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Psychiatric Medication for Teens and Youth

Neuroscience research has improved our understanding of brain development and mental illness in youth. We know that one in five children experience mental illness and that half of all lifetime cases of mental illness begin by the age of fourteen. We also know that mental health conditions are brain based biologic conditions that interfere with mood, behavior, learning, and social relationships. Yet children, teens and families are often reluctant to speak out about their concerns because of the stigma associated with a psychiatric diagnosis. Additionally, myths and misconceptions about medication keep families from seeking evaluation or recommendations for treatment.

Mental illness is treatable and the best outcomes occur with early identification and intervention. Research has established evidence for safe and effective treatment of mental illness in children and youth, including psychotherapy and medication. Just as a child with a seizure disorder or diabetes requires medication, so is often the case for a child with psychiatric illness. A comprehensive psychiatric evaluation by a child and adolescent psychiatrist can lead to an informed multidisciplinary treatment plan, including medication when indicated. Family-centered care allows parents and youth to work along with their doctor to weigh the risks and benefits of various evidence-based treatment options and ultimately choose the treatment most appropriate for each child.

ADHD and the Impact on Learning

Attention Deficit/Hyperactivity Disorder (ADHD) is a common childhood illness. Approximately 11% of grade-school students have ADHD. All students can get distracted from time to time, but students with ADHD have more noticeable and long-lasting symptoms at school, home, and in social situations. Students with ADHD have difficulty focusing, make careless mistakes, have trouble listening, and trouble completing tasks like homework. They also have difficulty sitting still and controlling their impulses. These symptoms interfere with learning, family life, friendships and self-esteem.

The good news is that safe and effective treatment is available. An ideal treatment plan includes a combination of medication, counseling and school-based supports. The first step to treatment planning is a comprehensive evaluation by your child’s primary care doctor or a child and adolescent psychiatrist. Most children with ADHD do well with medication; symptoms of inattention, hyperactivity and impulsivity are reduced. Psychotherapy includes coaching parents in the use of behavioral interventions and therapy with the child or adolescent to teach social skills and build self-esteem. School-based supports may include help with study skills, assigned seating near the teacher, and additional time on tests or assignments.

Managing Disruptive Behavior

Children who experience repeated tantrums or outbursts, can cause serious disruption in their families and their classrooms. These students are often described as angry or defiant, but are more likely to be explosive as a result of underlying anxiety or learning issues. The challenge for parents and teachers is to avoid being reactive to the outbursts and instead learn to be preventive. A partnership between parent, teacher, and mental health professional can help to create a series of behavioral interventions that will over time reduce the outbursts and lead to more adaptive coping.

For example, students who experience outbursts as  a result of learning issues, can be taught how to ask for help when they’re feeling stuck. These students can also benefit from focus help, targeting their specific learning challenges. Other students who experience outbursts as a result of their anxiety can be taught how to use basic self-calming strategies.

Overcoming School Refusal

Many students will experience a brief period when they don’t want to go to school but actual school refusal continues for a longer time, is associated with more avoidant behavior and causes more distress or worry for the child.  For some students, a period of school refusal begins after an extended school holiday or an extended break from school due to illness. Students may be uncomfortable returning to the classroom, making up missed work, or reconnecting with their classmates. Sometimes school refusal may be associated with a stressful situation at school, such as teasing or bullying. For other students, school refusal is associated with an anxiety disorder, such as separation anxiety or social anxiety. For these students, anxious feelings are more widespread and may be associated with vague physical complaints (like headaches and stomachaches), tantrums associated with getting dressed for school, or repeated requests to leave school.

It’s important to catch school refusal early as the longer a student stays out of school, the more difficult it is to return to school. Students with brief or mild symptoms may respond to reassurance and strategies to help them address their fears. Students with more long-lasting or intense symptoms may require a more intensive approach. A comprehensive psychiatric evaluation by a qualified mental health professional, such as a child and adolescent psychiatrist, will help to identify the factors contributing to school refusal and also help to develop a treatment plan. Treatment often includes cognitive behavior therapy, a form of talk therapy that helps a student to recognize their anxious thoughts and overcome their avoidant behavior. This treatment also includes exposure therapy, where students gradually return to school, learn that they can manage their anxiety and discover that their worst fears won’t come true.

Depression and Teenage Angst

When dealing with a moody adolescent, parents and teachers will often ask, “Isn’t this just part of being a teenager?”  While it’s true that adolescent brain development and academic and social pressures can leave a teenager feeling moody, adolescents can also develop clinical depression, a biologically-based medical condition with specific signs and symptoms that can significantly impact day to day life. A student with depression will experience sadness or irritability as well as changes in energy, sleep, appetite, motivation, and interest. These symptoms will impact on learning, relationships, and self-esteem.

A student with depression can also experience hopelessness and suicidal thinking. In fact, suicide is now the second leading cause of death among teens. Students with depression are also at greater risk of substance use and other mood symptoms, such as anxiety. Fortunately, early intervention with evidence-based treatments can shorten the duration and intensity of symptoms and return a student to age appropriate experiences.

Treatment for depression may include psychotherapy and medication. Students with depression respond well to cognitive-behavior therapy. This type of talk therapy helps a student to recognize and challenge the negative thinking associated with depression. Students with moderate to severe depression may also require medication, specifically a selective serotonin reuptake inhibitor. In fact, research tells us that a combination of cognitive behavior therapy and medication works better that either treatment alone.

Suicide and Self-injury

Learning that your child is feeling hopeless, thinking about suicide, or intentionally hurting themselves can leave a parent feeling helpless or frightened. Suicidal thinking may occur in reaction to a stressful life event or may develop in the context of a mood disorder, such as depression. Adolescence is a time of incredible change and teens may not always be equipped to deal with the circumstances and emotions that they experience. It’s important for parents to keep lines of communication open, to validate their child’s feelings, and to offer guidance as to how to get help.

If you think your child may be experiencing suicidal thoughts, talk with him or her about her feelings. Sometimes parents are afraid to bring up the subject as they fear suicide will be more likely to happen. In fact, students who know they can talk with a caring adult feel better. Opening the door to a conversation about feelings, can lead to a meaningful discussion about seeking help from a qualified mental health professional. A comprehensive evaluation can identify the factors associated with suicidal thinking, such as depression, and then lead to appropriate treatment.

Self-injury, the act of intentionally hurting oneself, is not uncommon among teens, especially girls. Teens may cut or scratch themselves in response to emotional pain as a way to distract themselves from that pain or a way to communicate their distress to others. The impulse to self-injure may be triggered by a stressful life-event, such as being rejected by a friend. Self-injury is not the same as suicidal thinking but may lead to suicidal thinking. Psychotherapy, especially dialectical-behavior therapy (DBT) can teach a student to deal with uncomfortable feelings and develop more adaptive coping mechanisms.

Children and Anxiety

Some forms of anxiety can be adaptive. For instance, a student who worries about their performance on a test may spend quality time studying for that test. Some forms of anxiety are typical at certain ages. For instance, preschoolers are often afraid of the dark and call out for their parents’ help at bedtime. But children with anxiety disorders experience intense and persistent worries that interfere with daily life and their worries exist out of proportion to the situation that triggers them.  Untreated, anxiety disorders also tend to get worse over time, because as the child works to avoid the triggers, the worries only grow more powerful.

Anxiety disorders are among the most common reasons that children and teens will present to a mental health professional. Children with anxiety disorders are often born with a temperamental style that causes them to be slow to warm up to new situations and uncomfortable around unexpected changes in their routine or environment. Anxiety disorders also tend to run in families, as do other brain based biologic conditions. There are many types of anxiety disorders that impact students at different ages and stages. For instance, a grade school student with Separation Anxiety may refuse to go to school or may not want to play over a friend’s house.  A student with Generalized Anxiety Disorder worries too much about everyday things and can experience physical symptoms like stomachaches and headaches in addition to anxious and irritable mood.  A high school student with Social Anxiety will find it difficult to speak in class, or join classmates in the cafeteria, or participate in after-school activities.

Fortunately, anxiety disorders are treatable. Cognitive behavior therapy (CBT) is a form of talk therapy that teaches students to confront anxious thoughts and replace avoidant behavior with adaptive coping.  One important technique in CBT is exposure therapy. Students are gradually exposed to their anxious triggers and taught to use self-calming techniques to manage and overcome their anxiety. Students with moderate to severe anxiety may require medication to decrease the intensity of their symptoms. Selective serotonin receptor inhibitors (SSRIs) are safe and effective in children and adolescents. Research demonstrates that outcomes are improved for students receiving CBT and SSRIs, compared to either intervention alone.

Integrated Collaborative Care

Children’s overall health is dependent on physical as well as mental health. Effective physical and mental health care requires collaboration between primary care providers and mental health professionals. Pediatric Integrated Collaborative Care models promote the integration of medical and mental health services for children and adolescents by supporting system wide changes in health care delivery that promote sustainable models of collaboration and communication between all members of the health care delivery team. This includes changes in practice and policy that support screening and early intervention for psychiatric illness by primary care providers, the use of evidence-based treatments and real time clinical outcome data to track progress, linkage to mental health services for children and their families by care coordinators, and consultation with child adolescent psychiatrists to inform treatment planning and provide evaluation when indicated.