Here’s the third installment in our Summer 2013 blog series…Ten Questions Parents and Caregivers Ask About Kids and Medication. We’ll examine the question What type of evaluation should a child receive before starting medication?
The longer I’ve been in clinical practice, I’ve found myself needing more time as opposed to less for new patient evaluations. I’ve learned that there are more and more questions I need to ask to effectively anticipate challenges likely to arise during treatment. Taking the time up front to get a thorough understanding of a child’s situation greatly helps minimize the likelihood of problems down the road…and gives me credibility with parents when I can speak about complications before they occur.
For economic purposes, some clinics have a physician extender (physician assistant, nurse practitioner) or a non-physician clinician (psychologist, counselor, social worker) collect much of the child’s history in an initial assessment. I prefer to do this myself, because process matters as much as content. When I was on the lecture circuit, my physician colleagues would frequently ask me how I managed situations when I thought a child or teen needed medication and the parents refused to consent to the recommended treatment. My response was to share that I rarely had difficulty getting “buy-in” from parents as long as they felt I’d taken the time to understand their child’s condition and listen to their concerns. Unfortunately, our situation probably represents the exception as opposed to the norm in our modern reimbursement-driven healthcare system.
With that said, here’s my take on what physicians need to know prior to recommending medication for kids with mental health disorders…
They need to obtain a thorough history of presenting problems from the child and their parent(s). I need time with the parents without the child in the room to allow them to speak freely on a variety of topics, including their parenting approaches, the impact of the child’s condition on the family unit, their personal histories of mental illness and other sensitive topics. I need time with the child or teen alone to ask about concerns (substance use, sexual behavior, abuse, suicidal thoughts or self-injurious behavior) they might be reluctant to discuss in front of parents. This time is critical to developing a good clinical formulation leading to an effective treatment plan.
They need to screen for common mental health conditions that may appear unrelated to the child’s presenting problem(s). Much of the time I spend with kids and parents in an initial assessment is spent screening for other “comorbid” conditions that often confound our ability to treat what appears to be the primary problem. For example, kids with ADHD are more likely than kids in the general population are more likely to experience anxiety disorders and kids with anxiety are more likely to have symptoms of ADHD, after eliminating anxiety as a cause of their attention problems. Stimulant medication used to treat ADHD frequently exacerbates symptoms of anxiety while SSRIs used to treat anxiety may contribute to behavioral activation and decreased motivation for homework completion in kids with ADHD. We want to anticipate potential problems in advance.
They need to obtain a thorough understanding of the family’s history of mental health problems, regardless of whether the problems have been formally diagnosed. The apple literally doesn’t fall far from the tree. A parent who has struggled with the effects of an undiagnosed mental illness may not recognize the severity of a child’s functional impairment. A parent’s mental illness may impact their ability to effectively participate in or implement important components of their child’s treatment plan. At the same time, we need to exercise caution in not leaping to conclusions prematurely…i.e., a child presenting with moodiness and irritability isn’t automatically “bipolar” when a family member has been treated for bipolar disorder.
They need to review the child’s previous mental health treatment (including medication). This part of the evaluation can be time-consuming when kids have a long and complicated history. Parents frequently forget names of clinicians who treated their child in the past. Recollections of responses to medications (and doses) are frequently foggy. We have a very detailed intake packet that parents download from our website that asks lots of detailed questions about medication, yet many parents don’t take the time to complete that section thoroughly, even when their primary concern revolves around medication recommendations. I frequently encourage parents to visit their local drugstore to obtain a printout of all the prescriptions they’ve had filled for their child prior to their initial evaluation when they haven’t maintained detailed records.
They need to review of child’s medical history and developmental history. It’s a good idea for the child to have had a current physical (within the last six to twelve months) from their primary care physician when parents are seeking treatment from a psychiatrist. We often find that kids with developmental delays in language or motor skills may qualify for and benefit from intervention available through local schools.
They need to review report cards, educational records and psychoeducational testing (if available). School records are often a treasure trove of information. Kids with ADHD frequently have characteristic comments about work completion and/or behavior for several years preceding the child’s referral. Multifactored evaluations may contain reports of detailed classroom observations from trained observers, or psychological assessments (Child Behavior Checklists-CBCL) from teachers and parents with measures across multiple domains. On occasion, kids present to the office with emotional or behavioral issues related to inappropriate school placement or lack of access to necessary special education services or accommodations.
They may want to obtain rating scales from parents and teachers, along with observations from other corroborating sources (when appropriate). Diagnostic criteria for many common mental health disorders are extremely subjective. Diagnostic clarity is enhanced when the clinician has access to information from as broad a range of adults/caregivers as possible involved in the child’s life.
They need to perform a detailed evaluation of the child’s mental status. When considering medication, clinicians need to establish a solid baseline sense of the child’s thought processing, affect, mood, appearance, memory and motor movements to appreciate changes resulting from any prescribed medication.
Bottom line…Parents need to feel confident that their child’s physician has truly taken the time to understand the causes of their child’s situation and considered a full range of medical and non-medical alternatives prior to moving forward with a treatment plan that includes prescription medication.
Resource: Here’s a download from the American Academy of Child and Adolescent Psychiatry to help parents understand what they should expect from a psychiatric evaluation.
Photos courtesy of http://www.freedigitalphotos.net
Key Ministry offers a resource center on ADHD, including helpful links, video and a blog series on the impact of ADHD upon spiritual development in kids and teens. Check it out today and share the link with others caring for children and youth with ADHD.