Psychopharmacology for

Child Advocates, Clinicians

and Counselors

Joe Wegmann, PD, LCSW

Joe@ThePharmaTherapist.com

504.587.9798

www.pharmatherapist.com

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I’ll Address…

Describe the maturational and

developmental issues regarding response to

medication in youth

Discuss the mental disorders that typically

emerge during childhood and adolescence

Examine symptoms, how to differentiate

among disorders, and medications employed

in treatment

Special Aspects of Child

Psychopharmacology

In the U.S., any psychiatric medication

prescribed for adults can be prescribed for

children

Prescribers diagnose based on interviews,

checklists of symptoms and observations

Parents, school systems and other

environmental factors exert influence on

prescribers

Yet-to-be-developed neurotransmitter

systems

Mood Disturbances in Children

Symptoms of Pediatric

Depression

Persistent mood disturbance that is a

change from prior functioning

Lack of energy, motivation or enthusiasm

Changes in sleep or eating patterns

Irritability, agitation, unwarranted crying

Pervasive anhedonia

Sad or morbid play that concentrates on

harming themselves or others

Manifestations in Children

Demoralization;

Esteem and Image

Issues

Physiological

Demoralization Issues

I see many kids with disturbed mood and unhappiness

related to challenging life circumstances: bad schools,

problematic family or parents, poor peer

relationships, poverty, trauma, violence

All of the above can profoundly affect how these kids do in school, behave at home and in social settings

Public sector counseling services have been cut to the bone in Louisiana, leaving many affected children with few if any coping skills

The number of kids suffering from clinical depression is small compared to those who are demoralized

Case Example: Demoralization

During the past two months, 11 year old Kyle has appeared

distracted, agitated and irritable throughout the school

day. He’s often not paying attention, gets aggressive with

other students, getting him into trouble. His grades have

fallen off somewhat, but he’s in no danger of failing.

His teachers report he’s confident and assertive in class and

recreational activities, but seems “down.”

When you address these issues and ask him what’s been

going on, he responds, “my dad lost his job and he and my

mom are fighting all the time.” “It makes me mad and

unhappy to hear them fighting and I want it to stop, but I

don’t know what to do.”

What To Look For

Kyle is willing to express his concerns about how

difficult the situation between his mom and dad has

become

Kyle is coming to school every day and is engaged.

His grades have fallen off somewhat, but this is likely

a by-product of the frustration he’s feeling, which in

turn is affecting his concentration and desire to apply

himself.

How To Proceed

Demoralized youth will better respond to time-

honored problem-solving techniques. Let him tell

his story about the situation and what really

bothers him about the discord between his

mother and father

Use Kyle’s confidence and assertiveness as

strengths to help him confront his parents

Assist him with developing a script he can try out

– “mom and dad, it upsets me when you

constantly fight and I wish you would stop,

please don’t do it in front of me”

Mindfulness techniques work well with

demoralized kids

Informal Mindfulness Techniques Mindfulness is simply grounding oneself by focusing on and

becoming aware of thoughts, feelings and sensations happening in

the present with curiosity and interest.

Mindfulness can help any of us to shift our troublesome thoughts,

feelings and worries to something more positive, relaxing and

rewarding by keeping us in the here and now.

Have the child just notice his breathing. In and out…in and out, it

goes. No need to complicate this with specific breathing exercises,

and don’t have the child count the breaths. Give this about 10-15

seconds tops

Challenge the child to start looking around and hunt for things

they’ve never noticed, then let them share their findings and why

they think they haven’t seen them before

Remind them that all of these things are happening LIVE, in the

very moment in which they’re operating

Mix these up, create your own, or ask the kids to come up with

their own suggestions for staying in the present, BE IMAGINATIVE!

Clinical Depression Depression is very confusing and there is no general consensus as to

what’s going on or even what’s wrong with the brain

Psychomotor slowing

Acute attention and concentration problems – often report

struggles with absorbing material when studying, and reading in

particular

Usual onset age: 15-18

If I see an unhappy 6 or 7 year old, I’m going first to

demoralization or anxiety

Diurnal variation in mood – which is a worse mood in the morning,

but improving throughout the day. Involves “phase shifting” and

often sleep deprivation

Inability to experience pleasure – some will openly say “I’m

miserable”

Medical conditions (asthma); Drugs: (substance abuse, steroid

inhalers

Most Frequently Prescribed

Antidepressants

Prozac – FDA approved for kids 8 and older

Zoloft

Paxil

Celexa

Lexapro – FDA approved for kids 12 and older

Effexor

Wellbutrin

Children Taking

Antidepressants Antidepressant effectiveness today is no better than the

1950s

The journal Lancet recently: “Antidepressants provide small or modest efficacy in the majority of adult users

What does this translate to in youth with only growing and developing neurotransmitter systems?

Side effects can be persistent (anxiety, sedation, insomnia)

What about discontinuation? - withdrawal can be tough

Fix The Physiology First…Not The

Brain

We have been animals that move for a lot longer than we have been animals that talk and convey

It’s difficult for an animal operating in its natural habitat, with an acceptable status in its chosen group to be depressed

Scientific evidence is clear – exercise and nature significantly reduce depression and anxiety

Because…it returns us to our more natural and healthy animal state – where we are moving and our endorphins are rushing

Fixing the physiology comes first – not pills, not counseling not mindfulness

Kids (and adults) MUST get out and move!

Bipolar

(Disruptive Mood Dysregulation

Disorder)

Comments to Start

Diagnosing this disorder in youth is difficult

as well as controversial

Bipolar symptoms can easily be mistaken for symptoms of other disorders, such as ADHD, oppositional defiance, conduct problems and certain anxiety disorders

Genetics play a significant role

Diagnosis in youth and teens is complex and requires careful observation over a long period of time. Approximately 25-30 percent of cases first appear in late childhood or early adolescence

Definitely be on the lookout for substance abuse problems with this disorder

Symptoms of Early-onset

Mania Rage, sometimes intense – possibly lasting a few

hours

Pressured speech – displays as a quick, starting and stopping speech pattern without continuity or flow

Marked mood swings – rage and irritability switching to dissatisfaction and unhappiness

Mood swings are often rapid – cycling frequently throughout the day

Grandiosity – a display of inflated ego about self, accomplishments

Decreased need for sleep – demonstrates ability to function and manage well on little sleep, with much of the daytime energy coming from manic-like feelings

Increase in risk-taking behavior

Marked oppositional behavior – aggressive, bullying, fighting

Depressive Symptoms

Stomachaches and headaches

Sleeping too much or too little

Changes in appetite

Guilt, worthlessness

Extreme sadness

Decreased interest in school activities

Assessing a Child for Bipolar: The

3 Best Questions to Get Started

1. Has there been a time when you can

remember having lots of energy for getting

things done, where you needed little sleep,

and people noticed this and thought you

were acting strange or different?

2. Has there been a time when you felt sad

and down and isolated yourself, and people

noticed that you were absent?

3. Is there anyone in your family as far back as

you can remember who has been treated for

what I just asked you?

Medications for Bipolar

Disorder Lithium

Depakote

Lithium

Treats acute mania

Produces “normalizing” effect by smoothing

out manic highs and depressive lows

Most effective single agent for bipolar

disorder

Used to treat aggression or self-injury in

children and adolescents with conduct

disorder, autism and intellectual disability

FDA approved in children at least 12 years of

age

Side Effects of Lithium

Thirst

Excessive urination

Weight gain

Nausea, vomiting,

diarrhea

Depakote

Classified as an anticonvulsant

Effective for mania, but not as effective as lithium

Treats rage reactions and extreme mood instability

Depakote Side Effects

Weight gain

Sedation

Can cause birth defects – completely

contraindicated in pregnancy

Polycystic ovary syndrome – development of

ovarian cysts, decreased fertility, menstrual

irregularities

Anxiety

Overview Children and adolescents have their struggles with

nervousness, tension and that sense of something stirring

inside of them in ways similar to adults

Anxiety starts with a situation or circumstance that feels

uncomfortable or difficult to manage. Sometimes the

distressing thoughts precede the situation

This is known as “worrying in advance” of something that

may never happen, or won’t happen in the way it’s

perceived

The worry gives rise to threatening feelings followed by

fear – which is just waiting on the doorstep to pounce

The response to the fear is to fight back, flee or freeze

Generalized Anxiety

Chronic, low-level type of anxiety that tends

to be free-floating without any boundaries

Children with GAD engage in irrational worry about many things such as academic performance, athletic capability and peer relationships

Resolved worries are quickly replaced with new ones, consuming excessive amounts of time

Obsessive-Compulsive Disorder…

I Get Lots of Questions

“My 12-year-old son is

adamant about toilet

tissue being placed on the

roller so that the tissue

dispenses from the top of

the roll, not the bottom.

When other family place

it on the roller in reverse,

he becomes irritated and

immediately changes it

back. Does this mean he

has OCD?”

Obsessive-Compulsive Disorder

We all have eccentricities, oddities, habits

The full-time companion

A disorder of excessive carefulness accompanied by an exaggeration of possible danger

Persistent thoughts and compulsions accompanied by shame and guilt

Often incapacitating

Emerges in late childhood, prevalent in children and adolescents

If untreated, symptoms remain remarkable throughout life

OCD is no longer DSM-classified as an anxiety disorder, rather it is neurological in nature, generating obsessive thoughts and behaviors

What To Look For

Writing a sentence or phrase, erasing it or lining

through it, and then writing the same thing again

Slow to complete tests and other exercises

Checking work repeatedly before actually turning

it in

Becoming upset when rules aren’t followed by

other kids, as on the playground

Being precise, meticulous, demonstrates a need

for near perfect order; fastidious about

appearance; need for symmetry

Examining backpacks and gym bags for needed

items repeatedly, particularly when leaving school

for the day

Best Practices for Managing OCD

Use of logic results in abject failure

Expose and prevent; expose and prevent –

THIS IS HOW AFFECTED CHILDREN GET

BETTER

Example: A child with an excessive

“checking” type of OCD

Visual and audio confirmation

For those who stick with E&P and practice

regularly – 85% improve

Serotonin antidepressants so often impede

progress.

Medicating Anxiety Medication management

studies are virtually non-existent and inconclusive

Mood stabilizer and antipsychotics are often used “off-label” for the treatment of violent outbursts, severe aggression, tantrums, destructive behavior

Antihistamines (Benadryl) Not so much for anxiety, but more to initiate sleep

ADHD ADHD is definitively…a neurodevelopmental disorder with

onset in mid-childhood through early adolescence

Those with ADHD have racecar brains with bicycle brakes

CDC: Nearly 20 % of high school age boys in the U.S. and 11%

of school-age children have received a diagnosis of ADHD;

53% rise in diagnosis in those 4-17 this past decade alone

Some diagnosticians are hastily viewing any complaints of

inattention as ADHD – so the diagnosis is poorly established

Parents pressure doctors for pills, instead of challenging and

questioning this diagnosis

Once started on pills as a child, the now high school student

or college student “can’t be without them”

The 5 Ps (Stimulants)

The Pills:

Ritalin; Focalin; Adderall

The Pump:

Concerta

The Pellets:

Ritalin LA; Focalin XR; Adderall XR

The Patch:

Daytrana

The Pro-Drug

Vyvanse

Psychostimulant Side Effects

Appetite suppression in the beginning, but not

persistent

Insomnia can occur, but usually not a significant issue (sleep improves due to less bedtime rumination) or because of decreased blood levels of the drug

Irritability, particularly with amphetamines

Dry mouth

Curbing The Misuse of

Psychotropic Medication Children make excellent targets for psychiatric medications

Once started on drugs, many never discontinue them

Aging; Environmental and Developmental influences

Recommendations for Parents

Become fully informed consumers

Does the presenting problem conform to an approved indication for a particular drug

Safety; side effects

What might better explain the child’s behavior?

For Clinicians, Counselors, Child Advocates

Medication and psychotherapy are not mutually exclusive

Biology affects psychology and vice versa

We as therapists need to be attuned to reactions, side effects, results so as to have input on directing medicated youth going forward

Resources

Adapted from:

Wegmann, J. 2018. Behavior

Management Guide for the Classroom.

Eau Claire, WI: Premier Publishing &

Media

Thanks for Attending!

Joe Wegmann, PD, LCSW