To Medicate or Not to Medicate? The Ethics of Recommending Medication for Minors

1. To Medicate or Not to Medicate?The Ethics of Recommending Medication for Minors By: Jennifer Bucceri Rosmond Ginieczki Tiffany LaBarbera Marie Le & Adria Stern

2. Fact or Fiction? • Prescribing medication for an off-label use is no big deal? • FALSE By providing medication for off-label uses, the healthcare professionals concerned are accepting risk and liability. 2. Psychotropic medications are prescribed for kids as young as two. • TRUE

3. Fact or Fiction? Continued 3. Schools have a vested interest in having students diagnosed with ADHD? • TRUE • Black children are more likely than white children to be diagnosed with ADHD? • FALSE White non-Hispanic children are more than two times as likely as Hispanic and black non-Hispanic children to be diagnosed with ADHD. They are up to four times as likely to take Ritalin.

4. Why is medication used for ADHD ? • ADHD is a biochemical problem, related to an imbalance of the neurotransmitters in the brain. • For ADHD people the prefrontal cortex is under-active and doesn’t prioritize and select or inhibit input, resulting in a flood of data bits that keep the mind and body unfocused. • Stimulant medications allow the prefrontal cortex to perform traffic direction more efficiently. • Although some stimulants have been used on children as young as age 2, most are recommended for age 6 or older.

5. Stimulants Amphetamines (Adderall) Methylphenidate (Ritalin, Concerta, Metadate) Dextroamphetamine (Dexedrine, Dextrostat) Pemoline (Cylert - less commonly prescribed because can cause liver damage) Non-stimulant- Strattera- the newest treatment. It is a reuptake inhibitor that acts on norepinephrine. Because it is a non-stimulant, it may be less objectionable to some families, but they still have similar side effects. Antidepressants and anti- anxiety medications In some cases, antidepressants or anti-anxiety medications may be prescribed either in addition to or instead of stimulants. What are the medications for treating ADHD?

6. ADHD Medication Side Effects • decreased appetite or weight loss • headaches • upset stomach, nausea or vomiting • insomnia or sleep difficulties • jitteriness, nervousness, or irritability • lethargy, dizziness, or drowsiness • social withdrawal

7. What are SSRIs? • SSRI stands for Selective Serotonin-reuptake inhibitor • Drug binds to postsynaptic serotonin receptors • It blocks the ability of serotonin to activate the postsynaptic receptors • The blockage of serotonin receptors sends a feedback signal to the presynaptic neuron • The feedback signal increases the level of serotonin, which is broken down in the synapse resulting in elevated serotonin levels (Pinel, 2003)

8. Prozac • Only Prozac has FDA approval for use in children and adolescents with depression • However other SSRIs are routinely prescribed to children • Prozac is the most commonly prescribed SSRI due in part to its number of side effects

9. Nausea Sexual problems Diarrhea Dizziness Drowsiness Gas Indigestion Insomnia Mouth dryness (Cotton mouth) Sweating Common Side Effects of SSRIs

10. Why is the use of medications for ADHD and depression controversial? • Overuse • Long-range effects on the developing brain are not known. • Many children are prescribed drugs by doctors who do not specialize in behavioral issues and are not fully trained to diagnose or treat these disorders (Kuwana, 2000). • Doctors may not try less invasive treatments, such as behavioral interventions • This is complicated by insurance which can limit the number of doctor visits.

11. Why is the use of medications for ADHD and depression controversial? Continued • Age of children • Doctors are diagnosing and prescribing medications for children as young as age 2, even though the controlled studies on these medications were not done on pre-school children. • NIMH is planning a $6 million, 5 year study on the use of Ritalin in children under the age of six. (Kuwana, 2000) • It is unknown how these drugs affect developing brains • Additional problems suggested from animal studies (Kuwana, 2000) • Understanding of normal child development and family behavioral management skills might be a more appropriate intervention for such young children.

12. Why is the use of medications for ADHD and depression controversial? Continued • Misdiagnosis • There is no specific test for ADHD or depression. • Behaviors that are common to ADHD and depression may be caused by a variety of other sources, such as: • domestic violence • abuse (sexual, physical or emotional) • neglect • alcoholism in the family • inadequate parenting • ineffective behavior management • poor attachment to a stable caregiver • or a number of other medical conditions.

13. Pros • ADHD medication can improve daily functioning when carefully managed, individually tailored, and combined with behavioral therapy. • The increased availability of medications has de-stigmatized psychiatric disorders and freed families and communities to seek medication intervention for troubled kids. • The variety and increase of medications in the 90s has served the needs of untreated children. • Antidepressants may lift children out of emotional danger and self-destruction. • The neurological or biochemical roots of disorders may best be regulated through medication.

14. Cons • For some young people, the risks of suicidal behaviors caused by antidepressants may be especially high. • Ritalin may be prescribed to control behavior that may not be accurately diagnosed as ADHD. • There is a lack of research on the use of ADHD medications and antidepressants on young children. • Young children on psychotropic medications may not know how to accurately report side effects. • Risk of overuse of medication as a fast fix.

15. Ethical Issues Law and Order episode, Mania A child killed two of his classmates while on the anti-depression medication Apteral

16. Except for legally authorized "involuntary" treatment, patients who are legally competent to make medical decisions and who are judged by health care providers to have decision-making capacity have the legal and moral right to refuse any or all treatment. This is true even if the patient chooses to make a "bad decision" that may result in serious disability or even death. The Right to Refuse

17. ACA Code of Ethics • A.2. Non discrimination: Counselors do not condone or engage in discrimination based on age, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital status, or socioeconomic status. APA Ethics Codes • Unfair Discrimination: In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law. • Respect for People’s Rights and Dignity: Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination.

18. School and Ritalin • Ritalin is a stimulant that is used to treat children with ADHD in schools • Over-prescribing by public school administrators where they are relying on pharmaceuticals for “difficult children”. • Parents are being forced against their will. • Challenge to parents rights to make choices. -no longer free access to public schools -CPS involved • Parents overall concern about medication. -long-term effects -personality change

19. APA’s stance on children and medication • Proper diagnosis by an expert. • Make sure health professionals know the difference between normal health development and childhood disorders. • Psycho-stimulant medication alone is either inappropriate or inadequate. • An integrated collaboration of mental health professionals. -issues of confidentiality

20. References • American Psychological Association. (2004). What Parents Should Know About Treatment of Behavioral and Emotional Disorders in Preschool Children. Retrieved November 23, 2004 from http://www.apa.org/pubinfo/kidsmed.html. • Depression in Childhood and Adolescence. (2003). Retrieved November 21, 2004 from http://my.webmd.com/hw/depression/ty4655.asp • DeNoon, Daniel. (2002). ChildMental-Health Woes Multiply. Retrieved November 29, 2004 from http://my.webmd.com/content/Article/57/66040.htm?pagenumber=1 • Diller, L.H.(2000) Just Say Yes to Ritalin! Parents are being pressured by schools to medicate their kids-or else. Retrieved November 23, 2004 from http://www.freerepublic.com • Fowler, R.D. (2002) ADD/HD- Are Children Being Overmedicated? Retrieval October 19, 2004 from http://www.apa.org/ppo/issues/padhdtest902.html • Kottler, J. (2005). Introduction to Therapeutic Counseling- Voices from the Field (5th ed.). Pacific Grove, CA: Wadsworth Publishing. • Kuwana, E. (2000). Increasing Use of Stimulants and Antidepressants In Children Sounds an Alarm. Retrieved November 20, 2004 from http://faculty.washington.edu/chudler/ritalin.html • Kuwana, E. (2000). New Guidelines for Diagnosing ADHD. Retrieved November 20, 2004 from http://faculty.washington.edu/chudler/adhdpro.html • Mahler, J.(2004) The Antidepressant Dilemma. Retrieved November 23, 2004 from http://www.nytimes.com • National Institute of Mental Health. (2004). Treatment of Children with Mental Disorders. A booklet with answers to frequently asked questions about the treatment of mental disorders in children. Retrieved November 23, 2004 from http://www.nimh.nih.gov/publicat/childqa.cfm. • Pinel, J.P.J. (2003). Biopsychology (5th ed.). Boston: Pearson Education, Inc. • Turkington, C. & Kaplan,E.F. (2001). Selective Serotonin Reuptake Inhibitors (SSRIs). Retrieved November 23, 2004 from http://my.webmd.com/content/Article/87/99352.htm?pagenumber=1 • U.S. Food and Drug Administration. (2004). FDA Proposed Medication Guide: About Using Antidepressants in Children or Teenagers. Retrieved November 23, 2004 from http://www.fda.gov/cder/drug/antidepressants/SSRIMedicationGuide.htm. • Zwillich, Todd. (2004). FDA Orders Strict Anti-depressant Warnings. Retrieved November 21, 2004 from http://my.webmd.com/content/Article/95/103293.htm?pagenumber=1