Here’s the fourth installment in our Summer 2013 blog series…Ten Questions Parents and Caregivers Ask About Kids and Medication. Today, we’ll examine the question Who’s qualified to prescribe medication for my child?
Parents of kids with mental health concerns are confronted with the need to navigate a maze of specialists and service delivery systems with roles that frequently overlap. When the need to consider medication as part of a comprehensive treatment plan arises, parents are often confused when they discover that physicians from a number of different specialties may be involved in prescribing psychotropics to kids. Today, in an effort to relieve some of the confusion, we’ll take a brief look at the specialists who prescribe medication for kids and the differences between them in training and expertise.
Child and Adolescent Psychiatrists: I’ll admit my bias as a past-President of our child psychiatry society in Northeast Ohio…in my opinion, child and adolescent psychiatrists, on the basis of our training, are best equipped to do the detailed evaluation integrating biological, psychological, environmental, genetic and family systems influences that contribute to mental illness in kids, and receive the most extensive training and experience in understanding the medications prescribed to kids with these conditions. Here’s a page from the American Academy of Child and Adolescent Psychiatry briefly describing the nature of the training and supervision we receive during residency and fellowship.
Pediatric Neurologists: Specialists in pediatric neurology may actually be in shorter supply than child and adolescent psychiatrists. There’s also a little bit of overlap in the training pediatric neurologists and child psychiatrists receive, because the content of their exams for board certification overlaps. In our area, it’s not unusual for neurology practices to be composed of kids with ADHD and/or developmental disorders. Kids on the autism spectrum are frequently referred to neurologists because of stereotypic movements, difficulty/delays in development of motor skills or aggressive behavior. Kids with moderate to severe tic disorders as comorbid conditions are frequently seen first by neurologists. Most neurologists in our area are employed by large hospital systems that accept most insurance plans, while most child psychiatrists work for publicly funded mental health agencies primarily serving kids on Medicaid, with the remainder in private practices where contracting with insurance companies is unfeasible. As a result, we may have a higher percentage of kids with parents who rely upon private insurance to pay for treatment being seen by pediatric neurologists.
Developmental Pediatricians: Developmental pediatricians are typically found in academic medical centers and large pediatric hospitals. Locally, they are frequently involved in evaluating very young children with developmental delays well before the age when mental health concerns are frequently addressed with medication. Here’s a definition of the role of the developmental pediatrician from the American Academy of Pediatrics.
Pediatricians: Pediatricians write more prescriptions for psychotropic medication for kids than physicians of any other specialty. Compared to the subspecialty physicians listed above, pediatricians are frequently at an advantage because they may know a child for many years and have some understanding of the child’s developmental trajectory as well as the dynamics of the child’s family before the need to consider medication arises.
In my experience, the knowledge base and comfort level of pediatricians in prescribing psychotropics varies widely. In our area, most pediatricians are very comfortable making a diagnosis of ADHD and getting kids through one or two trials of stimulant medication for the condition. They are often less comfortable in treating conditions such as anxiety or depression because of safety concerns associated with serotonin reuptake inhibitors, and most uncomfortable with the use of antipsychotics. Some larger pediatric groups will have a physician within the practice take a special interest in kids with mental health concerns.
For many families, the local pediatrician may be the only option when a child needs medication because of difficulty accessing child psychiatry services (lack of availability outside large cities, cost barriers, gatekeepers in publicly-funded agencies).
Family Physicians: The typical family physician likely has more training and exposure in caring for persons with mental illness because of the number of adults they care for who require medication. Unfortunately, kids are not “little adults” and frequently react very differently to medication than do adults.
Primary care physicians (pediatricians, family physicians) face an additional challenge when caring for kids with mental health needs. The business model under which their practices operate isn’t conducive to lengthy appointments in which the physicians have the luxury of time to discuss a variety of treatment options or answer lots of in-depth questions from parents. A number of primary care physicians I know who do a good job of caring for kids do so through providing uncompensated time and challenging administrators responsible for maintaining the practice’s bottom line.
Nurse practitioners, physician assistants: As time goes on, more and more kids in need of medication are likely to be seen by “physician extenders.” Two of the major teaching hospitals in our area are using nurse practitioners as substitutes for child psychiatrists because wait lists are so long. One downside to physician extenders is their inability to prescribe stimulant medication in many states (including Ohio). We’re starting to see private practices employ physician extenders as well. The effectiveness of their services is likely to be highly dependent upon the specifics of their training and experience, along with the quality of input and level of involvement of their supervising physician.
Bottom line…If you’re open to considering psychotropic medication for your child or teen, you want an experienced clinician who will take the time to fully understand the nature of your child’s difficulties prior to whipping out the prescription pad. You want a clinician who appreciates the benefits and limitations of medication and is capable of recognizing situations when medication makes problems worse. You want a clinician with the time and availability to answer difficult questions when they arise.
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Confused about all the changes in diagnostic terminology for kids with mental heath disorders? Key Ministry has a resource page summarizing our recent blog series examining the impact of the DSM-5 on kids with mental health disorders. Click this link for summary articles describing the changes in diagnostic criteria for conditions common among children and teens, along with links to other helpful resources!