Are ADHD Medications Safe for Kids?

I see a troubling trend in the pharmacy that has been going on since I started working with a license. And it’s probably no surprise since if you clicked on the link, you already know what I’m going to be discussing today.

ADHD? No problem. There's a pill for that.

ADHD? No problem. There’s a pill for that.

I see kids as young as 3-4, yes that’s right, 36-48 months of life, on ADHD medications. That’s quite interesting to me. I’m not going to be discussing the idea that ADHD might not be real. I will discuss the drugs and implications.

The story usually goes something like this:

A child has a lot of energy and can’t focus in school. Parents of said child get a note or call from a teacher about the disruptions, lack of attention, not working on assignments etc. Mom takes a child to doctor and, after performing some routine tests (at least we hope so), mom receives a prescription for some Ritalin, Adderall or other stimulant, goes to the pharmacy and gets to talk to the pharmacist.

This is where more truth comes out because we pharmacist have to disclose more information than a doctor typically would, or would want to. Side effects include; dizziness, sleepiness, decreased appetite, weight loss (that’s why meth addicts are so skinny), high blood pressure, arrhythmias, seizures, priapism, growth suppression, nervousness, insomnia, tachycardia, nausea, headache, palpitations, and visual disturbances.

Truth be told, many people like the effects of stimulants because they get you going, help you feel good, and can hit the pleasure centers of the brain to cause euphoria and if used long enough, or if the effect is strong enough, addiction.

I’ve talked with moms who’ve seen some of these effects in their children. The most common is weight loss and lack of appetite, which go hand in hand. Many also have nausea, compounding the weight loss problem.

What’s worse is that many are getting antipsychotic medications and/or anti-anxiety medications. We’re talking the big guns like benzodiazepines (Xanax, Ativan, Klonopin) and dopamine blockers (Risperdal, Seroquel, Geodon). According to a report from Columbia University, rates of antipsychotics have doubled in children ages 2-5 from 2000-2007. [1]

What’s worse is that less than half of these children actually had any kind of mental health evaluation, visit with a psychiatrist or have a psychotherapy visit.

One story of an 18 month old, yes 18 months, can be read at the New York Times [2] about how he was prescribed medications for temper tantrums. His condition got worse until his parents and some good doctors were able to wean him off everything other than some Vyvanse (a stimulant for ADHD).  He was overweight and his mother described him as having “blankness” in his eyes by the time he was three.

Part of the problem may be that our public school system is a one size fits all approach to students. We try to fit some square students into a round hole approach. For some children, the public school system works well, especially with good parent involvement. For others, it fails them horribly. I have no data to support the idea that a change in paradigm with public schools’ approach to education might actually curb the rate of prescribing of these medications, but I think it would.

That’s for another post though.

This type of problem solving is analogous to a report I heard on NPR recently about nursing homes and long-term care facilities. A team went to discover if the residents in these types of facilities were really demented and had other mental health problems. Many residents of these types of facilities will yell out and make other types of disturbances during the day and night.

The tea tasked itself with discovering if their really was mental illness or something else going on. In one instance, a woman would yell out at night. Many times in this type of situation, nurses will administer depakote (an anti-seizure medication) or benzodiazepines to calm a patient down.

This team tried to communicate with her. What they found was, after some time and effort, was that she was cold at night. They got her a blanket and she calmed down and slept, all without medications.

Communication: what an amazing concept!

Rather than not listening to yelling and grunting and crying, we should listen and see if we can discover the real problem

Rather than not listening to yelling and grunting and crying, we should listen and see if we can discover the real problem

Now I know some people do legitimately have mental illness, there is no doubt about it. Getting a proper diagnoses from the proper channels is important though. Immediately throwing a drug at a problem is a mentality that unfortunately, too many doctors and patients and patient’s moms have. Working through a problem rather than throwing a tablet at it is harder, but can be worth it. Avoiding problems like the story in the New York Times is advisable.

Proper nutrition and activity is generally a good idea, especially for very active kids. Some kids are content to live in their brains more so than others. Others just can’t sit still. They need to move.

A child’s brain is also continuously developing. To address problems like ADHD at 2 or 3, or a temper tantrum at the same age is probably very premature.

My little 3 year old gets frustrated sometimes because she desperately wants to say something. Even when my wife or I is listening intently she’ll get mad or begin to cry. When asked the problem her reply is usually, “I just don’t know how to say it.” Her vocab isn’t quite up to par so her mode of expression goes from words to crying. I certainly don’t fault her for being unable to adequately express in words what’s she’s feeling at the age of 3.

If you think your child may have problems with ADHD and want to take them to a doctor, that’s fine. I don’t disagree with that. But a psychological evaluation by a professional recommended by the doctor is a good place to start. In some cases, if medication is needed on top of a healthy diet and activities, there are alternatives like clonidine which can be prescribed that don’t carry some of the risks of stimulants, or the potential abuse among children or their friends.

CIAO

 

1.Olfson, Mark, et al. “Trends in antipsychotic drug use by very young, privately insured children.” Journal of the American Academy of Child & Adolescent Psychiatry 49.1 (2010): 13-23.

2.http://query.nytimes.com/gst/fullpage.html?res=9D02E0DE1E3CF931A3575AC0A9669D8B63

 

Anxiety and Sleep Medications

Anxiety and sleep medications can be dangerous, especially when used inappropriately. Zolpidem (Ambien) is a very common one that many people take to get to sleep at night. Alprazolam (Xanax) and clonazepam (Valium) are also fairly common drugs that are seen in the pharmacies and in the cupboards of many people. They are taken whenever a person feels anxious, which these days seems like all the time.

Zolpidem is classified as a sedative-hypnotic. It puts you to sleep and that is why so many people like it. Take one sometime before bed and it’s lights out for the next few hours. So what’s the problem?

Zolpidem affects a specific omega-subtype of the GABA receptor in the central nervous system. This subtype is what puts you to sleep but doesn’t seem to affect muscle tone and doesn’t show anxiolytic properties (anti-anxiety). This also may be why so many people have reported all kinds of crazy incidences of sleep walking or other activities without remembering a thing. You can read about some of those here:

http://www.peoplespharmacy.com/2013/01/10/fda-lowers-dose-of-popular-sleeping-pill-ambien-zolpidem/

As with many receptors it’s also likely that since they are being activated so often by meds like zolpidem they get down regulated with time and people don’t get the benefit of the drug. I’ve talked with several people in the pharmacy about this. They are so frustrated that they can’t get sleep. Some take double the dose that is normally prescribed and still only sleep a couple of hours.

This quite honestly scares me. I’m worried that some people are going to take it too far one day for that one night of sleep and then not wake up. We Americans especially forget that more isn’t better to a problem that actually requires less.

Another problems that scares me is the sharing of these types of meds between family and friends. This is especially true among teenagers. A recent article talks about this:

http://www.foxnews.com/health/2014/11/24/abuse-sleep-anti-anxiety-drugs-growing-issue-among-teenagers-study-shows/

SAMSHA (Substance Abuse and Mental Health Administration) reported that “the estimated number of emergency department visits involving zolpidem overmedication (taking more than the prescribed amount) nearly doubled from 21,824 visits in 2005-2006 to 42,274 visits in 2009-2010” [1]. By comparison they report that in 2010 there were a total of 4,916,328 drug-related visits to emergency departments throughout the nation.

It’s not the most abused drug in the country but it is on the rise.

Drugs like clonazepam mentioned earlier aren’t so selective as zolpidem and can cause other problems. Originally they were developed for people with seizure disorders and they work well for that. People now take them primarily for finding relief from anxiety and stress.

Like zolpidem, people can become tolerant to them over time and require higher and higher doses to get the desired effect. It’s no different from a person on pain medications. These are more likely to cause a euphoric effect on a person than the zolpidem and many become psychologically dependant. It’s very important to note that people wishing to discontinue these after having been on them for some time must do so slowly. The withdrawal symptoms in people on high enough doses can actually land them in the hospital and cause death. While going cold turkey off narcotics isn’t recommended it typically doesn’t cause death like the benzodiazepines (clonazepam, alprazolam) can.

What can a person do to help with sleep?

insomnia

Exercise seems to be beneficial to those who have insomnia. In a study with insomniacs, researchers looked at walking on the treadmill for 50 minutes at a time, 3 days a week for 6 months. What they found was that participants were able to fall asleep faster and had decreased amounts of wakefulness during the night. [2] The effect was seen in both the morning and evening groups.

Another study found similar results but the best were achieved in those performing moderate amounts of activity and not all out, balls to the wall type of stuff. It was also done on the treadmill for 50 minute intervals.[3]

In another analysis done in diabetics, the loss of belly fat with diet or exercise or a combination of both resulted in better sleep. [4]

There are other things that can help. Getting into a sleep schedule and actually going to sleep at the same time every day. I know that seems impossible or at best unlikely but it does help.

Managing a proper diet and exercise/activity level also decreases anxiety and symptoms of depression. I realize the catch-22 of people with depression. They don’t want to do anything, especially exercise. They don’t have the energy to do it and even if it makes sense logically that it will help, emotionally they are too drained to even think about it. If that’s you I encourage you to do whatever you can, even if it is walk to the mailbox. Any start is better than nothing.

CIAO

 

1.http://www.samhsa.gov/newsroom/press-announcements/201408111015

2.Passos, Giselle Soares, et al. “Effects of moderate aerobic exercise training on chronic primary insomnia.” Sleep medicine 12.10 (2011): 1018-1027.

3.Passos, Giselle S., et al. “Effect of acute physical exercise on patients with chronic primary insomnia.” Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 6.3 (2010): 270.

4.http://www.hopkinsmedicine.org/news/media/releases/losing_weight_especially_in_the_belly_improves_sleep_quality_according_to_a_johns_hopkins_study