Welcome to Part Six of our Summer 2013 blog series…Ten Questions Parents and Caregivers Ask About Kids and Medication.In this segment, we’ll review the question: How well should medication work for my child’s condition?
Once parents have expressed an openness to a trial of medication for their child, I try to give them as well as their child/teen (when appropriate) a realistic expectation for the change they might expect see, and the time frame in which they can expect results. From time to time, I have parents call me in search of a second opinion when their child has had a positive response to medications because of unmet expectations. One important reason why I don’t see kids engaged with psychologists or counselors with whom I don’t have a working relationship stems from experiences early in my career when therapists sent kids my way with expectations that a “magic pill” would resolve a crisis or prevent a child from engaging in self-harm.
It’s important to families to understand that some disorders are far more responsive to medication than others, and within a given category of medications, some may produce a greater effect than others
We’ve discussed effect size in earlier posts. When a pharmaceutical company submits a drug to the FDA for marketing approval, two unique clinical trials are required demonstrating that the drug works better than nothing (placebo). As a clinician, I want to know how much better than nothing the drug is for the problem I’m attempting to treat. Effect size is a measure of how big a difference we see with an active treatment compared to a placebo. Effect size is usually indicated by a ratio ranging from zero to 1.0, with the number on occasion exceeding 1.0. When an effect size is below 0.20, the benefit of the treatment to an external observer would be difficult to detect. An effect size of 0.50 suggests a moderate effect. Effect sizes of 0.80 and above suggest a robust effect.
Effect sizes for ADHD medications are among the largest that child psychiatrists encounter in clinical practice. Here’s data from an analysis of 29 controlled studies of ADHD medications involving over 4,400 kids, the effect size of amphetamine-based stimulants (Adderall, Adderall XR, Vyvanse) was 0.92, the effect size of methylphenidate-based stimulants (Ritalin, Concerta, Focalin, Daytrana) was 0.80, and the effect size of atomoxetine (Strattera) was 0.73. ADHD medications, when well-tolerated, are very effective. Typically, 75-80% of kids with ADHD will improve following an initial trial with an adequate dose of stimulant medication, while 92% will respond to at least one drug when given trials of both an amphetamine-based and a methylphenidate-based stimulant. FYI…the effect size of Omega-3s for ADHD is 0.36, and the effect size for restricted diets in ADHD is 0.19.
In contrast, the effect sizes for serotonin reuptake inhibitors (SSRIs)-medications commonly used for depression, anxiety and OCD-are considerably more modest, and vary greatly depending upon the condition we’re treating. This data comes from a review of 27 controlled studies of SSRIs registered with the FDA involving 5,310 children and teens who were being treated for either depression, Obsessive-Compulsive Disorder (OCD), or non-OCD anxiety. SSRIs are effective anti-anxiety medications. They’re moderately effective in the treatment of OCD. The smallest effect size noted is for depression…in fact, the majority of controlled studies of SSRIs in children and teens with depression failed to demonstrate a benefit of the active drug compared to placebo.
Some of our most aggressive treatment is reserved for kids and teens diagnosed with bipolar disorder. At this point in time, the approved treatments for bipolar disorder include several second-generation antipsychotics (SGAs)…risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel) and olanzapine (Zyprexa), along with lithium carbonate. Short-term treatment studies of antipsychotics suggest a wide range of response rates. One study suggests that as many as half the kids who responded positively to SGAs in short-term studies for bipolar disorder relapsed within one year of beginning treatment.
Anticonvulsant medications have been widely used in the treatment of pediatric bipolar disorder, with significant effects reported in short-term studies without control groups. These findings weren’t replicated in studies using placebo controls. Two controlled studies have failed to demonstrate efficacy of valproic acid (Depakote) in pediatric bipolar disorder. We have one small controlled study (25 patients total, ranging in age from 12-18) reporting a response rate of 46% to lithium among a sample of youth diagnosed with bipolar I, bipolar II, mania or major depressive disorder with risk of future bipolar disorder.
Our best comparison study for the effectiveness of medication in teens with early-onset schizophrenia is the TEOSS study, comparing effectiveness of risperidone, olanzapine and molindone. In the TEOSS study, positive response rates to medication were 50% with molindone, 46% with risperidone and 34% to olanzapine. In a short-term treatment study of early-onset schizophrenia, the majority of teens treated with commonly used antipsychotics failed to respond to treatment.
The take-home point from our discussion is that medication typically isn’t a panacea for kids and teens experiencing mental illness, and in general, the more serious the symptoms of mental illness experienced by children and teens, the lower the likelihood is that medication will lead to an ongoing remission of the child’s symptoms.
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!