We all know that medication use for psychiatric disorders in kids has been increasing over the past 10 years, and that it plays an important role in treatment. We also know that side effects can cause alarm among parents and young patients.
In the name of providing the best treatment (ie, making sure patients take their medication), psychiatrists may be reluctant to emphasize and assess for medication adverse effects. This creates a mismatch between the patient’s and the prescriber’s attention to side effects, which may ultimately result in lower adherence. Not to mention that briefing parents and, in developmentally appropriate ways, children and adolescents on side effects of medications is essential to ethical informed consent before starting any treatment, and asking about side effects at every appointment is similarly essential to good medical practice.
By increasing your awareness of common side effects, and how to effectively anticipate and manage them, you will help your patients achieve better outcomes by improving adherence and monitoring efficacy and response.
Much of the data on using these medications in children are extrapolated from studies in adults. However, as with most things, children are not “little adults.” They metabolize and react to medications differently from adults.
Due to differences in body size, proportions of body fat and body water, and blood protein levels, kids have a smaller volume of distribution and faster metabolism and elimination (Vitiello B. Developmental aspects of pediatric pharmacology. In: McVoy M & Findling RL, eds. Clinical Manual of Child and Adolescent Psychopharmacology, 2nd Ed. Arlington, VA: American Psychiatric Publishing; 2013:1-30). This may mean that medications that you regularly dose once daily in adults need to be dosed twice daily in your pediatric patients, and that children are more susceptible to withdrawal effects.
In general, the best approach to managing side effects is by non-pharmacological means. Often, side effects can be relieved by reducing the dose or titrating the dose more slowly. (“Start low and go slow” is a useful maxim.) The next step is to stop and switch to a different medication in the same class. If these approaches are not an option or are not clinically indicated, you can think about adding medication to manage side effects.
Another helpful principle is to assess for baseline symptoms that may later be incorrectly attributed to medication. For example, apathy can be a symptom of pediatric depression, and it is also a potential side effect of longer term use of antidepressants.
Having a collaborative relationship in which side effects are discussed on an ongoing basis will help you gauge progress, without falsely attributing a symptom to a medication or misinterpreting a side effect as part of the disorder you are treating.
These are by far the most commonly prescribed psychiatric medications in kids, as a class prescribed to 3.9% of adolescents (Olfson M et al, JAACAP 2013;52(4):378-388). Selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed in this class, followed by serotonin-norepinephrine reuptake inhibitors (SNRIs), and much less commonly, tricyclic antidepressants.
Although generally well tolerated, SSRIs and SNRIs have some common, mostly idiopathic side effects, such as headaches, stomach upset, and fatigue. These are not dangerous and often go away after a period of one to two weeks, but may return with dose increases. encourage patients to stick with it for this short period of time to see if they will adjust to the medication. You can also consider changing the timing of medications to lessen the impact of side effects on functioning (eg, if your patient is feeling fatigued, switch to nighttime dosing).
The most serious adverse effect to monitor for with SSRIs and SNRIs is increased suicidality. There is some evidence of a modest increase in reported suicidality in people less than 24 years old, although there does not appear to be an increase in completed suicides (Hammad TA et al, Arch Gen Psychiatry 2006;63:332-339). This usually occurs in the first month of treatment, and as with any intervention, you must weigh the risk against the potentially life-saving benefit of treating the underlying mood or anxiety disorder. In fact, in 2004 and 2005, after the initial warnings about suicidality in young people treated with SSRIs, there was a decrease in the prescription rate of SSRIs and an increase in death from suicide in children and adolescents in the United States and the Netherlands (Gibbons et al, Am J Psychiatry 2007;164(9):1356- 1363).
If your patient does experience new or worsening suicidal thoughts, you should stop the medication and determine if a higher level of care is needed. Alternative medications, such as other SSRIs or atypical antidepressants like buproprion (Wellbutrin), should be considered, and the patient should be closely monitored.
Especially in patients with a family history of bipolar disorder, pediatric patients should be monitored for treatment emergent mania, which appears to occur in less than 2% of patients (Goldsmith M et al, Paediatr Drugs 2011;13(4),225-243). More common (2% to 10%) is general activation, such as restlessness or akathisia, silliness or giddiness, and perhaps difficulty sleeping. Propranolol can help with akathisia, as can lowering the dose or switching to a different SSRI. [For a critical analysis of SSRIs, see “A commentary on Editor’s Perspective: Do Antidepressants Work in Kids?” CCPR, October 2010.]
Stimulant medications are used primarily to treat ADHD. Side effects relevant to children and adolescents fall into three categories: cardiovascular, growth, and psychiatric (Posner J & Greenhill L. Attention-deficit/hyperactivity disorder. In: McVoy M & Findling RL, eds. Clinical Manual of Child and Adolescent Psychopharmacology, 2nd Ed. Arlington, VA: American Psychiatric Publishing; 2013:31-95).
Elevations in heart rate and blood pressure can occur, and should be monitored, but appear to be clinically insignificant for most kids. Growth slowdown is infrequent, inconsistently demonstrated in studies, and likely has very little clinical significance. Nonetheless, parents and kids may report low appetite (Posner & Greenhill ibid). Height and weight should be monitored on a regular basis.