditional psychotherapies),

I do not believe pharmaceutical companies are the problem. What Murray
(2009) refers to as the PPIC contributes enormously to the greater good of soci-
ety. Nor are physicians, notably psychiatrists, necessarily the problem. Frankly,
I see modem psychopharmacology as more a solution to psychological disor-
ders. Yet selecting (or at least integrating) a medication approach to behavior
requires openness, scientific awareness, clinical insight, and attention to treat-
ment monitoring (see Julien, 2008), Though dmgs are well-established in the
modem biomédical context, dmgs alone are not always well-suited to a given
client. Therefore, mental health practitioners must conceptualize the pharma-
ceutical-client interface (Figure 1) as a flinction of modem reductionism, while
recognizing the limits of dmg specificity in relation to what I term the gradient
of environmental infiuence (Figure 2) for each condition.

Indeed, contextual analysis is the clinical advantage of mental health
providers—something that dmgs independently cannot provide. Management
of client mental health is thus a privileged aspect of a profession that skillfully
recognizes how to identify the relative influence on behavior of various inter-
nal and extemal variables (Figure 2) while helping clients understand the role
of different treatment options (see. Table 1) in the development of adaptive
behavior (see DeNelsky, 1996),

218 JOURNAL OF MENTAL HEALTH COUNSELING

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ENDNOTES:

1 The reader is encouraged to consult some of the excellent websites established by pharma-
ceutical manufacturers, such as Merck (www.merck.com), Eli Lilly (www.lilly.com), and Pfizer
Inc. (www.pnzer.com). The intent is not to promote specific products but to highlight the far-reach-
ing work in health care the companies are doing. Certainly, a review of products is enlightening and
helps place psychopharmacology within the broader health care context (e.g., cancer, cardiology,
neuroscience, antivirals, vaccines). The Lilly site offers helpful product information (click on
‘Products’) on such neuroscience drugs as Cymbalta®, Prozac®, Strattera®, Symbyax®, and
Zyprexa®.

Kaut / PSYCHOPHARMACOLOGY AND MENTAL HEALTH 221

2 A review of Medline-referenced publications, 1970-2010, shows a significant increase in
research on biomédical issues, particularly brain-related studies, over the last 40 years (key terms:
brain-behavior; brain-depression; brain-schizophrenia; see inset figure below, dashed lines).
Indeed, such studies noticeably exceed research limited to those publications queried without a
brain reference (e.g., key terms: psychotherapy-behavior; psychotherapy-depression; psychother-
apy-schizophrenia; solid lines). From 2000 through 2010, there were over 50,000 citations for
brain-related research involving behavior (31,411), schizophrenia (8,163), and depression (10,654);
there were markedly fewer citations for psychotherapy-related research associated with behavior
(3,175), schizophrenia (1.392), and depression (4,303).

35,000

30,00

0-

25,000-

20,000-

15,000-

10,000-
5,000-

0-

• Psych-Behavior

• Psych-Schizophrenia

• Psych-Depression

Brain-Behavior

Brain-Schizophrenia

Brain-Depression

7 0 – 7 9 8 0 – 8 9 9 0 – 9 9 2 0 0 0 – 1 0

3 The reader may be interested in examining some of the research pipelines for major phar-
maceutical companies. For example, the GlaxoSmithKline (www.gsk.com) product development
pipeline (click on Research & Development, then follow Development) contains numerous new
drugs for conditions (and putative mechanisms) like depression and anxiety (CRFl antagonist),
drug dependency (DA3 antagonist), bipolar disorder (sodium channel blocker), sleep disorders
(orexin antagonist), and dementia (5-HT5 antagonist) (February 2010 download). Lilly, Merck, and
Pfizer have similar pipelines.

4 One of the most helpful starting points can be such online resources as RxList.com and
Drugs.com, both of which offer exceptionally instructive information about psychoactive drugs.
Even if an individual disagrees with the use of a particular medication for a given condition, the
information can be of substantial value for client monitoring and education.

5 By systems level, 1 mean appreciation of the neurological structures and systems involved
in higher-order thought (prefrontal cortex); emotional behavior (limbic system); memory systems
(e.g., hippocampus); sensation; perception; and motor behavior (e.g., basal ganglia).

6 The interested reader is encouraged to review online information about Parkinson’s disease
(e.g., Wikipedia.org/wiki/Parkinson’s disease). Wikipedia gives an overview of the biological
basis of this condition, underscoring dopamine as the primary neurotransmitter of interest (scroll
down to the Management section: see references to Levodopa (L-DOPA); and dopamine antago-
nists; MAO-B). It is also noteworthy that other problems—such as sleep, cognitive, and mood dis-
turbances (under Signs and Symptoms)—are cited as related to this brain disorder. It is also of
interest to follow the links to deep brain stimulation (DBS) as a remarkable treatment alternative
that reinforces the relevance of reductionism and biomédical research in thinking about human
behavior. Interestingly, one of the potential applications for DBS is the treatment of major depres-
sion (see Wikipedia.org/wiki/Deep brain stimulation). Note: This online source is readily avail-
able and its review of a topic is often helpful, but care is warranted in relation to the scientific
sources used and how the content is interpreted.

7 Wikipedia.org/wiki/Biology of_depression identifies various neural structures, neuro-

222 JOURNAL OF MENTAL HEALTH COUNSELING

transmitter systems (monoamine hypothesis), and even genetic factors related to depression. While
not intended to be exhaustive, the site provides helpful information, especially in conjunction with
the Wikipedia.org/wiki/Major depressive_disorder, which deals with Causes (e.g,, monoamine,
‘other’ biological mechanisms, psychological, social, evolutionary, and drug-related),

8 Clinical experience with individuals diagnosed with schizophrenia has shed some light on
the mental health approach to pharmacology. Psychiatrists, psychologists, and case workers cer-
tainly view such conditions through a biomédical lens and often encourage clients, and caregivers,
to stay vigilant about drug adherence. It is helpful to review the extensive medication information
available on excellent web sites as a basis for evaluating intended drug effects and possible emer-
gence of side effects.

9 Without criticizing the extensive history of psychodynamic perspectives on behavior, or
minimizing the extensive coursework and clinical practice devoted to highly questionable projec-
tive techniques (Rorschach; Hand Test), I have yet to see a reliable measure or therapeutic applica-
tion of such non-empirically-established constructs. On the other hand, and despite some criticism,
few would question—for example—the intraceiiular IP3 pathway responsive to Lithium ions (Li+)
as a mechanism for mood stabilization (see Agam & Shaltiel, 2003; Julien et al,, 2008; Manji,
Moore, & Chen, 1999).

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CHAPTER NINE Medicating Children

This chapter is divided into seven sections. Section One is an overview that discusses current trends in medicating children, problems the trends cause, and directions for the future. It also discusses developmental issues. Section Two focuses on stimulant medication and the diagnosis of attention deficit hyperactivity disorder

(

ADHD). Section Three focuses on research on combined interventions and particularly the Multimodal Treatment Study (MTA study) of Children with ADHD. Section Four focuses on children taking mood stabilizers. Section Five focuses on antipsychotics and children. Sections Six and Seven focus on anxiolytics and antidepressants in children, respectively.

SECTION ONE: PERSPECTIVES, DILEMMAS, AND FUTURE PARADIGMS

Learning Objective

s

· • Understand the problematic increase in psychotropic medications for children despite a dearth of evidence of the effectiveness of these drugs.

· • Have a general understanding of the impact of the FDA Modernization Act and the Best Pharmaceuticals Act for Children.

· • Be able to state the “developmental unknowns” associated with giving kids psychotropic medications.

Thus far, we have explored the medical model and psychological, cultural, and social perspectives as they relate to psychopharmacology. In this chapter, we demonstrate that using psychotropic medications with children and adolescents raises particular problems and concerns from several perspectives. As discussed in

Chapter Three

, we frequently see explanations and justifications from the medical model perspective used to reduce childhood disorders to chemical and genetic problems, excluding crucial consideration of environmental traumas, developmental foreclosures, or life stressors.

We explore child and adolescent psychopharmacology primarily from the medical model perspective but complement this approach with information from the other perspectives (psychological, cultural, and social). We set the stage by exploring the current status of the treatment of children and adolescents with mental and emotional disorders. This chapter is structured differently from the others in this book. We begin by discussing the context from the social and cultural perspectives and the problems with prescribing psychotropic medications to children. Then we cover an introduction to stimulants used to treat symptoms of ADHD. Finally, we give the status of their current use since the last edition of the book if that is possible.

THE COMPLEX STATE OF THERAPY

Dr. Frank O’Dell, Professor Emeritus of Counseling in the College of Education and Human Services at Cleveland State University, has argued in all his lectures on counseling children and adolescents that the United States is an “anti-kid” society (Personal Communication, 2001). By that he means fewer

and fewer therapists and psychiatrists choose to treat or continue to work with children in counseling. To support his argument, O’Dell points out that resources for children, including the number of hospital beds in mental health wards for children, have been shrinking. He believes the rules of managed care companies, dwindling personnel resources, and increasing difficulty in working with parents or guardians and their struggling children all contribute to the current trend. This has been a problem for at least 45 years.

The

American Academy of Child & Adolescent Psychiatry (AACAP) (2001)

summarized the following facts, which support O’Dell’s assertion, indicating little has changed:

· • There is a dearth of child psychiatrists.

Satcher (2001)

stated further that many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals who are available and that places a burden on pediatricians, family physicians, and other gatekeepers to identify children for referral and treatment decisions (

U.S. Department of Health and Human Services, 2001

).

· • The AACAP’s report projected that between 1995 and 2020, the need for child and adolescent psychiatrists will increase by 120%, whereas the need for general psychiatry is projected to increase at 22% for the adult population.

· •

McCarty, Russo, and Rossman (2011)

demonstrated that only 13% of youth with suicidal behaviors and ideation receive mental health services.

· • In November 2010, the Coalition for Juvenile Justice estimated that up to 75% of teenagers in the juvenile justice system nationwide have a diagnosable mental disorder, and these numbers continue.

· • One in 10 children suffers from mental illnesses severe enough to impair development. Fewer than 1 in 5 children get treatment for mental illness.

The

U.S. Department of Health and Human Services (2001)

concluded that burgeoning numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by the institutions and systems created to care for them. As the number of children and adolescents needing psychological treatment rises and the number of service providers falls, the primary treatment modality becomes psychotropic medications rather than therapy. Imagine if you were a parent of one of these children.

Debner (2001a)

reported that in a one-year period, 350 children needing hospitalization were turned away from hospitals in the Boston area. This phenomenon is occurring in most major U.S. cities and is exacerbated by hospitals holding onto children who are ready to be discharged, because there is no suitable placement for them. In another article,

Debner (2001b)

noted that the chief pediatricians from the five major academic health centers in Massachusetts indicated there is a serious crisis in psychiatric services for youth in the state. The doctors said they and their staffs could not find appropriate therapy and other mental health services for mentally ill children. As a result, many such children deteriorate to the point of crisis.

Thomas and Holzer (2006)

reported that America suffers from a serious longterm shortage of child psychiatrists that is taking a toll on young people, their parents, and their doctors. It is further recognized that the demand for psychotropic drugs is intense in spite of dangerous side effects.

The

Washington Post

(2002)

published an article about a woman who desperately needed a psychiatric evaluation for her teenage daughter and who left 36 phone messages for various psychiatrists. She received only four replies. All the replies were from practitioners who refused to take the case because they did not treat adolescents. The article further detailed how, more and more, in-network providers (clinicians) prefer not to take patients covered by managed care plans, because reimbursements are so low and restrictions so numerous. The article also highlighted the disparity and arguments between the treating professionals and spokespeople from managed care companies. It is more than fair to say that desperate parents and anguished children are caught in the political policy dilemma over the cost and reimbursement of mental health treatment for children and adolescents.

Since the first edition of this book, there has been a movement to train more primary care physicians in pediatric mental health services to try to address the shortage of pediatric mental health professionals.

Aupont et al. (2013)

describe a model called Targeted Child Psychiatric Services designed for primary care physicians as well as child psychiatrists. This was associated with improved access to the child psychiatric services that exist, helped identify optimal care settings for patients and helped pediatricians be more likely to accept a patient back after that patient had been under psychiatric care.

Another problematic topic is who dispenses medications in schools. Most states have a policy on this and many states have a Nurse Delegated Medication Administration program (

Ryan, Katsiyannis, Losinski, Reid, & Ellis, 2014

). Most standardized curricula include trainings of approximately 30 hours with 8-hour updates every two years or so. These are by and large directed by professional nurses (

Spector & Doherty, 2007

). Nationwide lists of states and their programs can be found at

http://www.nasbe.org/healthy_schools/hs/bytopics.php?topicid=4110&catExpand=acdnbtm_catD

and

http://www.healthinschools.org/health-in-schools/health-services/schoolhealth-services/school-health-issues/medicationmanagement/state-policies-on-administration-of-medication-in-schools.aspx

.

THE EXPLOSION OF PSYCHOTROPIC MEDICATION PRESCRIPTIONS FOR CHILDREN AND ADOLESCENTS

With diminishing psychological supports for children and adolescents, using psychotropic medications with them has become the treatment of choice, even though the majority of medications used with them lack FDA “on-label” approval for them (

Werry, 1999

). Researchers currently estimate that between 7.5 and 14 million children in the United States experience significant mental health problems (

Riddle, Kastelic, & Frosch, 2001

;

Wozniak, Biederman, Spencer, & Wilens, 1997

). These statistics vary a little from
Satcher (2001)
, cited earlier; clearly, millions of children in this country require mental health services. Children are increasingly prescribed psychotropic medications as part of their treatment; in many cases, the medications replace the therapy (

Jensen et al., 1999

;

Phelps, Brown, & Power, 2002

). Given the explosion in the use of psychotropic medication with children, it is important also to note that this population has been excluded from clinical trials of these drugs. Hence, decisions about juvenile medication obviously rest more on extrapolation of adult data to children and adolescents than on direct research and evaluation of the safety and efficacy of psychotropic medication with children (

Riddle et al., 2001

;

Vitiello & Jensen, 1997

).

Coyle (2000)

indicated that 80% of all medications prescribed to children and adolescents in the United States have not been studied for the safety and benefit of these populations. As of 2011, The National Institutes of Health indicated that methylphenidate, lithium, all atypical antipsychotics, lorazepam, and amitriptyline were still on the highest priority list of needs in Pediatric Therapeutics of drugs to be studied in pediatric populations.

Even though there is a black box warning related to the risk of increased suicidality in children and adolescents prescribed SSRIs and SNRIs, the use of these psychotropic agents has increased with children and adolescents (

Markowitz & Cuellar, 2007

). The trend in treating children and adolescents with off-label psychotropic medications, mostly in lieu of counseling and psychotherapy, has triggered concern both in the general public and the mental health community.
Coyle (2000)
,

Furman (1993)

, and Zito (

Zito et al., 2000

,

2003

) argue that there is little or no evidence to support psychotropic drug use with very young children and conclude that such treatment could have harmful psychological, developmental, and physical effects. In a multinational study, American youths were three times more likely to be on an antidepressant medication than their peers in Denmark, Germany, and the Netherlands (

Zito et al., 2006

). In 2010, the pharmaceutical companies research protocols were really challenged when uncovered pharmaceutical studies on many highly utilized

psychotropics were found to be no more efficacious than the placebo. In fact, the second author has personal communications with several psychiatrists in their fourth or fifth decade of practice who question the overall effectiveness of psychopharmacology with patients, especially children (Ramirez, Personal Communication, 2014).

In another multinational study,

Zito et al. (2008)

found that the annual prevalence of youth taking psychotropic medication was threefold greater in the United States than in the Netherlands and Germany. The atypical antipsychotics represented 5% of antipsychotic use in Germany but 66% in the United States. Interestingly, though, anxiolytics were twice as common in Dutch youth than as in U.S. or German youth.

With proper research, mental health professionals may be able to head off disasters such as aspirin precipitating Reye’s syndrome or valproate leading to sudden death in infants (
Riddle et al., 2001
). Given the lack of knowledge about the long-term and adverse effects of psychotropic medication on children, it is crucial that mental health clinicians be alert to the impact of these drugs on children and advocate for youth when the evidence that such drugs would be helpful is questionable (

Ingersoll, Bauer, & Burns, 2004

). At this point, we would like to introduce a case that highlights many of the treatment and medication dilemmas children and adolescents encounter.

THE CASE OF PHILLIP

Phillip is a 7-year-old first-grader from a singleparent home. His mother is on public assistance, and he is the oldest of four boys. Although some of the details of his developmental history are sparse, Phillip began to exhibit impulse control problems at the age of 2 years and 4 months, shortly after his father moved out of the house. He was hypervigilant, easily distractible, aggressive with his younger sibling, and frequently irritable. Initially, his mother believed he was going through a stage of rebelliousness, but after several months she became concerned about his behavior and mentioned this to the pediatrician. After a brief examination, the pediatrician indicated that Phillip was likely suffering from ADHD and recommended against medication unless his behavior got too out of control at home. However, she felt he would need a course of methylphenidate/ Ritalin, a prescription stimulant, once he began preschool. Phillip’s mother accepted this recommendation and planned to have him evaluated when he began preschool. Phillip’s behavior improved slightly over the next several months, without therapy or psychotropic medication.

When he began preschool, it took only a few days before all his active symptoms returned. After observing him for several weeks, the teacher recommended to Phillip’s mother that he see a physician to be assessed for a stimulant medication. After the evaluation, the physician prescribed 10 mg of methylphenidate/Ritalin daily for Phillip. Methylphenidate/Ritlain is one of the most common stimulants used for symptoms of ADHD in children. It is intended to reduce inattentiveness, distractibility, impulsivity, and motor hyperactivity, with a goal of improved academic productivity. Phillip’s symptoms slightly improved over the next eight weeks, but his aggressive behavior toward other children increased. Phillip’s mother noticed more unpredictable behavior at home, as well as sleeplessness and restlessness followed by long periods of lethargy. She took him back to his physician, who referred them to a psychiatrist. The psychiatrist, after a three-session assessment, diagnosed Bipolar I (BPI) Disorder, took him off the methylphenidate/Ritalin, and prescribed 50 mg of carbamazepine/Tegretol daily and 0.01 mg of clonazepam/ Klonopin. The carbamazepine/Tegretol was used to reduce his manic symptoms. This antiseizure medication has over time been found very effective with Bipolar Disorder (

Phelps et al., 2002

).

The clonazepam/Klonopin was used to address Phillip’s anxious and agitated symptoms. This antianxiety medication often relaxes children and reduces anxiety without inducing sleep.

Many of Phillip’s symptoms diminished, but his mother noticed both a sluggishness and apathy in him that were new. Over the course of the next year, Phillip’s teacher addressed several of his learning and cognitive processing problems. Up to this

point, the focus of Phillip’s treatment had been psychopharmacologic. No psychosocial interventions were given to Phillip, as is often the case (
Phelps et al., 2002
). No one seemed to have any awareness or discussion about the optimal level of medication for Phillip, and there was no referral for a psychosocial assessment. As his symptoms worsened, he was evaluated by a psychiatrist schooled in prescribing adult psychotropic medications off label to children. Finally, Phillip’s mother took him to see a therapist, who focused on Phillip’s attachment issues, his phobic anxiety triggered by sudden loss or the anticipation of sudden loss, and his physiologic symptoms, which the therapist considered powerful side effects of the pharmacologic therapy.

Analysis of Phillip’s Case

Analyzing the case, Phillip was treated by pharmacology in the medical model method and rational thinking centered on pharmacology dominated the case. The combination of methylphenidate/Ritalin and carbamazepine/Tegretol on Phillip’s system was supposed to reduce some of his externalizing symptoms in the constellation of ADHD or Bipolar I disorders, but the psychological aspects of his personality were ignored. Not until much later in the course of his illness did Phillip get some assistance in those domains. Culturally, Phillip’s mother had little power in society and was torn between accepting the opinion of the medical experts, and watching the negative impact the medications were having on her son. As mental health professionals, we need to understand the medical psychiatry’s rapid efforts to address most disorders of childhood and adolescents with psychotropic medication. Far too often, medicating professionals view talk therapy and other psychosocial interventions as ineffective and second rate. Because medical professionals hold more power in our society than mental health professionals, their medical opinions are frequently given more weight. Today, psychiatrists burdened by enormous caseloads are open to what is known as split-treatment, a joint effort by the mental health professional and psychiatrist to plan and integrate treatment and be vigilant for client manipulation. We must integrate care into a larger model of treatment that addresses each of the four perspectives equally and where mental health professionals’ opinions on mental health treatment are given more weight. In addition, the power of pharmaceutical companies must be monitored.

Bodenheimer (2000)

has documented numerous cases where companies prevented important research findings from being published because they were not favorable regarding the compounds being tested. To what extent may such situations affect clients like Phillip? This will be discussed later in the chapter.

Remember, Phillip was in the 4 to 7 age range when he began treatment.
Coyle (2000)
comments that there is “no empirical evidence to support psychotropic drug treatment in very young children and that such treatment could have deleterious effects on the developing brain” (p. 1060).
Furman (1993)
posited that psychiatrists in the United States are recklessly “out of control” in prescribing methylphenidate/ Ritalin and other stimulants for children, in contrast to the extreme caution that physicians in almost all European countries use in recommending this treatment approach. With the increasing trend to medicate a younger and younger population (
Zito et al., 2000
), mental health professionals not only need to understand the impact and therapeutic effectiveness of these medications, but also their limitations and potential for harming children.

THE MEDICATION OF CHILDREN AND THE FEDERAL LAWS

As we have noted in previous chapters, the laws of the land hold great influence over cultural and social paradigms. To a large extent, laws are the result of a dynamic interaction of forces that influence other areas such as socioeconomic status and the fiscal systems of a society. Socioeconomic status and fiscal systems shape laws in very powerful ways, and people with financial resources are able to buy influence with lawmakers. This is nothing new, but bears stating in this chapter. Although recent legislation has been introduced to address

the many problems of prescribing psychotropic medications for children, most such laws require only voluntary testing of psychotropic drugs, diminishing any real impact. In this section, we summarize recent laws and comment on them, beginning with a summary in

Table 9.1

.

TABLE 9.1 Major Emphases of Recent Legislation on Pediatric Pharmacology

Law/Rule

Summary

FDA Modernization Act

(Public Law Number 105-115, 1997)

Recognizes rights of children as patients
Sets specific standards for research of pediatric drugs
Encourages pediatric labeling

Best Pharmaceuticals for Children Act
(Public Law Number 107-109, 2002)

Voluntary pediatric studies of currently marketed drugs
Created list of all pediatric drugs needing documentation
Requires timely labeling of pediatric drugs
Establishes a mandate to include children of all cultures in studies
Voluntary studies of new drugs

Pediatric Rule Bill of 2002
a

Required timely pediatric studies and adequate labeling

aChild & Family Services Improvement Act: Language on how the use of medications is to be monitored.

© Cengage Learning®

FDA Modernization Act

Buck (2000)

traced the unfolding need for greater specific labeling of drugs used with patients less than 18 years of age. The burgeoning use of almost all drugs approved for children by the FDA compelled pediatric health care providers to use these drugs off label without a clear knowledge of dosing, administration, or adverse-effect information. In 1992, the FDA took steps to improve both pediatric labeling and research, which resulted in support for building a network of pharmacologic research by the National Institutes of Health (NIH). These efforts began to address the problem, and passage of the

FDA Modernization Act (1997)

for the first time set specific requirements to tighten regulations relating to pediatric pharmacology. This law encouraged pediatric labeling on drugs used widely with children and adolescents where the lack of labeling might lead to serious misuse. However, the FDA website (2013) warns that users of methylphenidate/ Ritalin may have an erection lasting many hours. This from an agency that still cannot conduct pediatric studies that evaluate the full impact of the drug on that population.

This law goes a long way toward recognizing the rights of children as patients, protecting their health, and assisting pediatric providers with essential information. Unfortunately, the law did not go far enough. Many practitioners and lawmakers felt the need for a comprehensive law to mandate pharmacologic research, monitor it, and further protect children.

The Best Pharmaceuticals for Children Act

On January 4, 2002, President George W. Bush signed Public Law Number 107-109, the Best Pharmaceuticals for Children Act (

Dodd, 2001

), with the anticipation that it would address many of the dilemmas and controversies surrounding the eruption in use of pharmaceuticals for children. This law aims to initiate critical studies with pharmaceuticals already prescribed to a population for whom there exists little research, and it tightens the monitoring and development of new drugs released for children and adolescents. The law seeks to integrate viewpoints on medicating children with the medical, cultural, and social perspectives. Unfortunately, its most powerful provisions regarding the conduct of pharmaceutical companies are voluntary.

The Best Pharmaceuticals for Children Act (BPCA) has 19 sections that can be viewed at

http://www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/SignificantAmendmentstotheFDCAct/ucm148011.htm

).

This law encourages voluntary pediatric studies of already marketed drugs, the so-called off-label psychotropic drugs in widespread use with children, and it creates a research fund for studying these drugs (see

http://blogs.fda.gov/fdavoice/index.php/tag/best-pharmaceuticals-for-children-act-bpca/

). Both efforts are critical to understanding the effectiveness and efficacy of psychotropic medications for children and adolescents. Further, the law establishes an ongoing program for the pediatric study of drugs, including a list of all drugs for which documentation is needed. This aspect of the law is monitored by the commissioner of the FDA and the director of the National Institutes of Health, who have the power to make written requests to pharmaceutical companies for pediatric studies. The law requires timely labeling changes for pediatric drugs under study.

As of this edition, the status of most pharmaceuticals for children and adolescents remains similar to what it was in 2006. There was the black-box effort with SSRIs and SNRIs, but they are prescribed at rates higher than in 2006 (

Cummings & Fristad, 2007

) and most other psychotropics are used with children and adolescents to quiet anxiety, agitation, and rage.

However, the pharmaceutical companies continue to challenge the Pediatric Rule on all fronts and now it is 2014 and most important drugs for children have not been studied with a pediatric group. So goes the Pediatric Rule. On October 17, 2002, the U.S. District Court for the District of Columbia ruled that the FDA did not have the authority to issue the Pediatric Rule and has barred the FDA from enforcing it. The Pediatric Rule would have required timely pediatric studies and adequate labeling of all human drugs.

Child and Family Services Improvement Act

The Child and Family Services Improvement Act of 2011 (Public Law 112-34) includes new language that addresses the social-emotional and mental health of children who have been traumatized by maltreatment. State Child and Family Services Plans now have to include details about how emotional trauma associated with maltreatment and removal is addressed. They also have to describe how the use of psychotropic medications is monitored.

A WORD ON CROSS-CULTURAL PERSPECTIVES

Tseng (2003)

proposed many variables and differences in prescribing psychotropic medications to children and adolescents from various cultures. He stressed that one must consider not only the physician’s attitudes about treating people from different cultures, but also the patients’ perspectives on how they feel about psychotropic medications. Thus, the giving and receiving of medications has many implications. This factor is greatly enhanced for children and adolescents, because the physician must not only communicate with the parents about the diagnosis and the psychotropic medications (neither of which may make sense in the parents’ worldview) but must also weigh carefully the cultural issues that the family brings to treatment.

Tseng (2003)
also addresses the enculturation issues of children. His research has described how not every culture emphasizes the fast-paced and often accelerated approach to growing up that characterizes the United States.

Enculturation

is defined as a process through which an individual, starting in early childhood, acquires a cultural system through the environment, particularly from parents, school, and so on. Some cultures, such as many Asian cultures, have a laid-back attitude toward babies and toddlers that is more indulgent. Yet later, they show a dramatic shift for these children, who, when they arrive at latency, the developmental period between the ages of 6 and 11 or 12, experience enormous pressure to be diligent and to achieve. Thus, as clinicians treat children and adolescents from all cultures, they need to reconsider cross-cultural adjustment and revise the psychosocial stages of

Erikson (1968)

, which depended on developmental understandings in a particular culture.

With the upsurge in the use of psychotropic medications, it is impossible to monitor the expected and unexpected adverse effects. Given the expanding knowledge of the varying developmental trajectories of children from other cultures, mental health practitioners and psychiatrists need to exercise further caution when prescribing psychotropic medications

for these children.

Lin and Poland (1995)

described in detail the remarkably large interindividual variability in drug responses and side effect profiles. This can be partially accounted for in differences of ethnicity and/or culture apart from physiological pace. Some cultures are very suspicious of medication and may delay the decision for more than a year.

Lin and Poland (1995)
have made significant contributions to the understanding of

cultural psychiatry

and to the fact that genetic factors associated with individual and ethnic backgrounds contribute greatly to responses to medication in children, adolescents, and adults.

Kirmayer and Ban (2013)

note that cultural differences in self and personhood are equally important. All researchers we reviewed point to variations within the same ethnic group and variations among ethnic groups. This further complicates the integrative dilemma, which is how to view psychopharmacology and cases from the four perspectives outlined in

Chapter One

as well as consider important developmental lines and levels. Mental health professionals recognize that researchers have much to learn about psychopharmacology with children and adolescents, as shown by the research cited in this chapter. We need to integrate our growing understanding of cultural psychiatry with our limited understanding of how psychotropic medications work in children. The Best Pharmaceutical Act for Children (2002) provided for including in studies children from various racial and ethnic backgrounds. The law calls for studying the impact of medications on children of different cultures.

PSYCHOLOGICAL PERSPECTIVES OF CHILDREN AND ADOLESCENTS

Medicating children and adolescents for all types of psychological disorders is a solution that only reflects partial truth. The overt behaviors and symptom profile for which they receive medication may only mask the deeper psychological wounds of loss, trauma, abuse, sibling rivalry, neglect, sexual abuse, or gender conflict.

Furman (2000)

has indicated that if mental health professionals carefully examined the overuse of stimulants with children, they would discover a variety of conflicts and problems fueling the hyperactive behavior. These issues could include cruelty in the home, harsh toilet training, neglect, sexual abuse, delay in language development, and more.

Young children cannot address their inner conflicts without the help of a caring therapist and the modality of play therapy, yet far too often they are diagnosed with Bipolar I or ADHD and medicated in an attempt to quickly suppress their active symptoms. There should be far more effort to get the child to a therapist to uncover the underlying cause(s) of the child’s anguish, but this requires resources that, at the time of this writing, lawmakers are not giving a high priority.

The American Academy of Pediatrics (2011)

for ADHD makes clear that parent and teacher assessments at home and school, respectively, along with clinical review and examination by pediatrician or psychiatrist, often omit psychological assessment of the child by a mental health professional to rule out abuse, neglect, loss, sleeplessness, or other potential causes of hyperactivity or mania. In this protocol (the AAP guidance), the psychology and clinical history of the child are treated as unimportant. Many authors unfortunately support rapid assessment of ADHD children to speed up treatment with stimulant medication.

OPPOSITION TO THE CURRENT TREND OF MEDICATING

Opponents to exclusive medication treatment for ADHD, Bipolar I, and other conditions have pointed out significant regional variations in the amount of psychotropic medications prescribed to children and wide variations in regional diagnostic criteria for ADHD and other conditions (

Safer, Zito, & Fine, 1996

;

Wolraich, Hannah, Pinnock, Baumgaertel, & Brown, 1996

). These variances have legislators and mental health advocates from various regions of the country clamoring for more judicious use of psychotropic medications with children, with more careful attention to the range of adverse effects from them, and a more formalized protocol for diagnosing ADHD, Bipolar I, and

other conditions. This protocol should go well beyond the traditional oral report from teacher to parent about a child’s externalizing behavior. Opponents of psychotropic medication use in children call for a more specific and guided differential diagnosis of these disorders because the symptoms commonly overlap with Oppositional Defiant Disorder, Conduct Disorder, Major Depressive Disorder, various anxiety disorders, and many developmental disorders (

American Academy of Child and Adolescent Psychiatry, 2007

;

August, Realmuto, MacDonald, Nugent, & Crosby, 1996

). Many researchers and practitioners still feel that ADHD in particular is a myth and that the explosion in use of the diagnosis renders differential diagnosis impotent (

Armstrong, 1997

;

Furman, 2000

).
Furman (2000)
concluded,

· I have tried to trace the thinking that followed the discovery of the vastly different approaches in the United States and Europe to the management of the active or overactive child.… This thinking led to the conclusion that ADHD is not a specific disorder or pathological entity but rather a collection of symptoms that could be manifested by a child in distress, a child in conflict within himself and/or with his environment. It has no more specificity than that, and likewise methylphenidate has no specificity in producing its effects.… Suppressing these symptoms by “subduing” the child with medication hides from all the source of the child’s troubles, precludes his being able to obtain mastery of his troubles through understanding, and subjects him to a false label of brain pathology. (p. 141)

Furman, now deceased, indicated that his conclusions were not new but simply ignored.

AN OVERVIEW OF PEDIATRIC AND ADOLESCENT PSYCHOPHARMACOLOGY

By the time this text has been published, only a handful of psychotropic medications will have been approved as on label for the preschool age group. Examples include methylphenidate/Ritalin, amphetamine/Adderall, haloperidol/Haldol, and chlorpromazine/Thorazine (

Zito et al., 2003

). Methylphenidate/Ritalin is now under great scrutiny (

Zaicek, 2009

). For preschool-age children, it is aggressive behavior that generally triggers a referral for treatment (

Bassarath, 2003

). A few more psychotropic medications have been approved for use in older children and adolescents (

Kluger, 2003

), but those (such as the antidepressant fluoxetine) are hotly debated because of suicidal risk.

Table 9.2

lists as many medications as we were able to find with on-label approval for children.

We have mentioned the national dilemma that more children and adolescents demand psychological services each year, yet there are fewer service providers. Concurrent with this expanding problem is the dramatic increase in the use of psychotropic medications off label for a variety of mental and emotional conditions and disorders. Although this is problematic in and of itself, the focus on psychological and interpersonal factors in treating children and adolescents has dangerously diminished. Whereas it used to be common practice for child psychiatrists to choose in each case from among drug therapy—primary drug therapy and secondary counseling, or primary counseling and secondary drug therapy (

Kraft, 1968

)—today these choices are rarely discussed routinely.

Also note that DSM criteria are primarily normed on adults and are more difficult to apply with children.

House (1999)

has indicated that over half of the time, children who meet the criteria for one mental or emotional disorder meet criteria for other disorders as well. This multiple nature of children’s problems frequently results in a polypharmacy approach and requires careful decisions by the physician and/or treating team (

Brown & Sammons, 2002

). How carefully those decisions are made varies from setting to setting and clinician to clinician and are more random today (Leslie, 2011).

Researchers do know that the preschool years are one of the key developmental periods for maturation of the brain dopamine system, which is targeted by stimulants (

Coyle, 2000

). The FDA-approved package insert on methylphenidate/Ritalin warns against its use with children under age 6. Given all the unknowns, many scholars and physicians are concerned about the quality and care and the current explosion of prescribing practices with preschoolers. Mental health professionals do not have enough clear evidence about how preschoolers respond to psychotropic medications, and researchers are very uncertain about the impact of such medications on the development of preschoolers. Let’s examine some of the major developmental issues.

TABLE 9.2 Drugs with FDA On-Label Approved Uses in Children

Generic Name

Brand Name

Dosage

Ages

ADHD Medications

Methylphenidate

Ritalin

10–60 mg

6 and older

Immediate Release (IR)

Methylin

20–60 mg

6 and older

Methylphenidate

Ritalin SR

Sustained or Extended

Metadate SR

Release (SR/ER)

Concerta

Methylphenidate

Transdermal

Daytrana

10 mg/9 hours

6 and older

Dextroamphetamine

Focalin

5–40 mg

6 and older

Dextroamphetamine

Extended Release

Focalin XR

10–40 mg

6 and older

Lisdexamfetamine

Vyvanse

30–70 mg

6 and older

Amphetamine/Dextroamphetamine

Adderall

5–40 mg

3 and older

Atomoxetine

Strattera

.5 to 1.4 mg

6 and older

Guanfacine

Intuniv

1–4 mg

6 and older

Clonidine

Kapvay

.1 to .4 mg

6 and older

Antipsychotics/Mood Stabilizers

Aripiprazole

Abilify

2–30 mg

For BPI 10 and older

2–15 mg

Irritability/Autism 6 and older

2–30

Schizophrenia 13 and older

Risperidone

Risperdal

.25–3 mg

Autism 5 and older

.5–6 mg

BP Mania 10–17

.5–6 mg

Schizophrenia 13–17

Olanzapine

Zyprexa

2.5–20 mg

BPI/Schizophrenia 13 and Older

Paliperidone

Invega

2.5–20 mg

BPI/Schizophrenia 12–17

Quetiapine

Seroquel

50–600 mg

BPI 10 and older

50–800 mg

Schizophrenia 13 and older

Lithium

Eskalith

900–2400 mg

BPI 12 and older

Lithobid

900–1800

?

Neuroleptics

Chlorpromazine

Thorazine

.5–200 mg Psychosis

6 and older

Haliperodol

Haldol

.5 to .15 mg

Tourette’s 3–12

Pimozide

Orap

.05–2 mg

Tourette 12 and older

Antidepressants

Escitalopram

Lexepro

10–20

12 and older

Fluoxetine

Prozac

10–20

for depression 8–18

10–60

for OCD 7–17

Fluvoxamine

Luvox

25–200 mg

for OCD 8–17

Sertraline

Zoloft

25–200

for OCD 6–17

Amitripyline

Elavil

25–100

for depression 12 and older

Clomipramine

Anafranil

25–100

for OCD 10 and older

Imipramine

Tofranil

30–100 mg

depression 12 and older

25–75 mg

eneuresis 6 and older

Protriptyline

Vivactil

15–20 mg

depression 12 and older

Developmental Issues

For many of you, this section on human growth and development in children and adolescents is a review. Most texts on development emphasize cognitive, language, moral, and psychosocial developmental paths. We briefly consider these lines of development

and include others that are potentially affected by the ingestion of psychotropic medication. Understanding development is further complicated by the construct of

developmental lines

—the simultaneous occurrence of several aspects of human growth and development.

Developmental Lines

Although there are dozens of lines of human development, this multiplicity is still not a focus for mental health professionals outside of developmental studies. What should be common knowledge for mental health professionals is still peripheral to their training. For example, the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) requires only one human development course for a master’s degree in school or clinical mental health counseling. There may be dozens of lines of human development. These include physical development, cognitive development, emotional development, sexual development, moral development, spiritual development, kinesthetic development, socioemotional development, gender identity, and role-taking ability. These are just a few of the lines of development to which every person has access, and, for the most part, everyone proceeds through them unevenly.

The sheer number of developmental lines and the fact that most people proceed unevenly through them raise enormous, unaddressed issues for psychopharmacology. We noted earlier that scientists know very little about how brains develop and that many researchers are concerned that psychotropic medications could profoundly damage the brains of children and adolescents when taken long term. Glen Elliott, director of the Langley Porter Psychiatric Institute Children’s Center of the University of California at San Francisco, noted that the current use of psychotropic medications on children “has outstripped our knowledge base . . . we are experimenting on these kids without tracking the results” (

Kluger, 2003
, p. 51). For example, even when an adolescent truly appears to suffer from Bipolar I Disorder, the sequelae of mood stabilizer side effects such as weight gain and perhaps hair loss are likely to be more devastating for a person of that age than for an adult—but there is no research on such psychological issues.

Perhaps the greatest problem of studying child and adolescent psychopharmacology from the four integrative perspectives is that whenever the issue of medicating children comes up, the only perspective represented is that of the medical model. A good example is a Time magazine cover story, by

Kluger (2003)

that basically explores only the medical model perspective, with only minor attention to psychological, cultural, and social issues. The same article presents a diagram showing what parts of the brain are believed to be correlated with different mental or emotional disorders. At no point in the article does the author state that these areas are hypothesized to be correlated with symptoms and there is no evidence that they cause symptoms. This remains true as of the second edition of this book.

As we have noted throughout the book, many symptoms that are psychogenic in origin register in the brain, but this does not mean the symptoms were caused by the brain. This bias toward the medical model perspective leads laypeople to assume that mental/emotional disorders, whether in children or adults, are strictly medical disorders. This assumption is not currently supported by the evidence we have been covering in this book. A full-scale multimodal approach to mental and emotional disorders in children and adolescents considers medication and possible brain pathology as only one part of the story in a very complex interaction of tentative causes and interventions.

Developmental Pharmacology

Developmental psychopharmacology is a newer area of research that studies brain development focused on brain plasticity (the brain’s ability to shape itself to environmental or chemical input) and sensitive periods (during which experience can alter neural representation before hardwiring occurs) (

Carrey, Mendella, MacMaster, & Kutcher, 2002

). Pediatric psychopharmacology is an equally young enterprise with the first published reports dated in 1937 but by the 1980s the United States

had become the world leader in medicating children (

Riddle, Walkup, & Vitiello, 2008

).

Although these disciplines are examining development strictly from the medical model perspective, its overarching question is, “What happens in the complex process of neural development when an infusion of psychotropic medications is introduced to address particular environmental stressors during periods of accelerated brain development?” Compared to adults, children and adolescents respond to psychotropic medications in different and distinctive ways that have implications for efficacy and safety (

Vitiello & Jensen, 1995

). The rate at which prescriptions of psychotropic medications have grown for children despite the dearth of research to support their efficacy raises the question “are we doing too much or too little?”

Epstein (2001)

posited that active brain growth spurts occur stagewise in correlation with Piagetian types of development. Thus, a child who is making the transition from the sensory motor stage to Piaget’s preoperational stage is in a very active brain growth stage (from age 2 to 4 years).

Epstein cites Boothroyd (1997)

, who noted that lexical knowledge and syntactic knowledge grow rapidly until age 4. At about 6 (from age 6 to 8), the next rapid brain growth period parallels Piaget’s concrete reasoning stage, where a child begins to think logically about experienced inputs, the concrete operational stage. Epstein discussed the next brain growth period as slow (from age 12 to 14 years), a time of practicing and consolidating new networks in preparation for the next rapid brain growth stage (between ages 14 and 16 years). Psychotropics often are administered to preschoolers in the rapid growth period between ages 2 and 4 years, and to early-latency children between the ages of 6 and 8 years. Mental health professionals do not know enough about the impact of both on-label and off-label psychotropics in these rapid brain growth periods to be administering them to children and adolescents.

Bramble (2003)

concluded that given the changing nature of pediatric pharmacology and developmental pharmacology, this society needs a rapid expansion of pediatric research and academic inquiry into the impact of psychotropics on children’s development. The second author in an extensive review of developmental pharmacology articles found only those supported fully by pharmaceutical companies or ones that cost between $29.50 and $40.00. Almost all recommended the use of a psychotropic as a first-line intervention. Interestingly, the pharmaceutical companies signed documents stating that they had no “conflict of interest.” In addition, the medications being used are only partially successful 40–50% of the time (

Rapoport, 2013

).

Another problem with pediatric psychopharmacology is

polypharmacy

: the use of more than one psychotropic simultaneously, a usage that interacts with children’s metabolism in a variety of unpredictable ways (
Brown & Sammons, 2002
). Clinicians who observe children and adolescents under the influence of polypharmacy are often startled not only by the dramatic change in the clients’ affective and behavioral state but also by the array of side effects they experience. Tonya, a very aggressive 12-year-old, was placed on olanzapine/Zyprexa (an atypical antipsychotic), sertraline/Zoloft (an SSRI antidepressant), lorazepam/Ativan (an anxiolytic), and valproate/Divalproex (a mood stabilizer). This combination of medications was ostensibly for what appeared to the attending psychiatrist as Bipolar I with severe agitation and aggression in the manic phase. Tonya’s symptoms diminished, but her teacher noticed new ones: slurred speech, mild tics, and a constant staring off without responding when addressed. Now, rather than disrupting the class, she slept through it. Although from the perspective of the teacher and other students this was an improvement, was Tonya being helped, or was she merely medicated into submission when she might have been more fundamentally helped with assessment and therapy from a wider interpersonal perspective?

Other developmental considerations include adverse cardiovascular effects. We have many reports of sudden deaths of children and adolescents treated with psychotropic medications, including methylphenidate/Ritalin, TCAs, SSRIs, bupropion/ Wellbutrin, lithium, and most neuroleptic medications.

Gutgesell et al. (1999)

detailed the

cardiovascular and electrophysiologic effects of commonly used psychotropic medication, which can be deadly. Although the precise causes of the deaths have not been documented, severe heart spasms (cardiac arrhythmias) and delayed repolarization of the heart rhythm (delayed QTc interval) make the heart muscle vulnerable to possibly lethal changes (such as ventricular tachycardia). These tragedies call on mental health professionals to be vigilant and cautious when prescribing psychotropic medication. With many high-risk medications, cardiovascular monitoring is particularly important. In fact,

Wagner and Fershtman (1993)

recommended ECG monitoring at baseline and during drug therapy for children and adolescents who are on the medications associated with cardiovascular side effects.

Brown and Sammons (2002)

argued that the use of most psychotropic medication exceeds data available for efficacy, effectiveness, and safety.

Many concerns also remain related to the physiological impact on children who take psychotropic medication. One is the controversy about the impact of stimulant treatment on brain growth in children (

Bell, Alexander, Schwartzman, & Yu, 1982

). Researchers have recently learned that methylphenidate and other stimulants decrease blood flow to selected parts of the brain, specifically the cortex area that controls conscious movement (

Zeiner, 1995

). In a recent study (

Castellanos et al., 2002

), the research team concluded that developmental trajectories for all brain structures, except caudal, remain parallel for children and adolescents in ADHD patients and controls. This suggested that genetic and early environmental influences on brain development in ADHD are fixed, nonprogressive, and unrelated to stimulant treatment.

However, initial brain scans of patients with ADHD showed significantly smaller brain volumes in all regions than what appeared in the brain scans of the controls. In general, because of brain plasticity (the brain’s ability to shape itself), it is possible for children to be highly susceptible to a negative impact on their brain development during one period of development and less so in another period of development (

Carrey et al., 2002

). Does treatment with psychotropic medications constitute a negative impact? These authors further concluded that researchers are only beginning to understand the long-term effect of psychotropic medication on neuron cell factors and their overall impact on brain development. All these developmental concerns or issues involve potential adverse effects for children and adolescents taking psychotropic medication.

At this point, we cover the different categories of medications used on children and adolescents. We begin the next section with a more thorough treatment of stimulant medications.

Review Question

s

· • What are some of the main problems with the increase in psychotropic medication prescriptions for children?

· • What was the impact of the FDA Modernization Act and the Best Pharmaceuticals Act for Children? Name at least three changes these acts initiated.

· • What are the “developmental unknowns” that make prescribing psychotropic medications for children problematic?

SECTION TWO: STIMULANT MEDICATION

Learning Objectives

· • Understand the mechanism of action and side effects of stimulant medications.

· • Be able to discuss the type of symptoms stimulants seem most helpful for.

Even though stimulants are currently the beststudied psychotropic medication used on children, many issues regarding their use are still unresolved. Because stimulants are prescribed almost exclusively for children, we have included information on them in this chapter. Before discussing some of

the controversial issues, let’s examine some background and general information on these widely prescribed medications.

Some History

The first known stimulant in the West was cocaine. It was isolated in 1859 by a German chemist named Albert Niemann and was given to Bavarian soldiers to decrease fatigue. In 1884 Karl Koller perfected its use as an analgesic during eye surgery. His assistant, a young neurologist named Sigmund Freud, was off visiting his fiancé at the time and so missed out on credit for that discovery. Freud had been personally experimenting with cocaine and wrote the paper “Uber Coca” (“On Cocaine”) prior to realizing its addictive qualities (

Freud & Carter, 2011

). Many people in South American societies still regularly chew coca leaves with little ill effect, because unprocessed leaves are far less dependence inducing than is refined cocaine powder (

Siegel, 1989

). Efforts to synthesize amphetamine began in 1887, when physicians believed it useful for treating asthma. This belief emerged from the use of an herbaceutical called ma huang in Chinese medicine. Ma huang is discussed more thoroughly in

Chapter Ten

on herbaceuticals, but for now understand that it is the ingredient ephedra that is central to the story of amphetamines. This ingredient produces the bronchial dilation that relieves the wheezing of asthma.

In the 1920s, a Chinese pharmacologist working for Eli Lilly (K. K. Chen) was working to isolate and synthesize ephedra from ma huang. He succeeded in synthesizing a compound so structurally similar to ephedra that it was named ephedrine. Although this could be taken orally, the goal for asthma treatment was a compound that could be inhaled. Gordon Alles succeeded in developing another variation of the molecule that could be delivered in an inhaler. Called Benzedrine, this variation was successful in treating asthma. Aside from treating asthma, it also seemed to induce euphoria. People soon realized they could open the inhaler and ingest the contents for what became known as “the amphetamine rush.” This also became a popular pastime on college campuses during exams. Amphetamines were experimented with to manage a number of disorders, and one of their early uses was treating children for what was described as “overactivity.”

Werry has asserted that research in psychopharmacology for children began with publication of

Bradley’s (1937)

paper on how amphetamine seems to calm overactive children and help children with learning disabilities. The only other noteworthy investigations of the same period were studies on the effects of antihistamines on children (

Connors, 1972

). These works are thought to be the only primary contributions to child psychopharmacology until very recently (
Werry, 1999
).

Bradley’s work reemerged in the 1960s after psychiatry began moving away from a psychodynamic model toward the biological model dominant today. Psychiatrists at that time were not well trained in the statistical methods that were becoming the norm in evaluating medications. They turned to psychologists for assistance. The psychologists emphasized the need to look at medication effects on learning and academic performance (
Werry, 1999
). Such research has, until very recently, remained focused primarily on stimulant medication.

Research in pediatric psychopharmacology received an unintentional boost in the 1960s with the creation of a diagnosis called Minimal Brain Dysfunction (MBD). MBD was one of the several precursors to the current ADHD diagnosis. MBD was treated with stimulant medications such as methylphenidate. Although later discarded because it was too vague, the MBD diagnosis did much to lead to the development of a norm for a methodology with which to evaluate the effects of drugs, and particularly stimulants, on children.

In WorldWar II, German, British, American, and Japanese soldiers all used amphetamines, a practice still common in the U.S. Air Force to help pilots keep alert on bombing missions (

Knickerbocker, 2002

). After World War II, the Japanese had such huge surpluses of amphetamines that they marketed them to civilians. These drugs were advertised for the elimination of drowsiness and repletion of spirit. Researchers estimate that by 1948, 5% of the Japanese population between the ages of 15 and 25 was dependent on amphetamines.

After World War II, it became evident that amphetamines have appetite suppressant qualities, and chemists tried to tease these out from the reinforcing properties that were connected to abuse. However, most of these initial efforts (such as methylphenidate/Ritalin) failed, and then the drugs were simply marketed as amphetamines.

The amphetamine molecule is a simple and highly malleable molecule that acts as the chemical template for over 50 pharmacologically active substances (

Grilly, 1994

). Amphetamine is basically made of two compounds (isomers) labeled “L” and “D” amphetamine. D-Amphetamine is more potent and was marketed as Dexedrine. A minor modification in this molecule yields methamphetamine marketed as Methedrine. Other variations of the amphetamine molecule can produce MAO inhibitors. Modifying amphetamine to dimethoxy-methylamphetamine (DOM) produces a psychedelic compound similar to mescaline, and further modification produces the empathogen methylene-dioxymethamphetamine (MDMA, street name “ecstasy”). The latter was a promising psychotherapeutic compound until criminalized (

Eisner, 1994

). The therapeutic effects revolved around chemically induced states of empathy, euphoria, and well-being that facilitated insights that were then to be integrated into clients’ normal awareness (

Stevens, 2009

).

Table 9.3

outlines stimulant medications used to treat ADHD in children.

TABLE 9.3 Stimulant Drugs Used to Treat ADHD in Children

Generic Name

Brand Name

Type of Drug

Daily Dose

Amphetamine and D-amphetamine compound

Adderall

Stimulant

5–40 mg

D-Amphetamine

Focalin

Stimulant

5–40 mg

Methylphenidate

Ritalin

Stimulant

5–60 mg

Lisdexamfetamine

Vyvanse

Stimulant

30–70

Atomoxetinea Stratter
a

NE reuptake inhibitor

0.5–1.2 mg

0.5–1.2 mg

aAtomoxetine is not a stimulant but an SNRI (see

Chapter Five

).

© Cengage Learning®

Mechanisms of Action in Amphetamines

Amphetamines exert almost all their effects by causing the release of norepinephrine and dopamine from the synaptic vesicles into the synaptic cleft. There are different mechanisms for amphetamines to act as dopamine agonists and the number of mechanisms used depends on the type of amphetamine. There are two isomers of amphetamine, “L” and “D.” The “L” isomer amphetamine mechanisms of action include:

· • Pure reuptake inhibitor for DA

· • No presynaptic activity

· • Enhances NMDA receptor response

· • Weak block monoamineoxidase

· • 80% metabolized

· • The classic L-isomer amphetamine is methylphenidate/ Ritalin

The D-isomer amphetamine mechanisms of action are similar to those of cocaine and include:

· • Reuptake inhibition of DA (inhibit DAT)

· • Drug taken into terminal by DAT & depletes vesicles (causes DA transporter to act in reverse) thus releasing DA from the presynaptic neuron

· • Enhances NMDA receptor response

· • Weak block of monoamineoxidase (MAO)

· • Releasing NE from presynaptic neuron

Amphetamine/Dexedrine is the classic D-isomer amphetamine but is less prescribed than Adderall. Mixed amphetamine salts/Adderall includes D-amphetamine.

In a study comparing methylphenidate to cocaine,

Volkow et al. (1995)

noted that although the mechanisms of action and effects are similar, methylphenidate clears more slowly from the brain, which, they hypothesize, makes it less dependence inducing. Readers are encouraged to think critically about this result, because when a similar mechanism of slow clearance is invoked to defend cannabis (marijuana) as low in dependenceinducing qualities, it is often rejected (

De Fonseca, Carrera, Navarro, Koob, & Weiss, 1997

). Either the mechanisms discussed decrease the probability of dependence or they do not. Pharmaceutical and political agendas should be separated from this debate so that people can objectively examine the issues. In previous chapters, we have listed the adverse effects of psychotropics being discussed. With ADHD, these effects are interwoven into the complex presentation of the stimulants. We ask you to consider why in the continent of Europe (an area of the world that has about the same population as the United States), stimulant medications are used with children for only about 5 to 8% of the treatment population so treated in the United States. Now let us examine the DSM-5.

ADHD Diagnosis and Assessment

According to the DSM-5, the diagnostic criteria for attention-deficit/hyperactivity disorder are

· A. Either (1) or (2):

· (1) six or more of the following symptoms of inattention have persisted for at least five months to a degree that is maladaptive and inconsistent with developmental level:
Inattention

· (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

· (b) often has difficulty sustaining attention in tasks or play activities

· (c) often does not seem to listen when spoken to directly

· (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

· (e) often has difficulty organizing tasks and activities

· (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

· (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

· (h) is often easily distracted by extraneous stimuli

· (i) is often forgetful in daily activities

· (2) Hyperactivity: Six (or more) of the following symptoms of hyperactivity impulsivity persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity

· (a) often fidgets with hands or feet or squirms in seat

· (b) often leaves seat in classroom or in other situations in which remaining seated is expected

· (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

· (d) often has difficulty playing or engaging in leisure activities quietly

· (e) is often “on the go” or often acts as if “driven by a motor”

· (f) often talks excessively

·
Impulsivity

· (g) often blurts out answers before questions have been completed

· (h) often has difficulty awaiting turn

· (i) often interrupts or intrudes on others (e.g., butts into conversations or games)

· B. Several hyperactive-impulsive or inattentive symptoms that caused impairment are present before age 12 years.

· C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings.

· D. There must be clear evidence of clinically significant impairment in social, or occupational functioning.

· E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). (

APA, 2013

, pp. 59–60)

Source: Diagnostic and statistical manual of mental disorders, 5th ed., (Washington, DC:

American Psychiatric Association, 2013

).

Both the “Consensus Statement” of the

National Institutes of Health (1998)

and the “Clinical Practice Guidelines” of the

American Academy of Pediatrics (AAP) (2011)

recommend careful diagnosis of ADHD and then an appropriate and judicious use of stimulants in combination with other psychosocial treatments to address the symptoms.

Epstein et al. (2010)

also emphasize that children treated with stimulant medication show improvement in ratings by parents and teachers but not in their level of functioning as measured by grades. Thus they note that mental health services in addition to medication are important.

In terms of assessment most protocols recommend a neurologic exam, a consultation with a psychiatrist or psychologist who specializes in ADHD, behavioral observation reports from parents, grandparents, teachers, and other school personnel.

Olfson, Gameroff, Marcus, and Jensen (2003)

, analyzing national data, reported the increased rates of treatment from 0.9 per 100 children in 1987 to 3.4 per 100 children in 1997. They posited that this increase along with fewer treatments (counseling) per child was attributed to a broader awareness of the diagnosis by special educators, growth of managed behavioral health care, and increased public acceptance of psychotropic medications. But we ask, has the mushrooming of the ADHD diagnosis in children led to improved assessment and treatment?

The answer is mixed. Although some teachers, school administrators, and pediatricians rapidly diagnose ADHD in children, the

NIH (1998)

, the

National Institute of Mental Health (NIMH) (1996

,

2000

), and the

AAP (2001)

all have developed diagnostic guidelines for ADHD for years. More recently, The

American Academy of Child & Adolescent Psychiatry (AACAP) (2007)

released a practical, evidence-based practice parameter. In 2011 the same group released a practice guideline with expanded treatment of how to make the diagnosis and how to add psychosocial interventions to treatment (

AACAP, 2011

). The initial guideline was again updated in 2012. In all cases, these expert societies recommend a careful evaluation by a trained psychiatrist or psychologist in conjunction with teachers, mental health professionals, and family members. They recommend an evaluation period that is not rushed, so the team can rule out other conditions that might be confused with ADHD, and which includes observation and rating scales.

In a 10-year review of rating scales assessing ADHD,

Collett, Ohan, and Myers (2003)

concluded that DSM IV-based rating scales can reliably, validly, and efficiently measure ADHD symptoms in youth. In this comprehensive review, the authors evaluated the validity and sensitivity of subscales on several rating scales to assess the symptoms of ADHD. The greater use of narrowband rating scales in the assessment of ADHD can supplement and complement clinical interviews and behavioral observations in the evaluation of ADHD in children and adolescents. It is now evident that reliable and valid ADHD rating scales can augment the accuracy and specificity of diagnosis.

In a comprehensive response to the Multimodal Treatment Study (

Owens et al., 2003

), the authors sought to answer the layered question, “What do we treat in ADHD?” and “Who treats it?” based on the needs of the child and her or his circumstances (

Paul, 1967

, p. 111). Their findings were remarkable. The children least likely to respond well to a combined treatment of stimulants and milieu therapy were those with depressed parents or caregivers and severe ADHD.

Owens et al. (2003)

examined several outcome predictors, using nine baseline child and family characteristics. None were

predictive, but the two issues discussed earlier along with a lower IQ of the identified child correlated with an outcome less-than-favorable with the combined treatment.

ADHD Efficacy, Effectiveness, and Conundrum

ADHD has been classified as one of the externalization disorders, along with Conduct Disorder and Oppositional Defiant Disorder. As opposed to the other two, stimulant medication has been the treatment of choice for ADHD for about 25 years in the United States (

Phelps et al., 2002
). In fact, stimulants for ADHD are the most widely researched and used medications in child psychiatry. Evidence indicates significant increase in the use of stimulants for both preschoolers and children despite the fact that the FDA approval is only for children ages 6 and older (
Brown & Sammons, 2002
;
Riddle et al., 2001
;
Zito et al., 2000
,
2003
). The data include empirical evidence on safety, efficacy, and adverse effects.

Research demonstrates the beneficial effects of stimulants on symptoms linked with ADHD. These effects include diminished inattention, impulsivity, overactivity (

Bennett, Brown, Carver, & Anderson, 1999

), improved classroom attention and academic efficiency (

DuPaul & Rappaport, 1993

), and improved mother–child relationships (

Barkley, Karlsson, Strzelecki, & Murphy, 1984

). However, with all the benefits cited for the use of stimulants with ADHD, available literature to date has not supported or demonstrated that stimulants enhance school achievement (
Phelps et al., 2002
). Short-term efficacy studies supported the impact of stimulants on the target symptoms. From this literature, clinicians can conclude that using stimulants with children appropriately diagnosed with ADHD diminish the child’s inattention, impulsivity, and hyperactivity, but do not necessarily improve his or her academic achievement. It is very possible that the child will adapt better to the demands of the classroom environment and become less externally driven. However, it would also be interesting to research whether or not stimulants improve performance in children who are not diagnosed with ADHD.

Proponents of stimulant treatment for ADHD are more convinced than ever that the disorder is passed on through heredity via the DRD4 receptor gene and that, as twin studies have suggested, up to 80% of the variance in the trait of hyperactivity/ impulsivity is now considered to be based on genetics (

Barkley, 1998

).

Peter Jaska (1998)

, president of the Attention Deficit Disorder Association (ADDA), is a staunch advocate of stimulant treatment for ADHD and argues that “we cannot and will not turn back decades of scientific research on the biological basis of ADHD, medical research, educational progress, and federal disability legislation, because some people selling books claim that ADHD is a ‘myth’ ” (p. 1). Both Jaska and Barkley are experts on the biological bases for ADHD derived from the medical model perspective and the resulting medication for treatment, but they seldom address intrapsychic, cultural, or social perspectives of ADHD.

Review Questions

· • What are the mechanisms of action and side effects of stimulant medications?

· • What types of symptoms are stimulants most useful for?

SECTION THREE: ADHD AND COMBINED INTERVENTIONS

Learning Objectives

· • Understand the differences between the initial, twoyear, and eight-year follow up of the MTA study group.

· • Be able to describe conditions that may be comorbid with ADHD and why this may also be a misdiagnosis.

Interventions with ADHD usually begin with assessing the child or adolescent for oral stimulant medication, because most studies have indicated short-term behavioral improvement related to the symptoms of

the disorder when stimulants are used (

American Academy of Pediatrics, 2001

;

Barkley, DuPaul, & Connor, 1999

;
Phelps et al., 2002
). Methylphenidate/ Ritalin accounts for 90% of the prescriptions for ADHD (

Advokat, Comaty, & Julien, 2014

). In the late 1990s studies demonstrated that Adderall (amphetamine/dextroamphetamine) is equally efficacious but methylphenidate/Ritalin is still the leader in medications used to treat ADHD.

As noted, most consensus statements on ADHD treatment recommend psychosocial interventions that assist the family as well as the person diagnosed with ADHD. These approaches include psychotherapy, cognitive-behavioral therapy, behavioral therapy, social skills training, impulse control therapy, parenting skills training, support groups, and family therapy. Each of these approaches alone or in conjunction with stimulant medication can help ameliorate some of the symptoms of ADHD and/or address some of the underlying factors affecting the person with the disorder. The

American Academy of Pediatrics (2001)

first treatment guideline specifically recommended behavioral therapy as the best adjunct intervention with stimulants to establish targeted outcomes and manage the child’s behavior both in the classroom and at home. They also stated that if one stimulant does not work at the highest feasible dose, the physician should recommend another. Clinicians learning about pharmacology may find it helpful to remember that stimulants generally provide only relief of symptoms, thus requiring other treatment modalities and followup. In a follow-up to that

Bader and Adesman (2010)

recommended a list of complementary and alternative treatments for ADHD. Although the American Academy of Pediatrics did not recommend these specifically they did note that essential fatty acid supplementation is well tolerated and modestly effective.

Results of the Multimodal Treatment Study for Children with ADHD (

MTA Cooperative Group, 1999

) demonstrated initially that stimulant treatment was slightly more effective than behavioral therapy alone, and equally effective to therapy and medication combined. It should be noted that parents preferred the behavioral therapy conditions to the stimulants-alone treatment. As with all treatment approaches for ADHD, the MTA study is not without its critics, who argue for a better match of patient with a treatment strategy tailored and selected for the individual’s needs (

Green & Albon, 2001

). When the selected management (interventions) for a child with ADHD has not met targeted outcomes, clinicians must evaluate the original diagnosis, adjust treatments and medications, and evaluate for coexisting conditions.

Another critic of the MTA study (

Leo, 2002

) noted that the fanfare surrounding publication of the study “was nothing short of extraordinary” (p. 53). Leo pointed out that ABC News reported that results indicated drug therapy was much better than counseling for ADHD. Leo contends that the MTA study was heavily biased toward medication treatment. He claims the study’s authors all had a history of strongly favoring medication, bringing their objectivity into question. He also points out that the MTA study had four groups: one received medication, one received behavior therapy, one received both, and a fourth group received no treatments from the MTA researchers but instead received standard treatment in the community. The most “robust” changes were reported in ratings by teachers and parents of children in the study. The problem with this, according to Leo, is that the investigators preselected a group of parents who believe it is acceptable to medicate children; in fact, in all cases the parents contacted the investigators to enroll children in the study. This fact, according to Leo, points to a bias in the sample.

Edwards (2002)

addressed the important follow-up outcomes of studies and interventions in the wake of the report from the

MTA Cooperative Group study (1999)

. He recommended that a specific family-based intervention be used in a mental health setting in conjunction with pharmacologic treatment. He specifically cited Parent Management Training (PMT) as an approach that through cognitive-behavioral coaching helps parents manage their child’s difficulties. Whatever the method, more physicians, researchers, and clinicians are recommending family interventions with children and adolescents diagnosed with

ADHD. The research in treatment outcomes of ADHD is complicated, and we encourage you to evaluate many strategies and interventions for your clinical work, especially those that include family/ parent strategies.

The MTA study was followed up at two years and at eight years. Here is a summary of the findings. At two years, cessation of drug treatment was correlated with significant clinical decline. Continued drug therapy was correlated with moderate decline and initiation of stimulant therapy for those in control group was correlated with significant improvement (

MTA Cooperative Group, 2004

). So at this point again the cornerstone of treatment seemed to be with the medication. At the eight-year follow up, 33% of the subjects were still on medication (and 83% of them were on stimulants). Improvement was maintained but the group had not “normalized” meaning there were still significant achievement gaps between them and so-called “normal” controls. Thirty percent still met the DSM-IV criteria for ADHD (though one suspects more would meet criteria under DSM-5 because you only need five criteria met rather than six). Overall, medicated children did better in math and reading. There was still a significant test score gap between children in the study and the control group. Also, interestingly, approximately 30% showed signs of antisocial behavior and 25% showed signs of Oppositional Defiant Disorder (

Barnard-Brak & Brak, 2011

; Sheffler et al., 2009). This is interesting because many specialists felt that the antisocial behavior often comorbid with ADHD was because the ADHD was untreated. It seems that there may be something else to the antisocial behavior because it seemed to persist in so many people despite their longterm treatment for ADHD.

We spoke with one interventionist who provides a learning/coaching service to children with ADHD (

Joyce Kubik, Personal Communication, April 2003

). Kubik not only conducts specific skill-building training/coaching for ADHD children but also conducts support groups for parents. She also gives workshops for teacher in-service programs. Her overall message is that children with ADHD are capable of developing specific learning strategies that will lead to improved academic learning and success. She outlines these specific skills in her book S.C.O.P.E.: Student Centered Outcome Plan and Evaluation (

Kubik, 2002

). The central theme of her work is to help parents and teachers find ways to help students with attention difficulties. The

American Academy of Child & Adolescent Psychiatry (2001)

stated,

· Research also should include the role of school and community-based professionals, as well as primary care clinicians, in delivering treatment services. Little is known about how short or long-term effectiveness varies as a function of the school and community-based professional involvement…. They should consider child and family outcomes and cost-effectiveness of care. Linking outcomes to service parameters is an important step in encouraging practice in system change. (p. 10)

In this summary statement, you can recognize aspects of the multimodal model that forms the basis of this book in analyzing and evaluating interventions with children and adolescents diagnosed with ADHD. It calls for more comprehensive research on the multiple factors that contribute to ADHD in children and adolescents and initiates the process to improve research on outcomes with this disorder.

ADHD and Comorbidity

The
American Academy of Pediatrics (2001)
also stressed that evaluation for ADHD should include an assessment for coexisting or comorbid conditions. The literature on ADHD identifies several psychological and developmental disorders that coexist in children with ADHD (

Biederman, Mick, Faraone, & Burback, 2001

;
Phelps et al., 2002
;

Spencer, Biederman, & Wilens, 2002

). These disorders included conduct and oppositional defiant disorders, mood disorders, anxiety and depressive disorders, mental retardation, learning disabilities, tics, substance abuse, and medical conditions. Researchers have estimated that among children with ADHD, the prevalence rate of

Oppositional Defiant Disorder is up to 35%, Conduct Disorder up to 26%, anxiety disorders up to almost 26%, and depression up to 18% (

AAP, 2001

). It is more difficult to estimate comorbidity rates of Bipolar Disorder, substance abuse, and tics. Most authors who discuss comorbidity and ADHD tend to discuss the issue from a pharmacologic perspective rather than a counseling perspective (

Levy & Hay, 2001

;

Solanto, Arnsten, & Castellanos, 2001

). This is a burgeoning and complex conundrum in the treatment of ADHD. We encourage you to be alert to the great variability in children and adolescents diagnosed with ADHD and to assess for other conditions or factors.

Susan L. Andersen (2005)

studied stimulants and the developing brain. She found that the effects of stimulant drugs during different stages have unique short-term, acute effects that also influence their long-term effects. Chronic, pre-pubertal exposure alters the expected developmental trajectory of brain structure and function and results in a different topography in adulthood. She also discovered that the timing of exposure (childhood vs. adolescence), the age of examination after drug exposure (immediately or delayed into adulthood), and sex influenced observable effects. Hopefully this can provide new treatment options for ADHD.

Mental health clinicians should be able to recognize the evidence recommending cautious use of stimulants with children and adolescents diagnosed with ADHD, and should remain alert to the potential for overdiagnosis or misdiagnosis of the disorder and the extensive range of comorbid/coexisting conditions.

Phelps et al. (2002)

summarized issues surrounding comorbidity of ADHD, ODD, and CD related to the evidence that when two or more of these disorders occur together, the prognosis is more guarded. They also addressed the hypothesis that ADHD occurs first in the child and the symptoms of impulsivity and inattention interact with the psychosocial issues of family turmoil, parental problems, and abuse factors to trigger ODD and/or CD. Clinicians need to be alert to the range of symptoms of several disorders when assessing and evaluating symptoms of impulsiveness and hyperactivity. These conditions could emanate from psychological family and environmental factors. Although the debate continues about the effectiveness of stimulant medication with ADHD,

Greenhill (1998)

and
NIH (1998)
concluded that stimulants used for ADHD children and adolescents

· 1. Producemoderate tomarked short-termimprovement in motor restlessness, on-task behavior, compliance, and academic performance.

· 2. In studies of six months or longer, children fail to maintain academic improvement or improve social problem-solving skills (

Greenhill, 1998

, p. 53).

Atomoxetine, a Nonstimulant

Recently, atomoxetine/Strattera, a nonstimulant and a selective norepinephrine reuptake inhibitor (SNRI) has demonstrated some promising results in reducing ADHD symptoms (

Brown University, 2002

). It was approved for use in children ages 6 and older in 2003 and for maintenance treatment of ADHD in children and adolescents in 2008. Atomoxetine/Strattera is metabolized primarily through the CYP2D6 enzymatic pathways. It demonstrates an adverse event percentage of between 3.5 and 7% (poor metabolizers) in clinical trials. These adverse events include gastrointestinal problems, irritability, insomnia, aggression, and dizziness. As a nonpsychostimulant, atomoxetine/ Straterra has potential as an alternative to the stimulants now used with ADHD. As with any new medication, only time and continued research will tell if atomoxetine will improve on the side effect profile of stimulant medications.

In a very sad and disappointing statement, the status of the treatment of ADHD has not changed in seven years since the first edition of this text.

· • Children, adolescents, and adults are being diagnosed at accelerated rates.

· • The first and second course of treatment is pharmaceuticals.

· • Efforts by the FDA, legislation like the Best Pharmaceuticals for Children Act have been marginalized.

· • Limited assistance for the poor, Medicaid, wards of the county or state, orphans and other children,

· and adolescents with restricted access to quality medical care.

· • A belief still that life is better through pharma— just watch TV since the Health Care Act passed in 2009.

· • Society’s intolerance for anxious, agitated, and aggressive children.

· • Large metropolitan school systems’ inability to understand the impact of bullying on students with disabilities.

So with little progress, more children take the drugs and some experience improvement whereas many others graduate to more potent pharmaceuticals.

Review Questions

· • What were the differences between the initial findings of the MTA study and the two-year and eight-year follow up?

· • What does the eight-year follow-up tell us about antisocial behavior and ADHD treatment?

· • What conditions may be comorbid with ADHD and why may these be a case of misdiagnosis?

SECTION FOUR: MOOD STABILIZERS AND BIPOLAR I DISORDER IN CHILDREN

Learning Objectives

· • Be able to think critically about the problems of putting children and adolescents on medications tested on adults.

· • Be able to articulate alternatives to so-called mood stabilizing medications for children.

The DSM-5 (

American Psychiatric Association, 2013
) provides the following diagnostic criteria for Bipolar Disorder, Single Manic Episode:

· A. Presence of only one Manic Episode and no past Major Depressive Episodes.
Note: Recurrence is defined as either a change in polarity from depression or an interval of at least two months without manic symptoms.

· B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Criteria for Manic Episode

· A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).

· B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

· (1) inflated self-esteem or grandiosity

· (2) decreased need for sleep (e.g., feels rested after only three hours of sleep)

· (3) more talkative than usual or pressure to keep talking

· (4) flight of ideas or subjective experience that thoughts are racing

· (5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

· (6) increase in goal-directed activity (either socially, at work, or school, or sexually) or psychomotor agitation

· (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

· C. The symptoms do not meet criteria for a Mixed Episode.

· D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

· E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Source: Diagnostic and statistical manual of mental disorders (5th ed., Text Revision, pp. 123–125). Washington, DC: American Psychiatric Association, 2013.

We have seen in the past decade an increasing interest and shift in focus from Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD) to Bipolar I Disorder in children and adolescents (

Kusumaker, Lazier, MacMaster, & Santor, 2002

;

Milkowitz et al., 2014

). We illustrated this in the case of Phillip at the beginning of this chapter. Although in our

Chapter Eight

discussion of mood stabilizers we focused on Bipolar I Disorder, in this chapter we use the more general BPI, because that is the construct common to the literature on children and adolescents. Many diagnostic scholars tell us the prevalence of BPI is growing, especially in preadolescent children, with almost no gender differences (

Bland, 1997

;

Hirschfeld et al., 2003

;

Zarate & Tohen, 1996

). The case for increased incidence is still undecided.

In the Diagnostic and Statistical Manual of Mental Disorder, 5th Edition (DSM-5;

American Psychiatric Association [APA], 2013

), BPI is the basis of a new category, Bipolar and Related Disorders. BPI is the centerpiece of this section, which also includes Bipolar II Disorder, Cyclothymic Disorder, Bipolar Disorders related to substance use or medical conditions, and other specified and unspecified Bipolar and Related Disorders. In order to stem the tide of BPI misdiagnoses in children, Disruptive Mood Dysregulation Disorder was introduced to the DSM-5 section on Depressive Disorders. The jury is still out on whether this will reduce the false diagnosis of BPI in children (

Margulies, Weintraub, Basile, Grover, & Carlson, 2012

) or, for that matter, how we should treat Disruptive Mood Dysregulation (

Jairam, Prabhuswamy, & Dullur, 2012

).

There is considerable controversy regarding the appropriateness of a BPI diagnosis in children. Questions regarding the appropriateness of such a diagnosis are founded on the idea that criteria for BPI may overlap with criteria for developmental issues; other disorders usually diagnosed during infancy, childhood, or adolescence (e.g., what the DSM-5 calls Neurodevelopmental Disorders); and other problems known to affect people of all ages (e.g., depressive, anxiety, substance use, and impulse-control disorders) (

Chang, 2008

). Further, there are currently no pediatric diagnostic guidelines for BPI in children, and it is inappropriate to use the DSM criteria for BPI because they were normed on adults (

Kowatch et al., 2005

;

Sahling, 2009

).

One of the most problematic issues is assuming that any type of irritability or acting out is somehow related to the invalid notion of a “bipolar spectrum.” Differentiating between irritability (very common in children and adolescents) and symptoms of BPI is an ethical imperative for clinicians, particularly those working in foster care or with other children and adolescents who have no one to advocate for them (

Banaschewski, 2009

;
Sahling, 2009
). Although published studies using functional brain-scanning technologies to investigate early-onset BPI are few, some show brain anomalies similar to those that correlate with adult BPI (

Frazier et al., 2005

). Only longitudinal studies will answer the question regarding how predictive such anomalies are for the development of BPI because brain scans can only suggest endophenotypes that are related to vulnerability to a disorder (

Jackson, 2006

).

The problems with the exponential increase in diagnosing pediatric bipolar disorder are many. In many children, rapid mood swings can be normal. The treatment guidelines (
Kowatch et al., 2005
) admit that “no one can say for sure what these children will look like when they grow up” (p. 214). This is a disturbing statement because BPI, properly diagnosed, is thought to be a chronic disorder. The authors of the treatment guidelines admit that the DSM symptoms for adult mania are problematic when used for children, but then they recommend continuing to use them. Overall, the treatment guidelines fail to draw distinctions between normal children and those really afflicted with BPI (
Sahling, 2009
).

Currently, the DSM-5 diagnostic criteria for Bipolar Disorder are used for children and adolescents without any major modifications and the features providing the best distinction between ODD,

CD, ADHD, and BPI are the presence of a flight of ideas, grandiosity, and the episodic nature of the grandiosity (

Carlson, 1996

;

Kusumaker et al., 2002

). As we summarize the literature on BPI in children and adolescents, we learn that it is difficult to diagnose, more clinicians are recognizing its prevalence at an earlier age of onset, three tentative developmental theories are linked to it (

McMahon & DePaulo, 1996

), and more clinicians are using antimanic medications to treat BPI in both children and adolescents.

Soutullo et al. (2005)

concluded that there is an overdiagnosis of Bipolar Disorder in the United States when compared to several countries like Spain, Turkey, India, Brazil, Switzerland, Denmark, and Finland. This difference may be attributed to a relative lack of data, differences in diagnostic criteria, different levels of recognition of child and adolescent psychiatry as a true specialty in Europe, clinician bias against Bipolar Disorder, an overdiagnosis in the United States, and/or a true higher prevalence of BD in the United States. It sounds like the same case with ADHD.

Viesselman (1999)

addressed the general symptoms of BPI as expansive mood, inflated selfesteem, decreased need to sleep, talkativeness, flight of ideas, distractibility, psychomotor agitation, and excessive involvement with pleasurable activities.
Phelps et al. (2002)
addressed the fact that BPI youth often are incorrectly diagnosed as having Schizophrenia; thus, BPIs are difficult to discern in children and adolescents because many present with an agitated depressed mood rather than mania (

Weller, Weller, & Fristad, 1995

).

Lewinsohn, Klein, and Seeley (1995)

stated that pediatric clients with BPI present with more psychomotor agitation, elevated mood, increased verbalizations, inflated self-esteem, distractibility, and a decreased need for sleep.

Duffy (2010)

detailed with great specificity the potential genetic markers for children who might be vulnerable to inherit Bipolar I.

The treatment of choice for BPI in children and adolescents is the mood stabilizers covered in
Chapter Eight
. These drugs include lithium/Eskalith, Lithobid, valproate/Depakote/Depakene/Divalproex), carbamazepine/Tegretol, oxcarbazepine/Trileptal, and olanzapine/Zyprexa. Many scholars already cited in this chapter argue against indiscriminate use of these medications with pediatric populations without further study and argue for more complete awareness of the dynamics affecting the child.

Riddle et al. (2001)

discussed the finding that the older antiepileptic drugs had been well researched as mood stabilizers in adults but not in pediatric populations.

Campbell, Kafantaris, and Cueva (1995)

have studied lithium/Eskalith, carbamazepine/ Tegretol, and valproate/Divalproex used for children with nonspecific aggression and found lithium/Eskalith was superior to placebo and to the other antiepileptic drugs in reducing aggression. One very important note:

Eberle (1998)

found that one type of adverse event of using valproate with girls is that of polycystic ovarian disease, which can have profound consequences for females.

In the early 21st century, children and teens are 40 times more likely to be diagnosed with Bipolar Disorder than they were in the late 20th century (

Miller & Barnett, 2008

). As noted above there is evidence that this is due to diagnostic inflation and not an epidemic-level increase in the disorder.

Geller et al. (2012)

compared lithium/Eskalith, valproic acid/Divalproex, and risperidone/Risperdal in a trial called Treatment of Early Age Mania (TEAM). The response rate for risperidone/Risperdal was significantly higher (68%) than for lithium/ Eskalith (36%) or valproic acid/Divalproex (24%).

Advokat et al. (2014)

note that quetiapine/Seroquel and aripiprazole/Abilify are as effective as risperidone/ Risperdal. As noted in the chapter on antipsychotics though, these drugs come with severe side effects like weight gain and disruption of metabolic functions that can lead to type 2 diabetes.

In our clinical work of over 40 years, we have found that the comorbid substance use disorders were a major missing piece in several cases with children and adolescents. These clients were diagnosed with ODD, CD, or BPI and seemingly did not improve with psychotherapy or psychotropic interventions. The missing link and confounding variable was their hidden polysubstance abuse or

dependence, which exacerbated some symptoms and masked others. The links in the literature show how the onsets of BPD, ADHD, CD, or ODD become significant risk factors in diagnosing substance use disorders. It should be noted that any attempts to procure research papers on pediatric or child papers on the research topics of developmental pharmacology, ADHD, BP I, and pharmaceuticals related to these disorders published in 2013 or 2014 were sponsored by pharmaceutical companies and cost $39.00.

The following case may provide additional understanding of these complex variables.

THE CASE OF NICOLE

Nicole, a 14-year-old Caucasian girl currently living in a foster home, had just been referred to a Severe Emotional Disturbance (SED) unit in her school system. Nicole had a history of acting out, impulsivity, distractibility, conduct, and learning problems from a very early age. Initially, Nicole was referred to a specialist for her impulsivity and distractibility both at home and in preschool at the age of 4.

During the assessment, the clinician suspected a mood disorder but seemed to have more evidence for ADHD. He recommended a daily course of amphetamine salts/Adderall with behavior management therapy at home and school, focused on specific age-appropriate behaviors. At the time of the evaluation, he did not notice Nicole’s intermittent scratching of her genital area. Over the next six months, Nicole showed little improvement in her symptoms and behaviors as a result of the amphetamine salts/Adderall and the milieu behavioral therapy. In fact, some of her behaviors worsened: she attacked other children, was cruel to animals, and was overtly curious about male and female genitals. After nine months, the psychologist consultant at the school recommended another neuropsychiatric evaluation and an outside therapist who would address some of Nicole’s apparent psychological conflicts along with her behavior.

The second psychiatric evaluation yielded a change in diagnostic perspective. This time, the psychiatrist diagnosed BPI and prescribed valproic acid/Divalproex and a low dose of lorazepam/ Ativan, an anxiolytic. The new therapist, a female, stopped the behavior therapy and began to treat Nicole with a combination of play therapy and insight-oriented therapy. The play produced associations to remote possibilities of earlier sexual abuse and abandonment, and the insight therapy captured her already highly critical superego (obsessive thought patterns and preoccupation with sexual act) and her deep affection for the rituals of the Catholic Church. Nicole remained on this treatment regimen for about two-and-a-half years. During treatment, she never really settled down in class or at home, but her behavior and attention were slightly more manageable. (We have all had cases where there is just enough improvement from the medication to raise expectations even if the client seems not to be making progress in many important areas of her life.) Later, Nicole developed a passion for reading 7 to 10 books a week that she got from the local library. On her trips back and forth to the library, she befriended some older boys (ages 10 to 13) who offered her street stimulants at a very low cost. Nicole welcomed the friendship and experimented with the drugs (stimulants, soapers, cocaine), but was gangraped by the boys one Saturday afternoon. Overwhelmed by this horrific sexual trauma, Nicole did not speak of it to anyone. She also immediately stopped associating with the boys. Her response to this event was alternately to withdraw into a cocoonlike isolation and to become aggressive with people.

She verbally assaulted teachers and foster parents and attacked her friends and other students. She was unreachable and totally out of control. She stopped attending her therapy sessions with the counselor, but she continued to seek street drugs.

Puzzled and frustrated, the school crisis team recommended an additional psychiatric evaluation and assessment for Nicole and possible hospitalization. This triggered a series of episodes in which she ran away, had several foster and specialized school placements, a brief stay at a juvenile detention facility, one abortion, and two attempts at drug rehabilitation for her dependence on stimulants, cocaine,

and now alcohol. Somehow Nicole survived and is now in an SED classroom with a specialized social worker as an aide. She is on olanzapine/Zyprexa for psychotic mania, sertraline/Zoloft for depression and anxiety, low doses of valproic acid/Divalproex for violent and aggressive outbursts, and zolpidem/ Ambien as needed for sleep. In essence, at 14, Nicole was loaded with psychotropic medications (polypharmacy). She was referred to a new female therapist, with whom she rarely spoke; when she did, she mentioned missing her former, caring play therapist, one of the most stable objects (people) in her life. Although Nicole did attend her class regularly and her behavior was quite manageable, her teachers reported very little learning progress and a total inability to interact with her classmates. Her therapist echoed much of the same descriptions, but voiced marginal hope when she and Nicole engaged in drawing or other forms of play therapy or discussed issues related to an all-loving versus all-punishing God. The concluding remarks in her individual educational plan (IEP) at school read, “No change, few academic gains, impulsive/ aggressive behavior stabilized, little socialization, continues in counseling.”

Examining this case from our four perspectives yields some important insights and omissions. Nicole did receive a more extensive assessment early on and participated in behavioral therapy first, which is recommended by the literature (

AAP, 2001
;
Kusumaker et al., 2002
;
Phelps et al., 2002
) followed by art therapy and insight therapy when the behavioral therapy failed. It is critical to note that the second therapist helped Nicole discuss psychological and cultural issues and learned about the pressure from her complicated feelings about her upbringing in the Catholic Church and her deep awareness of her selfcritical feelings and thoughts.

As is so often the situation with a foster child, other social and cultural pressures intervened, such as drug abuse, negative and exploitive peer relationships, and sexual trauma. It is not clear whether Nicole ever experienced sexual or physical abuse earlier in her life. The most recent team is faced with an early adolescent girl with a long history of psychotropic and psychotherapeutic treatments whose life is further complicated and traumatized by rape and drug dependence. Given the assumption that the significant others in her life—case managers, foster parents, teachers— feel she is out of control, the attending psychiatrist then addressed her range of symptoms and conflicts with a polypharmaceutical strategy. This approach numbs and tranquilizes Nicole so she is more appropriate in her various living environments but fails to address the boiling issues, anguish, and conflicts from the other aspects of her life. Treatment for Nicole should begin by recognizing the extreme complexity of her life space and developing a treatment plan and approach to gradually help her titrate off some of her medications while addressing in counseling the complex issues of abuse, drug dependence, abandonment, and loss of self that so plague her. She will need a very extended and interpersonal treatment approach if she is to recapture hope and resiliency in her life. We also would speculate about the accuracy of her diagnosis, because of the interplay of her conflicts and varying presenting problems and lack of empathy in her counseling.

Review Questions

· • What are some of the problems of putting children and adolescents on medications tested on adults?

· • What alternatives do we have to so-called mood stabilizing medications for children?

SECTION FIVE: CHILDREN AND ANTIPSYCHOTIC MEDICATION

Learning Objectives

· • Know the diagnoses for which typical and atypical antipsychotics are being used in children.

· • Be able to discuss the problems with this practice.

Schizophrenia with adolescent onset has been noted since the earliest descriptions of the disorder. Readers will recall Emil Kraepelin’s initial diagnosis of a

patient as having “dementia praecox,” which means “youthful insanity.” As

Russell (2001)

notes, given that the disorder has been linked with adolescents through the evolution of its diagnostic forms, one might think there would be ample treatment literature regarding these populations, but there is not. Childhood-onset schizophrenia (prior to age 12) is even rarer than adolescent onset. It is estimated that maybe 1 child in 10,000 would suffer this before the age of 12 (

Remschmidt, 2002

). The differential diagnosis must include substance-use disorders, depressive disorders with psychotic symptoms, and what DSM-5 calls other neurodevelopmental disorders like Autism Spectrum Disorder (

Androutsos, 2012

). Even when criteria are met it is very difficult to diagnose schizophrenia in a child. The Child Psychiatry Branch at the National Institute of Mental Health (NIMH) conducted a longitudinal study of childhood onset schizophrenia. Outpatient screening accurately diagnosed 55% of the 121 cases. However, inpatient observation including medication-free observation ruled out 96 children with alternative diagnoses. Outpatient screening only accurately diagnosed 62% of this same group. The conclusion the researchers drew was that inpatient, unmedicated observation was the most accurate way to diagnose these children (

Gochman, Miller, & Rapoport, 2011

).

In a review of controlled studies of antipsychotic agents to treat Schizophrenia,

Campbell, Rapoport, and Simpson (1999)

found only one controlled study of the use of these agents with adolescents and one report on their use with children younger than age 12. Therefore,
Russell (2001)
notes, until more research is conducted clinicians must extrapolate from adult studies to children and adolescents, which poses many risks. Although he comments this is not cause to adopt a nihilistic attitude, it does call for clinical skepticism. Russell maintains it may be true that people with early-onset Schizophrenia have more severe forms of the disorder, but this has yet to be determined conclusively and it does not mean pharmacologic treatment will not be effective. Further, early-onset Schizophrenia seems to have more severe negative symptoms, making the atypical antipsychotics a better choice if the children can tolerate the adverse drug effects (

Botteron & Geller, 1999

).

Although few data are available regarding the use of antipsychotics with childhood psychoses, in the 20th century the neuroleptic haloperidol/ Haldol was used because it tended to be less sedating (

Andreasen, 2000

). Because of the potential for Parkinsonian-like symptoms, this medication was often prescribed with an anti-Parkinsonian agent such as benztropine/Cogentin.

Ernst et al. (1999)

;
Phelps et al. (2002)
; and
Riddle et al. (2001)
also addressed the use of the “atypical” newer neuroleptics for children diagnosed with tics, behavioral problems in autism, psychotic illness, and nonspecific aggression. In 2004, Toren et al. (

Toren, Ratner, Laor, & Weizman, 2004

) did a benefit-risk assessment of atypical antipsychotics in treating schizophrenia and comorbid disorders in children. They found the atypicals seemed to work better than neuroleptics and now it seems that neuroleptics like haloperidol/ Haldol are only used if the patient does not respond to an atypical. Of the atypical, risperidone/ Risperdal and olanzapine/Zyprexa seemed to improve cognitive functions and inhibit suicidal behavior.

Madaan, Dvir, and Wilson (2008)

noted that the FDA concluded there was enough support for using atypicals in children and approved two atypicals for childhood schizophrenia.

As we noted in

Chapter Seven

, evidence is mounting that atypical antipsychotics are also correlated with increased risk for diabetes and hyperglycemia and that this risk includes children and adolescents (

Koller, Cross, & Schneider, 2004

). Research by

Correll et al. (2009)

confirmed these mounting suspicions. The study concluded that use of aripiprozole, olanzapine, quetiapine, and risperidone for 12 weeks all produced weight gain, and varied in lipid and metabolic parameters. The authors called for more careful monitoring of the child’s health before using an atypical. Whatever medication a clinician chooses,
Russell (2001)
emphasizes the need for multimodal treatment that includes psychosocial interventions such as individual and family therapy, psychoeducational counseling, and social skills training.

A more common problem is raised by

Pappadopulos et al. (2002)

in a study that examines the range of off-label prescribing of atypical antipsychotics for aggression. These authors state that although in theory doctors seem to agree about optimal prescribing practices, in the “real world” there is wild disparity in the prescriptions written. Apparently, even the agreement between researchers and front-line doctors can be influenced by staff pressure, limited staff resources, managed care limits on inpatient stays, and the movement away from physical restraint.

Another problem that requires further debate and research concerns the notion that Schizophrenia is a wide spectrum of early-onset disorders manifesting in a variety of the disorder called “schizotaxia,” which refers to a genetic predisposition to Schizophrenia (

Meehl, 1962

).

Tsuang, Stone, and Faraone (2001)

advocate treating Schizophrenia prophylactically. These authors maintain that the theoretically genetic predisposition toward Schizophrenia may be associated with reversible problems and may improve the child’s quality of life. Despite this strong medical model perspective, they admit that psychosocial interventions may also work. They conducted a six-week trial of risperidone (prescribed at low levels) in six subjects identified as schizotaxic. They reported that five of the six reported increased cognitive abilities during the trial as well as greater enjoyment of social activities. Obviously, there is no way to determine the amount of placebo effect until a double-blind, placebo-controlled trial is done.

Great caution needs to be exercised here, as the implications are that asymptomatic children might be given antipsychotics in the hope that their diagnosis as schizotaxic is correct. The antipsychotic market currently amasses $5 billion a year, and many fear that the theory of schizotaxia is just another way of bending the parameters of diagnosis to help pharmaceutical companies profit from a new market. Currently, no diagnostic system in the world identifies adolescents in the phase before onset as ill, so this approach would have ramifications for the diagnosis. Ideally, the issues surrounding the politics of research and publishing described in

Chapter Two

, need to be more adequately addressed before any further medicating of asymptomatic populations. As

Frances (2013)

noted, preventive psychiatry could only work if we know the etiology of a disorder and have a safe and effective treatment for the disorder. We have neither where schizophrenia is concerned.

In
Chapter Seven
, we discussed neuroleptics and their affinities for different CNS receptors, their pharmacokinetics, and pharmacodynamics.

Marriage (2002)

spoke to our inability to predict the response of an individual patient (child or adolescent) to a typical or atypical neuroleptic. He addressed the enormous response variation, especially with adolescent males, Asians, Native Americans, and people suffering fromvarious forms of organicity. For children or adolescents exhibiting symptoms of psychosis, the longterm prognosis is poor (
Phelps et al., 2002
), and we need to learn a great deal more about the adverse side effects of both the typical and atypical medications (
Riddle et al., 2001
). Given the outcome of

Olfson et al. (2006)

National Trends Study, which indicated that children treated with second-generation medication (atypical antipsychotics) included descriptive behavior disorders (37.8%), mood disorders (31.8%), pervasive developmental disorders or mental retardation (17.3%), and psychotic disorders (14.2%), we are again reluctant to endorse atypicals as a treatment of choice for childhood psychosis.

Review Questions

· • What are some of the conditions for which children are being put on antipsychotic medications?

· • What are the main drawbacks to this practice?

SECTION SIX: ANTIANXIETY MEDICATIONS AND CHILDREN AND ADOLESCENTS

Learning Objective

· • Understand particularly how anxiolytic medications are used with children who have school anxiety.

Despite the high prevalence of anxiety disorders in children (10 to 20%), very few controlled medication trials have been conducted. In DSM-5, Obsessive-Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) have been given their own categories. Children’s anxiety disorders, Separation Anxiety Disorder, Selective Mutism, Specific Phobia and Generalized Anxiety. In the late 20th century,

Brown and Sawyer (1998)

concluded that regarding anxiolytic medication with children, “few published empirical studies support their long term efficacy for children and adolescents” (p. 83).

Bernstein and Shaw (1997)

noted that psychotropic medications should not be the sole intervention but should be used as an adjunct to counseling. Interventions that facilitate active mastery are important, to prevent symptoms returning after discontinuation of medication. Little has changed and almost 20 years later anxiety disorders in children are first best treated with nonpharmacological therapies like behavior therapy, cognitive-behavior therapy, and internalizing prevention programs.
House (1999)
noted that children’s disorders can be generally grouped as externalizing (like acting out against others) and internalizing. Internalizing often results in anxiety symptoms. Young children with anxiety disorders are more likely to be depressed and to exhibit temperamental inhibition and sleep problems (

Doughert et al., 2013

).

The 2013 article of Rapp et al. will guide our complex study of anxiety disorders. The DSM-5 and earlier versions have really not assisted our journey to discover effective treatments for children and adolescents suffering from anxiety disorders (AD). It is the second author’s opinion that there have been too many changes in the DSM related to AD since 1980. Our focus needs to shift to treatment with safe and effective outcomes.

Bernstein, Borschardt, and Perwien (1996)

viewed these changes as placing at risk a decade of research on childhood anxiety disorders, although
Phelps et al. (2002)
supported elimination of some categories of childhood anxiety disorders from DSM III-R as a research-based simplification of the categories. Although prevalence rates vary for current anxiety disorders with children and adolescents (
Botteron & Geller, 1999
;

Garland, 2002

), incidences of Generalized Anxiety Disorders (GAD), and Separation Anxiety Disorder (SAD) are frequently thought to require both psychopharmacologic and psychotherapeutic interventions. Currently, although almost all the drugs are used off label, SSRIs such as paroxetine/ Paxil, fluvoxamine/Luvox, fluoxetine/Prozac, citalopram/ Celexa, and sertraline/Zoloft are prescribed for children and adolescents with anxiety disorders.
Advokat et al. (2014)
noted that fluoxetine/Prozac may be the best medication if medication is necessary. The current concern over safety of these medications for children and adolescents applies to their use in anxiety disorders as well as in depression. One of chronic side effect of SSRIs recognized in children is a behavioral activation (

Riddle et al., 1991

), like an increased agitation different from a mania. As noted earlier the

Food and Drug Administration (2003)

issued a Public Health Advisory stating that use of SSRIs and similar types of antidepressants with depressed children and adolescents may be linked to increased suicide rates. How this will affect use of these antidepressants for anxiety disorders remains unclear.

Rapp, Dodds, Walkup, and Rynn (2013)

continued to use SSRIs in their combined treatment approaches with children diagnosed with GAD, SP, and SAD. Their study gave very high marks to Cognitive-Behavioral Therapy (CBT) in conjunction with a psychopharmacological approach.

In a review of the literature on anxiolytic medications used in pediatric populations,

Livingston (1995)

noted mixed results with benzodiazepines and said that in cases where studies show initial results, the results fail to be significant in replications of the studies. Livingston notes that if children are going to be placed on these medications, prescribers need to “start low and go slow” (p. 248). Recall from

Chapter Six

, benzodiazepines such as alprazolam/ Xanax and diazepam/Valium have an inhibitory impact on the CNS at the GABA receptor complex. As
Advokat et al. (2014)
note these drugs usually cause cognitive impairments and so are not recommended except in the case of shortterm medical procedures (e.g., dental procedures).

SCHOOL ISSUES, ANXIETY, AND CHILDREN

A relevant law when addressing anxiety in children is the Individuals with Disabilities Education Act (IDEA). Services to children are provided under a number of provisions in this act, and often many DSM anxiety disorders can be used to qualify a child for services. The diagnostic categories of DSM do not automatically correspond to the eligibility categories in IDEA. The interested reader can go to

http://www.ed.gov/offices/OSERS/IDEA/the_law.html

for a listing of the relevant diagnoses. IDEA services focus on disability conditions that interfere with a child achieving academically or vocationally.

Anxiety disorders have been used to qualify a child for special services. A key symptom is fears associated with personal or school problems that persist over a period of time and adversely affect educational performance. Anxiety disorders are one of the most common childhood disorders and may impair a child’s life even if symptoms are below the threshold for a DSM diagnosis. For example, some studies show “subclinical” anxiety to be highly correlated with reading difficulty (

Bernstein & Shaw, 1997

). Currently, studies are underway to measure the impact of bullying on anxiety (

Twemlow, Fonagy, Sacco, & Brethour, 2006

).

Developmental differences exist in the presentation of the anxiety disorders. For example, younger children with Separation Anxiety Disorder have far more symptoms than older children. In adolescents, somatic complaints and school refusal are more common than in younger children. Conversely, older children with GAD show more symptoms than younger ones. This is probably caused by cognitive differences, because older children have more mental tools with which to craft their worries.

Interestingly, in several studies with benzodiazepines, the medicated groups did no better than placebo controls. Two studies did yield significant differences among school refusers and children with selective mutism and social phobia. In one study, the school refusers did better than controls when given Tofranil/imipramine, a tricyclic antidepressant. The other study, on selective mutism and social phobia, showed that the experimental subjects did better than controls when given Prozac.

A related childhood disorder is Separation Anxiety Disorder. Here, the anxiety is aroused by separation from familiar people (usually parents) or leaving home. The reaction is excessive and may include fears that something will happen to the parents or to prevent reunification. Somatic complaints are also common. The distinction must be made between developmentally normal separation anxiety and this disorder. If refusal to go to school is thought to be due to Separation Anxiety Disorder, the child will go if accompanied by the parent. Although benzodiazepines and antihistamines have been used to treat this (

Wozniak et al., 1997

), exposure-based interventions and relaxation are likely to be more effective.

Another subthreshold condition is shyness. It is consistently correlated with adult and childhood anxiety disorders. Although common (90% of people report feeling it at some time in their lives), it can be debilitating as the person gets older. Shy men marry later and become parents later than their counterparts who are not shy. Although shy women marry and become parents at ages comparable to their counterparts who are not shy, they are less likely to attend college or work outside the home. Social phobia is a severe manifestation of shyness that afflicts about 5% of children. It delays social and emotional development. The overwhelming fear of doing or saying something embarrassing or humiliating keeps such people from eating, drinking, or writing in public or engaging in everyday conversations.

Although children generally outgrow shyness, they do not outgrow Social Phobia. Children with social phobias are usually depressed and lonely and almost always solitary. They may show extreme anxiety in situations where they feel they are being evaluated by others. The onset of Social Phobia is usually in adolescence and without treatment, the course is often chronic. There is high comorbidity with depression, other anxiety disorders, and substance abuse to self-medicate. As with other

childhood anxiety disorders, the recommended treatments include rehearsal, imagery, and drug treatment with antidepressant compounds. Behavior therapy has a 70% success rate for both children and adults, with systematic desensitization and exposure being the common treatments. Although more children and adolescents are being prescribed SSRIs and SNRIs for shyness and Social Phobia, there is literature supporting the practice.

Rapp et al. (2013)

continued to use SSRIs as the pharmacological treatment of choice in their protocols with some success and marginal adverse effects in the pediatric population. They reported on one study that used pregabalin (Lyrica) with promising results with a pediatric population. There are too many adverse effects to pregabalin.

Review Question

· • How could anxiolytics be helpful to children with school anxiety?

SECTION SEVEN: ANTIDEPRESSANTS AND CHILDREN AND ADOLESCENTS

Learning Objectives

· • Understand why the black-box warning on antidepressants for children is important.

· • Be able to suggest the type of monitoring necessary if a child is on an antidepressant.

· • Know the “placebo problem” especially in reference to children and antidepressants.

Many reports have appeared on an increased incidence of MDD in children and adolescents. Although more studies on this have begun, there is always error in the epidemiologic methods used to gather such data, so such reports are far from conclusive (

Ingersoll & Burns, 2001

). As

McClure, Kubiszyn, and Kaslow (2002b)

noted, many approaches are used for diagnosing and treating mood disorders in children, only a few have any empirical support. It does seem that when identified, childhood or adolescent depression is characterized by high rates of comorbidity with conduct, anxiety and attention deficit disorders, impaired social and vocational functioning, increased rates of substance abuse, eating disorders, and higher risk for completed suicide (

West, 1997

). Given that, it is important to consider all treatments that may be helpful when a child or adolescent does manifest symptoms of depression.

Depression (unipolar) can be very difficult to discover, discern, and diagnose in children and adolescents. In children, the symptoms manifest themselves as hyperactivity, impulsivity, and aggressiveness. Grief and loss may trigger enuresis, sleeplessness, nightmares, and extreme stubbornness, depending on the age of the child (
Brown & Sammons, 2002
;
Riddle et al., 2001
;

Ryan, 2002

;

Viesselman, 1999

). In fact,

Ryan (2002)

noted that depressive illnesses in children and adolescents can be protracted, recurrent, and continue into adulthood.

Newer research into the complexities of antidepressant action can help neurologists and clinicians better understand developmentally important age differences in the nervous system. Researchers are beginning to see that developing animals differ from older ones in serotonin-mediated responses. Very-early-onset stress may compromise later adaptive capacity of some of these systems (

Goldman-Rakic & Brown, 1982

). Juvenile depression may also differ substantially from adult depression regarding the role of noradrenergic mechanisms and thus in the responsiveness to compounds that target norepinephrine. Practitioners need to be alert to warnings such as those by
Coyle (2000)
, who noted there is “no empirical evidence to support psychotropic drug treatment in very young children and that such treatment could have deleterious effects on the developing brain” (p. 1060).

Tricyclic Antidepressants in Children

Overall, the results have not supported data found in adult studies regarding the efficacy of tricyclic antidepressants in treating juvenile depression

(

Cohen, Gerardin, Mazet, Purper-Ouakil, & Flament, 2004

;

Rosenberg, Holttum, & Gershon, 1994

). The weight of currently available evidence suggests that TCAs as a group are indistinguishable from placebo, except in side effects (

Kutcher et al., 1994

;

Puig-Antich et al., 1987

). The highest response rate in a study is about 44%. In addition, a significant risk arises of serious cardiac problems in developing bodies. The same conclusions hold true for the TCA derivatives such as desipramine/Norpramin and nortriptyline/Trazodone. Both have been fairly well studied, and researchers have failed to show significant therapeutic differences from placebo but did show a high number of adverse side effects. In addition, both still carry the risk of cardiovascular complications.

Research has demonstrated that TCAs (and MAOIs) have not revealed greater efficacy than that for placebo, and their adverse side effect profile is extensive, including reports of sudden cardiac death (

Birmaher, 1998

;
Brown & Sammons, 2002
;

Kye et al., 1996

;

Riddle, Geller, & Ryan, 1993

;
Werry, 1999
). There is little support if any for the routine use of TCAs as a first line of treatment in children and adolescents. Therefore, it is disturbing that millions of prescriptions for desipramine and related compounds have been written for young people under age 18 (

Goleman, 1993

).

Sommers-Flanagan and Sommers-Flanagan (1996)

recommended that such prescriptions be reserved for special cases where other treatments have proven ineffective or intolerable and that a thorough physical (including cardiovascular exam) should be conducted before beginning the medication. TCAs should be used in children only under the following conditions:

· • Full informed consent of patient and parent

· • A history of lack of response to more appropriate treatments

· • Full disclosure of side effect profile

· • Disclosure of cardiotoxicity of these compounds

· • When trials of more effective, available pharmacotherapies (SSRIs) have failed

Also, TCAs should be used with extreme caution, because the noradrenergic system (on which TCAs operate) does not fully develop until early adulthood (
Goldman-Rakic & Brown, 1982
). This evidence has not changed.

SSRIs in Children

As noted, the

FDA (2003)

has currently issued a Public Health Advisory cautioning about a possible link to the use of certain SSRI antidepressants in pediatric populations and increased suicide rates. The antidepressants in the advisory are listed in

Table 9.4

.

As noted, the SSRIs currently are used with children and adolescents for anxiety and depression. Fluoxetine/Prozac has received FDA approval for use in pediatric populations, and fluvoxamine/ Luvox is approved for treating OCD in children (
Brown & Sammons, 2002
). All other SSRIs are prescribed as off label to children with depression as of this writing. Children and adolescents encounter the same adverse effects as when the SSRIs are employed with anxiety disorders. These compounds are more effective in children but not as effective as in adult samples. Glaxo-SmithKline pled guilty to criminal charges for promoting paroxetine for use in the pediatric agerange for the treatment of depression (

Hensley, 2012

).

TABLE 9.4 Antidepressants Listed in 2003 FDA Public Health Advisory

Generic Name

Brand Name

Fluoxetine

Prozac

Fluvoxamine

Luvox

Citalopram

Celexa

Escitalopram

Lexapro

Mirtazapine

Remeron

Nefazodone

Serzone

Paroxetine

Paxil

Sertraline

Zoloft

Venlafaxine

Effexor

Bupropion

Wellbutrin

© Cengage Learning®

It is important to note that adolescent girls are particularly vulnerable to depression when entering puberty (

Phelps et al., 2002
;

Silberg et al., 1999

). Clinicians should be sensitive to gender, family history of depression, impacting life events, loss, or death when assessing children for depression. Current trends and preliminary understandings of the research suggest that in addressing childhood depression, the clinician must consider both psychotherapy and medication (

Badal, 1988

,
2003
).
Ryan (2002)
indicated that 30 to 40% of children do not have a sufficient response to the first SSRI treatment.

There is almost no literature on the effects of SSRIs on infants and preschoolers (

McClure, Kubiszyn, & Kaslow, 2002a

); however, evidence shows SSRI prescriptions are on the increase for this age group (
Zito et al., 2000
). The majority of researchers looked at the effects of fluoxetine (Prozac) on older children and adolescents, which has shown mixed results (

Emslie et al., 1997

). Some studies looking at the effects of paroxetine on children and adolescents are also promising (

Findling et al., 2000

;

Keller et al., 2001

), but more doubleblind, placebo-controlled studies need to be done. Juveniles with a family history for manic or hypomanic symptoms are at higher risk for SSRIinduced manic or hypomanic episodes. If children or adolescents are treated with SSRI medications, treatment should be cautious and should observe the following conditions:

· • SSRIs are used in addition to supportive psychotherapy or counseling to deal with psychological issues.

· • SSRIs should be supported by education regarding the symptoms, the medication, and what relief the medication is to provide.

· • Effective treatment involves parents or caregivers as much as possible.

· • Effective treatment includes use of a depression scale (HAM-D or BDI-II) if the child is old enough to take one, to monitor symptoms.

· • The acute phase of treatment should take place over 8 to 12 weeks followed by maintenance of 4 to 6 months.

McClure et al. (2002a)

conclude that when medication is warranted, the SSRIs are the medication of first choice.

Jureidini et al. (2004)

disagree, however. They recently reviewed and critiqued seven published randomized, controlled trials of newer antidepressants for depressed children. These researchers found that pharmaceutical companies paid for the trials, the benefits of the drugs were small, and the adverse effects were downplayed, and they concluded antidepressant drugs could not be confidently recommended as a firstline treatment option. This is only one metaanalysis, but it points to the need for validity in published data and full disclosure of biases resulting from funding sources or researchers. Karger (2013) concluded that SSRI and even SNRI treatments for pediatric populations were/are too risky and this is from an international perspective. He stated that the SSRIs were more effective with anxiety disorders. Studies have been more compromised in pediatric populations with depression. Also,

Craighead, Miklowitz, and Craighead (2013)

summarized the work of Dr. Du of Shanghai who indicated that his studies demonstrate that SSRIs are safer in adolescents than in children. Dr. Du encouraged universal efforts of prevention to address the 17–20% of children who are depressed in all of our cultures.

From an integrative perspective, it is important to review all literature as it comes in, as well as review the researchers and the funding sources to check for possible bias. At the time of this writing, a new government-funded study of SSRIs and children was completed but not officially released in a peer-reviewed journal. The study was the Treatment for Adolescent with Depression Study (TADS), sponsored by the National Institute of Mental Health (NIMH). When we called NIMH to get a copy of the study, we were told the study needed to be peer-reviewed and the results would not be released until that process was complete. Nevertheless, Time magazine (

Lemonick, 2004

) and The New York Times (

Harris, 2004

) reported

(without benefit of peer review) that the study supported the use of the medications with children. When we asked the NIMH representative how the popular press would have gotten the results to report before the peer review, she said she didn’t know. Until a peer review of the study is concluded, the writers have no basis for these conclusions other than their own opinions of the study. Without including the results of peer review, readers are likely to come away with a “sound byte” interpretation of the results that may not be accurate. Readers can access the latest results of drug trials on the NIMH website

http://www.nimh.nih.gov/studies/2mooddisordersdep.cfm

. We did not try for the results in 2014.

THE PLACEBO PROBLEM

As we noted in
Chapter Five
, the placebo effects of compounds and the place and type of placebo in studies has yet to be explicated. According to

Fisher and Fisher (1997)

, “A probe of the available scientific reservoir of pertinent studies does not reveal any serious evidence that antidepressants do more for childhood depression than do placebos” (p. 308). An earlier overview of studies by

Thurber, Ensign, Punnett, and Welter (1995)

concluded that the more adequate the experimental methods in each study, the less likely to be found superior to placebo were the drugs tested. Although
Fisher and Fisher (1997)
noted that the evidence is still limited for the effectiveness of many counseling/psychotherapy approaches to depressed children and adolescents, this does not excuse the prescribing of compounds for which very little evidence of efficacy and effectiveness exists.

In concluding this section, we remind the reader that clinicians are using off-label psychotropic medication for several other disorders. In each case, the clinician must weigh the benefit versus the potential adverse effects of the drug on the child. We must also speak to the child about his or her reaction and feelings about the medication and request feedback from the parents or guardians about the child’s progress or struggles with the psychotropic medications. We believe it is an enormous responsibility to counsel children and adolescents who are on psychotropic medication where little research has been conducted on the efficacy, effectiveness, and safety of the drugs.

In April 2003, the recommendations were published of the Research Forum approved by the American Academy of Child and Adolescent Psychiatry (AACAP) on strategies for psychopharmacological studies on preschool children (

Greenhill et al., 2003

). The six workgroups of the Research Forum were (1) diagnosis/assessment, (2) research design, (3) ethics/institutional review board (IRB), (4) preschool protocol modifications, (5) FDA/regulatory industry, and (6) training/public issues. Finally, when our text was reviewed in 2005, most psychiatrists challenged us on our strident positions about pharmaceutical research, medicating children, split-treatment (working together—psychiatrist and mental health professional), and the general tone of our text. Now we wish to extend our empathy to all psychiatrists who work under tremendous pressure to cure the incurable and find the magic pill.

Review Questions

· • Why is the black-box warning on antidepressants for children important?

· • If a child is put on an antidepressant, what sort of monitoring is necessary for the child?

· • What is the placebo problem with regard to children and antidepressants?

CONCLUSION

We have sought to highlight the complexity, controversy, and conundrums of child and adolescent psychopharmacology. By now, you are alert to factors from all four perspectives that impinge on this issue, generate “word magic,” provide partial truths, or stimulate errors. In the colossal debate over ADHD, we discover not only errors but an inflexibility that may harm children rather than treat them. We recognize the power and influence of the pharmaceutical companies to market so many “off-label”

psychotropic medications to children and adolescents with such confidence or, more accurately, grandiosity. Central to this dilemma are the shortages of mental health professionals and psychiatrists who exclusively treat children and adolescents. This shortage, coupled with the growing confidence of the effectiveness of psychopharmacology with some diagnoses, permitted pharmaceutical companies to market “off-label” drugs for children and adolescents on a grand scale while clinicians observe the phenomenon, almost powerless. Even the passage of the Best Pharmaceuticals Act for Children 12 years ago is not enough to slow this trend.

SUMMARY

The use of psychotropic medications with children and adolescents is very complex. Clearly there is no simple answer to this dilemma. Because most of the medications are prescribed off label, it is important that mental health professionals learn all that they can in order to protect the health and well-being of their clients who are children and adolescents. The information provided here spans the four perspectives to challenge the reader to consider medical, psychological, cultural, and social paradigms. The discussion of stimulant medications serves as a template for practitioners as they consider psychotropic applications with other disorders. When children or adolescents are placed on a psychotropic, it is always recommended that they receive counseling or other supportive services. The federal government through recent legislation is emphasizing how important and critical this issue is. Finally, the question is asked, “Do we as a society use psychotropic medication as the ultimate modality of behavior and anger management?”

CHAPTER NINE Medicating Children

This chapter is divided into seven sections. Section One is an overview that discusses current trends in medicating children, problems the trends cause, and directions for the future. It also discusses developmental issues. Section Two focuses on stimulant medication and the diagnosis of attention deficit hyperactivity disorder (ADHD). Section Three focuses on research on combined interventions and particularly the Multimodal Treatment Study (MTA study) of Children with ADHD. Section Four focuses on children taking mood stabilizers. Section Five focuses on antipsychotics and children. Sections Six and Seven focus on anxiolytics and antidepressants in children, respectively.

SECTION ONE: PERSPECTIVES, DILEMMAS, AND FUTURE PARADIGMS
Learning Objectives
· • Understand the problematic increase in psychotropic medications for children despite a dearth of evidence of the effectiveness of these drugs.
· • Have a general understanding of the impact of the FDA Modernization Act and the Best Pharmaceuticals Act for Children.
· • Be able to state the “developmental unknowns” associated with giving kids psychotropic medications.

Thus far, we have explored the medical model and psychological, cultural, and social perspectives as they relate to psychopharmacology. In this chapter, we demonstrate that using psychotropic medications with children and adolescents raises particular problems and concerns from several perspectives. As discussed in
Chapter Three
, we frequently see explanations and justifications from the medical model perspective used to reduce childhood disorders to chemical and genetic problems, excluding crucial consideration of environmental traumas, developmental foreclosures, or life stressors.

We explore child and adolescent psychopharmacology primarily from the medical model perspective but complement this approach with information from the other perspectives (psychological, cultural, and social). We set the stage by exploring the current status of the treatment of children and adolescents with mental and emotional disorders. This chapter is structured differently from the others in this book. We begin by discussing the context from the social and cultural perspectives and the problems with prescribing psychotropic medications to children. Then we cover an introduction to stimulants used to treat symptoms of ADHD. Finally, we give the status of their current use since the last edition of the book if that is possible.

THE COMPLEX STATE OF THERAPY
Dr. Frank O’Dell, Professor Emeritus of Counseling in the College of Education and Human Services at Cleveland State University, has argued in all his lectures on counseling children and adolescents that the United States is an “anti-kid” society (Personal Communication, 2001). By that he means fewer

and fewer therapists and psychiatrists choose to treat or continue to work with children in counseling. To support his argument, O’Dell points out that resources for children, including the number of hospital beds in mental health wards for children, have been shrinking. He believes the rules of managed care companies, dwindling personnel resources, and increasing difficulty in working with parents or guardians and their struggling children all contribute to the current trend. This has been a problem for at least 45 years. The
American Academy of Child & Adolescent Psychiatry (AACAP) (2001)
summarized the following facts, which support O’Dell’s assertion, indicating little has changed:

· • There is a dearth of child psychiatrists.
Satcher (2001)
stated further that many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals who are available and that places a burden on pediatricians, family physicians, and other gatekeepers to identify children for referral and treatment decisions (
U.S. Department of Health and Human Services, 2001
).
· • The AACAP’s report projected that between 1995 and 2020, the need for child and adolescent psychiatrists will increase by 120%, whereas the need for general psychiatry is projected to increase at 22% for the adult population.
· •
McCarty, Russo, and Rossman (2011)
demonstrated that only 13% of youth with suicidal behaviors and ideation receive mental health services.
· • In November 2010, the Coalition for Juvenile Justice estimated that up to 75% of teenagers in the juvenile justice system nationwide have a diagnosable mental disorder, and these numbers continue.
· • One in 10 children suffers from mental illnesses severe enough to impair development. Fewer than 1 in 5 children get treatment for mental illness.

The
U.S. Department of Health and Human Services (2001)
concluded that burgeoning numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by the institutions and systems created to care for them. As the number of children and adolescents needing psychological treatment rises and the number of service providers falls, the primary treatment modality becomes psychotropic medications rather than therapy. Imagine if you were a parent of one of these children.

Debner (2001a)
reported that in a one-year period, 350 children needing hospitalization were turned away from hospitals in the Boston area. This phenomenon is occurring in most major U.S. cities and is exacerbated by hospitals holding onto children who are ready to be discharged, because there is no suitable placement for them. In another article,
Debner (2001b)
noted that the chief pediatricians from the five major academic health centers in Massachusetts indicated there is a serious crisis in psychiatric services for youth in the state. The doctors said they and their staffs could not find appropriate therapy and other mental health services for mentally ill children. As a result, many such children deteriorate to the point of crisis.
Thomas and Holzer (2006)
reported that America suffers from a serious longterm shortage of child psychiatrists that is taking a toll on young people, their parents, and their doctors. It is further recognized that the demand for psychotropic drugs is intense in spite of dangerous side effects.

The
Washington Post

(2002)
published an article about a woman who desperately needed a psychiatric evaluation for her teenage daughter and who left 36 phone messages for various psychiatrists. She received only four replies. All the replies were from practitioners who refused to take the case because they did not treat adolescents. The article further detailed how, more and more, in-network providers (clinicians) prefer not to take patients covered by managed care plans, because reimbursements are so low and restrictions so numerous. The article also highlighted the disparity and arguments between the treating professionals and spokespeople from managed care companies. It is more than fair to say that desperate parents and anguished children are caught in the political policy dilemma over the cost and reimbursement of mental health treatment for children and adolescents.

Since the first edition of this book, there has been a movement to train more primary care physicians in pediatric mental health services to try to address the shortage of pediatric mental health professionals.
Aupont et al. (2013)
describe a model called Targeted Child Psychiatric Services designed for primary care physicians as well as child psychiatrists. This was associated with improved access to the child psychiatric services that exist, helped identify optimal care settings for patients and helped pediatricians be more likely to accept a patient back after that patient had been under psychiatric care.

Another problematic topic is who dispenses medications in schools. Most states have a policy on this and many states have a Nurse Delegated Medication Administration program (
Ryan, Katsiyannis, Losinski, Reid, & Ellis, 2014
). Most standardized curricula include trainings of approximately 30 hours with 8-hour updates every two years or so. These are by and large directed by professional nurses (
Spector & Doherty, 2007
). Nationwide lists of states and their programs can be found at
http://www.nasbe.org/healthy_schools/hs/bytopics.php?topicid=4110&catExpand=acdnbtm_catD
and
http://www.healthinschools.org/health-in-schools/health-services/schoolhealth-services/school-health-issues/medicationmanagement/state-policies-on-administration-of-medication-in-schools.aspx
.

THE EXPLOSION OF PSYCHOTROPIC MEDICATION PRESCRIPTIONS FOR CHILDREN AND ADOLESCENTS

With diminishing psychological supports for children and adolescents, using psychotropic medications with them has become the treatment of choice, even though the majority of medications used with them lack FDA “on-label” approval for them (
Werry, 1999
). Researchers currently estimate that between 7.5 and 14 million children in the United States experience significant mental health problems (
Riddle, Kastelic, & Frosch, 2001
;
Wozniak, Biederman, Spencer, & Wilens, 1997
). These statistics vary a little from
Satcher (2001)
, cited earlier; clearly, millions of children in this country require mental health services. Children are increasingly prescribed psychotropic medications as part of their treatment; in many cases, the medications replace the therapy (
Jensen et al., 1999
;
Phelps, Brown, & Power, 2002
). Given the explosion in the use of psychotropic medication with children, it is important also to note that this population has been excluded from clinical trials of these drugs. Hence, decisions about juvenile medication obviously rest more on extrapolation of adult data to children and adolescents than on direct research and evaluation of the safety and efficacy of psychotropic medication with children (
Riddle et al., 2001
;
Vitiello & Jensen, 1997
).

Coyle (2000)
indicated that 80% of all medications prescribed to children and adolescents in the United States have not been studied for the safety and benefit of these populations. As of 2011, The National Institutes of Health indicated that methylphenidate, lithium, all atypical antipsychotics, lorazepam, and amitriptyline were still on the highest priority list of needs in Pediatric Therapeutics of drugs to be studied in pediatric populations.

Even though there is a black box warning related to the risk of increased suicidality in children and adolescents prescribed SSRIs and SNRIs, the use of these psychotropic agents has increased with children and adolescents (
Markowitz & Cuellar, 2007
). The trend in treating children and adolescents with off-label psychotropic medications, mostly in lieu of counseling and psychotherapy, has triggered concern both in the general public and the mental health community.
Coyle (2000)
,
Furman (1993)
, and Zito (
Zito et al., 2000
,
2003
) argue that there is little or no evidence to support psychotropic drug use with very young children and conclude that such treatment could have harmful psychological, developmental, and physical effects. In a multinational study, American youths were three times more likely to be on an antidepressant medication than their peers in Denmark, Germany, and the Netherlands (
Zito et al., 2006
). In 2010, the pharmaceutical companies research protocols were really challenged when uncovered pharmaceutical studies on many highly utilized

psychotropics were found to be no more efficacious than the placebo. In fact, the second author has personal communications with several psychiatrists in their fourth or fifth decade of practice who question the overall effectiveness of psychopharmacology with patients, especially children (Ramirez, Personal Communication, 2014).

In another multinational study,
Zito et al. (2008)
found that the annual prevalence of youth taking psychotropic medication was threefold greater in the United States than in the Netherlands and Germany. The atypical antipsychotics represented 5% of antipsychotic use in Germany but 66% in the United States. Interestingly, though, anxiolytics were twice as common in Dutch youth than as in U.S. or German youth.

With proper research, mental health professionals may be able to head off disasters such as aspirin precipitating Reye’s syndrome or valproate leading to sudden death in infants (
Riddle et al., 2001
). Given the lack of knowledge about the long-term and adverse effects of psychotropic medication on children, it is crucial that mental health clinicians be alert to the impact of these drugs on children and advocate for youth when the evidence that such drugs would be helpful is questionable (
Ingersoll, Bauer, & Burns, 2004
). At this point, we would like to introduce a case that highlights many of the treatment and medication dilemmas children and adolescents encounter.

THE CASE OF PHILLIP
Phillip is a 7-year-old first-grader from a singleparent home. His mother is on public assistance, and he is the oldest of four boys. Although some of the details of his developmental history are sparse, Phillip began to exhibit impulse control problems at the age of 2 years and 4 months, shortly after his father moved out of the house. He was hypervigilant, easily distractible, aggressive with his younger sibling, and frequently irritable. Initially, his mother believed he was going through a stage of rebelliousness, but after several months she became concerned about his behavior and mentioned this to the pediatrician. After a brief examination, the pediatrician indicated that Phillip was likely suffering from ADHD and recommended against medication unless his behavior got too out of control at home. However, she felt he would need a course of methylphenidate/ Ritalin, a prescription stimulant, once he began preschool. Phillip’s mother accepted this recommendation and planned to have him evaluated when he began preschool. Phillip’s behavior improved slightly over the next several months, without therapy or psychotropic medication.

When he began preschool, it took only a few days before all his active symptoms returned. After observing him for several weeks, the teacher recommended to Phillip’s mother that he see a physician to be assessed for a stimulant medication. After the evaluation, the physician prescribed 10 mg of methylphenidate/Ritalin daily for Phillip. Methylphenidate/Ritlain is one of the most common stimulants used for symptoms of ADHD in children. It is intended to reduce inattentiveness, distractibility, impulsivity, and motor hyperactivity, with a goal of improved academic productivity. Phillip’s symptoms slightly improved over the next eight weeks, but his aggressive behavior toward other children increased. Phillip’s mother noticed more unpredictable behavior at home, as well as sleeplessness and restlessness followed by long periods of lethargy. She took him back to his physician, who referred them to a psychiatrist. The psychiatrist, after a three-session assessment, diagnosed Bipolar I (BPI) Disorder, took him off the methylphenidate/Ritalin, and prescribed 50 mg of carbamazepine/Tegretol daily and 0.01 mg of clonazepam/ Klonopin. The carbamazepine/Tegretol was used to reduce his manic symptoms. This antiseizure medication has over time been found very effective with Bipolar Disorder (
Phelps et al., 2002
).

The clonazepam/Klonopin was used to address Phillip’s anxious and agitated symptoms. This antianxiety medication often relaxes children and reduces anxiety without inducing sleep.

Many of Phillip’s symptoms diminished, but his mother noticed both a sluggishness and apathy in him that were new. Over the course of the next year, Phillip’s teacher addressed several of his learning and cognitive processing problems. Up to this

point, the focus of Phillip’s treatment had been psychopharmacologic. No psychosocial interventions were given to Phillip, as is often the case (
Phelps et al., 2002
). No one seemed to have any awareness or discussion about the optimal level of medication for Phillip, and there was no referral for a psychosocial assessment. As his symptoms worsened, he was evaluated by a psychiatrist schooled in prescribing adult psychotropic medications off label to children. Finally, Phillip’s mother took him to see a therapist, who focused on Phillip’s attachment issues, his phobic anxiety triggered by sudden loss or the anticipation of sudden loss, and his physiologic symptoms, which the therapist considered powerful side effects of the pharmacologic therapy.

Analysis of Phillip’s Case

Analyzing the case, Phillip was treated by pharmacology in the medical model method and rational thinking centered on pharmacology dominated the case. The combination of methylphenidate/Ritalin and carbamazepine/Tegretol on Phillip’s system was supposed to reduce some of his externalizing symptoms in the constellation of ADHD or Bipolar I disorders, but the psychological aspects of his personality were ignored. Not until much later in the course of his illness did Phillip get some assistance in those domains. Culturally, Phillip’s mother had little power in society and was torn between accepting the opinion of the medical experts, and watching the negative impact the medications were having on her son. As mental health professionals, we need to understand the medical psychiatry’s rapid efforts to address most disorders of childhood and adolescents with psychotropic medication. Far too often, medicating professionals view talk therapy and other psychosocial interventions as ineffective and second rate. Because medical professionals hold more power in our society than mental health professionals, their medical opinions are frequently given more weight. Today, psychiatrists burdened by enormous caseloads are open to what is known as split-treatment, a joint effort by the mental health professional and psychiatrist to plan and integrate treatment and be vigilant for client manipulation. We must integrate care into a larger model of treatment that addresses each of the four perspectives equally and where mental health professionals’ opinions on mental health treatment are given more weight. In addition, the power of pharmaceutical companies must be monitored.
Bodenheimer (2000)
has documented numerous cases where companies prevented important research findings from being published because they were not favorable regarding the compounds being tested. To what extent may such situations affect clients like Phillip? This will be discussed later in the chapter.

Remember, Phillip was in the 4 to 7 age range when he began treatment.
Coyle (2000)
comments that there is “no empirical evidence to support psychotropic drug treatment in very young children and that such treatment could have deleterious effects on the developing brain” (p. 1060).
Furman (1993)
posited that psychiatrists in the United States are recklessly “out of control” in prescribing methylphenidate/ Ritalin and other stimulants for children, in contrast to the extreme caution that physicians in almost all European countries use in recommending this treatment approach. With the increasing trend to medicate a younger and younger population (
Zito et al., 2000
), mental health professionals not only need to understand the impact and therapeutic effectiveness of these medications, but also their limitations and potential for harming children.

THE MEDICATION OF CHILDREN AND THE FEDERAL LAWS
As we have noted in previous chapters, the laws of the land hold great influence over cultural and social paradigms. To a large extent, laws are the result of a dynamic interaction of forces that influence other areas such as socioeconomic status and the fiscal systems of a society. Socioeconomic status and fiscal systems shape laws in very powerful ways, and people with financial resources are able to buy influence with lawmakers. This is nothing new, but bears stating in this chapter. Although recent legislation has been introduced to address

the many problems of prescribing psychotropic medications for children, most such laws require only voluntary testing of psychotropic drugs, diminishing any real impact. In this section, we summarize recent laws and comment on them, beginning with a summary in
Table 9.1
.

TABLE 9.1 Major Emphases of Recent Legislation on Pediatric Pharmacology

Law/Rule

Summary

FDA Modernization Act
(Public Law Number 105-115, 1997)

Recognizes rights of children as patients
Sets specific standards for research of pediatric drugs
Encourages pediatric labeling

Best Pharmaceuticals for Children Act
(Public Law Number 107-109, 2002)

Voluntary pediatric studies of currently marketed drugs
Created list of all pediatric drugs needing documentation
Requires timely labeling of pediatric drugs
Establishes a mandate to include children of all cultures in studies
Voluntary studies of new drugs

Pediatric Rule Bill of 2002
a

Required timely pediatric studies and adequate labeling

aChild & Family Services Improvement Act: Language on how the use of medications is to be monitored.

© Cengage Learning®

FDA Modernization Act

Buck (2000)
traced the unfolding need for greater specific labeling of drugs used with patients less than 18 years of age. The burgeoning use of almost all drugs approved for children by the FDA compelled pediatric health care providers to use these drugs off label without a clear knowledge of dosing, administration, or adverse-effect information. In 1992, the FDA took steps to improve both pediatric labeling and research, which resulted in support for building a network of pharmacologic research by the National Institutes of Health (NIH). These efforts began to address the problem, and passage of the
FDA Modernization Act (1997)
for the first time set specific requirements to tighten regulations relating to pediatric pharmacology. This law encouraged pediatric labeling on drugs used widely with children and adolescents where the lack of labeling might lead to serious misuse. However, the FDA website (2013) warns that users of methylphenidate/ Ritalin may have an erection lasting many hours. This from an agency that still cannot conduct pediatric studies that evaluate the full impact of the drug on that population.

This law goes a long way toward recognizing the rights of children as patients, protecting their health, and assisting pediatric providers with essential information. Unfortunately, the law did not go far enough. Many practitioners and lawmakers felt the need for a comprehensive law to mandate pharmacologic research, monitor it, and further protect children.

The Best Pharmaceuticals for Children Act

On January 4, 2002, President George W. Bush signed Public Law Number 107-109, the Best Pharmaceuticals for Children Act (
Dodd, 2001
), with the anticipation that it would address many of the dilemmas and controversies surrounding the eruption in use of pharmaceuticals for children. This law aims to initiate critical studies with pharmaceuticals already prescribed to a population for whom there exists little research, and it tightens the monitoring and development of new drugs released for children and adolescents. The law seeks to integrate viewpoints on medicating children with the medical, cultural, and social perspectives. Unfortunately, its most powerful provisions regarding the conduct of pharmaceutical companies are voluntary.

The Best Pharmaceuticals for Children Act (BPCA) has 19 sections that can be viewed at
http://www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/SignificantAmendmentstotheFDCAct/ucm148011.htm
).

This law encourages voluntary pediatric studies of already marketed drugs, the so-called off-label psychotropic drugs in widespread use with children, and it creates a research fund for studying these drugs (see
http://blogs.fda.gov/fdavoice/index.php/tag/best-pharmaceuticals-for-children-act-bpca/
). Both efforts are critical to understanding the effectiveness and efficacy of psychotropic medications for children and adolescents. Further, the law establishes an ongoing program for the pediatric study of drugs, including a list of all drugs for which documentation is needed. This aspect of the law is monitored by the commissioner of the FDA and the director of the National Institutes of Health, who have the power to make written requests to pharmaceutical companies for pediatric studies. The law requires timely labeling changes for pediatric drugs under study.

As of this edition, the status of most pharmaceuticals for children and adolescents remains similar to what it was in 2006. There was the black-box effort with SSRIs and SNRIs, but they are prescribed at rates higher than in 2006 (
Cummings & Fristad, 2007
) and most other psychotropics are used with children and adolescents to quiet anxiety, agitation, and rage.

However, the pharmaceutical companies continue to challenge the Pediatric Rule on all fronts and now it is 2014 and most important drugs for children have not been studied with a pediatric group. So goes the Pediatric Rule. On October 17, 2002, the U.S. District Court for the District of Columbia ruled that the FDA did not have the authority to issue the Pediatric Rule and has barred the FDA from enforcing it. The Pediatric Rule would have required timely pediatric studies and adequate labeling of all human drugs.

Child and Family Services Improvement Act

The Child and Family Services Improvement Act of 2011 (Public Law 112-34) includes new language that addresses the social-emotional and mental health of children who have been traumatized by maltreatment. State Child and Family Services Plans now have to include details about how emotional trauma associated with maltreatment and removal is addressed. They also have to describe how the use of psychotropic medications is monitored.

A WORD ON CROSS-CULTURAL PERSPECTIVES

Tseng (2003)
proposed many variables and differences in prescribing psychotropic medications to children and adolescents from various cultures. He stressed that one must consider not only the physician’s attitudes about treating people from different cultures, but also the patients’ perspectives on how they feel about psychotropic medications. Thus, the giving and receiving of medications has many implications. This factor is greatly enhanced for children and adolescents, because the physician must not only communicate with the parents about the diagnosis and the psychotropic medications (neither of which may make sense in the parents’ worldview) but must also weigh carefully the cultural issues that the family brings to treatment.

Tseng (2003)
also addresses the enculturation issues of children. His research has described how not every culture emphasizes the fast-paced and often accelerated approach to growing up that characterizes the United States.
Enculturation
is defined as a process through which an individual, starting in early childhood, acquires a cultural system through the environment, particularly from parents, school, and so on. Some cultures, such as many Asian cultures, have a laid-back attitude toward babies and toddlers that is more indulgent. Yet later, they show a dramatic shift for these children, who, when they arrive at latency, the developmental period between the ages of 6 and 11 or 12, experience enormous pressure to be diligent and to achieve. Thus, as clinicians treat children and adolescents from all cultures, they need to reconsider cross-cultural adjustment and revise the psychosocial stages of
Erikson (1968)
, which depended on developmental understandings in a particular culture.

With the upsurge in the use of psychotropic medications, it is impossible to monitor the expected and unexpected adverse effects. Given the expanding knowledge of the varying developmental trajectories of children from other cultures, mental health practitioners and psychiatrists need to exercise further caution when prescribing psychotropic medications

for these children.
Lin and Poland (1995)
described in detail the remarkably large interindividual variability in drug responses and side effect profiles. This can be partially accounted for in differences of ethnicity and/or culture apart from physiological pace. Some cultures are very suspicious of medication and may delay the decision for more than a year.

Lin and Poland (1995)
have made significant contributions to the understanding of
cultural psychiatry
and to the fact that genetic factors associated with individual and ethnic backgrounds contribute greatly to responses to medication in children, adolescents, and adults.
Kirmayer and Ban (2013)
note that cultural differences in self and personhood are equally important. All researchers we reviewed point to variations within the same ethnic group and variations among ethnic groups. This further complicates the integrative dilemma, which is how to view psychopharmacology and cases from the four perspectives outlined in
Chapter One
as well as consider important developmental lines and levels. Mental health professionals recognize that researchers have much to learn about psychopharmacology with children and adolescents, as shown by the research cited in this chapter. We need to integrate our growing understanding of cultural psychiatry with our limited understanding of how psychotropic medications work in children. The Best Pharmaceutical Act for Children (2002) provided for including in studies children from various racial and ethnic backgrounds. The law calls for studying the impact of medications on children of different cultures.

PSYCHOLOGICAL PERSPECTIVES OF CHILDREN AND ADOLESCENTS

Medicating children and adolescents for all types of psychological disorders is a solution that only reflects partial truth. The overt behaviors and symptom profile for which they receive medication may only mask the deeper psychological wounds of loss, trauma, abuse, sibling rivalry, neglect, sexual abuse, or gender conflict.
Furman (2000)
has indicated that if mental health professionals carefully examined the overuse of stimulants with children, they would discover a variety of conflicts and problems fueling the hyperactive behavior. These issues could include cruelty in the home, harsh toilet training, neglect, sexual abuse, delay in language development, and more.

Young children cannot address their inner conflicts without the help of a caring therapist and the modality of play therapy, yet far too often they are diagnosed with Bipolar I or ADHD and medicated in an attempt to quickly suppress their active symptoms. There should be far more effort to get the child to a therapist to uncover the underlying cause(s) of the child’s anguish, but this requires resources that, at the time of this writing, lawmakers are not giving a high priority.

The American Academy of Pediatrics (2011)
for ADHD makes clear that parent and teacher assessments at home and school, respectively, along with clinical review and examination by pediatrician or psychiatrist, often omit psychological assessment of the child by a mental health professional to rule out abuse, neglect, loss, sleeplessness, or other potential causes of hyperactivity or mania. In this protocol (the AAP guidance), the psychology and clinical history of the child are treated as unimportant. Many authors unfortunately support rapid assessment of ADHD children to speed up treatment with stimulant medication.

OPPOSITION TO THE CURRENT TREND OF MEDICATING

Opponents to exclusive medication treatment for ADHD, Bipolar I, and other conditions have pointed out significant regional variations in the amount of psychotropic medications prescribed to children and wide variations in regional diagnostic criteria for ADHD and other conditions (
Safer, Zito, & Fine, 1996
;
Wolraich, Hannah, Pinnock, Baumgaertel, & Brown, 1996
). These variances have legislators and mental health advocates from various regions of the country clamoring for more judicious use of psychotropic medications with children, with more careful attention to the range of adverse effects from them, and a more formalized protocol for diagnosing ADHD, Bipolar I, and

other conditions. This protocol should go well beyond the traditional oral report from teacher to parent about a child’s externalizing behavior. Opponents of psychotropic medication use in children call for a more specific and guided differential diagnosis of these disorders because the symptoms commonly overlap with Oppositional Defiant Disorder, Conduct Disorder, Major Depressive Disorder, various anxiety disorders, and many developmental disorders (
American Academy of Child and Adolescent Psychiatry, 2007
;
August, Realmuto, MacDonald, Nugent, & Crosby, 1996
). Many researchers and practitioners still feel that ADHD in particular is a myth and that the explosion in use of the diagnosis renders differential diagnosis impotent (
Armstrong, 1997
;
Furman, 2000
).
Furman (2000)
concluded,

· I have tried to trace the thinking that followed the discovery of the vastly different approaches in the United States and Europe to the management of the active or overactive child.… This thinking led to the conclusion that ADHD is not a specific disorder or pathological entity but rather a collection of symptoms that could be manifested by a child in distress, a child in conflict within himself and/or with his environment. It has no more specificity than that, and likewise methylphenidate has no specificity in producing its effects.… Suppressing these symptoms by “subduing” the child with medication hides from all the source of the child’s troubles, precludes his being able to obtain mastery of his troubles through understanding, and subjects him to a false label of brain pathology. (p. 141)

Furman, now deceased, indicated that his conclusions were not new but simply ignored.

AN OVERVIEW OF PEDIATRIC AND ADOLESCENT PSYCHOPHARMACOLOGY

By the time this text has been published, only a handful of psychotropic medications will have been approved as on label for the preschool age group. Examples include methylphenidate/Ritalin, amphetamine/Adderall, haloperidol/Haldol, and chlorpromazine/Thorazine (
Zito et al., 2003
). Methylphenidate/Ritalin is now under great scrutiny (
Zaicek, 2009
). For preschool-age children, it is aggressive behavior that generally triggers a referral for treatment (
Bassarath, 2003
). A few more psychotropic medications have been approved for use in older children and adolescents (
Kluger, 2003
), but those (such as the antidepressant fluoxetine) are hotly debated because of suicidal risk.
Table 9.2
lists as many medications as we were able to find with on-label approval for children.

We have mentioned the national dilemma that more children and adolescents demand psychological services each year, yet there are fewer service providers. Concurrent with this expanding problem is the dramatic increase in the use of psychotropic medications off label for a variety of mental and emotional conditions and disorders. Although this is problematic in and of itself, the focus on psychological and interpersonal factors in treating children and adolescents has dangerously diminished. Whereas it used to be common practice for child psychiatrists to choose in each case from among drug therapy—primary drug therapy and secondary counseling, or primary counseling and secondary drug therapy (
Kraft, 1968
)—today these choices are rarely discussed routinely.

Also note that DSM criteria are primarily normed on adults and are more difficult to apply with children.
House (1999)
has indicated that over half of the time, children who meet the criteria for one mental or emotional disorder meet criteria for other disorders as well. This multiple nature of children’s problems frequently results in a polypharmacy approach and requires careful decisions by the physician and/or treating team (
Brown & Sammons, 2002
). How carefully those decisions are made varies from setting to setting and clinician to clinician and are more random today (Leslie, 2011).

Researchers do know that the preschool years are one of the key developmental periods for maturation of the brain dopamine system, which is targeted by stimulants (
Coyle, 2000
). The FDA-approved package insert on methylphenidate/Ritalin warns against its use with children under age 6. Given all the unknowns, many scholars and physicians are concerned about the quality and care and the current explosion of prescribing practices with preschoolers. Mental health professionals do not have enough clear evidence about how preschoolers respond to psychotropic medications, and researchers are very uncertain about the impact of such medications on the development of preschoolers. Let’s examine some of the major developmental issues.

TABLE 9.2 Drugs with FDA On-Label Approved Uses in Children

Generic Name

Brand Name

Dosage

Ages

ADHD Medications

Methylphenidate

Ritalin

10–60 mg

6 and older

Immediate Release (IR)

Methylin

20–60 mg

6 and older

Methylphenidate

Ritalin SR

Sustained or Extended

Metadate SR

Release (SR/ER)

Concerta

Methylphenidate

Transdermal

Daytrana

10 mg/9 hours

6 and older

Dextroamphetamine

Focalin

5–40 mg

6 and older

Dextroamphetamine

Extended Release

Focalin XR

10–40 mg

6 and older

Lisdexamfetamine

Vyvanse

30–70 mg

6 and older

Amphetamine/Dextroamphetamine

Adderall

5–40 mg

3 and older

Atomoxetine

Strattera

.5 to 1.4 mg

6 and older

Guanfacine

Intuniv

1–4 mg

6 and older

Clonidine

Kapvay

.1 to .4 mg

6 and older

Antipsychotics/Mood Stabilizers

Aripiprazole

Abilify

2–30 mg

For BPI 10 and older

2–15 mg

Irritability/Autism 6 and older

2–30

Schizophrenia 13 and older

Risperidone

Risperdal

.25–3 mg

Autism 5 and older

.5–6 mg

BP Mania 10–17

.5–6 mg

Schizophrenia 13–17

Olanzapine

Zyprexa

2.5–20 mg

BPI/Schizophrenia 13 and Older

Paliperidone

Invega

2.5–20 mg

BPI/Schizophrenia 12–17

Quetiapine

Seroquel

50–600 mg

BPI 10 and older

50–800 mg

Schizophrenia 13 and older

Lithium

Eskalith

900–2400 mg

BPI 12 and older

Lithobid

900–1800

?

Neuroleptics

Chlorpromazine

Thorazine

.5–200 mg Psychosis

6 and older

Haliperodol

Haldol

.5 to .15 mg

Tourette’s 3–12

Pimozide

Orap

.05–2 mg

Tourette 12 and older

Antidepressants

Escitalopram

Lexepro

10–20

12 and older

Fluoxetine

Prozac

10–20

for depression 8–18

10–60

for OCD 7–17

Fluvoxamine

Luvox

25–200 mg

for OCD 8–17

Sertraline

Zoloft

25–200

for OCD 6–17

Amitripyline

Elavil

25–100

for depression 12 and older

Clomipramine

Anafranil

25–100

for OCD 10 and older

Imipramine

Tofranil

30–100 mg

depression 12 and older

25–75 mg

eneuresis 6 and older

Protriptyline

Vivactil

15–20 mg

depression 12 and older

Developmental Issues
For many of you, this section on human growth and development in children and adolescents is a review. Most texts on development emphasize cognitive, language, moral, and psychosocial developmental paths. We briefly consider these lines of development

and include others that are potentially affected by the ingestion of psychotropic medication. Understanding development is further complicated by the construct of
developmental lines
—the simultaneous occurrence of several aspects of human growth and development.

Developmental Lines
Although there are dozens of lines of human development, this multiplicity is still not a focus for mental health professionals outside of developmental studies. What should be common knowledge for mental health professionals is still peripheral to their training. For example, the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) requires only one human development course for a master’s degree in school or clinical mental health counseling. There may be dozens of lines of human development. These include physical development, cognitive development, emotional development, sexual development, moral development, spiritual development, kinesthetic development, socioemotional development, gender identity, and role-taking ability. These are just a few of the lines of development to which every person has access, and, for the most part, everyone proceeds through them unevenly.

The sheer number of developmental lines and the fact that most people proceed unevenly through them raise enormous, unaddressed issues for psychopharmacology. We noted earlier that scientists know very little about how brains develop and that many researchers are concerned that psychotropic medications could profoundly damage the brains of children and adolescents when taken long term. Glen Elliott, director of the Langley Porter Psychiatric Institute Children’s Center of the University of California at San Francisco, noted that the current use of psychotropic medications on children “has outstripped our knowledge base . . . we are experimenting on these kids without tracking the results” (
Kluger, 2003
, p. 51). For example, even when an adolescent truly appears to suffer from Bipolar I Disorder, the sequelae of mood stabilizer side effects such as weight gain and perhaps hair loss are likely to be more devastating for a person of that age than for an adult—but there is no research on such psychological issues.

Perhaps the greatest problem of studying child and adolescent psychopharmacology from the four integrative perspectives is that whenever the issue of medicating children comes up, the only perspective represented is that of the medical model. A good example is a Time magazine cover story, by
Kluger (2003)
that basically explores only the medical model perspective, with only minor attention to psychological, cultural, and social issues. The same article presents a diagram showing what parts of the brain are believed to be correlated with different mental or emotional disorders. At no point in the article does the author state that these areas are hypothesized to be correlated with symptoms and there is no evidence that they cause symptoms. This remains true as of the second edition of this book.

As we have noted throughout the book, many symptoms that are psychogenic in origin register in the brain, but this does not mean the symptoms were caused by the brain. This bias toward the medical model perspective leads laypeople to assume that mental/emotional disorders, whether in children or adults, are strictly medical disorders. This assumption is not currently supported by the evidence we have been covering in this book. A full-scale multimodal approach to mental and emotional disorders in children and adolescents considers medication and possible brain pathology as only one part of the story in a very complex interaction of tentative causes and interventions.

Developmental Pharmacology

Developmental psychopharmacology is a newer area of research that studies brain development focused on brain plasticity (the brain’s ability to shape itself to environmental or chemical input) and sensitive periods (during which experience can alter neural representation before hardwiring occurs) (
Carrey, Mendella, MacMaster, & Kutcher, 2002
). Pediatric psychopharmacology is an equally young enterprise with the first published reports dated in 1937 but by the 1980s the United States

had become the world leader in medicating children (
Riddle, Walkup, & Vitiello, 2008
).

Although these disciplines are examining development strictly from the medical model perspective, its overarching question is, “What happens in the complex process of neural development when an infusion of psychotropic medications is introduced to address particular environmental stressors during periods of accelerated brain development?” Compared to adults, children and adolescents respond to psychotropic medications in different and distinctive ways that have implications for efficacy and safety (
Vitiello & Jensen, 1995
). The rate at which prescriptions of psychotropic medications have grown for children despite the dearth of research to support their efficacy raises the question “are we doing too much or too little?”

Epstein (2001)
posited that active brain growth spurts occur stagewise in correlation with Piagetian types of development. Thus, a child who is making the transition from the sensory motor stage to Piaget’s preoperational stage is in a very active brain growth stage (from age 2 to 4 years).
Epstein cites Boothroyd (1997)
, who noted that lexical knowledge and syntactic knowledge grow rapidly until age 4. At about 6 (from age 6 to 8), the next rapid brain growth period parallels Piaget’s concrete reasoning stage, where a child begins to think logically about experienced inputs, the concrete operational stage. Epstein discussed the next brain growth period as slow (from age 12 to 14 years), a time of practicing and consolidating new networks in preparation for the next rapid brain growth stage (between ages 14 and 16 years). Psychotropics often are administered to preschoolers in the rapid growth period between ages 2 and 4 years, and to early-latency children between the ages of 6 and 8 years. Mental health professionals do not know enough about the impact of both on-label and off-label psychotropics in these rapid brain growth periods to be administering them to children and adolescents.
Bramble (2003)
concluded that given the changing nature of pediatric pharmacology and developmental pharmacology, this society needs a rapid expansion of pediatric research and academic inquiry into the impact of psychotropics on children’s development. The second author in an extensive review of developmental pharmacology articles found only those supported fully by pharmaceutical companies or ones that cost between $29.50 and $40.00. Almost all recommended the use of a psychotropic as a first-line intervention. Interestingly, the pharmaceutical companies signed documents stating that they had no “conflict of interest.” In addition, the medications being used are only partially successful 40–50% of the time (
Rapoport, 2013
).

Another problem with pediatric psychopharmacology is
polypharmacy
: the use of more than one psychotropic simultaneously, a usage that interacts with children’s metabolism in a variety of unpredictable ways (
Brown & Sammons, 2002
). Clinicians who observe children and adolescents under the influence of polypharmacy are often startled not only by the dramatic change in the clients’ affective and behavioral state but also by the array of side effects they experience. Tonya, a very aggressive 12-year-old, was placed on olanzapine/Zyprexa (an atypical antipsychotic), sertraline/Zoloft (an SSRI antidepressant), lorazepam/Ativan (an anxiolytic), and valproate/Divalproex (a mood stabilizer). This combination of medications was ostensibly for what appeared to the attending psychiatrist as Bipolar I with severe agitation and aggression in the manic phase. Tonya’s symptoms diminished, but her teacher noticed new ones: slurred speech, mild tics, and a constant staring off without responding when addressed. Now, rather than disrupting the class, she slept through it. Although from the perspective of the teacher and other students this was an improvement, was Tonya being helped, or was she merely medicated into submission when she might have been more fundamentally helped with assessment and therapy from a wider interpersonal perspective?

Other developmental considerations include adverse cardiovascular effects. We have many reports of sudden deaths of children and adolescents treated with psychotropic medications, including methylphenidate/Ritalin, TCAs, SSRIs, bupropion/ Wellbutrin, lithium, and most neuroleptic medications.
Gutgesell et al. (1999)
detailed the

cardiovascular and electrophysiologic effects of commonly used psychotropic medication, which can be deadly. Although the precise causes of the deaths have not been documented, severe heart spasms (cardiac arrhythmias) and delayed repolarization of the heart rhythm (delayed QTc interval) make the heart muscle vulnerable to possibly lethal changes (such as ventricular tachycardia). These tragedies call on mental health professionals to be vigilant and cautious when prescribing psychotropic medication. With many high-risk medications, cardiovascular monitoring is particularly important. In fact,
Wagner and Fershtman (1993)
recommended ECG monitoring at baseline and during drug therapy for children and adolescents who are on the medications associated with cardiovascular side effects.
Brown and Sammons (2002)
argued that the use of most psychotropic medication exceeds data available for efficacy, effectiveness, and safety.

Many concerns also remain related to the physiological impact on children who take psychotropic medication. One is the controversy about the impact of stimulant treatment on brain growth in children (
Bell, Alexander, Schwartzman, & Yu, 1982
). Researchers have recently learned that methylphenidate and other stimulants decrease blood flow to selected parts of the brain, specifically the cortex area that controls conscious movement (
Zeiner, 1995
). In a recent study (
Castellanos et al., 2002
), the research team concluded that developmental trajectories for all brain structures, except caudal, remain parallel for children and adolescents in ADHD patients and controls. This suggested that genetic and early environmental influences on brain development in ADHD are fixed, nonprogressive, and unrelated to stimulant treatment.

However, initial brain scans of patients with ADHD showed significantly smaller brain volumes in all regions than what appeared in the brain scans of the controls. In general, because of brain plasticity (the brain’s ability to shape itself), it is possible for children to be highly susceptible to a negative impact on their brain development during one period of development and less so in another period of development (
Carrey et al., 2002
). Does treatment with psychotropic medications constitute a negative impact? These authors further concluded that researchers are only beginning to understand the long-term effect of psychotropic medication on neuron cell factors and their overall impact on brain development. All these developmental concerns or issues involve potential adverse effects for children and adolescents taking psychotropic medication.

At this point, we cover the different categories of medications used on children and adolescents. We begin the next section with a more thorough treatment of stimulant medications.

Review Questions

· • What are some of the main problems with the increase in psychotropic medication prescriptions for children?
· • What was the impact of the FDA Modernization Act and the Best Pharmaceuticals Act for Children? Name at least three changes these acts initiated.
· • What are the “developmental unknowns” that make prescribing psychotropic medications for children problematic?

SECTION TWO: STIMULANT MEDICATION
Learning Objectives

· • Understand the mechanism of action and side effects of stimulant medications.
· • Be able to discuss the type of symptoms stimulants seem most helpful for.
Even though stimulants are currently the beststudied psychotropic medication used on children, many issues regarding their use are still unresolved. Because stimulants are prescribed almost exclusively for children, we have included information on them in this chapter. Before discussing some of
the controversial issues, let’s examine some background and general information on these widely prescribed medications.

Some History

The first known stimulant in the West was cocaine. It was isolated in 1859 by a German chemist named Albert Niemann and was given to Bavarian soldiers to decrease fatigue. In 1884 Karl Koller perfected its use as an analgesic during eye surgery. His assistant, a young neurologist named Sigmund Freud, was off visiting his fiancé at the time and so missed out on credit for that discovery. Freud had been personally experimenting with cocaine and wrote the paper “Uber Coca” (“On Cocaine”) prior to realizing its addictive qualities (
Freud & Carter, 2011
). Many people in South American societies still regularly chew coca leaves with little ill effect, because unprocessed leaves are far less dependence inducing than is refined cocaine powder (
Siegel, 1989
). Efforts to synthesize amphetamine began in 1887, when physicians believed it useful for treating asthma. This belief emerged from the use of an herbaceutical called ma huang in Chinese medicine. Ma huang is discussed more thoroughly in
Chapter Ten
on herbaceuticals, but for now understand that it is the ingredient ephedra that is central to the story of amphetamines. This ingredient produces the bronchial dilation that relieves the wheezing of asthma.

In the 1920s, a Chinese pharmacologist working for Eli Lilly (K. K. Chen) was working to isolate and synthesize ephedra from ma huang. He succeeded in synthesizing a compound so structurally similar to ephedra that it was named ephedrine. Although this could be taken orally, the goal for asthma treatment was a compound that could be inhaled. Gordon Alles succeeded in developing another variation of the molecule that could be delivered in an inhaler. Called Benzedrine, this variation was successful in treating asthma. Aside from treating asthma, it also seemed to induce euphoria. People soon realized they could open the inhaler and ingest the contents for what became known as “the amphetamine rush.” This also became a popular pastime on college campuses during exams. Amphetamines were experimented with to manage a number of disorders, and one of their early uses was treating children for what was described as “overactivity.”

Werry has asserted that research in psychopharmacology for children began with publication of
Bradley’s (1937)
paper on how amphetamine seems to calm overactive children and help children with learning disabilities. The only other noteworthy investigations of the same period were studies on the effects of antihistamines on children (
Connors, 1972
). These works are thought to be the only primary contributions to child psychopharmacology until very recently (
Werry, 1999
).

Bradley’s work reemerged in the 1960s after psychiatry began moving away from a psychodynamic model toward the biological model dominant today. Psychiatrists at that time were not well trained in the statistical methods that were becoming the norm in evaluating medications. They turned to psychologists for assistance. The psychologists emphasized the need to look at medication effects on learning and academic performance (
Werry, 1999
). Such research has, until very recently, remained focused primarily on stimulant medication.

Research in pediatric psychopharmacology received an unintentional boost in the 1960s with the creation of a diagnosis called Minimal Brain Dysfunction (MBD). MBD was one of the several precursors to the current ADHD diagnosis. MBD was treated with stimulant medications such as methylphenidate. Although later discarded because it was too vague, the MBD diagnosis did much to lead to the development of a norm for a methodology with which to evaluate the effects of drugs, and particularly stimulants, on children.

In WorldWar II, German, British, American, and Japanese soldiers all used amphetamines, a practice still common in the U.S. Air Force to help pilots keep alert on bombing missions (
Knickerbocker, 2002
). After World War II, the Japanese had such huge surpluses of amphetamines that they marketed them to civilians. These drugs were advertised for the elimination of drowsiness and repletion of spirit. Researchers estimate that by 1948, 5% of the Japanese population between the ages of 15 and 25 was dependent on amphetamines.

After World War II, it became evident that amphetamines have appetite suppressant qualities, and chemists tried to tease these out from the reinforcing properties that were connected to abuse. However, most of these initial efforts (such as methylphenidate/Ritalin) failed, and then the drugs were simply marketed as amphetamines.

The amphetamine molecule is a simple and highly malleable molecule that acts as the chemical template for over 50 pharmacologically active substances (
Grilly, 1994
). Amphetamine is basically made of two compounds (isomers) labeled “L” and “D” amphetamine. D-Amphetamine is more potent and was marketed as Dexedrine. A minor modification in this molecule yields methamphetamine marketed as Methedrine. Other variations of the amphetamine molecule can produce MAO inhibitors. Modifying amphetamine to dimethoxy-methylamphetamine (DOM) produces a psychedelic compound similar to mescaline, and further modification produces the empathogen methylene-dioxymethamphetamine (MDMA, street name “ecstasy”). The latter was a promising psychotherapeutic compound until criminalized (
Eisner, 1994
). The therapeutic effects revolved around chemically induced states of empathy, euphoria, and well-being that facilitated insights that were then to be integrated into clients’ normal awareness (
Stevens, 2009
).

Table 9.3
outlines stimulant medications used to treat ADHD in children.

TABLE 9.3 Stimulant Drugs Used to Treat ADHD in Children

Generic Name

Brand Name

Type of Drug

Daily Dose

Amphetamine and D-amphetamine compound

Adderall

Stimulant

5–40 mg

D-Amphetamine

Focalin

Stimulant

5–40 mg

Methylphenidate

Ritalin

Stimulant

5–60 mg

Lisdexamfetamine

Vyvanse

Stimulant

30–70

Atomoxetinea Stratter
a

NE reuptake inhibitor

0.5–1.2 mg

0.5–1.2 mg

aAtomoxetine is not a stimulant but an SNRI (see
Chapter Five
).

© Cengage Learning®

Mechanisms of Action in Amphetamines
Amphetamines exert almost all their effects by causing the release of norepinephrine and dopamine from the synaptic vesicles into the synaptic cleft. There are different mechanisms for amphetamines to act as dopamine agonists and the number of mechanisms used depends on the type of amphetamine. There are two isomers of amphetamine, “L” and “D.” The “L” isomer amphetamine mechanisms of action include:
· • Pure reuptake inhibitor for DA
· • No presynaptic activity
· • Enhances NMDA receptor response
· • Weak block monoamineoxidase
· • 80% metabolized
· • The classic L-isomer amphetamine is methylphenidate/ Ritalin
The D-isomer amphetamine mechanisms of action are similar to those of cocaine and include:
· • Reuptake inhibition of DA (inhibit DAT)
· • Drug taken into terminal by DAT & depletes vesicles (causes DA transporter to act in reverse) thus releasing DA from the presynaptic neuron
· • Enhances NMDA receptor response
· • Weak block of monoamineoxidase (MAO)
· • Releasing NE from presynaptic neuron
Amphetamine/Dexedrine is the classic D-isomer amphetamine but is less prescribed than Adderall. Mixed amphetamine salts/Adderall includes D-amphetamine.

In a study comparing methylphenidate to cocaine,
Volkow et al. (1995)
noted that although the mechanisms of action and effects are similar, methylphenidate clears more slowly from the brain, which, they hypothesize, makes it less dependence inducing. Readers are encouraged to think critically about this result, because when a similar mechanism of slow clearance is invoked to defend cannabis (marijuana) as low in dependenceinducing qualities, it is often rejected (
De Fonseca, Carrera, Navarro, Koob, & Weiss, 1997
). Either the mechanisms discussed decrease the probability of dependence or they do not. Pharmaceutical and political agendas should be separated from this debate so that people can objectively examine the issues. In previous chapters, we have listed the adverse effects of psychotropics being discussed. With ADHD, these effects are interwoven into the complex presentation of the stimulants. We ask you to consider why in the continent of Europe (an area of the world that has about the same population as the United States), stimulant medications are used with children for only about 5 to 8% of the treatment population so treated in the United States. Now let us examine the DSM-5.

ADHD Diagnosis and Assessment

According to the DSM-5, the diagnostic criteria for attention-deficit/hyperactivity disorder are
· A. Either (1) or (2):
· (1) six or more of the following symptoms of inattention have persisted for at least five months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
· (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
· (b) often has difficulty sustaining attention in tasks or play activities
· (c) often does not seem to listen when spoken to directly
· (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
· (e) often has difficulty organizing tasks and activities
· (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
· (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
· (h) is often easily distracted by extraneous stimuli
· (i) is often forgetful in daily activities
· (2) Hyperactivity: Six (or more) of the following symptoms of hyperactivity impulsivity persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
· (a) often fidgets with hands or feet or squirms in seat
· (b) often leaves seat in classroom or in other situations in which remaining seated is expected
· (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
· (d) often has difficulty playing or engaging in leisure activities quietly
· (e) is often “on the go” or often acts as if “driven by a motor”
· (f) often talks excessively

· Impulsivity

· (g) often blurts out answers before questions have been completed
· (h) often has difficulty awaiting turn
· (i) often interrupts or intrudes on others (e.g., butts into conversations or games)
· B. Several hyperactive-impulsive or inattentive symptoms that caused impairment are present before age 12 years.
· C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings.
· D. There must be clear evidence of clinically significant impairment in social, or occupational functioning.

· E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). (
APA, 2013
, pp. 59–60)

Source: Diagnostic and statistical manual of mental disorders, 5th ed., (Washington, DC:
American Psychiatric Association, 2013
).

Both the “Consensus Statement” of the
National Institutes of Health (1998)
and the “Clinical Practice Guidelines” of the
American Academy of Pediatrics (AAP) (2011)
recommend careful diagnosis of ADHD and then an appropriate and judicious use of stimulants in combination with other psychosocial treatments to address the symptoms.
Epstein et al. (2010)
also emphasize that children treated with stimulant medication show improvement in ratings by parents and teachers but not in their level of functioning as measured by grades. Thus they note that mental health services in addition to medication are important.

In terms of assessment most protocols recommend a neurologic exam, a consultation with a psychiatrist or psychologist who specializes in ADHD, behavioral observation reports from parents, grandparents, teachers, and other school personnel.
Olfson, Gameroff, Marcus, and Jensen (2003)
, analyzing national data, reported the increased rates of treatment from 0.9 per 100 children in 1987 to 3.4 per 100 children in 1997. They posited that this increase along with fewer treatments (counseling) per child was attributed to a broader awareness of the diagnosis by special educators, growth of managed behavioral health care, and increased public acceptance of psychotropic medications. But we ask, has the mushrooming of the ADHD diagnosis in children led to improved assessment and treatment?

The answer is mixed. Although some teachers, school administrators, and pediatricians rapidly diagnose ADHD in children, the
NIH (1998)
, the
National Institute of Mental Health (NIMH) (1996
,
2000
), and the
AAP (2001)
all have developed diagnostic guidelines for ADHD for years. More recently, The
American Academy of Child & Adolescent Psychiatry (AACAP) (2007)
released a practical, evidence-based practice parameter. In 2011 the same group released a practice guideline with expanded treatment of how to make the diagnosis and how to add psychosocial interventions to treatment (
AACAP, 2011
). The initial guideline was again updated in 2012. In all cases, these expert societies recommend a careful evaluation by a trained psychiatrist or psychologist in conjunction with teachers, mental health professionals, and family members. They recommend an evaluation period that is not rushed, so the team can rule out other conditions that might be confused with ADHD, and which includes observation and rating scales.

In a 10-year review of rating scales assessing ADHD,
Collett, Ohan, and Myers (2003)
concluded that DSM IV-based rating scales can reliably, validly, and efficiently measure ADHD symptoms in youth. In this comprehensive review, the authors evaluated the validity and sensitivity of subscales on several rating scales to assess the symptoms of ADHD. The greater use of narrowband rating scales in the assessment of ADHD can supplement and complement clinical interviews and behavioral observations in the evaluation of ADHD in children and adolescents. It is now evident that reliable and valid ADHD rating scales can augment the accuracy and specificity of diagnosis.

In a comprehensive response to the Multimodal Treatment Study (
Owens et al., 2003
), the authors sought to answer the layered question, “What do we treat in ADHD?” and “Who treats it?” based on the needs of the child and her or his circumstances (
Paul, 1967
, p. 111). Their findings were remarkable. The children least likely to respond well to a combined treatment of stimulants and milieu therapy were those with depressed parents or caregivers and severe ADHD.
Owens et al. (2003)
examined several outcome predictors, using nine baseline child and family characteristics. None were

predictive, but the two issues discussed earlier along with a lower IQ of the identified child correlated with an outcome less-than-favorable with the combined treatment.

ADHD Efficacy, Effectiveness, and Conundrum

ADHD has been classified as one of the externalization disorders, along with Conduct Disorder and Oppositional Defiant Disorder. As opposed to the other two, stimulant medication has been the treatment of choice for ADHD for about 25 years in the United States (
Phelps et al., 2002
). In fact, stimulants for ADHD are the most widely researched and used medications in child psychiatry. Evidence indicates significant increase in the use of stimulants for both preschoolers and children despite the fact that the FDA approval is only for children ages 6 and older (
Brown & Sammons, 2002
;
Riddle et al., 2001
;
Zito et al., 2000
,
2003
). The data include empirical evidence on safety, efficacy, and adverse effects.

Research demonstrates the beneficial effects of stimulants on symptoms linked with ADHD. These effects include diminished inattention, impulsivity, overactivity (
Bennett, Brown, Carver, & Anderson, 1999
), improved classroom attention and academic efficiency (
DuPaul & Rappaport, 1993
), and improved mother–child relationships (
Barkley, Karlsson, Strzelecki, & Murphy, 1984
). However, with all the benefits cited for the use of stimulants with ADHD, available literature to date has not supported or demonstrated that stimulants enhance school achievement (
Phelps et al., 2002
). Short-term efficacy studies supported the impact of stimulants on the target symptoms. From this literature, clinicians can conclude that using stimulants with children appropriately diagnosed with ADHD diminish the child’s inattention, impulsivity, and hyperactivity, but do not necessarily improve his or her academic achievement. It is very possible that the child will adapt better to the demands of the classroom environment and become less externally driven. However, it would also be interesting to research whether or not stimulants improve performance in children who are not diagnosed with ADHD.

Proponents of stimulant treatment for ADHD are more convinced than ever that the disorder is passed on through heredity via the DRD4 receptor gene and that, as twin studies have suggested, up to 80% of the variance in the trait of hyperactivity/ impulsivity is now considered to be based on genetics (
Barkley, 1998
).
Peter Jaska (1998)
, president of the Attention Deficit Disorder Association (ADDA), is a staunch advocate of stimulant treatment for ADHD and argues that “we cannot and will not turn back decades of scientific research on the biological basis of ADHD, medical research, educational progress, and federal disability legislation, because some people selling books claim that ADHD is a ‘myth’ ” (p. 1). Both Jaska and Barkley are experts on the biological bases for ADHD derived from the medical model perspective and the resulting medication for treatment, but they seldom address intrapsychic, cultural, or social perspectives of ADHD.

Review Questions

· • What are the mechanisms of action and side effects of stimulant medications?
· • What types of symptoms are stimulants most useful for?

SECTION THREE: ADHD AND COMBINED INTERVENTIONS
Learning Objectives
· • Understand the differences between the initial, twoyear, and eight-year follow up of the MTA study group.
· • Be able to describe conditions that may be comorbid with ADHD and why this may also be a misdiagnosis.
Interventions with ADHD usually begin with assessing the child or adolescent for oral stimulant medication, because most studies have indicated short-term behavioral improvement related to the symptoms of

the disorder when stimulants are used (
American Academy of Pediatrics, 2001
;
Barkley, DuPaul, & Connor, 1999
;
Phelps et al., 2002
). Methylphenidate/ Ritalin accounts for 90% of the prescriptions for ADHD (
Advokat, Comaty, & Julien, 2014
). In the late 1990s studies demonstrated that Adderall (amphetamine/dextroamphetamine) is equally efficacious but methylphenidate/Ritalin is still the leader in medications used to treat ADHD.

As noted, most consensus statements on ADHD treatment recommend psychosocial interventions that assist the family as well as the person diagnosed with ADHD. These approaches include psychotherapy, cognitive-behavioral therapy, behavioral therapy, social skills training, impulse control therapy, parenting skills training, support groups, and family therapy. Each of these approaches alone or in conjunction with stimulant medication can help ameliorate some of the symptoms of ADHD and/or address some of the underlying factors affecting the person with the disorder. The
American Academy of Pediatrics (2001)
first treatment guideline specifically recommended behavioral therapy as the best adjunct intervention with stimulants to establish targeted outcomes and manage the child’s behavior both in the classroom and at home. They also stated that if one stimulant does not work at the highest feasible dose, the physician should recommend another. Clinicians learning about pharmacology may find it helpful to remember that stimulants generally provide only relief of symptoms, thus requiring other treatment modalities and followup. In a follow-up to that
Bader and Adesman (2010)
recommended a list of complementary and alternative treatments for ADHD. Although the American Academy of Pediatrics did not recommend these specifically they did note that essential fatty acid supplementation is well tolerated and modestly effective.

Results of the Multimodal Treatment Study for Children with ADHD (
MTA Cooperative Group, 1999
) demonstrated initially that stimulant treatment was slightly more effective than behavioral therapy alone, and equally effective to therapy and medication combined. It should be noted that parents preferred the behavioral therapy conditions to the stimulants-alone treatment. As with all treatment approaches for ADHD, the MTA study is not without its critics, who argue for a better match of patient with a treatment strategy tailored and selected for the individual’s needs (
Green & Albon, 2001
). When the selected management (interventions) for a child with ADHD has not met targeted outcomes, clinicians must evaluate the original diagnosis, adjust treatments and medications, and evaluate for coexisting conditions.

Another critic of the MTA study (
Leo, 2002
) noted that the fanfare surrounding publication of the study “was nothing short of extraordinary” (p. 53). Leo pointed out that ABC News reported that results indicated drug therapy was much better than counseling for ADHD. Leo contends that the MTA study was heavily biased toward medication treatment. He claims the study’s authors all had a history of strongly favoring medication, bringing their objectivity into question. He also points out that the MTA study had four groups: one received medication, one received behavior therapy, one received both, and a fourth group received no treatments from the MTA researchers but instead received standard treatment in the community. The most “robust” changes were reported in ratings by teachers and parents of children in the study. The problem with this, according to Leo, is that the investigators preselected a group of parents who believe it is acceptable to medicate children; in fact, in all cases the parents contacted the investigators to enroll children in the study. This fact, according to Leo, points to a bias in the sample.

Edwards (2002)
addressed the important follow-up outcomes of studies and interventions in the wake of the report from the
MTA Cooperative Group study (1999)
. He recommended that a specific family-based intervention be used in a mental health setting in conjunction with pharmacologic treatment. He specifically cited Parent Management Training (PMT) as an approach that through cognitive-behavioral coaching helps parents manage their child’s difficulties. Whatever the method, more physicians, researchers, and clinicians are recommending family interventions with children and adolescents diagnosed with

ADHD. The research in treatment outcomes of ADHD is complicated, and we encourage you to evaluate many strategies and interventions for your clinical work, especially those that include family/ parent strategies.

The MTA study was followed up at two years and at eight years. Here is a summary of the findings. At two years, cessation of drug treatment was correlated with significant clinical decline. Continued drug therapy was correlated with moderate decline and initiation of stimulant therapy for those in control group was correlated with significant improvement (
MTA Cooperative Group, 2004
). So at this point again the cornerstone of treatment seemed to be with the medication. At the eight-year follow up, 33% of the subjects were still on medication (and 83% of them were on stimulants). Improvement was maintained but the group had not “normalized” meaning there were still significant achievement gaps between them and so-called “normal” controls. Thirty percent still met the DSM-IV criteria for ADHD (though one suspects more would meet criteria under DSM-5 because you only need five criteria met rather than six). Overall, medicated children did better in math and reading. There was still a significant test score gap between children in the study and the control group. Also, interestingly, approximately 30% showed signs of antisocial behavior and 25% showed signs of Oppositional Defiant Disorder (
Barnard-Brak & Brak, 2011
; Sheffler et al., 2009). This is interesting because many specialists felt that the antisocial behavior often comorbid with ADHD was because the ADHD was untreated. It seems that there may be something else to the antisocial behavior because it seemed to persist in so many people despite their longterm treatment for ADHD.

We spoke with one interventionist who provides a learning/coaching service to children with ADHD (
Joyce Kubik, Personal Communication, April 2003
). Kubik not only conducts specific skill-building training/coaching for ADHD children but also conducts support groups for parents. She also gives workshops for teacher in-service programs. Her overall message is that children with ADHD are capable of developing specific learning strategies that will lead to improved academic learning and success. She outlines these specific skills in her book S.C.O.P.E.: Student Centered Outcome Plan and Evaluation (
Kubik, 2002
). The central theme of her work is to help parents and teachers find ways to help students with attention difficulties. The
American Academy of Child & Adolescent Psychiatry (2001)
stated,

· Research also should include the role of school and community-based professionals, as well as primary care clinicians, in delivering treatment services. Little is known about how short or long-term effectiveness varies as a function of the school and community-based professional involvement…. They should consider child and family outcomes and cost-effectiveness of care. Linking outcomes to service parameters is an important step in encouraging practice in system change. (p. 10)

In this summary statement, you can recognize aspects of the multimodal model that forms the basis of this book in analyzing and evaluating interventions with children and adolescents diagnosed with ADHD. It calls for more comprehensive research on the multiple factors that contribute to ADHD in children and adolescents and initiates the process to improve research on outcomes with this disorder.

ADHD and Comorbidity

The
American Academy of Pediatrics (2001)
also stressed that evaluation for ADHD should include an assessment for coexisting or comorbid conditions. The literature on ADHD identifies several psychological and developmental disorders that coexist in children with ADHD (
Biederman, Mick, Faraone, & Burback, 2001
;
Phelps et al., 2002
;
Spencer, Biederman, & Wilens, 2002
). These disorders included conduct and oppositional defiant disorders, mood disorders, anxiety and depressive disorders, mental retardation, learning disabilities, tics, substance abuse, and medical conditions. Researchers have estimated that among children with ADHD, the prevalence rate of

Oppositional Defiant Disorder is up to 35%, Conduct Disorder up to 26%, anxiety disorders up to almost 26%, and depression up to 18% (
AAP, 2001
). It is more difficult to estimate comorbidity rates of Bipolar Disorder, substance abuse, and tics. Most authors who discuss comorbidity and ADHD tend to discuss the issue from a pharmacologic perspective rather than a counseling perspective (
Levy & Hay, 2001
;
Solanto, Arnsten, & Castellanos, 2001
). This is a burgeoning and complex conundrum in the treatment of ADHD. We encourage you to be alert to the great variability in children and adolescents diagnosed with ADHD and to assess for other conditions or factors.

Susan L. Andersen (2005)
studied stimulants and the developing brain. She found that the effects of stimulant drugs during different stages have unique short-term, acute effects that also influence their long-term effects. Chronic, pre-pubertal exposure alters the expected developmental trajectory of brain structure and function and results in a different topography in adulthood. She also discovered that the timing of exposure (childhood vs. adolescence), the age of examination after drug exposure (immediately or delayed into adulthood), and sex influenced observable effects. Hopefully this can provide new treatment options for ADHD.

Mental health clinicians should be able to recognize the evidence recommending cautious use of stimulants with children and adolescents diagnosed with ADHD, and should remain alert to the potential for overdiagnosis or misdiagnosis of the disorder and the extensive range of comorbid/coexisting conditions.
Phelps et al. (2002)
summarized issues surrounding comorbidity of ADHD, ODD, and CD related to the evidence that when two or more of these disorders occur together, the prognosis is more guarded. They also addressed the hypothesis that ADHD occurs first in the child and the symptoms of impulsivity and inattention interact with the psychosocial issues of family turmoil, parental problems, and abuse factors to trigger ODD and/or CD. Clinicians need to be alert to the range of symptoms of several disorders when assessing and evaluating symptoms of impulsiveness and hyperactivity. These conditions could emanate from psychological family and environmental factors. Although the debate continues about the effectiveness of stimulant medication with ADHD,
Greenhill (1998)
and
NIH (1998)
concluded that stimulants used for ADHD children and adolescents

· 1. Producemoderate tomarked short-termimprovement in motor restlessness, on-task behavior, compliance, and academic performance.
· 2. In studies of six months or longer, children fail to maintain academic improvement or improve social problem-solving skills (
Greenhill, 1998
, p. 53).
Atomoxetine, a Nonstimulant

Recently, atomoxetine/Strattera, a nonstimulant and a selective norepinephrine reuptake inhibitor (SNRI) has demonstrated some promising results in reducing ADHD symptoms (
Brown University, 2002
). It was approved for use in children ages 6 and older in 2003 and for maintenance treatment of ADHD in children and adolescents in 2008. Atomoxetine/Strattera is metabolized primarily through the CYP2D6 enzymatic pathways. It demonstrates an adverse event percentage of between 3.5 and 7% (poor metabolizers) in clinical trials. These adverse events include gastrointestinal problems, irritability, insomnia, aggression, and dizziness. As a nonpsychostimulant, atomoxetine/ Straterra has potential as an alternative to the stimulants now used with ADHD. As with any new medication, only time and continued research will tell if atomoxetine will improve on the side effect profile of stimulant medications.

In a very sad and disappointing statement, the status of the treatment of ADHD has not changed in seven years since the first edition of this text.

· • Children, adolescents, and adults are being diagnosed at accelerated rates.
· • The first and second course of treatment is pharmaceuticals.
· • Efforts by the FDA, legislation like the Best Pharmaceuticals for Children Act have been marginalized.
· • Limited assistance for the poor, Medicaid, wards of the county or state, orphans and other children,
· and adolescents with restricted access to quality medical care.
· • A belief still that life is better through pharma— just watch TV since the Health Care Act passed in 2009.
· • Society’s intolerance for anxious, agitated, and aggressive children.
· • Large metropolitan school systems’ inability to understand the impact of bullying on students with disabilities.

So with little progress, more children take the drugs and some experience improvement whereas many others graduate to more potent pharmaceuticals.

Review Questions

· • What were the differences between the initial findings of the MTA study and the two-year and eight-year follow up?
· • What does the eight-year follow-up tell us about antisocial behavior and ADHD treatment?
· • What conditions may be comorbid with ADHD and why may these be a case of misdiagnosis?

SECTION FOUR: MOOD STABILIZERS AND BIPOLAR I DISORDER IN CHILDREN
Learning Objectives
· • Be able to think critically about the problems of putting children and adolescents on medications tested on adults.
· • Be able to articulate alternatives to so-called mood stabilizing medications for children.

The DSM-5 (
American Psychiatric Association, 2013
) provides the following diagnostic criteria for Bipolar Disorder, Single Manic Episode:

· A. Presence of only one Manic Episode and no past Major Depressive Episodes.
Note: Recurrence is defined as either a change in polarity from depression or an interval of at least two months without manic symptoms.
· B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Criteria for Manic Episode

· A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).
· B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
· (1) inflated self-esteem or grandiosity
· (2) decreased need for sleep (e.g., feels rested after only three hours of sleep)
· (3) more talkative than usual or pressure to keep talking
· (4) flight of ideas or subjective experience that thoughts are racing
· (5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
· (6) increase in goal-directed activity (either socially, at work, or school, or sexually) or psychomotor agitation
· (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
· C. The symptoms do not meet criteria for a Mixed Episode.
· D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
· E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Source: Diagnostic and statistical manual of mental disorders (5th ed., Text Revision, pp. 123–125). Washington, DC: American Psychiatric Association, 2013.

We have seen in the past decade an increasing interest and shift in focus from Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD) to Bipolar I Disorder in children and adolescents (
Kusumaker, Lazier, MacMaster, & Santor, 2002
;
Milkowitz et al., 2014
). We illustrated this in the case of Phillip at the beginning of this chapter. Although in our
Chapter Eight
discussion of mood stabilizers we focused on Bipolar I Disorder, in this chapter we use the more general BPI, because that is the construct common to the literature on children and adolescents. Many diagnostic scholars tell us the prevalence of BPI is growing, especially in preadolescent children, with almost no gender differences (
Bland, 1997
;
Hirschfeld et al., 2003
;
Zarate & Tohen, 1996
). The case for increased incidence is still undecided.

In the Diagnostic and Statistical Manual of Mental Disorder, 5th Edition (DSM-5;
American Psychiatric Association [APA], 2013
), BPI is the basis of a new category, Bipolar and Related Disorders. BPI is the centerpiece of this section, which also includes Bipolar II Disorder, Cyclothymic Disorder, Bipolar Disorders related to substance use or medical conditions, and other specified and unspecified Bipolar and Related Disorders. In order to stem the tide of BPI misdiagnoses in children, Disruptive Mood Dysregulation Disorder was introduced to the DSM-5 section on Depressive Disorders. The jury is still out on whether this will reduce the false diagnosis of BPI in children (
Margulies, Weintraub, Basile, Grover, & Carlson, 2012
) or, for that matter, how we should treat Disruptive Mood Dysregulation (
Jairam, Prabhuswamy, & Dullur, 2012
).

There is considerable controversy regarding the appropriateness of a BPI diagnosis in children. Questions regarding the appropriateness of such a diagnosis are founded on the idea that criteria for BPI may overlap with criteria for developmental issues; other disorders usually diagnosed during infancy, childhood, or adolescence (e.g., what the DSM-5 calls Neurodevelopmental Disorders); and other problems known to affect people of all ages (e.g., depressive, anxiety, substance use, and impulse-control disorders) (
Chang, 2008
). Further, there are currently no pediatric diagnostic guidelines for BPI in children, and it is inappropriate to use the DSM criteria for BPI because they were normed on adults (
Kowatch et al., 2005
;
Sahling, 2009
).

One of the most problematic issues is assuming that any type of irritability or acting out is somehow related to the invalid notion of a “bipolar spectrum.” Differentiating between irritability (very common in children and adolescents) and symptoms of BPI is an ethical imperative for clinicians, particularly those working in foster care or with other children and adolescents who have no one to advocate for them (
Banaschewski, 2009
;
Sahling, 2009
). Although published studies using functional brain-scanning technologies to investigate early-onset BPI are few, some show brain anomalies similar to those that correlate with adult BPI (
Frazier et al., 2005
). Only longitudinal studies will answer the question regarding how predictive such anomalies are for the development of BPI because brain scans can only suggest endophenotypes that are related to vulnerability to a disorder (
Jackson, 2006
).

The problems with the exponential increase in diagnosing pediatric bipolar disorder are many. In many children, rapid mood swings can be normal. The treatment guidelines (
Kowatch et al., 2005
) admit that “no one can say for sure what these children will look like when they grow up” (p. 214). This is a disturbing statement because BPI, properly diagnosed, is thought to be a chronic disorder. The authors of the treatment guidelines admit that the DSM symptoms for adult mania are problematic when used for children, but then they recommend continuing to use them. Overall, the treatment guidelines fail to draw distinctions between normal children and those really afflicted with BPI (
Sahling, 2009
).

Currently, the DSM-5 diagnostic criteria for Bipolar Disorder are used for children and adolescents without any major modifications and the features providing the best distinction between ODD,

CD, ADHD, and BPI are the presence of a flight of ideas, grandiosity, and the episodic nature of the grandiosity (
Carlson, 1996
;
Kusumaker et al., 2002
). As we summarize the literature on BPI in children and adolescents, we learn that it is difficult to diagnose, more clinicians are recognizing its prevalence at an earlier age of onset, three tentative developmental theories are linked to it (
McMahon & DePaulo, 1996
), and more clinicians are using antimanic medications to treat BPI in both children and adolescents.

Soutullo et al. (2005)
concluded that there is an overdiagnosis of Bipolar Disorder in the United States when compared to several countries like Spain, Turkey, India, Brazil, Switzerland, Denmark, and Finland. This difference may be attributed to a relative lack of data, differences in diagnostic criteria, different levels of recognition of child and adolescent psychiatry as a true specialty in Europe, clinician bias against Bipolar Disorder, an overdiagnosis in the United States, and/or a true higher prevalence of BD in the United States. It sounds like the same case with ADHD.

Viesselman (1999)
addressed the general symptoms of BPI as expansive mood, inflated selfesteem, decreased need to sleep, talkativeness, flight of ideas, distractibility, psychomotor agitation, and excessive involvement with pleasurable activities.
Phelps et al. (2002)
addressed the fact that BPI youth often are incorrectly diagnosed as having Schizophrenia; thus, BPIs are difficult to discern in children and adolescents because many present with an agitated depressed mood rather than mania (
Weller, Weller, & Fristad, 1995
).
Lewinsohn, Klein, and Seeley (1995)
stated that pediatric clients with BPI present with more psychomotor agitation, elevated mood, increased verbalizations, inflated self-esteem, distractibility, and a decreased need for sleep.
Duffy (2010)
detailed with great specificity the potential genetic markers for children who might be vulnerable to inherit Bipolar I.

The treatment of choice for BPI in children and adolescents is the mood stabilizers covered in
Chapter Eight
. These drugs include lithium/Eskalith, Lithobid, valproate/Depakote/Depakene/Divalproex), carbamazepine/Tegretol, oxcarbazepine/Trileptal, and olanzapine/Zyprexa. Many scholars already cited in this chapter argue against indiscriminate use of these medications with pediatric populations without further study and argue for more complete awareness of the dynamics affecting the child.

Riddle et al. (2001)
discussed the finding that the older antiepileptic drugs had been well researched as mood stabilizers in adults but not in pediatric populations.
Campbell, Kafantaris, and Cueva (1995)
have studied lithium/Eskalith, carbamazepine/ Tegretol, and valproate/Divalproex used for children with nonspecific aggression and found lithium/Eskalith was superior to placebo and to the other antiepileptic drugs in reducing aggression. One very important note:
Eberle (1998)
found that one type of adverse event of using valproate with girls is that of polycystic ovarian disease, which can have profound consequences for females.

In the early 21st century, children and teens are 40 times more likely to be diagnosed with Bipolar Disorder than they were in the late 20th century (
Miller & Barnett, 2008
). As noted above there is evidence that this is due to diagnostic inflation and not an epidemic-level increase in the disorder.
Geller et al. (2012)
compared lithium/Eskalith, valproic acid/Divalproex, and risperidone/Risperdal in a trial called Treatment of Early Age Mania (TEAM). The response rate for risperidone/Risperdal was significantly higher (68%) than for lithium/ Eskalith (36%) or valproic acid/Divalproex (24%).
Advokat et al. (2014)
note that quetiapine/Seroquel and aripiprazole/Abilify are as effective as risperidone/ Risperdal. As noted in the chapter on antipsychotics though, these drugs come with severe side effects like weight gain and disruption of metabolic functions that can lead to type 2 diabetes.

In our clinical work of over 40 years, we have found that the comorbid substance use disorders were a major missing piece in several cases with children and adolescents. These clients were diagnosed with ODD, CD, or BPI and seemingly did not improve with psychotherapy or psychotropic interventions. The missing link and confounding variable was their hidden polysubstance abuse or

dependence, which exacerbated some symptoms and masked others. The links in the literature show how the onsets of BPD, ADHD, CD, or ODD become significant risk factors in diagnosing substance use disorders. It should be noted that any attempts to procure research papers on pediatric or child papers on the research topics of developmental pharmacology, ADHD, BP I, and pharmaceuticals related to these disorders published in 2013 or 2014 were sponsored by pharmaceutical companies and cost $39.00.

The following case may provide additional understanding of these complex variables.

THE CASE OF NICOLE
Nicole, a 14-year-old Caucasian girl currently living in a foster home, had just been referred to a Severe Emotional Disturbance (SED) unit in her school system. Nicole had a history of acting out, impulsivity, distractibility, conduct, and learning problems from a very early age. Initially, Nicole was referred to a specialist for her impulsivity and distractibility both at home and in preschool at the age of 4.
During the assessment, the clinician suspected a mood disorder but seemed to have more evidence for ADHD. He recommended a daily course of amphetamine salts/Adderall with behavior management therapy at home and school, focused on specific age-appropriate behaviors. At the time of the evaluation, he did not notice Nicole’s intermittent scratching of her genital area. Over the next six months, Nicole showed little improvement in her symptoms and behaviors as a result of the amphetamine salts/Adderall and the milieu behavioral therapy. In fact, some of her behaviors worsened: she attacked other children, was cruel to animals, and was overtly curious about male and female genitals. After nine months, the psychologist consultant at the school recommended another neuropsychiatric evaluation and an outside therapist who would address some of Nicole’s apparent psychological conflicts along with her behavior.
The second psychiatric evaluation yielded a change in diagnostic perspective. This time, the psychiatrist diagnosed BPI and prescribed valproic acid/Divalproex and a low dose of lorazepam/ Ativan, an anxiolytic. The new therapist, a female, stopped the behavior therapy and began to treat Nicole with a combination of play therapy and insight-oriented therapy. The play produced associations to remote possibilities of earlier sexual abuse and abandonment, and the insight therapy captured her already highly critical superego (obsessive thought patterns and preoccupation with sexual act) and her deep affection for the rituals of the Catholic Church. Nicole remained on this treatment regimen for about two-and-a-half years. During treatment, she never really settled down in class or at home, but her behavior and attention were slightly more manageable. (We have all had cases where there is just enough improvement from the medication to raise expectations even if the client seems not to be making progress in many important areas of her life.) Later, Nicole developed a passion for reading 7 to 10 books a week that she got from the local library. On her trips back and forth to the library, she befriended some older boys (ages 10 to 13) who offered her street stimulants at a very low cost. Nicole welcomed the friendship and experimented with the drugs (stimulants, soapers, cocaine), but was gangraped by the boys one Saturday afternoon. Overwhelmed by this horrific sexual trauma, Nicole did not speak of it to anyone. She also immediately stopped associating with the boys. Her response to this event was alternately to withdraw into a cocoonlike isolation and to become aggressive with people.
She verbally assaulted teachers and foster parents and attacked her friends and other students. She was unreachable and totally out of control. She stopped attending her therapy sessions with the counselor, but she continued to seek street drugs.
Puzzled and frustrated, the school crisis team recommended an additional psychiatric evaluation and assessment for Nicole and possible hospitalization. This triggered a series of episodes in which she ran away, had several foster and specialized school placements, a brief stay at a juvenile detention facility, one abortion, and two attempts at drug rehabilitation for her dependence on stimulants, cocaine,
and now alcohol. Somehow Nicole survived and is now in an SED classroom with a specialized social worker as an aide. She is on olanzapine/Zyprexa for psychotic mania, sertraline/Zoloft for depression and anxiety, low doses of valproic acid/Divalproex for violent and aggressive outbursts, and zolpidem/ Ambien as needed for sleep. In essence, at 14, Nicole was loaded with psychotropic medications (polypharmacy). She was referred to a new female therapist, with whom she rarely spoke; when she did, she mentioned missing her former, caring play therapist, one of the most stable objects (people) in her life. Although Nicole did attend her class regularly and her behavior was quite manageable, her teachers reported very little learning progress and a total inability to interact with her classmates. Her therapist echoed much of the same descriptions, but voiced marginal hope when she and Nicole engaged in drawing or other forms of play therapy or discussed issues related to an all-loving versus all-punishing God. The concluding remarks in her individual educational plan (IEP) at school read, “No change, few academic gains, impulsive/ aggressive behavior stabilized, little socialization, continues in counseling.”

Examining this case from our four perspectives yields some important insights and omissions. Nicole did receive a more extensive assessment early on and participated in behavioral therapy first, which is recommended by the literature (
AAP, 2001
;
Kusumaker et al., 2002
;
Phelps et al., 2002
) followed by art therapy and insight therapy when the behavioral therapy failed. It is critical to note that the second therapist helped Nicole discuss psychological and cultural issues and learned about the pressure from her complicated feelings about her upbringing in the Catholic Church and her deep awareness of her selfcritical feelings and thoughts.

As is so often the situation with a foster child, other social and cultural pressures intervened, such as drug abuse, negative and exploitive peer relationships, and sexual trauma. It is not clear whether Nicole ever experienced sexual or physical abuse earlier in her life. The most recent team is faced with an early adolescent girl with a long history of psychotropic and psychotherapeutic treatments whose life is further complicated and traumatized by rape and drug dependence. Given the assumption that the significant others in her life—case managers, foster parents, teachers— feel she is out of control, the attending psychiatrist then addressed her range of symptoms and conflicts with a polypharmaceutical strategy. This approach numbs and tranquilizes Nicole so she is more appropriate in her various living environments but fails to address the boiling issues, anguish, and conflicts from the other aspects of her life. Treatment for Nicole should begin by recognizing the extreme complexity of her life space and developing a treatment plan and approach to gradually help her titrate off some of her medications while addressing in counseling the complex issues of abuse, drug dependence, abandonment, and loss of self that so plague her. She will need a very extended and interpersonal treatment approach if she is to recapture hope and resiliency in her life. We also would speculate about the accuracy of her diagnosis, because of the interplay of her conflicts and varying presenting problems and lack of empathy in her counseling.

Review Questions

· • What are some of the problems of putting children and adolescents on medications tested on adults?
· • What alternatives do we have to so-called mood stabilizing medications for children?

SECTION FIVE: CHILDREN AND ANTIPSYCHOTIC MEDICATION
Learning Objectives
· • Know the diagnoses for which typical and atypical antipsychotics are being used in children.
· • Be able to discuss the problems with this practice.
Schizophrenia with adolescent onset has been noted since the earliest descriptions of the disorder. Readers will recall Emil Kraepelin’s initial diagnosis of a

patient as having “dementia praecox,” which means “youthful insanity.” As
Russell (2001)
notes, given that the disorder has been linked with adolescents through the evolution of its diagnostic forms, one might think there would be ample treatment literature regarding these populations, but there is not. Childhood-onset schizophrenia (prior to age 12) is even rarer than adolescent onset. It is estimated that maybe 1 child in 10,000 would suffer this before the age of 12 (
Remschmidt, 2002
). The differential diagnosis must include substance-use disorders, depressive disorders with psychotic symptoms, and what DSM-5 calls other neurodevelopmental disorders like Autism Spectrum Disorder (
Androutsos, 2012
). Even when criteria are met it is very difficult to diagnose schizophrenia in a child. The Child Psychiatry Branch at the National Institute of Mental Health (NIMH) conducted a longitudinal study of childhood onset schizophrenia. Outpatient screening accurately diagnosed 55% of the 121 cases. However, inpatient observation including medication-free observation ruled out 96 children with alternative diagnoses. Outpatient screening only accurately diagnosed 62% of this same group. The conclusion the researchers drew was that inpatient, unmedicated observation was the most accurate way to diagnose these children (
Gochman, Miller, & Rapoport, 2011
).

In a review of controlled studies of antipsychotic agents to treat Schizophrenia,
Campbell, Rapoport, and Simpson (1999)
found only one controlled study of the use of these agents with adolescents and one report on their use with children younger than age 12. Therefore,
Russell (2001)
notes, until more research is conducted clinicians must extrapolate from adult studies to children and adolescents, which poses many risks. Although he comments this is not cause to adopt a nihilistic attitude, it does call for clinical skepticism. Russell maintains it may be true that people with early-onset Schizophrenia have more severe forms of the disorder, but this has yet to be determined conclusively and it does not mean pharmacologic treatment will not be effective. Further, early-onset Schizophrenia seems to have more severe negative symptoms, making the atypical antipsychotics a better choice if the children can tolerate the adverse drug effects (
Botteron & Geller, 1999
).

Although few data are available regarding the use of antipsychotics with childhood psychoses, in the 20th century the neuroleptic haloperidol/ Haldol was used because it tended to be less sedating (
Andreasen, 2000
). Because of the potential for Parkinsonian-like symptoms, this medication was often prescribed with an anti-Parkinsonian agent such as benztropine/Cogentin.
Ernst et al. (1999)
;
Phelps et al. (2002)
; and
Riddle et al. (2001)
also addressed the use of the “atypical” newer neuroleptics for children diagnosed with tics, behavioral problems in autism, psychotic illness, and nonspecific aggression. In 2004, Toren et al. (
Toren, Ratner, Laor, & Weizman, 2004
) did a benefit-risk assessment of atypical antipsychotics in treating schizophrenia and comorbid disorders in children. They found the atypicals seemed to work better than neuroleptics and now it seems that neuroleptics like haloperidol/ Haldol are only used if the patient does not respond to an atypical. Of the atypical, risperidone/ Risperdal and olanzapine/Zyprexa seemed to improve cognitive functions and inhibit suicidal behavior.
Madaan, Dvir, and Wilson (2008)
noted that the FDA concluded there was enough support for using atypicals in children and approved two atypicals for childhood schizophrenia.

As we noted in
Chapter Seven
, evidence is mounting that atypical antipsychotics are also correlated with increased risk for diabetes and hyperglycemia and that this risk includes children and adolescents (
Koller, Cross, & Schneider, 2004
). Research by
Correll et al. (2009)
confirmed these mounting suspicions. The study concluded that use of aripiprozole, olanzapine, quetiapine, and risperidone for 12 weeks all produced weight gain, and varied in lipid and metabolic parameters. The authors called for more careful monitoring of the child’s health before using an atypical. Whatever medication a clinician chooses,
Russell (2001)
emphasizes the need for multimodal treatment that includes psychosocial interventions such as individual and family therapy, psychoeducational counseling, and social skills training.

A more common problem is raised by
Pappadopulos et al. (2002)
in a study that examines the range of off-label prescribing of atypical antipsychotics for aggression. These authors state that although in theory doctors seem to agree about optimal prescribing practices, in the “real world” there is wild disparity in the prescriptions written. Apparently, even the agreement between researchers and front-line doctors can be influenced by staff pressure, limited staff resources, managed care limits on inpatient stays, and the movement away from physical restraint.

Another problem that requires further debate and research concerns the notion that Schizophrenia is a wide spectrum of early-onset disorders manifesting in a variety of the disorder called “schizotaxia,” which refers to a genetic predisposition to Schizophrenia (
Meehl, 1962
).
Tsuang, Stone, and Faraone (2001)
advocate treating Schizophrenia prophylactically. These authors maintain that the theoretically genetic predisposition toward Schizophrenia may be associated with reversible problems and may improve the child’s quality of life. Despite this strong medical model perspective, they admit that psychosocial interventions may also work. They conducted a six-week trial of risperidone (prescribed at low levels) in six subjects identified as schizotaxic. They reported that five of the six reported increased cognitive abilities during the trial as well as greater enjoyment of social activities. Obviously, there is no way to determine the amount of placebo effect until a double-blind, placebo-controlled trial is done.

Great caution needs to be exercised here, as the implications are that asymptomatic children might be given antipsychotics in the hope that their diagnosis as schizotaxic is correct. The antipsychotic market currently amasses $5 billion a year, and many fear that the theory of schizotaxia is just another way of bending the parameters of diagnosis to help pharmaceutical companies profit from a new market. Currently, no diagnostic system in the world identifies adolescents in the phase before onset as ill, so this approach would have ramifications for the diagnosis. Ideally, the issues surrounding the politics of research and publishing described in
Chapter Two
, need to be more adequately addressed before any further medicating of asymptomatic populations. As
Frances (2013)
noted, preventive psychiatry could only work if we know the etiology of a disorder and have a safe and effective treatment for the disorder. We have neither where schizophrenia is concerned.

In
Chapter Seven
, we discussed neuroleptics and their affinities for different CNS receptors, their pharmacokinetics, and pharmacodynamics.
Marriage (2002)
spoke to our inability to predict the response of an individual patient (child or adolescent) to a typical or atypical neuroleptic. He addressed the enormous response variation, especially with adolescent males, Asians, Native Americans, and people suffering fromvarious forms of organicity. For children or adolescents exhibiting symptoms of psychosis, the longterm prognosis is poor (
Phelps et al., 2002
), and we need to learn a great deal more about the adverse side effects of both the typical and atypical medications (
Riddle et al., 2001
). Given the outcome of
Olfson et al. (2006)
National Trends Study, which indicated that children treated with second-generation medication (atypical antipsychotics) included descriptive behavior disorders (37.8%), mood disorders (31.8%), pervasive developmental disorders or mental retardation (17.3%), and psychotic disorders (14.2%), we are again reluctant to endorse atypicals as a treatment of choice for childhood psychosis.

Review Questions

· • What are some of the conditions for which children are being put on antipsychotic medications?
· • What are the main drawbacks to this practice?

SECTION SIX: ANTIANXIETY MEDICATIONS AND CHILDREN AND ADOLESCENTS
Learning Objective
· • Understand particularly how anxiolytic medications are used with children who have school anxiety.

Despite the high prevalence of anxiety disorders in children (10 to 20%), very few controlled medication trials have been conducted. In DSM-5, Obsessive-Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) have been given their own categories. Children’s anxiety disorders, Separation Anxiety Disorder, Selective Mutism, Specific Phobia and Generalized Anxiety. In the late 20th century,
Brown and Sawyer (1998)
concluded that regarding anxiolytic medication with children, “few published empirical studies support their long term efficacy for children and adolescents” (p. 83).
Bernstein and Shaw (1997)
noted that psychotropic medications should not be the sole intervention but should be used as an adjunct to counseling. Interventions that facilitate active mastery are important, to prevent symptoms returning after discontinuation of medication. Little has changed and almost 20 years later anxiety disorders in children are first best treated with nonpharmacological therapies like behavior therapy, cognitive-behavior therapy, and internalizing prevention programs.
House (1999)
noted that children’s disorders can be generally grouped as externalizing (like acting out against others) and internalizing. Internalizing often results in anxiety symptoms. Young children with anxiety disorders are more likely to be depressed and to exhibit temperamental inhibition and sleep problems (
Doughert et al., 2013
).

The 2013 article of Rapp et al. will guide our complex study of anxiety disorders. The DSM-5 and earlier versions have really not assisted our journey to discover effective treatments for children and adolescents suffering from anxiety disorders (AD). It is the second author’s opinion that there have been too many changes in the DSM related to AD since 1980. Our focus needs to shift to treatment with safe and effective outcomes.
Bernstein, Borschardt, and Perwien (1996)
viewed these changes as placing at risk a decade of research on childhood anxiety disorders, although
Phelps et al. (2002)
supported elimination of some categories of childhood anxiety disorders from DSM III-R as a research-based simplification of the categories. Although prevalence rates vary for current anxiety disorders with children and adolescents (
Botteron & Geller, 1999
;
Garland, 2002
), incidences of Generalized Anxiety Disorders (GAD), and Separation Anxiety Disorder (SAD) are frequently thought to require both psychopharmacologic and psychotherapeutic interventions. Currently, although almost all the drugs are used off label, SSRIs such as paroxetine/ Paxil, fluvoxamine/Luvox, fluoxetine/Prozac, citalopram/ Celexa, and sertraline/Zoloft are prescribed for children and adolescents with anxiety disorders.
Advokat et al. (2014)
noted that fluoxetine/Prozac may be the best medication if medication is necessary. The current concern over safety of these medications for children and adolescents applies to their use in anxiety disorders as well as in depression. One of chronic side effect of SSRIs recognized in children is a behavioral activation (
Riddle et al., 1991
), like an increased agitation different from a mania. As noted earlier the
Food and Drug Administration (2003)
issued a Public Health Advisory stating that use of SSRIs and similar types of antidepressants with depressed children and adolescents may be linked to increased suicide rates. How this will affect use of these antidepressants for anxiety disorders remains unclear.
Rapp, Dodds, Walkup, and Rynn (2013)
continued to use SSRIs in their combined treatment approaches with children diagnosed with GAD, SP, and SAD. Their study gave very high marks to Cognitive-Behavioral Therapy (CBT) in conjunction with a psychopharmacological approach.

In a review of the literature on anxiolytic medications used in pediatric populations,
Livingston (1995)
noted mixed results with benzodiazepines and said that in cases where studies show initial results, the results fail to be significant in replications of the studies. Livingston notes that if children are going to be placed on these medications, prescribers need to “start low and go slow” (p. 248). Recall from
Chapter Six
, benzodiazepines such as alprazolam/ Xanax and diazepam/Valium have an inhibitory impact on the CNS at the GABA receptor complex. As
Advokat et al. (2014)
note these drugs usually cause cognitive impairments and so are not recommended except in the case of shortterm medical procedures (e.g., dental procedures).

SCHOOL ISSUES, ANXIETY, AND CHILDREN

A relevant law when addressing anxiety in children is the Individuals with Disabilities Education Act (IDEA). Services to children are provided under a number of provisions in this act, and often many DSM anxiety disorders can be used to qualify a child for services. The diagnostic categories of DSM do not automatically correspond to the eligibility categories in IDEA. The interested reader can go to
http://www.ed.gov/offices/OSERS/IDEA/the_law.html
for a listing of the relevant diagnoses. IDEA services focus on disability conditions that interfere with a child achieving academically or vocationally.

Anxiety disorders have been used to qualify a child for special services. A key symptom is fears associated with personal or school problems that persist over a period of time and adversely affect educational performance. Anxiety disorders are one of the most common childhood disorders and may impair a child’s life even if symptoms are below the threshold for a DSM diagnosis. For example, some studies show “subclinical” anxiety to be highly correlated with reading difficulty (
Bernstein & Shaw, 1997
). Currently, studies are underway to measure the impact of bullying on anxiety (
Twemlow, Fonagy, Sacco, & Brethour, 2006
).

Developmental differences exist in the presentation of the anxiety disorders. For example, younger children with Separation Anxiety Disorder have far more symptoms than older children. In adolescents, somatic complaints and school refusal are more common than in younger children. Conversely, older children with GAD show more symptoms than younger ones. This is probably caused by cognitive differences, because older children have more mental tools with which to craft their worries.

Interestingly, in several studies with benzodiazepines, the medicated groups did no better than placebo controls. Two studies did yield significant differences among school refusers and children with selective mutism and social phobia. In one study, the school refusers did better than controls when given Tofranil/imipramine, a tricyclic antidepressant. The other study, on selective mutism and social phobia, showed that the experimental subjects did better than controls when given Prozac.

A related childhood disorder is Separation Anxiety Disorder. Here, the anxiety is aroused by separation from familiar people (usually parents) or leaving home. The reaction is excessive and may include fears that something will happen to the parents or to prevent reunification. Somatic complaints are also common. The distinction must be made between developmentally normal separation anxiety and this disorder. If refusal to go to school is thought to be due to Separation Anxiety Disorder, the child will go if accompanied by the parent. Although benzodiazepines and antihistamines have been used to treat this (
Wozniak et al., 1997
), exposure-based interventions and relaxation are likely to be more effective.

Another subthreshold condition is shyness. It is consistently correlated with adult and childhood anxiety disorders. Although common (90% of people report feeling it at some time in their lives), it can be debilitating as the person gets older. Shy men marry later and become parents later than their counterparts who are not shy. Although shy women marry and become parents at ages comparable to their counterparts who are not shy, they are less likely to attend college or work outside the home. Social phobia is a severe manifestation of shyness that afflicts about 5% of children. It delays social and emotional development. The overwhelming fear of doing or saying something embarrassing or humiliating keeps such people from eating, drinking, or writing in public or engaging in everyday conversations.

Although children generally outgrow shyness, they do not outgrow Social Phobia. Children with social phobias are usually depressed and lonely and almost always solitary. They may show extreme anxiety in situations where they feel they are being evaluated by others. The onset of Social Phobia is usually in adolescence and without treatment, the course is often chronic. There is high comorbidity with depression, other anxiety disorders, and substance abuse to self-medicate. As with other

childhood anxiety disorders, the recommended treatments include rehearsal, imagery, and drug treatment with antidepressant compounds. Behavior therapy has a 70% success rate for both children and adults, with systematic desensitization and exposure being the common treatments. Although more children and adolescents are being prescribed SSRIs and SNRIs for shyness and Social Phobia, there is literature supporting the practice.
Rapp et al. (2013)
continued to use SSRIs as the pharmacological treatment of choice in their protocols with some success and marginal adverse effects in the pediatric population. They reported on one study that used pregabalin (Lyrica) with promising results with a pediatric population. There are too many adverse effects to pregabalin.

Review Question

· • How could anxiolytics be helpful to children with school anxiety?

SECTION SEVEN: ANTIDEPRESSANTS AND CHILDREN AND ADOLESCENTS
Learning Objectives
· • Understand why the black-box warning on antidepressants for children is important.
· • Be able to suggest the type of monitoring necessary if a child is on an antidepressant.
· • Know the “placebo problem” especially in reference to children and antidepressants.

Many reports have appeared on an increased incidence of MDD in children and adolescents. Although more studies on this have begun, there is always error in the epidemiologic methods used to gather such data, so such reports are far from conclusive (
Ingersoll & Burns, 2001
). As
McClure, Kubiszyn, and Kaslow (2002b)
noted, many approaches are used for diagnosing and treating mood disorders in children, only a few have any empirical support. It does seem that when identified, childhood or adolescent depression is characterized by high rates of comorbidity with conduct, anxiety and attention deficit disorders, impaired social and vocational functioning, increased rates of substance abuse, eating disorders, and higher risk for completed suicide (
West, 1997
). Given that, it is important to consider all treatments that may be helpful when a child or adolescent does manifest symptoms of depression.

Depression (unipolar) can be very difficult to discover, discern, and diagnose in children and adolescents. In children, the symptoms manifest themselves as hyperactivity, impulsivity, and aggressiveness. Grief and loss may trigger enuresis, sleeplessness, nightmares, and extreme stubbornness, depending on the age of the child (
Brown & Sammons, 2002
;
Riddle et al., 2001
;
Ryan, 2002
;
Viesselman, 1999
). In fact,
Ryan (2002)
noted that depressive illnesses in children and adolescents can be protracted, recurrent, and continue into adulthood.

Newer research into the complexities of antidepressant action can help neurologists and clinicians better understand developmentally important age differences in the nervous system. Researchers are beginning to see that developing animals differ from older ones in serotonin-mediated responses. Very-early-onset stress may compromise later adaptive capacity of some of these systems (
Goldman-Rakic & Brown, 1982
). Juvenile depression may also differ substantially from adult depression regarding the role of noradrenergic mechanisms and thus in the responsiveness to compounds that target norepinephrine. Practitioners need to be alert to warnings such as those by
Coyle (2000)
, who noted there is “no empirical evidence to support psychotropic drug treatment in very young children and that such treatment could have deleterious effects on the developing brain” (p. 1060).

Tricyclic Antidepressants in Children
Overall, the results have not supported data found in adult studies regarding the efficacy of tricyclic antidepressants in treating juvenile depression

(
Cohen, Gerardin, Mazet, Purper-Ouakil, & Flament, 2004
;
Rosenberg, Holttum, & Gershon, 1994
). The weight of currently available evidence suggests that TCAs as a group are indistinguishable from placebo, except in side effects (
Kutcher et al., 1994
;
Puig-Antich et al., 1987
). The highest response rate in a study is about 44%. In addition, a significant risk arises of serious cardiac problems in developing bodies. The same conclusions hold true for the TCA derivatives such as desipramine/Norpramin and nortriptyline/Trazodone. Both have been fairly well studied, and researchers have failed to show significant therapeutic differences from placebo but did show a high number of adverse side effects. In addition, both still carry the risk of cardiovascular complications.

Research has demonstrated that TCAs (and MAOIs) have not revealed greater efficacy than that for placebo, and their adverse side effect profile is extensive, including reports of sudden cardiac death (
Birmaher, 1998
;
Brown & Sammons, 2002
;
Kye et al., 1996
;
Riddle, Geller, & Ryan, 1993
;
Werry, 1999
). There is little support if any for the routine use of TCAs as a first line of treatment in children and adolescents. Therefore, it is disturbing that millions of prescriptions for desipramine and related compounds have been written for young people under age 18 (
Goleman, 1993
).
Sommers-Flanagan and Sommers-Flanagan (1996)
recommended that such prescriptions be reserved for special cases where other treatments have proven ineffective or intolerable and that a thorough physical (including cardiovascular exam) should be conducted before beginning the medication. TCAs should be used in children only under the following conditions:

· • Full informed consent of patient and parent
· • A history of lack of response to more appropriate treatments
· • Full disclosure of side effect profile
· • Disclosure of cardiotoxicity of these compounds
· • When trials of more effective, available pharmacotherapies (SSRIs) have failed

Also, TCAs should be used with extreme caution, because the noradrenergic system (on which TCAs operate) does not fully develop until early adulthood (
Goldman-Rakic & Brown, 1982
). This evidence has not changed.

SSRIs in Children

As noted, the
FDA (2003)
has currently issued a Public Health Advisory cautioning about a possible link to the use of certain SSRI antidepressants in pediatric populations and increased suicide rates. The antidepressants in the advisory are listed in
Table 9.4
.

As noted, the SSRIs currently are used with children and adolescents for anxiety and depression. Fluoxetine/Prozac has received FDA approval for use in pediatric populations, and fluvoxamine/ Luvox is approved for treating OCD in children (
Brown & Sammons, 2002
). All other SSRIs are prescribed as off label to children with depression as of this writing. Children and adolescents encounter the same adverse effects as when the SSRIs are employed with anxiety disorders. These compounds are more effective in children but not as effective as in adult samples. Glaxo-SmithKline pled guilty to criminal charges for promoting paroxetine for use in the pediatric agerange for the treatment of depression (
Hensley, 2012
).

TABLE 9.4 Antidepressants Listed in 2003 FDA Public Health Advisory

Generic Name

Brand Name

Fluoxetine

Prozac

Fluvoxamine

Luvox

Citalopram

Celexa

Escitalopram

Lexapro

Mirtazapine

Remeron

Nefazodone

Serzone

Paroxetine

Paxil

Sertraline

Zoloft

Venlafaxine

Effexor

Bupropion

Wellbutrin

© Cengage Learning®

It is important to note that adolescent girls are particularly vulnerable to depression when entering puberty (
Phelps et al., 2002
;
Silberg et al., 1999
). Clinicians should be sensitive to gender, family history of depression, impacting life events, loss, or death when assessing children for depression. Current trends and preliminary understandings of the research suggest that in addressing childhood depression, the clinician must consider both psychotherapy and medication (
Badal, 1988
,
2003
).
Ryan (2002)
indicated that 30 to 40% of children do not have a sufficient response to the first SSRI treatment.

There is almost no literature on the effects of SSRIs on infants and preschoolers (
McClure, Kubiszyn, & Kaslow, 2002a
); however, evidence shows SSRI prescriptions are on the increase for this age group (
Zito et al., 2000
). The majority of researchers looked at the effects of fluoxetine (Prozac) on older children and adolescents, which has shown mixed results (
Emslie et al., 1997
). Some studies looking at the effects of paroxetine on children and adolescents are also promising (
Findling et al., 2000
;
Keller et al., 2001
), but more doubleblind, placebo-controlled studies need to be done. Juveniles with a family history for manic or hypomanic symptoms are at higher risk for SSRIinduced manic or hypomanic episodes. If children or adolescents are treated with SSRI medications, treatment should be cautious and should observe the following conditions:

· • SSRIs are used in addition to supportive psychotherapy or counseling to deal with psychological issues.
· • SSRIs should be supported by education regarding the symptoms, the medication, and what relief the medication is to provide.
· • Effective treatment involves parents or caregivers as much as possible.
· • Effective treatment includes use of a depression scale (HAM-D or BDI-II) if the child is old enough to take one, to monitor symptoms.
· • The acute phase of treatment should take place over 8 to 12 weeks followed by maintenance of 4 to 6 months.

McClure et al. (2002a)
conclude that when medication is warranted, the SSRIs are the medication of first choice.
Jureidini et al. (2004)
disagree, however. They recently reviewed and critiqued seven published randomized, controlled trials of newer antidepressants for depressed children. These researchers found that pharmaceutical companies paid for the trials, the benefits of the drugs were small, and the adverse effects were downplayed, and they concluded antidepressant drugs could not be confidently recommended as a firstline treatment option. This is only one metaanalysis, but it points to the need for validity in published data and full disclosure of biases resulting from funding sources or researchers. Karger (2013) concluded that SSRI and even SNRI treatments for pediatric populations were/are too risky and this is from an international perspective. He stated that the SSRIs were more effective with anxiety disorders. Studies have been more compromised in pediatric populations with depression. Also,
Craighead, Miklowitz, and Craighead (2013)
summarized the work of Dr. Du of Shanghai who indicated that his studies demonstrate that SSRIs are safer in adolescents than in children. Dr. Du encouraged universal efforts of prevention to address the 17–20% of children who are depressed in all of our cultures.

From an integrative perspective, it is important to review all literature as it comes in, as well as review the researchers and the funding sources to check for possible bias. At the time of this writing, a new government-funded study of SSRIs and children was completed but not officially released in a peer-reviewed journal. The study was the Treatment for Adolescent with Depression Study (TADS), sponsored by the National Institute of Mental Health (NIMH). When we called NIMH to get a copy of the study, we were told the study needed to be peer-reviewed and the results would not be released until that process was complete. Nevertheless, Time magazine (
Lemonick, 2004
) and The New York Times (
Harris, 2004
) reported

(without benefit of peer review) that the study supported the use of the medications with children. When we asked the NIMH representative how the popular press would have gotten the results to report before the peer review, she said she didn’t know. Until a peer review of the study is concluded, the writers have no basis for these conclusions other than their own opinions of the study. Without including the results of peer review, readers are likely to come away with a “sound byte” interpretation of the results that may not be accurate. Readers can access the latest results of drug trials on the NIMH website
http://www.nimh.nih.gov/studies/2mooddisordersdep.cfm
. We did not try for the results in 2014.

THE PLACEBO PROBLEM

As we noted in
Chapter Five
, the placebo effects of compounds and the place and type of placebo in studies has yet to be explicated. According to
Fisher and Fisher (1997)
, “A probe of the available scientific reservoir of pertinent studies does not reveal any serious evidence that antidepressants do more for childhood depression than do placebos” (p. 308). An earlier overview of studies by
Thurber, Ensign, Punnett, and Welter (1995)
concluded that the more adequate the experimental methods in each study, the less likely to be found superior to placebo were the drugs tested. Although
Fisher and Fisher (1997)
noted that the evidence is still limited for the effectiveness of many counseling/psychotherapy approaches to depressed children and adolescents, this does not excuse the prescribing of compounds for which very little evidence of efficacy and effectiveness exists.

In concluding this section, we remind the reader that clinicians are using off-label psychotropic medication for several other disorders. In each case, the clinician must weigh the benefit versus the potential adverse effects of the drug on the child. We must also speak to the child about his or her reaction and feelings about the medication and request feedback from the parents or guardians about the child’s progress or struggles with the psychotropic medications. We believe it is an enormous responsibility to counsel children and adolescents who are on psychotropic medication where little research has been conducted on the efficacy, effectiveness, and safety of the drugs.

In April 2003, the recommendations were published of the Research Forum approved by the American Academy of Child and Adolescent Psychiatry (AACAP) on strategies for psychopharmacological studies on preschool children (
Greenhill et al., 2003
). The six workgroups of the Research Forum were (1) diagnosis/assessment, (2) research design, (3) ethics/institutional review board (IRB), (4) preschool protocol modifications, (5) FDA/regulatory industry, and (6) training/public issues. Finally, when our text was reviewed in 2005, most psychiatrists challenged us on our strident positions about pharmaceutical research, medicating children, split-treatment (working together—psychiatrist and mental health professional), and the general tone of our text. Now we wish to extend our empathy to all psychiatrists who work under tremendous pressure to cure the incurable and find the magic pill.

Review Questions

· • Why is the black-box warning on antidepressants for children important?
· • If a child is put on an antidepressant, what sort of monitoring is necessary for the child?
· • What is the placebo problem with regard to children and antidepressants?

CONCLUSION

We have sought to highlight the complexity, controversy, and conundrums of child and adolescent psychopharmacology. By now, you are alert to factors from all four perspectives that impinge on this issue, generate “word magic,” provide partial truths, or stimulate errors. In the colossal debate over ADHD, we discover not only errors but an inflexibility that may harm children rather than treat them. We recognize the power and influence of the pharmaceutical companies to market so many “off-label”
psychotropic medications to children and adolescents with such confidence or, more accurately, grandiosity. Central to this dilemma are the shortages of mental health professionals and psychiatrists who exclusively treat children and adolescents. This shortage, coupled with the growing confidence of the effectiveness of psychopharmacology with some diagnoses, permitted pharmaceutical companies to market “off-label” drugs for children and adolescents on a grand scale while clinicians observe the phenomenon, almost powerless. Even the passage of the Best Pharmaceuticals Act for Children 12 years ago is not enough to slow this trend.

SUMMARY

The use of psychotropic medications with children and adolescents is very complex. Clearly there is no simple answer to this dilemma. Because most of the medications are prescribed off label, it is important that mental health professionals learn all that they can in order to protect the health and well-being of their clients who are children and adolescents. The information provided here spans the four perspectives to challenge the reader to consider medical, psychological, cultural, and social paradigms. The discussion of stimulant medications serves as a template for practitioners as they consider psychotropic applications with other disorders. When children or adolescents are placed on a psychotropic, it is always recommended that they receive counseling or other supportive services. The federal government through recent legislation is emphasizing how important and critical this issue is. Finally, the question is asked, “Do we as a society use psychotropic medication as the ultimate modality of behavior and anger management?”

CITING FOR THESE PAGES 224-259

Ingersoll, R. E., & Rak, C. F. (2016). Psychopharmacology for mental health professionals: An integrative approach (2nd ed.). Boston, MA: Cengage Learning.

Chapter 11 Counseling Children and Adolescent

Monkey Business Images/Shutterstock

There you sit Alice Average midway back in the long-windowed classroom in the middle of Wednesday’s noontime blahs,

Adjusting yourself to the sound of a lecture and the cold of the blue plastic desk that supports you.

In a world full of light words, hard rock, Madonnas, long hair, high tech, confusion, and change dreams fade like blue jeans

And “knowing” goes beyond the books and disks that are packaged for time-limited consumption and studied until the start of summer. . . .

Reprinted from “Thoughts on Alice Average Midway Through the Mid-day Class on Wednesday,” by S. T. Gladding, 1980, Humanist Educator, 18, p. 203. Copyright © 1980, 1986 by S. T. Gladding.

Chapter Overview

From reading this chapter, you will learn about

· Mental health issues that affect children and adolescents

· Developmental, biological, and contextual issues that contribute to young people’s mental health

· Effective ways of working with children and adolescents

· Specific concerns young people face, including depression, eating disorders, ADHD, family disruption, grief and loss, and maltreatment

As you read, consider

· What developmental issues clinical mental health counselors need to consider when they work with young people

· What specific biological and contextual factors affect children’s mental health and well-being

· How common depression is among children and adolescents

· Why eating disorders are so prevalent among adolescents and how they are manifested

Poverty, violence, illness, school difficulties, and family disruption, as well as typical transitions associated with development, are factors that influence the mental health and well-being of a growing number of children and adolescents. Whether the increased prevalence of mental health issues in this population is due to a higher level of vulnerability or to increased efforts to identify problems, currently more young people are in need of mental health services than were in years past (

Erford, 2015

). According to the surgeon general’s report (

U.S. Department of Health and Human Services, 2000

) and the National Institute of Mental Health (NIMH;

2016b

), approximately 20% of children and adolescents are estimated to have mental disorders of some type, and 5% to 9% of youth have serious emotional disturbances. Although many youth are affected by mental health issues, an estimated 80% of young people who need treatment do not receive the mental health services they need (

U.S. Department of Health and Human Services, 2016

). Clearly, youth are not immune from mental health disorders, and a large majority of young people needing help are not getting it.

Mental health problems appear in youth of all social classes and backgrounds. Some children are at greater risk than others because of a wide range of factors, including genetic vulnerability, temperament, family dysfunction, poverty, caregiver separation, and abuse (

Moore et al., 2011

;

Surgeon General Report, 2000

). Clinical mental health counselors who work with children and adolescents need to be aware of these risk factors, as well as of the developmental factors that affect mental health. They also need to be skilled at implementing prevention and intervention strategies that target multiple levels, including the individual, the family, and the broader community.

This chapter describes developmental and bioecological influences on children’s mental health and focuses on the counseling process as it applies to children and adolescents. Following that, an overview is given of some of the specific issues that affect children and adolescents living in today’s society. Treatment suggestions for working with these issues are then described.

The Case of Brian

Four-year-old Brian is always on the go, according to his mother, Louise. He attends a local preschool for a half day, three days a week. Brian’s preschool teacher says that he is “very active” and that he frequently interrupts other children when they are playing, often pushing them when they won’t let him join them in their activities. Brian has one close friend, Bart, who tends to go along with whatever Brian wants to do. During circle time in preschool, Brian has trouble sitting still. He is easily distracted and will often try to leave the circle to go play with some of the toys in the room.

Brian has a new baby sister, Tamara, who is 3 months old. Louise, who is a single mother, enrolled Brian in preschool for the first time this fall, two months before Tamara was born. Tamara cries a lot and requires a lot of her mother’s attention. Last week, Louise discovered Brian pinching Tamara until she cried. Distressed, Louise called Family Services, a community mental health agency in town, to request help for Brian.

If you were one of the clinical mental health counselors at this agency, what additional information would you like to have? What issues raise the biggest concerns for you? How would you conduct an intake interview with Brian and Louise? If counseling is warranted, what are some ways you might proceed?

Developmental Considerations

Childhood and adolescence are characterized by dramatic developmental changes physically, cognitively, socially, and emotionally. To a large degree, mental health during these years is defined by achieving expected developmental milestones, establishing secure attachments, negotiating relationships with family members and peers, and learning effective coping skills. Mental health practitioners who work with young people need to be guided by developmental theory as they select strategies for prevention, support, and treatment.

Development is multidimensional and complex and is marked by qualitative changes that occur in multiple domains. A summary of developmental theories and counseling implications, which was adapted from several sources (e.g.,

Berk, 2014

;

Nystul, 2016

), is presented in

Table 11–1

. Although it is not our intent to describe the full range of developmental characteristics associated with children and adolescents, in the section that follows, an overview of some general characteristics of early childhood, middle childhood, and adolescence is provided.

Table 11–1 Developmental Theories and Implications for Counseling

Source: Adapted from Introduction to Counseling: An Art and Science Perspective (3rd ed., p. 303; 4th ed., p. 284), by Michael S. Nystul, 2006/2011, Boston: Allyn & Bacon.

Developmental Theory

Founder

Key Concepts

Implications for Counseling

Cognitive theory

Piaget and Elkind

Conceptualizes cognitive development in four stages: sensorimotor (birth to 2), preoperational (2 to 7), concrete operations (7 to 11), formal operations (usually after 11).

Counselors can adjust their approaches and select interventions to match a child’s level of cognitive functioning. For example, counselors working with young children will want to use some form of play media.

Moral development

Kohlberg and Gilligan

Kohlberg: Identifies three levels of moral development, beginning with a punishment and obedience orientation and progressing to higher stages of moral reasoning. Gilligan: Posits that feminine morality emphasizes an ethic of care, focusing on interpersonal relationships.

An understanding of moral reasoning can help children learn self-control and help parents with discipline issues. Girls and boys may make moral judgments in different ways.

Sociocultural theory

Vygotsky

Focuses on the zone of proximal development, which emphasizes a range of tasks too difficult for a child to complete alone but possible with the help of others.

Counselors can use groups to facilitate learning and accomplishment.

Psychosocial development

Erikson

Identifies eight psychosocial stages and their associated developmental tasks (e.g., from birth to 1 year of age, the central task is trust).

Counselors can help clients obtain the coping skills necessary to master developmental tasks so the clients can move forward in their development.

Developmental psychopathology

Kazdin, Kovacs, and others

Considers child and adolescent psychopathology in the context of maturational and developmental processes.

Counselors have a framework for understanding child psychopathology as unique from adult psychopathology, aiding in accurate assessment.

Classic theories of personality

Freud, Adler, and Jung

Emphasize the role of early life experiences on child and adolescent development.

Counselors can understand the dynamics of behavior before selecting counseling techniques to promote change.

Attachment theory

Ainsworth, Bowlby, and others

Focuses on the relationship between the emotional parent–child bond and the child’s psychosocial development over the life span.

An understanding of attachment relationships can provide useful insights into how to move toward optimal psychosocial development.

Emotional intelligence

Salovey and Mayer

Focuses on the role that emotions play in social and psychological functioning.

Counselors can help promote emotional intelligence through such activities as group social skills training.

Early Childhood

Children between the ages of 2 and 6 are in the early childhood stage, sometimes called the play years (

Berk, 2014

). During this period, motor skills are refined, children begin to build ties with peers, and thought and language skills expand rapidly. To understand the way young children think and use language, it is helpful to refer to Jean Piaget’s stage-constructed theory of cognitive development. Although current research indicates that the stages of cognitive development are more fluid than Piaget hypothesized, his descriptions of cognitive development provide a relatively accurate picture of how children think and reason at different ages (

Bjorklund, 2000

).

According to Piaget, children between 2 and 7 years of age are preoperational, which means they are developing the ability to represent objects and events through imitation, symbolic play, drawing, and spoken language. They are likely to be egocentric, implying that they cannot comprehend the viewpoint of another. Preoperational children may attribute lifelike qualities to inanimate objects and may have difficulty with abstract nouns and concepts, such as time and space (

Vernon, 2009

). For the first time, these children are entering into a stage where they are able to represent and recall their feelings. As they near the end of the preoperational stage, their emotional self-regulation improves.

Erik Erikson’s psychosocial theory provides another way to understand children’s development. Erikson describes development as a series of psychological crises that occur at various stages. The way in which a crisis is resolved, along a continuum from positive to negative, influences healthy or maladaptive outcomes at each stage. Young children are in the process of resolving the developmental crisis of initiative versus guilt (

Erikson, 1968

). Initiative refers to being enterprising, energetic, and purposeful. Children in this stage are discovering what kinds of people they are, particularly in regard to gender. Because of their increased language and motor skills, they are capable of imagining and trying out many new things. To navigate this period successfully, children need to be given a variety of opportunities to explore, experiment, and ask questions. The guidance of understanding adults can help young children develop self-confidence, self-direction, and emotional self-regulation.

Play is an extremely important activity for children in this age group. Through play, children find out about themselves and their world. Counselors who work with young children will want to use some form of play when counseling them. Play provides a way for children to express feelings, describe experiences, and disclose wishes. Although young children may not be able to articulate feelings, toys and other play media serve as the words they use to express emotions (

Landreth, 1993

). Materials used to facilitate play include puppets, art supplies, dolls and dollhouses, construction tools, and toy figures or animals.

Middle Childhood

Children between 7 and 11 years of age are in middle childhood. During this time period, children develop literacy skills and logical thinking. Cognitively, they are in Piaget’s concrete operational stage, meaning that they are capable of reasoning logically about concrete, tangible information. Concrete operational children are able to mentally reverse actions, although they can generalize only from concrete experiences. They grasp logical concepts more readily than before, but they typically have difficulty reasoning about abstract ideas. Children in this stage learn best through questioning, exploring, manipulating, and doing. As a rule, their increased reasoning skills enable them to understand the concept of intentionality and to be more cooperative.

From a psychosocial perspective, children in this age group are in the process of resolving the crisis of industry versus inferiority (

Erikson, 1968

). To maximize healthy development, they need opportunities to develop a sense of competence and capability. When adults provide manageable tasks, along with sufficient time and encouragement to complete the tasks, children are more likely to develop a strong sense of industry and efficacy. Alternatively, children who do not experience feelings of competence and mastery may develop a sense of inadequacy and pessimism about their capabilities. Experiences with family, teachers, and peers all contribute to children’s perceptions of efficacy and industry.

Negotiating relationships with peers is an important part of middle childhood. Acceptance in a peer group and having a “best friend” help children develop competence, self-esteem, and an understanding of others (

Vernon, 2009

). Some of the interpersonal skills children acquire during middle childhood include learning to get along with age mates, learning the skills of tolerance and patience, and developing positive attitudes toward social groups and institutions (

Havighurst, 1972

). Clinical mental health counselors can help children develop their interpersonal skills by implementing preventive strategies targeting social skills development.

Adolescence

Adolescence is the period when young people transition from childhood to adulthood. During adolescence, youth mature physically, develop an increased understanding of roles and relationships, and acquire and refine skills needed for performing successfully as adults. In many modern societies, the time span associated with adolescence can last for nearly a decade. Puberty marks the beginning of adolescence, with girls typically reaching puberty earlier than boys. As adolescence ends, young people ideally have constructed an identity, attained independence, and developed more mature ways of relating to others. In years past, adolescence was referred to as a time of storm and stress, but current research indicates that, although the period can be emotionally turbulent for some young people, the term storm and stress exaggerates what most adolescents experience (

Berk, 2014

).

As young people enter adolescence, they begin to make the shift from concrete to formal operational thinking. The transition takes time and usually is not completed until at least age 15, if then. Adolescents moving into the formal operational stage are able to deal with abstractions, form hypotheses, engage in mental manipulation, and predict consequences. As formal operational skills develop, they become capable of reflective abstraction, the ability to reflect on knowledge, rearrange thoughts, and discover alternative routes to solving problems. Consequently, counseling approaches that provide opportunities to generate alternative solutions are more likely to be effective with adolescents than with younger children. However, some adolescents and even adults do not become fully formal operational, perhaps because of restricted experiences (

Kuhn & Franklin, 2006

).

A new form of egocentrism often emerges during adolescence, characterized by a belief in one’s uniqueness and invulnerability. This egocentrism may be reflected in reckless behavior and grandiose ideas. Consequently, preventive strategies are warranted, addressing such issues as substance abuse, teenage pregnancy, reckless driving, and unsafe Internet use. Related to a heightened sense of uniqueness is the adolescent phenomenon of feeling constantly “on stage” or playing to an imaginary audience. It is not uncommon for adolescents to feel that everyone is looking at them, leading to increased anxiety and self-consciousness. These feelings tend to peak in early adolescence and then decline as formal operational skills improve (

Bjorklund, 2000

).

The onset of puberty often triggers the psychosocial crisis of identity versus role confusion (

Erikson, 1968

). A key challenge during adolescence is the formation of an identity, including self-definition and a commitment to goals, values, beliefs, and life purpose. To master this challenge, adolescents need opportunities to explore options, try on various roles and responsibilities, and speculate about possibilities. Sometimes adolescents enter a period of role confusion, characterized in part by overidentification with heroes or cliques, before they develop a true sense of individuality and recognize that they are valuable members of society.

Spending time with peers continues to be important throughout adolescence. As they develop self-confidence and sensitivity, adolescents base their friendships on compatibility and shared experiences. Intimate friendships increase, as do dating and sexual experimentation. Counseling may involve helping these young people deal with issues of complex relationships and decision making about the future.

It is important to keep in mind that developmental generalizations may not be applicable to all ethnic or cultural groups. For example, the search for self-identity may be delayed, compounded by a search for ethnic identity, or even nonexistent among certain groups of adolescents (

Herring, 1997

). Also, research on Piagetian tasks suggests that some forms of logic do not emerge spontaneously according to stages but are socially generated, based on cultural experiences (

Berk, 2014

). Developmental theories provide useful guides for understanding children and adolescents; however, no theory provides a complete explanation of development, nor does any theory take into account all cultural perspectives.

Bioecological Considerations

The characteristics of the person at a given time in his or her life are a joint function of the characteristics of the person and of the environment over the course of that person’s life up to that time.

Bronfenbrenner, 1989

, p. 190

Bronfenbrenner’s (1979

,

1989

,

1995)

bioecological model illustrates the way development is influenced by multilayered interactions of specific characteristics of a child (e.g., genetic, biological, and psychological factors), the immediate environment (e.g., family, school, peers, neighborhood, and community), and the more global culture, or macrosystem, within which the young person lives. The systems that compose Bronfenbrenner’s bioecological model are depicted in

Box 11–1

. These systems are not static, but instead are constantly changing. To work effectively with children and adolescents, counselors need to assess individual, environmental, and cultural factors and their interactive effects on development and adjustment. Teasing the different influences apart can be difficult, if not impossible.

Box 11–1 Bronfenbrenner’s Bioecological Model: Five Interactive Systems Microsystem:

A specific environment in which an individual develops. Young people are members of many different microsystems, such as family, peer groups, school, and church.

Mesosystem:

A system defined by interrelations among two or more microsystems. For example, what is going on with a child at school may affect what is going on in the family, or vice versa.

Exosystem:

A context that exerts an indirect influence on a child’s development. For example, a parent’s workplace may affect the parent in ways that then indirectly affect the child.

Macrosystem:

An overarching belief system or culture that exerts its effects indirectly through cultural tools and institutions.

Chronosystem:

The evolution of the four other systems over time. An awareness of the chronosystem allows counselors to take into account ways the particular systems and their interactions develop and change through a young person’s life.

Psychological, Biological, and Genetic Influences

A wide array of individual characteristics—including physical appearance, personality traits, cognitive functioning, and genetic predisposition—influence the manner in which children and adolescents adjust and adapt to their environments. A key factor affecting children’s development is temperament, which refers to specific traits with which each child is born and which influence the way the child reacts to the surrounding environment. Defined more simply, temperament refers to a person’s emotional style (

Berk, 2014

). Temperament includes traits such as attention span, goal orientation, activity level, curiosity, and emotional self-regulation. Differences in temperament are evidenced when one child is easily excitable and impulsive, another is shy and withdrawn, and a third is calm and attentive. Although there is some continuity in temperamental traits across the life span, temperament may be modified during development, particularly through interaction with family members (

Thomas & Chess, 1977

).

Cognitive factors also influence child and adolescent adjustment and well-being. Cognitive factors include intelligence, information processing skills, and neurological conditions. Cognitive skills can serve as protective factors, increasing children’s chances for success in school and their ability to solve problems effectively. In contrast, neurological deficits and lower levels of intellectual functioning increase the risk of school failure, thereby placing youth at a greater risk for delinquency (

Calhoun, Glaser, & Bartolomucci, 2001

). Genetic factors and biological abnormalities of the central nervous system caused by injury, exposure to toxins, infection, or poor nutrition can lead to deficits in cognitive development.

Faulty cognitive processing skills, such as attributional bias, can adversely affect an individual’s reactions to people and situations. For example, juvenile offenders often attribute hostility to others in neutral situations, resulting in unwarranted acts of aggression (

Calhoun et al., 2001

). As another example, depressed youth often have negative attributional styles, believing that they are helpless to influence events in their lives and that they are responsible for any failures or problems being experienced. In contrast, young people with more realistic attributional styles tend to be more adaptable and less likely to form misperceptions, leading to healthier coping and adjustment skills.

Just as genetic inheritance influences individual characteristics such as temperament and cognitive functioning, it also influences mental health. Although the precise manner in which heredity influences mental health is not fully understood, certain mental health conditions—including depression, anxiety, and chemical abuse—appear to have a genetic component. For example, children of depressed parents are three times as likely as children of nondepressed parents to experience a depressive disorder (

U.S. Department of Health and Human Services, 2016

). It is theorized that multiple gene variants act in conjunction with environmental factors and developmental events to make a person more likely to experience mental health problems. Children and adolescents who are genetically vulnerable to specific conditions may benefit from prevention efforts targeting certain areas, such as building resiliency and improving coping responses.

Contextual Influences

Even as genetic inheritance and other biological factors help determine individual traits and set the stage for child development, contextual influences also play critical roles in child and adolescent development. The many contexts in which young people live and interact have powerful effects on their mental health and well-being. Family, school, and peers are examples of contextual factors that influence psychological adjustment.

Family Influences

One of the most significant influences on the development of young people is the family, within which interactions typically occur on a daily basis. Within the family, unique bonds are formed that serve as models for relationships in the greater community. Family relationships are complex and influence development both directly and indirectly. A number of family-related variables have been identified as risk factors for adverse mental health, including severe parental discord, parent psychopathology, poor living conditions, and economic hardship (

U.S. Department of Health and Human Services, 2016

). In contrast, healthy interactions among family members can lead to positive outcomes, as well as serve as buffers against negative influences, such as illness or poverty, over which the family has little control.

The quality of the relationships between children and their caregivers is of principal importance to well-being across the life span. Parent–child interactions have been associated with a wide range of developmental outcomes, including self-confidence, academic achievement, psychological health, and conduct. In particular, parent–child interactions that are marked by high levels of parental support and behavioral control help children develop mastery and competence (

Maccoby & Martin, 1983

). Supportive behaviors are those that facilitate socialization through warmth, nurturance, responsiveness, and open communication. Controlling behaviors—including rule setting, negotiation, and consistent discipline—help establish guidance and flexibility within the power hierarchy of the family. By combining the dimensions of support and control along high and low extremes, parenting styles can be classified into four types: authoritative, authoritarian, indulgent, and neglecting (

Baumrind, 1991

;

Maccoby & Martin, 1983

). These four parenting types are depicted in

Figure 11–1

.

Figure 11–1 Four Parenting Styles

Source: Adapted from

Baumrind, 1991

; and

Maccoby and Martin, 1983

.

Authoritative parenting style · High in support (accepting, responsive, child-centered) · High in control (clear standards, high level of monitoring) · Goals for child: social responsibility, self-regulation, cooperation Authoritarian parenting style · Low in support (low in acceptance and responsiveness, parent-centered) · High in control (directive and demanding, high level of monitoring) · Goals for child: obedience, achievement, orderly environments Indulgent parenting style · High in support (warm, overly accepting of child’s behaviors and attitudes) · Low in control (few rules, permissive, low level of monitoring) · Goals for child: warm relationships, minimal confrontation or conflict in family Neglecting parenting style · Low in support (not responsive to child’s needs, ignoring or indifferent) · Low in control (little structure or monitoring of child’s activities, uninvolved) · Goals for child: minimal goals, if any. (This style is associated with the most negative outcomes for children, as compared to the other typologies.)

Authoritative families are characterized by emotional support, high standards, appropriate granting of autonomy, and clear communication (

Darling & Steinberg, 1993

). Authoritative parents monitor their children and set clear standards for conduct. Disciplinary methods are inductive (i.e., they explore the consequences of the child’s actions on others) rather than punitive, and parental responses are consistent. Children are listened to, and they participate in family decision making. Goals for children in an authoritative family include social responsibility, self-regulation, and cooperation.

Authoritative parenting has been linked with a wide range of positive child outcomes, including social competence, psychological well-being, fewer conduct problems, and higher scholastic performance (e.g.,

Baumrind, 1991

;

Supple & Small, 2006

). Systematic efforts to educate parents about effective parenting processes and authoritative parenting practices can help improve the quality of family life and parent–child relationships. A variety of forums can be used to implement the teaching of parenting skills, including community-based parent education programs and school-sponsored clinics for parents.

In addition to parenting styles and practices, several other family-related factors influence child adjustment. Family structure (e.g., divorced, single-parent, married), family size, socioeconomic status, the amount of time family members spend together, and issues such as neglect and abuse all influence adjustment in various ways. Clinical mental health counselors who work with children and adolescents need to be aware of these influences, help families build on strengths, and target areas in which improvement is needed.

School Influences

The unique characteristics of the school context give it special prominence in child and adolescent development. Through interactions with peers, teachers, and other adults in the school, young people make judgments about themselves, their capabilities, and their goals for the future. Consequently, experiences in school play a major role in the development of individual differences in children and adolescents.

Schools in which support, trust, respect, optimism, and intentionality are demonstrated foster the development of positive student attitudes and behaviors. In particular, supportive teachers can positively influence students’ self-confidence and performance (

Newsome, 1999

). Also, schools that are orderly and organized, with consistent and fair enforcement of rules, are conducive to positive student behaviors, although excessive teacher control and discipline can be detrimental to adolescent adjustment and achievement (

Eccles & Roeser, 2011

).

Clinical mental health counselors need to be aware of the powerful influence the school context has on young people. This awareness enables them to work collaboratively with school counselors, teachers, and other school personnel to optimize child and adolescent development.

Peer Influences

Relationships with peers—at home, at school, and in the community—become increasingly important as children grow older. Peer interaction plays a key role in helping children learn to take different perspectives and understand other points of view. Peer acceptance, which refers to being liked by other children, shapes the views children have of themselves as well as their views of others.

Whereas some children are well liked and make friends easily, others are rejected or neglected. Unfortunately, some children are the victims of frequent verbal and/or physical attacks by other children (i.e., bullying). Such victimization leads to a variety of adjustment difficulties, including depression, loneliness, and school avoidance. Counselors can intervene at various levels to assist children who are having difficulties with peers. Depending on the situation, it may be necessary to help children develop social skills or assertiveness skills. Individual and group counseling interventions can include coaching, modeling, reinforcing positive social skills, and teaching perspective taking. Clinical mental health counselors can intervene systemically by working collaboratively with schools to develop codes against bullying and by conducting parent education groups to help eliminate all forms of bullying.

During adolescence, young people begin spending more time with peers and less time with family members. Typically, friendships are formed with peers who have similar interests, values, and behaviors. Most often, peer group association positively influences well-being, as teenagers learn adaptive skills that benefit adjustment. In some cases, however, the peer group provides a negative context in which antisocial behaviors are the norm. For example, young people who were aggressive and rejected as children and who feel distanced from their families are likely to become involved with deviant peers and engage in antisocial behaviors (

Berk, 2014

). Difficult temperament, low intelligence, poor school performance, peer rejection in childhood, and involvement with antisocial peer groups are associated with juvenile delinquency, a widespread problem that accounts for a substantial proportion of criminal offenses committed in the United States.

Normative and Nonnormative Life Events

Many of the developmental challenges young people face are expected: physical changes, school transitions, emerging sexuality, changes in cognitive functioning, and changes in family and peer relationships. Developmental transitions of this nature are considered normative life events; that is, they are anticipated generic challenges that everyone encounters. In some contexts, developmental challenges are compounded by chronic stressors, which are enduring aspects of the environment that involve deprivation or hardship. Poverty, physical disability, and family dysfunction are examples of chronic stressors that can exert taxing demands on families.

Whereas normative life events are expected, nonnormative life events are those unexpected, acute demands that may alter the course of development, either directly or transactionally (

Compas, 1987

). Nonnormative life events include parental divorce, death of a family member, onset of illness or disability, and job loss. Catastrophic phenomena—sudden, powerful events (e.g., natural disasters, accidents, and terrorism) that require major adaptive responses from the groups sharing the experience—also are considered nonnormative events. Nonnormative events are not always negative, however. Examples of positive nonnormative events include inheriting a large amount of money or being selected for a coveted position.

Some students, the gifted, have nonnormative lives. By definition, gifted individuals are not normal on some metric. This nonnormative aspect of their lives can manifest itself in unexpected responses to others or from others. The exceptional abilities of gifted individuals contribute to different experiences from other students, which may be academic, interpersonal, or intrapersonal. These unique experiences and characteristics of gifted individuals tend to revolve around four issues: (a) unhealthy perfectionism, (b) anxiety, (c) depression, and (d) suicidality (

Cross & Cross, 2015

). It is as important for counselors to attend to these students and their issues as it is to focus on others who are having more normative experiences.

Normative and nonnormative events occur in multiple contexts and have a wide range of effects on the people experiencing them. The frequency, intensity, and timing of the events can affect a youth’s mental health, with outcomes moderated by subjective perceptions, parental and peer support, and coping skills. To understand young clients’ developmental trajectories, counselors need to assess the normative and nonnormative life events these clients have experienced. Counselors can help children handle negative life events more effectively by implementing stress management interventions that are tailored to helping children use active, problem-focused coping strategies.

Cultural Influences

A key ecological factor that exerts a powerful influence on the development and adjustment of young people is the broader culture in which they live. Cultural beliefs, values, and institutions compose what

Bronfenbrenner (1979

,

1995)

referred to as the macrosystem. On one level, children are influenced by the dominant culture of a society: its values, laws, customs, and resources. When children are members of one or more minority groups, they are affected not only by the belief system of the dominant culture but also by the values that guide the minority culture(s). The various sociocultural influences interact, and sometimes conflict, to shape a developing child’s subjective worldview.

McClure and Teyber (2003)

illustrate the effects cultural influences can have on the counseling process:

An adolescent African-American male who is “paranoid” around authority figures is often accurately discerning a persecutory or hostile environment given his life experiences. A counselor who diagnoses him as paranoid (which frequently occurs) and focuses on helping him see “reality” (i.e., the counselor’s subjective worldview) would quickly lose credibility. Similarly, encouraging a young adult from a traditional Asian family to emancipate and become more autonomous from her family may only engender increased distress. (pp. 7–8)

Competent counselors are aware of the array of cultural issues that influence child and adolescent development. They recognize the importance of evaluating which cultural aspects are relevant to a particular individual and plan interventions that build on cultural strengths.

Counseling Considerations

Working effectively with young people requires a special knowledge of child development, contextual influences, and child-related counseling procedures. Children’s needs, wishes, behaviors, and ways of viewing the world differ significantly from those of adults. Indeed, interventions that are appropriate for adults may be ineffective or even detrimental when applied to children and adolescents (

Sherwood-Hawes, 1993

). Through all stages of the counseling process, counselors need to take into account universal developmental principles as well as the unique, subjective way in which each child views the world.

Building a Counseling Relationship

The key to any successful counseling experience is developing an effective working relationship based on mutual trust and acceptance. The most important first step is being willing to enter completely into a child’s world, with no preconceptions, expectations, or agenda. All judgment needs to be suspended so that the counselor can remain open to what the child is sharing, either verbally or nonverbally. As the therapeutic relationship is being established, listening and observational skills are more important than questioning skills (

Erdman & Lampe, 1996

). By listening carefully to what young clients have to say, giving them undivided attention, and responding sensitively to feelings, reactions, and cultural cues, counselors can create bridges of trust and understanding.

Establishing Rapport

To build relationships successfully, counselors need to tailor their responses and interactions to fit the specific needs of each child, taking into account developmental experiences, sociocultural background, and reasons for referral (

McClure & Teyber, 2003

). With these considerations in mind, counselors can select from a variety of approaches to help establish rapport. When working with young children who have difficulty verbalizing, play and art media can be especially effective. With older children, age-appropriate games or activities can provide a nonthreatening introduction to the counseling process.

One of the factors that make building a relationship with children different from building a relationship with adults is that children often do not understand what counseling is. They may be confused about the nature and process of counseling, fearful of being in an unknown situation, and/or resistant to talking about issues with a stranger. Typically, children are brought to counseling by parents or by other significant adults in their lives, and it is these adults, not the children, who want change to occur. This is particularly true when children or adolescents are referred because of behavioral patterns that bother adults (

Sommers-Flanagan & Sommers-Flanagan, 2007

). The counselor’s task is to find ways to involve the child in the counseling process, first by clarifying the counseling role.

Clarifying the Counseling Role

During the initial session, counselors need to find ways to explain to the children what counseling is all about. Any delay in getting to the reason for counseling can cause undue anxiety for children. Many times, parents or caregivers are included in the initial sessions with children. When this is the case, it is helpful to clarify the counseling role with everyone involved. It is especially important to dissipate any misconceptions about the purpose of counseling, such as beliefs that counseling will “fix” the children. It also is wise to let parents know that things may get worse before they get better. Depending on a child’s age, it may be helpful to meet with everyone together at the outset and then meet separately with the child and the caregiver.

Explaining Confidentiality

Issues related to confidentiality can create challenging legal and ethical dilemmas for counselors who work with minors (

Lawrence & Kurpius, 2000

). Counselors have a responsibility to protect information received through confidential counseling relationships with all clients, including children. However, this responsibility often conflicts with legal rights of parents or guardians, which include the right to determine the need for counseling, the right to access pertinent information about their children’s treatment, and the right to control the release of information that results from counseling (

Glosoff, 2001

). It is important to clarify with parents and their children the conditions and limits of confidentiality before counseling begins. Ethical and legal guidelines related to confidentiality and other topics pertinent to counseling with minors are presented in

Figure 11–2

.

Figure 11–2 Legal and Ethical Issues Related to Counseling Minors

Source: From

Glosoff, 2001

;

Lawrence and Kurpius, 2000

; and

Remley and Herlihy, 2016

.

Professional Competence:

ACA’s (2014)

Code of Ethics mandates that counselors practice only within the bounds of their competence, based on education, training, supervised practice, and appropriate experience (C.2.a). Knowledge and skills needed to work effectively with minor clients differ from those needed to work with adult clients. Counselors who work with children need to be trained in child development and child counseling theory, as well as have an understanding of child psychopathology.

Informed Consent:
Informed consent is “the formal permission given by a client that signals the beginning of the legal contractual agreement that allows treatment to be initiated” (

Lawrence & Kurpius, 2000

, p. 133). Legally, minor clients cannot enter into contracts. The

ACA Code (2014)

states that when minors or other individuals cannot give voluntary informed consent, parents or guardians should be included in the counseling process (B.5). Ideally, if clients are minors, counselors should obtain signed informed consent from the parent(s) and assent from the minor client (

Glosoff, 2001

).

There are some instances in which minor clients can enter into treatment without parental consent, although the exceptions differ from state to state, depending on legal statutes. Typical exceptions include these:

· Mature or emancipated minors: A mature minor is usually over the age of 16 (in some states, 14) and is capable of understanding the nature and consequences of agreeing to a proposed treatment. An emancipated minor is a child under the age of 18 who lives separately from parents or guardians and manages his or her own financial affairs (

American Bar Association, 1980

). Being head of a household, employed, in the armed forces, or married may constitute an exception in which the adolescent can give informed consent (

Welfel, 2016

).

· In some states, parental informed consent may not be required when the minor is in treatment for drugs or narcotics, for sexually transmitted diseases, for pregnancy and birth control counseling, or when waiting for parental consent would endanger the minor client’s life or health.

Confidentiality:
Counselors have the ethical obligation to protect minor clients’ privacy, but parents and guardians have the legal right to determine the need for treatment and to access pertinent information about their children’s treatment. At times, ethical dilemmas arise in trying to balance legal requirements and ethical responsibilities. Because state laws differ, counselors need to be familiar with the legal requirements of the states in which they practice. Counselors can motivate minor clients to disclose on their own when such disclosures would be beneficial and can involve the parents in creating mutually agreed on guidelines for disclosure (

Lawrence & Kurpius, 2000

).

Counselors need to discuss confidentiality and its limits with parents and children before counseling begins. Minor clients need to know that if they make a threat to hurt themselves or others, counselors will be required to breach confidentiality. In some instances, duty to warn also applies to threats to destroy property (e.g.,

Peck v. Counseling Service of Addison County, 1985

).

Reporting Abuse:
All states have statutes requiring counselors and other professionals to report suspected child abuse and neglect (

Kemp, 1998

). Counselors are advised to become familiar with the wording of the statutes for their particular states. In general, statutes require counselors to report if they have reason to believe that (a) a child is currently being abused or neglected or (b) the child has been abused or neglected in the past. Requirements for reporting past abuse differ when the child is no longer in danger. Reporters are protected from liability as long as reports are made in good faith. When making the decision to report, it may be helpful to consult with professional colleagues or to gain legal advice. As with other counseling decisions, it is important to document the report and the reasons for making it.

In many cases, it is in the child’s best interest to involve the parents in the counseling process.

Taylor and Adelman (2001)

maintain that keeping information from parents can impede the counselor’s efforts to help the child. They recommend orienting the parents to the counseling process, educating them about confidentiality with minors, and letting them know that any vital information that affects their child’s well-being will be shared. If parents are oriented in this way, they are more likely to support the process and respect their child’s right to privacy (

Welfel, 2016

).

The way counselors approach the issue of confidentiality with children depends on their ages. Young children typically do not have an understanding of confidentiality or the need for it (

Remley & Herlihy, 2016

). It is important to explain the concept in words a child can understand. Therefore, the counselor might say, “Most of the things you and I talk about in here are between you and me, unless you tell me that you are planning to hurt yourself or someone else. If you tell me something that I think your mom [dad, other caregiver] needs to know, you and I will talk about it first.”

Adolescents often have a heightened concern about privacy and confidentiality in the counseling relationship (

Remley & Herlihy, 2016

). Clinicians who work with adolescents can help them understand confidentiality and its limits from the outset. It also is important for them to feel free to disclose their concerns in an atmosphere of trust. Balancing issues related to trust and minor consent laws can often be challenging.

It is not unusual for clinical mental health counselors to encounter dilemmas related to the requirements of confidentiality and counselors’ responsibilities to parents or other caregivers. By keeping the lines of communication open and taking responsibility for knowing state and federal law, it may be possible to circumvent potential problems before they arise (

Welfel, 2016

). Some helpful references regarding minors’ rights include the following (cited in

Henderson & Thompson, 2016

):

· State Minor Consent Laws: A Summary (

English, Bass, Boyle, & Eshragh, 2010

)—Provides a state-by-state description of the legal status of minors.

· Guttmacher Institute (

www.guttmacher.org

)—Publishes policy briefs and summaries of laws that pertain to young people.

· American Bar Association (

www.abanet.org/public.html

)—Provides information about state laws and minors.

· Books on ethical and legal issues in counseling and psychotherapy (e.g.,

Barnett & Johnson, 2015

;

Remley & Herlihy, 2016

;

Welfel, 2016

;

Wheeler & Bertram, 2015

).

Assessment and Evaluation

Assessment is an integral part of the counseling process. Assessment is an ongoing process in which counselors gather information about clients from several different sources and then use that information to make decisions about treatment planning. Assessment also provides a way to evaluate counseling progress and outcomes. Assessment methods, which can be formal or informal, help counselors understand children’s current problems or concerns within the context of their unique developmental histories.

Interviews

Initial assessment typically begins with an intake that involves the child and the child’s parents or guardians. The amount of time spent with everyone together versus time spent with each individual depends on the age of the child, the nature of the problem, family dynamics, agency policy, and the particular work setting (e.g., an inpatient setting will differ from a private practice setting). During the intake session, the types of rapport-building activities described earlier can be used to gather important information about the child. In many agencies, intake forms are available for use with children and families.

Early and ongoing assessment is necessary for accurate case conceptualization and effective intervention planning.

Orton (1997)

suggests conducting a complete developmental assessment that provides the counselor with the following information:

·
The specific concerns that brought the child to counseling.

The manifestation, intensity, frequency, and duration of the concerns should be explored. In what settings or around which individuals are the concerns evidenced? Expression, manifestation, and course of a disorder in children may be quite different from that in adults (

U.S. Department of Health and Human Services, 2016

). Certain behaviors may be normal at one age but represent a problem at another age (e.g., temper tantrums exhibited by a 3-year-old child versus tantrums exhibited by a 6-year-old). Assessment, diagnosis, and treatment planning need to occur within the context of the child’s overall development.

·
Physical, cognitive, emotional, and social development.

Evaluating each of these areas of development is essential to conducting a thorough assessment. When possible, the counselor will want to obtain information about the child’s medical history, perinatal history, motor development, cognitive functioning, and ability to express and regulate emotions. The counselor also will want to gather information about socioeconomic and sociocultural factors that have affected development. To facilitate information gathering, the counselor can ask parents or guardians to complete an information form prior to or immediately following the initial counseling session (

Orton, 1997

). The counselor can then use the form—which includes questions about the child’s physical, cognitive, emotional, and social development—to guide exploration of any areas that may be contributing to the problem.

·
Relationships with parents, siblings, and peers.

Understanding the nature and quality of relationships the child has with family members and peers is a key component of child assessment. Topics to be addressed include the child’s living arrangements, home responsibilities, methods of discipline used, the child’s response to discipline, typical family activities, and a “typical day.” Interview questions or qualitative assessment methods, such as a genogram or a kinetic family drawing (i.e., a picture of everyone in the family doing something), can provide rich information about relationships, as can ongoing observation of interactions as the counselor works with the child and the family.

·
School experiences, including academics, attendance, and attitude.

Academic and social successes or failures play an important part in children’s overall development. Children who experience repeated failures often have poor self-esteem and may engage in disruptive behaviors as a way of compensating. Also, school failure may signify a learning disorder that typically requires formal testing for diagnosis. Because of the pervasive effect school has on children’s lives, it is advisable to ask parents to sign a consent form for release of information so that the school can be contacted early in the counseling process.

·
Strengths, talents, and support system.

Implementing a strengths-based approach to assessment can help take the focus off the problem so that it is possible to begin moving toward solutions. Creative activities, checklists, and various qualitative assessment methods provide useful tools for evaluating strengths and supports. After learning about children’s special skills and interests, counselors can incorporate them into treatment planning. For example, if a child enjoys art, the counselor can select expressive art interventions to facilitate the change process.

Informal and Formal Assessment

Informal assessment includes direct observation and qualitative assessment methods. Qualitative assessment emphasizes holistic procedures that typically are not standardized and do not produce quantitative raw scores. A variety of qualitative assessment methods can be used with children and adolescents, including informal checklists, unfinished sentences, decision-making dilemmas, writing activities, games, expressive arts, storytelling, role-play activities, and play therapy strategies (

Gladding, 2016a

;

Vernon, 2009

). Informal assessment procedures of this nature can reveal patterns of thought and behavior relevant to concerns and issues. Such methods are especially helpful with young children, who may not know exactly what is bothering them or may lack the words to express their concerns verbally.

Formal assessment instruments

that have been standardized and have sound psychometric properties provide a way for counselors to gain a somewhat more objective view of children’s behaviors or attributes than informal methods provide. Whereas some instruments are designed to assess specific disorders—for example, the Children’s Depression Inventory (

Kovacs, 1992

)—others assess a full range of behavioral and emotional symptoms and disorders—for example, Achenbach System of Empirically Based Assessment. A number of questionnaires, scales, and checklists designed to assess attributes, behaviors, interests, and emotional states of children and adolescents have been published in recent years. The Mental Measurements Yearbook, published by the Buros Institute, provides descriptions and reviews of a wide range of published instruments. Carefully selected formal assessment tools can supplement and enhance the information counselors gather through less formal methods of assessment.

By appraising children’s therapeutic needs through interviews, informal assessment, and formal assessment, counselors gain a better understanding of the children’s development and concerns. This understanding can then be used to set goals, design and implement interventions, and evaluate the counseling process. As with adults, the information gained through assessment sometimes leads to a diagnosis, using an established diagnostic classification system such as the most current edition of the DSM. However, the criteria for diagnosing many mental disorders in children are derived from adult criteria, and less research has been conducted on children to verify their validity. Consequently, diagnosing childhood mental disorders is a challenging task and requires training and supervision.

Designing and Implementing a Treatment Plan

Several factors affect treatment planning for child and adolescent clients. The age and characteristics of the child; the nature of the presenting issue; and the counselor’s theoretical approach, past training, and current skills all influence the selection of interventions. Competent counselors take each of these factors into consideration. If they realize that the presenting issues are beyond their competence, they take steps to match the children with counselors who are prepared to work with those issues.

Intentionality and Flexibility

Counselors who work with children and adolescents need to be intentional and flexible as they conceptualize cases and design interventions. Being intentional refers to taking steps to set counseling goals collaboratively with the children and, in many cases, the children’s parents or caregivers. Being flexible refers to the counselors’ ability to adapt strategies to meet the specific needs of the children in their contexts. No single counseling approach is best for all children or all problems. Counselors who are familiar with a wide array of interventions and child-based counseling strategies can personalize a treatment plan so that the possibility of a positive outcome is enhanced. Also, to work effectively with children (as well as with adults), counselors need to be cognizant of ethnicity, gender, socioeconomic status, and other areas of diversity and respond accordingly.

One way counselors can intentionally plan interventions is by asking specific questions related to the following areas (

Vernon & Clemente, 2004

):

·
Vision:

What could be different? How could things be better? What would be ideal?

·
Goal setting:

What is going well? What needs to be worked on?

·
Analysis:

What is enabling or interfering with achieving these goals? What is getting in the way of solving the problem?

·
Objective:

What specifically does the child want to change?

·
Exploration of interventions:

What has already been tried, and how did it work? Who else will be involved in the counseling process? What types of activities does the child respond to best? What has research shown to be the most effective interventions for this type of concern?

Selecting Interventions

Using information gathered through assessment and goal setting, counselors can begin making decisions about which interventions to implement. No one theoretical approach to counseling children and adolescents has been found to be generally more effective than another (

Sexton, Whiston, Bleuer, & Walz, 1997

). Instead, a systematic, eclectic approach enables counselors to work constructively with the many different needs and concerns that bring young people to counseling.

Although more outcome-based research has been conducted with adults than with children, a body of information is beginning to accumulate matching efficacious interventions with specific concerns and needs. Consequently, clinical mental health counselors need to be familiar with current outcome research on effective treatment when selecting interventions. For example, an empirically supported approach to providing treatment for children with ADHD is a multimodal, multisystemic approach that involves parent training, counseling, and school interventions (

Edwards, 2002

). For adolescents with conduct disorder, a promising treatment is multisystemic therapy (MST), an intensive home- and family-focused treatment (

U.S. Department of Health and Human Services, 2016

). MST integrates empirically based treatment approaches such as cognitive skills training into an ecological framework that addresses the family, peer, school, and neighborhood contexts (

Schoenwald, Brown, & Henggeler, 2000

). Other examples of efficacious treatments include play or art therapy for sexually abused children and cognitive–behavioral approaches for children who are depressed or anxious. It is the counselors’ responsibility to keep up with current research to provide the best possible care for their young clients.

Creative Interventions

Counseling young people effectively often requires a departure from traditional talk therapy. In many cases, an integrative approach that uses a variety of techniques—including art, music, clay, puppetry, storytelling, drama, bibliotherapy, sand play, and other forms of directive and nondirective play therapy—can guide the counseling process and promote healing and growth. Counselors who work with children are encouraged to refer to the many excellent resources that are available to enhance their expertise in using play and expressive arts in counseling (

Gladding, 2016a

) (see

Box 11–2

).

Box 11–2 Using Expressive Arts in Counseling Young People

Expressive arts have been a part of my counseling since I began working as a counselor. I have worked with different ages and in different settings, and I have found that expressive arts easily transfer everywhere. My clients quickly come to understand that I may ask them to draw, paint, string beads, tell stories, act things out, or play, in addition to traditional talking. I may initially encounter surprise, disbelief, reluctance, or fear, but I have yet to be turned down.

What I have found by using creative arts is that my clients relax, have a sense of playfulness, and open up more quickly. I have used creative arts to draw out depressed clients who are locked up in their despair; gain trust with a mistrustful child; help a family learn to positively interact with one another; give an adolescent a chance to express herself in new ways; calm an anxious parent; and join a group together. The possibilities are only as limited as my mind. When I encounter my own limitations, I ask my clients for options. They often come up with the most creative ideas.

There are also personal advantages for me in using expressive arts as a counselor. I find my sessions to be exciting and packed with energy. I look forward to helping people find new ways to express themselves. As a counselor, I feel it is important to be myself. Being creative is a natural part of who I am. Using expressive arts in counseling is a perfect match for me. Elizabeth Vaughan, MA Ed, LPC

Concerns Affecting Children and Adolescents

Clinical mental health counselors who work with children and adolescents are likely to see a wide range of presenting problems, including mood disorders, anxiety disorders, ADHD, aggressive or antisocial behaviors, learning disorders, and eating disorders. They also are likely to work with young people coping with family disruption, poverty, abuse, violence, unemployment, and grief. In this section, an overview of three common disorders that may be experienced by young people—depression, eating disorders, and ADHD—is provided. To work effectively with young clients, counselors need to consult resources that deal specifically with children’s mental health issues and participate in additional educational experiences, training, and supervision.

Depression

Depression is a mood disorder that can affect thoughts, feelings, behaviors, and overall health. It can affect relationships, academic performance, sleep, appetite, self-esteem, and thought processes. A depressed child may pretend to be sick, refuse to go to school, become isolated, cling to caretakers, or worry that a caretaker may die. Depressed adolescents may exhibit excessive anger, frustration, moodiness, and/or destructive behaviors. The onset of major depressive disorders typically is between the ages of 13 and 19, with depression being one of the most common psychological problems of adolescence (

Costello, Erkanli, & Angold, 2006

). Unless treated, early onset of depression can predict more severe and negative symptoms later in life. Untreated mood disorders also increase the risk of suicide (

Sburlati, Lyneham, Mufson, & Schniering, 2012

). The

Child Welfare League of America (2008)

reports that suicide is the third leading cause of death for 15- to 24-year-olds and the sixth leading cause of death for 5- to 14-year-olds. Suicide attempts are even more common.

Manifestation of Depression

Levels of depression in young people can vary, ranging from depressed mood, which is not a clinical disorder, to more severe diagnosable mood disorders. Approximately one-third of adolescents experience depressed mood for short or extended periods of time. Depressed mood is characterized by negative emotions, which may include sadness, anxiety, guilt, disgust, anger, and fear.

For a clinical diagnosis of depression, a young person must exhibit a specific collection of symptoms that are of a specified intensity and duration and that meet the diagnostic criteria of a standardized classification system, such as the DSM-5 (

APA, 2013

). Symptoms must be serious enough to interfere with a young person’s level of functioning. Depressive disorders can include major depressive disorder, bipolar disorder, dysthymic disorder, cyclothymic disorder, and adjustment disorder with depressed mood (or mixed anxiety and depressed mood). Mood disorders due to medical conditions or substance abuse can also be diagnosed as depressive disorders.

Diagnosing depression in young people may be more challenging than in adults because young people have more difficulty articulating their feelings and often mask the symptoms. Instead, their behavior may be more indicative of depression. Depressed children and adolescents may withdraw or display anxiety symptoms, acting out or appearing irritable, or they may have more somatic complaints than adults do. A list of common signs and symptoms of depression in young people is presented in

Figure 11–3

.

Figure 11–3 Signs and Symptoms of Depression in Children and Adolescents

Source: “Depression in Children and Adolescents,” National Institute of Mental Health, 2011. Retrieved from

www.nimh.nih.gov/health/publications/depression-in-children-and-adolescents/index.shtml

.

· Feeling sad, empty, or hopeless · Increased emotional sensitivity · Lack of interest or ability to engage in pleasurable activities · Decreased energy level · Physical complaints (e.g., headaches, stomachaches, tiredness) · Frequent absences from school (or poor performance) · Outbursts (e.g., shouting, complaining, crying) · Being bored · Substance abuse · Fear of death · Suicidal ideation · Sleep/appetite disturbances · Reduced ability to think clearly and make decisions · Increased irritability, anger, or restlessness · Failure to make expected weight gains · Reckless behavior · Difficulty with relationships

Some two-thirds of children and adolescents with clinical depression also have another clinical disorder (

U.S. Department of Health and Human Services, 2016

). The most commonly associated disorders include anxiety disorders, disruptive disorders, eating disorders, substance abuse, and personality disorders. When a young person has more than one disorder, depression is more likely to begin after the onset of the other disorder, with the exception of substance abuse. Counselors will want to be alert to the possibility of dual or multiple diagnoses and be prepared to plan interventions accordingly.

Etiology and Risk Factors

Several factors are associated with the etiology (i.e., causes) of depression, including biological, cognitive, and environmental variables. Biological explanations focus on the role of genetics and biochemical factors associated with depression. It is theorized that multiple gene variants, rather than a single gene, act in conjunction with environmental factors and developmental events to make a person more likely to experience depressive symptoms (

NIMH, 2011a

). Various neurotransmitters—including serotonin, norepinephrine, and dopamine—are associated with depression. These neurotransmitters function within structures of the brain that regulate emotions, reactions to stress, and various physical drives (e.g., sleep, appetite, and sexuality).

Cognitive theory can help clinicians conceptualize depression because of the way it links thoughts, emotions, and behaviors. In other words, emotions and moods are affected by people’s interpretations of events, rather than the events themselves. Because these interpretations can influence how young people view themselves and the world around them, they can be affected by maladaptive information processing, such as negative attributions (e.g., when children believe they are helpless to influence events in their lives) and cognitive distortions (e.g., minimizing positive accomplishments and maximizing negative events). These inaccurate interpretations of events can lead to symptoms of depression.

Other explanations of depression emphasize the role played by stressful life events. Youth who experience numerous stressors may be more likely to experience depression than those who do not. Stressors can be categorized as normative life events (i.e., expected changes, such as school entry and puberty), nonnormative events (e.g., divorce, abuse, moving away), and daily hassles (e.g., conflict with friends, excessive schoolwork). Exposure to stress triggers several physical, emotional, and cognitive changes in the body, and long-term exposure can lead to physical and psychosocial difficulties, including depression (

Sharrer & Ryan-Wenger, 2002

). The manner in which stress is experienced varies from child to child. Preventive strategies, such as teaching constructive coping skills, can help children manage stress more effectively.

A number of other factors have been linked with depression, including family conflict, the emotional unavailability of parents, poor peer relationships, being considered “different,” loss of a loved one, breakup of a relationship, chronic illness, and abuse. A thorough developmental assessment can alert counselors to the presence of conditions that might make children more vulnerable to depression and thus can inform treatment planning.

Treatment Strategies

Because of the increased attention given to child and adolescent depression during the past three decades, treatments for this serious condition are getting more effective. Counselors who work with depressed young people typically involve both the individual and the family (

McWhirter & Burrow, 2001

). In some settings, counselors conduct group interventions, which can be especially effective with older children and adolescents.

Research has demonstrated the efficacy of certain approaches, especially cognitive–behavioral therapy (CBT), in alleviating depressive symptoms in young people (

Gledhill & Hodes, 2011

). The goal of CBT is to help clients develop cognitive structures that will positively influence their future experiences (

Kendall, 2012

). The cognitive component of CBT helps individuals identify and change negative, pessimistic thinking, biases, and attributions. Examples of cognitive-based strategies include the following:

1. Recognizing the connections among thoughts, feelings, and behaviors

2. Monitoring automatic negative thoughts

3. Examining evidence that refutes distorted automatic cognitions

4. Substituting more realistic interpretations for distorted cognitions

5. Regulating emotions and controlling impulses (

McWhirter & Burrow, 2001

, pp. 201–202)

The behavioral component, important to the process, focuses on increasing positive behavior patterns and improving social skills. Other behavioral strategies include relaxation training, social skills training, and behavioral rehearsal.

Case Study: Nick’s Group for Depressed Kids

Nick was a counselor in a large public school. His course work in clinical mental health had taught him a lot about depression and he wanted to help the kids in his school who were depressed get better. Thus, he decided to run a group for depressives. He reserved a quiet room away from foot traffic, talked with teachers about a good time to hold the group, and prepared materials announcing the beginning of the group. When the day came for the group to begin, Nick was surprised no one showed up. What do you think Nick could have done that would have attracted kids to his group? What do you think of conducting such a group with children?

Another type of counseling, interpersonal therapy for adolescents (IPT-A), was adapted from IPT for adults (

Mufson, Moreau, Weissman, & Klerman, 1993

;

Sburlati et al., 2012

). Depression is viewed as a conflict taking place in the context of interpersonal relationships. The two primary goals of IPT are to reduce depressive symptoms and to improve disturbed relationships that may contribute to depression. In treatment, five potential areas of concern are addressed: grief, interpersonal role disputes, role transitions, deficits in interpersonal skills, and single-parent families.

Family Interventions

Concurrent family consultation or family counseling is nearly always indicated when working with depressed children and adolescents (

McWhirter & Burrow, 2001

). Frequently, counselors need to consult with parents to educate them about depression and help them learn ways to encourage their children’s use of new skills (

Stark et al., 2006

). Moreover, family factors such as inconsistent parenting, family conflict, and divorce may contribute to the onset of depression (

Gledhill & Hodes, 2011

). Family interventions are designed to modify negative interactions and increase cohesion. Significant goals may include developing communication skills, enhancing family interactions, and sharing information about specific issues.

Antidepressant Medications

Certain antidepressant medications—usually selective serotonin reuptake inhibitors (SSRIs)—may benefit children and adolescents with depression (

Gledhill & Hodes, 2011

). However, our knowledge of the ways antidepressants affect young people, as compared to adults, is limited. The NIMH published research, the Treatment of Adolescents with Depression Study (TADS), in The Archives of General Psychiatry. In this study (

March et al., 2007

), a combination of psychotherapy and antidepressant medication appeared to be the most effective treatment for adolescents with major depressive disorder. However, because some studies have suggested that SSRIs and other antidepressants may have adverse effects on young people, in particular an increased risk of suicidal thinking, in 2004 the Food and Drug Administration (FDA) adopted a black box warning label on antidepressant medications. This label emphasizes that children, adolescents, and young adults (up through age 24) taking antidepressants should be closely monitored for adverse side effects of the medication, including suicidal ideation.

Early identification and treatment of depression can help alleviate symptoms and put young people on a healthy developmental trajectory. Through individual, group, and family counseling, clinical mental health counselors can help depressed youth address depressive symptoms and meet the challenges of development in ways that provide positive mental health.

Eating Disorders

Eating disorders often appear for the first time in pre- or early adolescence or during the transition to young adulthood, although they may develop during childhood or later life (

NIMH, 2011b

). Eating disorders involve serious disturbances in eating behaviors (e.g., unhealthy reduction of body weight or extreme overeating), as well as feelings of distress or excessive concern about body shape or weight. Girls and young women tend to exhibit eating problems at a much higher frequency than do boys or young men, although the prevalence rate in males is increasing. Although eating disorders have been more frequently associated with young, affluent, White females, it appears that disorders also exist among various ethnic and cultural minority groups (

Kalodner & Van Lone, 2001

). Counselors need to be aware of early warning signs in all populations so that preventive interventions can be implemented when necessary.

Types of Eating Disorders

There are several types of feeding and eating disorders in the DSM-5, but the three most prevalent are anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Individuals with anorexia nervosa weigh less than 85% of what is considered normal for their age and height (

APA, 2013

). They have a resistance to maintaining minimally normal weight, an intense fear of gaining weight or becoming fat, and a distorted view of their own bodies and weight. Youth with anorexia often stop (or fail to start) menstruating. Unusual eating habits develop, such as avoiding food, picking out only a few foods and eating them in small quantities, or weighing food servings. Whereas some young people with anorexia severely restrict eating (i.e., restricting type), others engage in compulsive exercise or purge by means of vomiting or use of laxatives (i.e., binge-eating/purging type). Youth with anorexia tend to deny that they have a problem, making treatment difficult.

Bulimia nervosa

is characterized by recurrent episodes of binge eating, typically twice a week or more, followed by attempts at compensating by purging or exercising (

APA, 2013

). Binge eating is defined by excessive, rapid overeating, often to the point of becoming uncomfortably full. An episode of binge eating is usually accompanied by a sense of lack of control, as well as by feelings of disgust, depression, and guilt. Subsequently, the individual engages in activities to compensate for overeating: vomiting or laxative use for the purging type of bulimia and excessive exercise or fasting for the nonpurging type. Youth with bulimia do not meet the severe underweight criterion associated with anorexia; indeed, they may appear to be within the normal weight range for their age and height. However, they are dissatisfied with their bodies and desire to lose weight or fear gaining weight.

Binge-eating disorder is characterized by recurrent binge-eating episodes with no purging, excessive exercise, or fasting. Consequently, young people with this disorder may be overweight or obese. They also are likely to experience guilt, shame, and distress about their binge eating (

NIMH, 2011b

).

Youth with eating disorders tend to be high achieving and sensitive to rejection. Eating disorders often coexist with other disorders, including depression, substance abuse, and anxiety disorders. Eating disorders are considered medical illnesses with complex psychological and biological causes. To make sure that these issues are addressed in treatment, clinicians need to conduct a thorough biopsychosocial assessment.

A number of physical complications are associated with eating disorders. In anorexia, the physical problems are related to malnutrition and starvation. In the most severe cases, major organ systems in the body are affected. The mortality rate associated with anorexia is around 5% per decade with death resulting “from medical complications rather than suicide” (

Fishman, 2016

, p. 25). In bulimia, the medical complications are due to vomiting or the use of laxatives or diuretics and can include dental problems, esophageal inflammation, gastrointestinal problems, and metabolic imbalances (

NIMH, 2011b

). With binge eating, individuals lose control over their eating. However, because young people diagnosed with binge-eating disorder do not purge, exercise excessively, or fast, they tend to be overweight or obese. They often have low self-esteem and may be at higher risk for developing cardiovascular disease and high blood pressure.

Etiology and Risk Factors

An interplay of biological, psychological, and sociocultural factors are thought to contribute to the development of disordered eating. Anorexia often arises during the transition to adolescence, when the chief developmental task is identity formation. Peer pressure, puberty, self-esteem issues, and societal messages that glorify thinness may all coalesce to trigger problematic eating patterns. Some of the factors that appear to be linked to eating disorders include media promotion of thinness as healthy and a sign of success, perfectionism, highly competitive environments (e.g., dance, gymnastics) that stress body thinness, a loss in personal relationships (e.g., family breakups or death), low sense of self-esteem, and a heightened concern for appearance and body shape (

Manley, Rickson, & Standeven, 2000

). Overall, eating disorders often reflect struggles with unmet needs, including the need to be loved, cared for, and respected, and disordered eating becomes a means of coping with feelings that are painful (

McClure & Teyber, 2003

).

Treatment Strategies

When eating disorders are treated early, positive outcomes are more likely. A comprehensive treatment plan is required that involves medical care and monitoring, counseling, nutritional consultation, and, at times, medication management. In some cases, when body weight is dangerously low, hospitalization is required. Treatment involves a team process, with the counselor working closely with the young person’s physician and nutritionist. The most effective treatment for anorexia nervosa is structural family therapy (SFT) where parents (or parental figures of a child) are charged with feeding their anorexic teenager together. This parsimonious intervention quickly addresses “the ubiquitous parental split (central to maintaining AN)” while successfully getting a teen to eat again (

Reichenberg & Seligman, 2016

, p. 25).

To successfully treat anorexia, NIMH recommends three phases:

1. Restoring the person to a healthy weight

2. Treating psychological issues related to the eating disorder

3. Reducing or eliminating thoughts and behaviors that lead to disordered eating, and then preventing relapse

For bulimia, the primary treatment goal is to reduce or eliminate binge eating and purging behaviors. Nutritional counseling and psychotherapy can be used to help the young person develop healthier patterns of thinking, feeling, and behaving. The counselor works collaboratively with the client to establish a pattern of regular meals that are not followed by binging, improve attitudes related to the eating disorder, encourage healthy but not excessive exercise, and alleviate co-occurring conditions such as mood or anxiety disorders. Cognitive–behavioral approaches, including group counseling, and interpersonal psychotherapy are usually effective in helping young people with bulimia. At times, medication may be prescribed.

Interventions for binge-eating disorder are similar to those used to treat bulimia. Cognitive–behavioral therapy that is tailored to the individual can be effective, and antidepressants are sometimes prescribed to reduce binge-eating episodes and lessen depression (

NIMH, 2011b

).

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioral disorder of childhood, can influence children’s emotional, behavioral, and social adjustment. To be diagnosed with ADHD, symptoms of inattention, impulsivity, and hyperactivity must appear prior to age 12 (

APA, 2013

). Boys are twice as likely as girls to be diagnosed with ADHD.

The DSM-5 (

APA, 2013

) identifies three types of ADHD: predominantly inattentive type, predominantly hyperactive–impulsive type, or a combined type. The two symptom clusters used to diagnose ADHD are the inattention cluster and the hyperactivity–impulsivity cluster. A child must exhibit at least six of the nine behaviors in the cluster to be considered significantly inattentive or hyperactive. Children with the combined subtype of ADHD, which is the most common presentation, exhibit six or more symptoms in both categories.

Children with ADHD are thought to have an underdeveloped inhibition of behavior, thus making it a disorder of impulse control (

Barkley, 1997

,

2015

). They typically have difficulty staying on task for more than a few minutes, are disorganized, and often ignore social rules. Children who have the inattentive type of ADHD have difficulty focusing (e.g., listening, following directions) and sustaining attention (e.g., staying on task, completing assignments). They frequently lose things and are forgetful. Children who have the hyperactive–impulsive type may act as though they are always on the go. They have difficulty sitting still and taking turns. Their social skills tend to be impaired, as evidenced by excessive talking, interrupting, and blurting out answers in class (

McClure & Teyber, 2003

).

ADHD can create numerous difficulties for children, their families, and their teachers. Because of impaired social skills and lack of behavioral control, children with ADHD may experience peer rejection, academic difficulties, and negative family interactions. Careful assessment is needed to ensure that counselors “look beyond the hallmark symptoms of the disorder and consider interventions that address comorbid problems as well” (

Nigg & Rappley, 2001

, pp. 183–184).

Etiology and Risk Factors

There is no conclusive proof of what causes ADHD. Some of the causal factors attributed to the development of ADHD include neurological factors, genetic factors, pre- and postnatal factors, and toxic influences (

Brown, 2000

;

NIMH, 2016a

). In particular, physical differences in brain structure and brain chemistry appear to play roles in the myriad symptoms associated with ADHD (

Lyoo et al., 1996

). Family factors also have been attributed to the development of ADHD; however, stressful home life does not cause ADHD. Instead, the disruptions brought about in a family as a result of the expression of ADHD symptoms can cause family stress and disorganization, which can then exacerbate preexisting symptoms.

Treatment Strategies

A multimodal, multicomponent approach to treatment is recommended for children with ADHD (e.g.,

Brown, 2000

;

NIMH, 2016a

). Prior to treatment, a comprehensive assessment is conducted that includes a developmental history, interviews with the child and significant adults, child observation, and a medical examination by the child’s physician. Typically, behavior rating scales such as the Conners–3 (

Conners, 2008

) or the Behavior Assessment System for Children–2 (BASC–2;

Reynolds & Kamphaus, 2004

) are used with parents and teachers to supplement information gathered during clinical interviews. If the assessment indicates that the child has ADHD, multimodal interventions that address the child, the family, and the environment are suggested. To develop a comprehensive treatment program, the following areas should be considered:

· Behavioral interventions in the family that include parent and child education about ADHD, parent training for behavior management, and ancillary family counseling when necessary are essential to treatment (

Nigg & Rappley, 2001

). Helping families develop predictable daily routines, organized households, and firm but affectionate discipline can improve family functioning.

Barkley (2015)

developed a comprehensive training program for parents that can be especially helpful.

· Individual and group counseling can provide a setting in which children feel understood and where issues of self-esteem and social relationships can be addressed. In particular, cognitive–behavioral self-regulation approaches to help children control their behavior and social-skills training to help children learn to take turns, follow rules, and develop hobbies or sports activities can be helpful (

McClure & Teyber, 2003

).

· Medication can be particularly effective in addressing the core symptoms of ADHD, although it is a controversial intervention for some educational and mental health professionals. The medications that appear to be most effective are stimulant medications. Not all children with ADHD need medication, and the decision to use it depends on several factors. Physicians who prescribe medication follow up with the child to determine whether the medication is working and to monitor potential side effects (

NIMH, 2016a

).

· School interventions are often instigated by clinical counselors as they work with teachers and school counselors to coordinate a child’s treatment plan (

Edwards, 2002

). Counselors can consult with teachers about behavior management and academic interventions.

Pfiffner and Barkley (1998)

have suggested a number of classroom interventions that can help children with ADHD experience school success.

· Intensive summer camp programs may benefit children with ADHD (

Edwards, 2002

). Such programs include sports-skill training, behavior management interventions, and opportunities for positive peer interactions.

As with any disorder, training is needed for counselors to work effectively with children who have ADHD and with their families. With training, clinical mental health counselors can coordinate multimodal, multicomponent treatment approaches that include parent management training, counseling, school interventions, and medication.

Case Study: Ellen and the Active First Graders

Ellen had taught first grade for three years and had a good experience with her children. This year was different though. She had three boys in her class who were out of their seats constantly and disturbing other children. She was not sure what to do so she asked the counselor in the school to come observe. He did and the disruptive behavior never materialized while he was in the room. When he left, the boys ran wild once more. Ellen was frustrated and talked to the counselor about the situation. He came again and the disruptive behavior failed to materialize until he left. Instead of having the counselor come a third time, Ellen thought there might be something she could do. If you were Ellen what would you do? Would you consult with the counselor about your plans?

Specific Issues of Concern

Young people in today’s society are faced with myriad issues that can affect development and adjustment. Child maltreatment, drug and alcohol abuse, cyberbullying, changing family situations, life-threatening illnesses, trauma, and the death of loved ones are just some of the many concerns that may affect children and precipitate a need for counseling. Divorce, grief and loss, maltreatment, and cyberbullying will be examined here.

Children of Divorce

Postdivorce family relationships are among the most common issues seen by counselors who work with young people (

McClure & Teyber, 2003

). Nearly half of all first marriages end in divorce, a statistic that has remained stable for several years (

Henderson & Thompson, 2016

). Research indicates that the children involved are often confronted with a wide range of adjustment challenges. Many studies document negative consequences for children whose parents divorce, particularly in regard to psychological adjustment, academic achievement, and behavior problems (e.g.,

Hetherington, 2006

;

Wallerstein, 2008

). However, there is a marked variability in children’s responses to divorce, with some children adjusting well and even showing improved behavior after the breakup, particularly if there has been a lot of conflict in the home.

Some of the factors that influence young people’s responses to divorce include their developmental level at the time of the separation, social support systems, individual resilience and coping styles, the level of parental conflict prior to and during the divorce, parenting quality after the divorce, and the degree of economic hardship experienced. There also may be gender differences in responses, with some studies indicating that boys appear to experience greater adjustment difficulties (e.g.,

Morrison & Cherlin, 1995

;

Wallerstein, 2008

).

Although responses vary, the initial experience of family disruption is painful for most children. Their responses to the experience tend to differ based on their developmental level. Preschoolers may feel frightened and insecure, experience nightmares, and regress to more infantile behaviors. Children between the ages of 6 and 8 may experience pervasive sadness, view the divorce as their fault, feel rejected, fear abandonment, and hold unrealistic hopes for reconciliation. Older children are more likely to feel anger and anxiety, develop psychosomatic symptoms, blame one parent or the other, and engage in troublesome behavior. Responses vary even more in adolescents than in younger children. Some adolescents feel betrayed, disengage from the family, and become depressed. Others show a positive developmental spurt and demonstrate maturity, compassion, and helpfulness toward their parents and younger siblings (

McClure & Teyber, 2003

).

It is important for counselors and parents to remember that adjusting to divorce takes time and requires continued patience and reassurance. During the adjustment period, children may benefit from individual or group counseling. Counselors can help children with the adjustment process by giving them opportunities to express their feelings and concerns. They also can assist children as they work through the following psychological tasks (

Henderson & Thompson, 2016

;

Wallerstein & Blakeslee, 2003

):

· Acknowledging the reality of the marital breakup

· Disengaging from parental conflict and distress and resuming typical activities

· Resolving the loss of what used to be

· Resolving anger and self-blame

· Accepting the permanence of the divorce

· Achieving realistic hope regarding relationships

Counselors may also work with the parents of children involved in divorce. Parent support groups and counselor–parent consultation can help parents cope more effectively with the changes brought about by the divorce. Counselors can encourage parents to do the following:

· Talk with children about the divorce in a way that is developmentally appropriate, making sure that they do not consider the divorce their fault

· Plan for ways to make the child’s life as stable and consistent as possible

· Arrange for regular visits from the absent parent to assure the child of both parents’ love

· Talk with children about the future, and involve them in the planning without overwhelming them

· Avoid asking children to take on responsibilities beyond their capabilities (

Henderson & Thompson, 2016

)

Grief and Loss

At one time or another, all children are affected by death, either of a pet, a grandparent, a parent or sibling, or a friend. Accepting the reality of death as part of life is a developmental task that often needs to be facilitated in counseling.

Children may experience a range of physical and emotional responses to grief experiences. Some of the physical reactions to loss include headaches, chest pains, and stomachaches. Children may experience a distortion in time or find it difficult to start new projects or begin new relationships. Some children regress to an earlier period in development, when they felt safer. Emotional responses may vary widely, ranging from feelings of anger or guilt to those of sadness, fear, or denial of pain.

As with divorce, several factors influence children’s responses to death, including their developmental level, support systems, and the manner in which the adults in their lives deal with grieving. The grief process is unique for each individual, and it is important not to assume that children in the same age group will respond in the same manner. Counselors can let children take the lead in sharing their grief experiences by requesting, “Help me find ways to help you tell me about what you feel.” One of the most beneficial things counselors can do is listen carefully to the children, trusting the children’s wisdom and giving them unhurried time to express their thoughts, feelings, and concerns.

In addition, the following counseling strategies can help children deal with loss from a death:

· Focus on what the child shares about specific thoughts, feelings, and concerns. Respond clearly and thoughtfully, keeping in mind the child’s cognitive level.

· Allow children to express their grief, talk freely, and ask questions. Play therapy, creative expression, puppetry, bibliotherapy, imagery, and letter writing are just a few of the methods that facilitate children’s expression of death.

· Help the children commemorate their loss and say good-bye, perhaps through compiling a scrapbook of their loved one or memorializing the loss in some significant way.

· Work collaboratively with parents to help the children learn more about the process of death and dying. Child-appropriate books about death, which are available in most libraries, can help answer questions, stimulate conversation, and provide new understanding (

Redcay, 2001

).

· Help families reduce stress in their children’s lives by maintaining structure and being aware of the possibility of regression. Family counseling may be needed.

· Be aware of triggers of grief, including birthdays, holidays, and the anniversary of the death.

· Help children give themselves permission to go on with life without feeling guilty. (

Henderson & Thompson, 2016

)

Child Maltreatment

Child maltreatment, which refers to abuse and neglect, is a serious concern. Approximately 905,000 cases of substantiated maltreatment were documented in the United States in 2014, with an estimated 1,580 fatalities (

U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, 2016

). That same year, over 3,600,000 cases of maltreatment were reported that received an investigation and/or assessment. Child abuse and neglect occur at all socioeconomic and educational levels (

Henderson & Thompson, 2016

). Maltreatment categories and associated conservative statistics include neglect (64%), physical abuse (16%), sexual abuse (8.8%), and psychological or emotional maltreatment (6.6%). Rates of maltreatment have fluctuated only slightly during the decade. Descriptions of each maltreatment category are presented in

Figure 11–4

.

Figure 11–4 Definitions, Signs, and Symptoms of Child Maltreatment

Sources:

American Humane Association, 1996

; and

Miller-Perrin, 2001

.

Child Neglect	Physical Abuse
· Deliberate failure by a caretaker to provide a child with shelter, food, clothing, education, supervision, medical care, and other basic necessities · Represents an ongoing pattern of inadequate care · Physical signs and symptoms: poor hygiene, poor weight gain, inadequate medical care, dressing inadequately for weather, being chronically late for or absent from school, constant complaints of hunger, severe developmental lags · Affective-behavioral signs and symptoms: low self-esteem, aggression, anger, frustration, conduct problems	· Any act that results in a nonaccidental physical injury; includes punching, beating, kicking, burning, cutting, twisting limbs, or otherwise harming a child · Often represents unreasonable and unjustified punishment of a child by a caregiver · Physical signs and symptoms: bruises, burns, and fractures · Affective-behavioral signs and symptoms: aggression, hopelessness, depression, low self-esteem, defiance, running away, property offenses, delinquency, substance abuse
Sexual Abuse	Psychological Maltreatment
· Any act that forces, coerces, or threatens a child to have any form of sexual contact or engage in any type of sexual activity · Includes both touching and nontouching offenses (e.g., indecent exposure) · Physical signs and symptoms: genital bleeding, odors, eating or sleep disturbances, somatic complaints, enuresis or encopresis · Affective-behavioral signs and symptoms: anxiety, nightmares, guilt, anger/hostility, depression, low self-esteem, sexualized behavior, aggression, regression, hyperactivity, self-injurious behavior, delinquency, running away, substance abuse	· A pattern of behavior that can seriously interfere with a child’s positive emotional development · Acts that communicate to a child that he or she is worthless, unloved, or unwanted · Includes emotionally neglectful behaviors and emotionally abusive behaviors · Affective-behavioral signs and symptoms: self-abusive behavior, aggression, anxiety, shame, guilt, anger/hostility, pessimism, dependency · Social deficits: insecure attachments, poor social adjustment

A particular concern is the fact that childhood maltreatment has escalated with advances in technology. Specifically, minors may be enticed or persuaded to meet online predators for sexual acts. The National Center for Missing and Exploited Children (NCMEC) provides information for parents and caretakers about ways to protect their children. Federal and state laws related to child pornography and other types of child sexual exploitation are summarized on the website at

www.ncmec.org

(

Henderson & Thompson, 2016

;

NCMEC, 2016

).

Every state has laws requiring professionals who work with children to report suspected child abuse or neglect to local child protective services. Also, each state and most counties have social services agencies that provide protective services to children. Counselors who work with children need to be aware of the agencies in their region to contact in cases of suspected abuse.

Victims of child maltreatment differ in regard to their preabuse histories, the nature of the abuse experiences, family and system responses to the abuse, available social supports, and individual coping resources. They also differ in regard to the types of symptoms displayed, with some children displaying many symptoms and others displaying few or none. Consequently, there is no single treatment approach that is appropriate or effective for all clients. Depending on the individual client’s presentation, clinicians should consider treatment approaches that include the following (

Miller-Perrin, 2001

):

·
Managing negative thoughts and feelings associated with the maltreatment, including guilt, anxiety, shame, fear, and stigmatization.

Counseling can give children opportunities to diffuse negative feelings by confronting the abuse experience within the safety of the therapeutic relationship. Older children and adolescents may be able to talk about their experiences. For younger children, reenacting the experiences through play or art may be helpful.

·
Providing clarification of cognitions and beliefs that might lead to negative attributions.

Confronting issues of secrecy and stigmatization are important. Cognitive–behavioral approaches that help children restructure their beliefs about themselves (e.g., being “different,” being at fault) can be effective. Group counseling may facilitate cognitive restructuring.

·
Reducing problem behavior.

Behavioral problems such as impulsivity, aggression, and sexualized behavior often need to be addressed in counseling. Parent training typically accompanies the counseling process when the parent is not the perpetrator.

·
Empowering the child survivor.

Prevention training that includes self-protection skills is often necessary. Self-protection skills involve teaching children to identify potential abuse situations, providing them with protective responses, and encouraging them to disclose any abuse experiences.

·
Enhancing developmental skills.

Children may have deficits in problem-solving skills and social skills. Depending on the age of the children when the abuse occurred, there also may be lags in regard to psychosocial development (e.g., learning to trust). Individual and group counseling can facilitate growth in these areas.

·
Improving parenting skills.

In many cases of child maltreatment, parent-focused interventions are warranted. Such interventions include educating parents about developmental processes to correct misperceptions and unrealistic expectations, teaching parents about appropriate disciplinary techniques, and teaching anger management and stress reduction skills.

Because of the complex nature of child maltreatment, counselors should consider accessing community resources and services to help families manage difficult situations more effectively. Examples of such services include substance abuse treatment, money management training, crisis hotlines, respite care services, preschool services, and parent education classes.

Cyberbullying

Over 93% of youth are active users of the Internet, and at least 75% own their own cell phones. Although the extent of cyberbullying and its prevalence are unclear, studies have found that anywhere from 9% to 40% of students are victims of cyberbullying (

Schneider, O’Donnell, Stueve, & Coulter, 2012

). The National Crime Prevention Council defines cyberbullying as using the Internet, cell phones, or other electronic devices to send or post text or images intended to hurt or embarrass another person (see

www.NCPC.org

).

In many ways, online attacks differ from and can cause more harm than traditional bullying (

Paterson, 2011

). Online attacks can take place anonymously and can quickly involve hundreds of participants and onlookers. Cyberbullying “isolates its intended targets and haunts its victims relentlessly because the attacks reside and proliferate throughout a primary social network for today’s youth—the Internet” (

Paterson, 2011

, p. 44).

Cyberbullying occurs over a number of media. Among the most prominent are social networking websites, such as Facebook; video-sharing websites, such as YouTube; instant messaging on the Internet; text messaging on cell phones; and “trash-polling” sites, where visitors are invited to post unflattering comments about someone, often based on photos (

Hinduja & Patchin, 2016

).

The harmful effects of cyberbullying are numerous. They include but are not limited to psychological distress (such as feeling scared, angry, and unable to trust others), decreased self-esteem, increased depression, social isolation, embarrassment, decreased confidence, feelings of worthlessness, and harassment. The most serious one is increased suicidal ideation and instances of suicide. Two widely reported tragic examples in the early part of the 21st century of young teenagers taking their lives as a result of cyberbullying concerned Ryan Halligan, from Vermont, and Megan Meier, from Missouri. Halligan committed suicide at the age of 13 after being bullied by his classmates in real life and cyberbullied online. Meier died of suicide attributed to cyberbullying through social networking by hanging three weeks before her 14th birthday.

Clinical mental health counselors can help in instances of adolescent cyberbullying by taking the issue seriously and learning more about it, for example, consulting the Cyberbullying Research Center website at

www.cyberbullying.us

. They can also provide psychoeducation to parents about being proactive and setting limits on social media for their teenagers, offer support groups for people who have been targets of cyberbullying, and provide supportive individual therapy that includes skill training. Clinical mental health counselors can also work with perpetrators of cyberbullying to help them gain a greater understanding of their actions, as well as advocate for laws and regulations that prohibit cyberbullying. A useful resource is the book Cyberbullying: What Counselors Need to Know (

Bauman, 2011

).

Other Issues

Divorce, grief, maltreatment, and cyberbullying are just a few of the many issues with which children and adolescents may struggle. Other issues include living in chemically dependent families, being homeless, having poor nutrition, living with chronic or terminal illness, adjusting to blended families, managing teenage pregnancy, and engaging in delinquent activities. It is beyond the scope of any text to cover all the concerns faced by young people; therefore, counselors who work with this population can acquire more expertise through continuing education workshops and online webinars.

Summary and Conclusion

Working with children and adolescents provides unique and exciting challenges for clinical mental health counselors. Clinicians who work with this population need to have a comprehensive understanding of the developmental issues that influence young people’s well-being. They also need to be aware of the various contextual influences on development, including the family, school, peers, life events, and culture.

Knowledge of development and bioecological influences provides a strong foundation for counseling children and adolescents. When counseling young people, special attention needs to be given to building a therapeutic relationship, assessing and evaluating, and selecting and implementing developmentally appropriate interventions.

Young people in today’s society are confronted with a wide array of issues, ranging from diagnosable mental health disorders to specific concerns related to life events. Some of the disorders discussed in this chapter include depression, eating disorders, and ADHD. Other concerns that may precipitate the need for counseling include parental divorce, death of a loved one, cyberbullying, and child maltreatment. These are just a few of the multiple concerns that may bring young people to counseling.

CITING FOR THESES PAGES 262-293:

Gladding, S. T., & Newsome, D. W. (2018). Clinical mental health counseling in community and agency settings. NY, NY: Pearson.