Psychotropic Medication

T I P S F O R P R A C T I C E Psychotropic Medication Psychotropic medications are symptomatic medications that affect attention, emotions, or behaviors. Communication between the physician, NDHHS and contracting agencies is vital for improving outcomes and minimizing serious, even life-threatening, complications. Key Considerations for Protection and Safety Workers February 2013 They treat symptoms, not brain chemicals The only valid measure of successful treatment is: Is it working? There are no blood tests, brain scans, or other objective indications of successful treatment. Everyone responsible for the child should know the target symptoms. Know the target symptoms For every treated child, someone should ask the physician, How will we know if this treatment works as expected? Successful treatment will be visible to those responsible for the child only if they know what to look for. Know the important side-effects Every psychotropic medication has the potential of causing sideeffects that range from bothersome to deadly. The physician should be asked to help those responsible for the child to understand and monitor the most important side-effects. Arrange follow-up with feedback Regular follow-up with the treating physician is always needed. Whenever possible, the physician should be provided with objective summary information about symptoms and side-effects as noted by those who interact with the child. Medication alone is never enough Many symptoms respond to behavioral methods that can be used in addition to medication. Children, youth, and parents need help understanding the treatment prescribed and additional effective ways to manage the child s symptoms. Informed Consent By law and by policy, the Child and Family Service Specialist must give informed consent for a child who is a ward of the state. This is not just a formality or something that can be done without being informed. The interaction between a physician who is prescribing the medication and the patient, or in this case the parent of the child who is the patient, is an important component of medication safety. According to the Agency for Healthcare Research and Quality (AHRQ) about half of all patient injuries from medical care involving medication use are preventable. The dialog between physician and parent is an important component in preventing these problems. The biggest risk for adverse drug events is polypharmacy, when a patient is taking more than five prescription medications. Poly-pharmacy is not uncommon in children who are in foster care. How to be informed. You should ask the doctor for the following information: R A R E What is the reason for giving the medication. including the target symptom(s) that warrant it? What are the alternatives to the treatment., including non-medication alternatives or safer medications that could be used instead? What are risks, or unanticipated adverse events that can happen with this type of treatment? What are the doctor s expectations (+ and -) including improvements to the target symptoms and common adverse effects that should be monitored? With this information, uninformed consent will be. RARE TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

Names Names Indications Psychotropic medications are prescribed because they have been found to be helpful in individuals with similar problems. They may alleviate troubling and sometimes dangerous or disabling symptoms, but they do not change or cure the underlying causes of the problem. Despite marketing claims, they are not used to balance neurotransmitters. Drugs affect more than one neurotransmitter system and we do not yet know enough about the effects of treatments to make such claims. Because these medications target symptoms, not underlying chemistry or diagnosis, it is especially important that those responsible for children and youth know the targeted symptom(s) and can inform the prescribing physician whether these symptoms are or are not altered by treatment. Changing doses and/or discontinuing psychotropic medications can only be safely done by a physician, and then only when the physician has accurate information about symptoms and sideeffects. For Information When first developed, drugs are marketed under a trade name chosen by the manufacturer, e.g., Ritalin. After the original manufacturer loses its patent protection (usually 12 years), any company can make the drug under a generic name, e.g., methylphenidate. The generic is usually less expensive, but has been determined by the FDA to be equally effective. Different medications may have similar names. Use care to use the correct name! Off-Label Rx No drug can be marketed unless the FDA approves it for a specific purpose in a specific age-group. Using a drug for this approved purpose is an onlabel use; it follows the FDA label. It is legal, however, for physicians to use a drug for other conditions or other age-groups, a practice called offlabel prescription. This is an ethical, legal, and professional practice as long as the physician relies on the peerreviewed experience of others. In fact, most psychotropic medication for children are off-label because there is simply not enough research available for the FDA to make a safe and effective finding. When a medication is used off-label, it is especially important to monitor both target symptoms and side- effects and to provide feedback to the physician. Side-Effects Every medication has the potential for a range of side-effects from only bothersome to very dangerous. Medication information materials will often give long lists of potential sideeffects that can be overwhelming and frightening. Parents and others should expect physicians to help sort out the most important possible side-effects in a given situation. In addition, the physician should obtain feedback about the occurrence of side-effects from those who spend time with the child or youth. Some possible side-effects are more dangerous so the FDA requires a warning, enclosed in a noticeable black box on package insert materials. For example, all antidepressants (see below) carry a black box warning about the possibility of increased suicidal thoughts or suicide attempts by children and adolescents taking antidepressants. 1. The prescribing physician: Informed consent requires a discussion with the prescribing physician about reasons for the medication, risks and common sideeffects, and alternatives to the recommended medication. 2. The dispensing pharmacist: Pharmacists have a wealth of information about medications and a professional responsibility to educate those responsible for the child who will be taking the medication. Ask them. 3. The internet: The first rule of the internet is, Who put it there and why should you believe them? Know the source. Adding the term term site:.gov to a Google search will retrieve only credible government sources including the National Library of Medicine, the Centers for Disease Control, the National Institutes of Health and the FDA. The commercial site http://drugs.com is a credible site that includes a very good utility for checking drug interactions. The National Library of Medicine site http://guidelines.gov is a source of best-practice protocols for many conditions. Use the internet to ask better questions of physicians and pharmacists, not to replace them. Protection and Safety & Juvenile Services New Worker Training

M A N A G I N G P S Y C H O T R O P I C M E D I C A T I O N Stimulants This category includes many effective, well researched treatments for the core symptoms of ADHD including hyperactivity, impulsivity, and inattentiveness; in general stimulants are safer than other psychotropic medications and have the best demonstrated efficacy. Key Considerations for Protection and Safety Workers Effective treatment for core ADHD symptoms Up to 80% of children with hyperactivity, impulsivity and distractibility will note improvement with stimulant medication. If a child does not respond to methylphenidate, they may respond to a different stimulant. It is not a paradoxical effect Research has shown that normal children become less active, less impulsive, and less distractible when taking stimulants. The effect is symptomatic and does not indicate anything about the cause of the symptoms or the need for medication. Know the common sideeffects Headaches & stomachaches are common when treatment starts & often get better as treatment continues. Loss of appetite is common and growth should be monitored. Too much medication causes overfocussed zombie-like behavior and/or tics. Rating scales are available Several rating scales are available for a more objective measure of a child s symptoms by teachers and parents. Physicians may have one available for follow-up of treated children. Information from both teachers and parents is important. Behavior management is effective as well Although medication alone is now recommended more frequently, school and home based behavior management is an effective measure, especially when the symptoms are less severe and may help even when medication is effective. Too Many Children? Some children do receive stimulant medication without a full assessment. It is also true that some children are denied effective treatment for very serious attention symptoms. Children with school problems related to ADHD symptoms deserve a careful evaluation, including for learning disabilities which affect 25% of children with ADHD, and then a careful evaluation of whether stimulant medication may be helpful. Behavior management is also safe and effective and may give children additional tools for managing their own behavior.! When standard stimulants are prescribed, be sure that the child or youth is actually getting the medication; they may be diverted for street value. The FDA cautions parents about 2 potentially serious risks: 1. Heart-related problems: sudden death in patients who have heart problems or defects increased blood pressure and heart rate The doctor should be told of any heart problems or heart defects or a family history of these. The doctor should check the child carefully for heart problems and should measure blood pressure and heart rate regularly during treatment. 2. Mental (psychiatric) problems: new or worse behavior and thought problems new or worse bipolar illness new or worse aggressive behavior or hostility in children and tens, new psychotic symptoms (hearing voices, believing things that are not true, suspicious) or new manic symptoms The doctor should be told about any mental problems the child has and about any family history of suicide, bipolar illness, or depression and notified immediately if the child has new or worsening mental symptoms or problems, especially seeing or hearing things that are not real, or believing things that are not real or are suspicious. TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

These are safe and effective treatments for ADHD. The basic products are short acting (4 hours) but many methods are used to create long acting forms. Although short acting forms can be abused and sold on the street, the long acting forms have less potential for abuse. Some research suggests that children with ADHD who are NOT treated with medication are at greater risk for addiction than those who are. Unlike most psychotropic medications, these drugs start acting quickly (hours) and can be safely discontinued quickly (only by the prescribing physician). Ritalin, Metadate, Methylin Standard Stimulant Preparations methylphenidate Different brand names are all the same drug. Long-acting time-release capsules are sold as Ritalin LA and SR, Metadate CD and ER. Methylin is available as a a chewable tablet. Concerta methylphenidate Concerta uses a special physical barrier that releases methylphenidate more slowly. Daytrana Patch methylphenidate The patch applied to the skin releases methylphenidate over a longer period of time. Focalin d-methylphenidate Since this is the right-handed (active) form only, the dose is half that of other methylphenidate drugs. Extended release form is Focalin XR Adderall d- and l-amphetamine This mixture of amphetamine salts has avoided the stigma (see below) and is frequently prescribed. An extended release form is available as Adderall XR Dexadrine, Dextrostat, d-amphetamine d-amphetamine (dextroamphetamine) was the first effective treatment for ADHD. It can be safely used and is effective, but the amphetamine term worries some people. Vyvanse lisdexamfetamine dimesylate This drug is metabolized by the body to become dextroamphetamine. The additional metabolism lengthens the time of action, and it usually needs to be given only once a day. The drug s effects and side-effects are like dextroamphetamine. Protection and Safety & Juvenile Services New Worker Training

Alternate Preparations These newer drugs have less abuse potential and longer action but are still second-line treatments. Like most other psychotropic drugs, but unlike standard stimulants, these drugs must be given for weeks before effect is seen. Strattera atomoxetine An antidepressant with stimulant effects. See warnings and side-effects under antidepressants. It is sometimes called the non-stimulant stimulant. Wellbutrin bupropion Bupropion is an antidepressant unrelated to SSRIs. sometimes use for ADHD. See Anti-depressant section. Catapres clonidine This is an antihypertensive drug with stimulant effects in the brain. It is sometimes used for its side-effect, sleepiness. Unlike other stimulants, this drug reduces rather than increases chance of tics. Because it lowers blood pressure, BP should be monitored. Tenex, Intuniv guanfacine Like clonidine, guanfacine acts on the brain as a stimulant and is dispensed as Tenex (short acting tablets) and Intuniv (long acting tablets). Like clonidine, this drug was initially developed to treat hypertension and is effective for ADHD. TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

M A N A G I N G P S Y C H O T R O P I C M E D I C A T I O N Antipsychotics These medications, also called neuroleptics, have the highest risk of serious side-effects. Although developed to treat psychotic symptoms, they are more commonly used to treat symptoms of bipolar disorder or aggressive, out-of-control behavior. Key Considerations for Protection and Safety Workers Know the target symptom in every case Because in most cases, pediatric treatment with antipsychotics is not for psychosis but for bipolar disorder or aggressive behavior, it is especially important to clarify with the physician what symptoms should improve and then report back the results. Use in autism Research has shown risperdone to be effective in the treatment of tantrums, aggression, and self-injurious behavior in children with autism. The FDA approval includes children 5-16 for irritability in children with autism. Know the important side-effects Most common sideeffects include sleepiness, increased appetite, fatigue, insomnia, sedation, abnormal motor movements, restlessness, nausea, constipation, cough, runny nose, dry mouth, abdominal pain, dizziness, anxiety, headache, and rash. Weight gain and high blood lipids Adolescents are at higher risk than adults for abnormally high weight gain which can be accompanied by high blood lipids, high blood sugar, or diabetes. Adolescents on antipsychotic mediation should be monitored carefully for this. Use is Increasing Antipsychotic use in children under 17 years has increased 22% in the past 5 years. Risperdone is the most commonly used in this age group followed by aripiprazole and quetiapine. Parents, and those acting in the place of parents, should be very sure in every case 1) that the child s symptoms warrant the risks, 2) that when they are indicated they are used carefully with daily monitoring, and 3) that they are discontinued as soon as it is clear that they are not helping.! Notify the physician immediately if the child shows abnormal motor movements, twisted neck, shuffling gate tremor, or restlessness or abnormal weight gain. The FDA warns about many potentially serious risks including, among other things: 1. Neuroleptic Malignant Syndrome: a rare but life-threatening syndrome with fever, muscular rigidity, and altered mental status. 2. Tardive Dyskinesia: involuntary movements of the tongue, lips, face, trunk, and extremities. 3. Diabetes Mellitus: with high blood sugar causing frequent urination and dehydration often associated with abnormal weight gain.. All patients should be monitored for these symptoms. 4. Orthostatic Hypotension: dizziness, heart rate changes, and low blood pressure upon standing. 5. Blood Disorders: including very low white cell counts. 6. Cognitive and motor impairment: may impair judgement, thinking and motor skills. [School performance should be monitored.] 7. Seizures: should be used with caution in patients with seizures. 8. Difficulty Swallowing 9. Suicide: There is increased risk of suicide attempt in patients with schizophrenia or bipolar disorder, and close supervision of high-risk patients should accompany drug therapy. Protection and Safety & Juvenile Services New Worker Training

S E Q U O I A C L U B Page 7 Atypical (2nd Generation) Antipsychotics Although atypical antipsychotics are safer than first generation antipsychotics, they are still bring the most serious risks of any medications given to children on an outpatient basis. Risperdal risperidone Specifically approved for treating irritability associated with autism in children 5 to 16 years. Zyprexa olanzapine All the concerns on the previous page are relevant. Seroquel quetiapine All the concerns on the previous page are relevant. Geodon ziprasidone Geodon includes an warning heart rhythm effects. Abilify aripiprazole All the concerns on the previous page are relevant. Invega paliperidone All the concerns on the previous page are relevant. Clozaril clozapine This was one of the first effective atypical antipsychotics, but serious blood disorders have limited its usefulness. Latuda lurasidone All the concerns on the previous page are relevant. Typical (1st Generation) Antipsychotics First generation antipsychotics are rarely used for ongoing treatment because the incidence of major side-effects is so great. They are sometimes used in a crisis situation for the acute control of dangerously aggressive behavior. If used long term the monitoring for side-effects is especially important including watching for effects on cognitive functioning (school performance) and the motor problems mentioned on the previous page. These drugs should never be used as a forme of chemical restraint. Thorazine Haldol Prolixin chlorpromazine haloperidol fluphenazine TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

M A N A G I N G P S Y C H O T R O P I C M E D I C A T I O N Mood Stabilizers Classic bipolar disorder starts in early adulthood and includes wide swings between mania and severe depression over many weeks. In children, the diagnosis of bipolar disorder is much less clear and may involve very rapid mood swings within a single day. These drugs, shown to be helpful in classic bipolar disorder, may be helpful in children but need careful monitoring. Key Considerations for Protection and Safety Workers They treat symptoms, not brain chemicals These medications do not treat bipolar disorder, they treat the symptoms of bipolar disorder. Be exceptionally clear what symptoms the physician hopes will improve when these drugs are given, and carefully monitor and report back the results to the physician. Sort out seizures Children with seizure disorders may be getting anticonvulsants for their seizures. If they also have a diagnosis of bipolar disorder, be sure that all treating physicians communicate with each other. Medications may interact with each other. Bipolar disorder may be changing The APA recommends that with the DSM-V released in 2013, most children now diagnosed with bipolar disorder be classified under Disruptive Mood Regulation Disorder, related to but more severe than Oppositional Defiant disorder. This is still controversial. Regardless of the name, drugs treat symptoms, not diagnoses. Monitor and provide doctor with feedback If these drugs are not working, notify the doctor. Serious side-effects include suicidal thoughts/ behaviors, serious skin rashes, cognitive effects and poor school performance. Discuss monitoring during treatment with the doctor. A Confusing Diagnosis The diagnosis of bipolar disorder is increasing and is one of the most confusing childhood diagnoses. This makes it especially important that the target symptoms of any psychotropic medication are clearly defined and that the parent, parent substitute if applicable, and the physician agree on how successful treatment will be defined. When symptomatic treatments, especially dangerous ones, are not helping, the physician should be asked about discontinuing.! A child on lithium should be very careful of fluid balance, should stay well hydrated, and may need to carry a water bottle and/or be allowed frequent bathroom breaks. The FDA cautions physicians that lithium toxicity occurs at levels very close to therapeutic levels. Facilities should be available to the physician for prompt and accurate measurement of lithium blood levels. Families should be warned to discontinue giving lithium and contact the physician with any signs of lithium toxicity including diarrhea, vomiting, tremor, mild ataxia (lack of muscle coordination), drowsiness or muscle weakness. Antiepileptic drugs (AEDs), increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior. Several antiepileptic drugs can cause cognitive changes which may interfere with school performance and/or behavior. See for example gabapentin and oxycarbazepine on the next page. Others may also have this effect. Boxed warnings, indicating an especially important risk, are given for several antiepileptic drugs. These are summarized in the table on the next page. Protection and Safety & Juvenile Services New Worker Training

S E Q U O I A C L U B Page 9 Lithium Lithium was the first drug to be effective against adult bipolar disorder and also effectively treats some children diagnosed with pediatric bipolar disorder. Unlike almost every other drug, it is a form of salt which is balanced by the kidneys. Lithium has a very narrow therapeutic window (a very short difference between the effective and toxic doses. Eskalith, Lithonate lithium carbonate See above. Mood Stabilizing Seizure Medications For unknown reasons, many medications developed to control seizures have been found to treat the wide mood swings of adult bipolar disorder. Some of these have also been found to be effective in children diagnosed with pediatric bipolar disorder. Antiepileptic drugs should be tapered gradually and not discontinued abruptly. Depakote divalproex (also called valproic acid or valproate) A boxed warning cautions that liver failure is a possibility at any age but especially in patients under two. Patients should be monitored for malaise, weakness, lethargy, facial edema, anorexia and vomiting. The doctor should be notified immediately. Blood tests for liver function should be done prior to treatment and frequently during treatment. Tegretol carbamazepine A boxed warning cautions that patients with ancestry across broad areas of asia should receive genetic screening prior to treatment because of the risk of lifethreatening reactions in some populations. Complete pretreatment blood component testing is recommended for all patients. Drug should be discontinued at first sign of a rash that is not clearly due to another cause. Neurontin gabapentin The package insert warns that gabapentin has caused mild to moderate cognitive changes including 1) emotional lability (behavior problems); 2) hostility, including aggressive behavior; 3) thought disorder including concentration difficulty and school problems; and 4) hyperkinesia, primarily restlessness and hyperactivity. Lamictal lamotrigine A boxed warning cautions about potentially dangerous skin rashes and advisees discontinuing the drug and contacting the physician at the first sign of a skin rash unless it is clearly not drug related. Trileptal oxycarbazepine Side-effects can include 1) cognitive symptoms including psychomotor slowing, difficulty with concentration, and speech or language problems, 2) somnolence or fatigue, and 3) coordination abnormalities, including ataxia and gait disturbances. Topomax topiramate Topiramate may interfere with sweating causing body temperature to rise. Notify the physician immediately. The package insert recommends measuring blood chemistry initially and periodically. TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

M A N A G I N G P S Y C H O T R O P I C M E D I C A T I O N Antidepressants Antidepressant medication has been effective at treating adult depression. The evidence for safe and effective treatment of depression in children is less clear. However, some of the SSRI antidepressants have now been approved for use in children. Key Considerations for Protection and Safety Workers Slow start, slow stop These medications take up to 8 weeks to reach their therapeutic effectiveness, and they should never be stopped abruptly. Always ask the doctor how to slowly decrease the dose. Side-effects Common SSRI sideeffects include nausea, dry mouth, headache, diarrhea, nervousness, agitation or restlessness, rash, increased sweating, weight gain, drowsiness, and insomnia. Suicide thoughts and behaviors Caregivers should be alerted to monitor daily for agitation, irritability, and unusual behavior as well as increased suicidal thoughts or behavior and notify the doctor immediately if these occur. Other Uses In addition to treating depression, these drugs are effective treatments for obsessive compulsive disorder (OCD) and other severe anxiety disorders. All of the same cautions apply when used for this indication. An Important Diagnosis Depression in both children and adults is a very important aspect of child maltreatment, both as a cause and as a result. Antidepressants are an effective treatment for adults and may be effective in children. Depression manifests differently in adults and children, and parents, parent substitutes when applicable, and physician should agree on the indications for the diagnosis and on the symptoms that may be relieved by medication. Cognitive behavioral therapy (CBT) has also been shown to be effective for treating depression and should also be considered.! Any child with depression may have or develop suicidal thinking. or behavior. Antidepressants may increase this risk slightly. Those working with the child should watch for this and notify the physician immediately if observed. Black Box Warning: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults. Anyone considering the use any antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidal thoughts and behaviors, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. SSRIs may also cause a syndrome like the Neuroleptic Malignant Syndrome with fever, muscular rigidity, and altered mental status. The doctor should be notified immediately with any of these symptoms. These drugs should never be used in combinations with antidepressants of the MAO inhibiter class. SSRIs should be prescribed with care in patients with seizure disorders. Protection and Safety & Juvenile Services New Worker Training

S E Q U O I A C L U B Page 11 Selective Reuptake Inhibiters These newer antidepressants avoid most of the side-effects of the older tricyclic medications. Headache, nausea, sleeplessness (or drowsiness) may occur but often get better in the first weeks of treatment. All affect seratonin and some affect the neurotransmitter norepinepherine as well. These drugs are referred to as SSRI (selective seratonin reuptake inhibitor) because they primarily affect this neurotransmitter. In addition to depression, these drugs are very effective in OCD (obsessive compulsive disorder). Prozac fluoxetine Fluoxetine is approved for use in pediatric patients age 8 to 18 with Major Depressive Disorder (MDD) and age 7 to 17 with Obsessive Compulsive Disorder Celexa citalopram Safety and effectiveness in the pediatric population have not been established Zoloft sertraline Safety and effectiveness in the pediatric population have not been established Paxil paroxetine Safety and effectiveness in the pediatric population have not been established Lexapro escitalopram Escitalopram is approved for use in pediatric patients age 12-17 with MDD The following drugs are referred to as SNRI (serotonin norepinepherine reuptake inhibitor) because of their action on both neurotransmitters. Effexor venlafaxine Safety and efficacy have not been established in children. Blood pressure should be monitored before and during treatment. Cymbalta duloxetine Safety and efficacy have not been established in children. Blood pressure should be monitored before and during treatment. Tricyclic Antidepressants (1st Generation) Tricyclic antidepressants were the first medications to show effectiveness in treating depression. They have many more side-effects than newer antidepressants including effects on cardiac rhythm, drowsiness, dry mouth, blurred vision, constipation, and urinary retention. They are rarely used as antidepressants, but they are occasionally used to treat bed wetting, perhaps because of the urinary retention side-effect. They carry the same boxed warning about suicide thoughts and behaviors as other antidepressants. These drugs have also been used for ADHD although safety and effectiveness have not been established. Elavil amitriptyline Amitriptyline can alter heart rhythm and cause life-threatening arrhythmias. An ECG is recommended before and periodically during treatment. Norpramin Tofranil Pamelor desipramine imipramine nortriptyline TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

Other Antidepressants Wellbutrin, Wellbutrin SR, Wellbutrin XL Aplenzin, Zyban bupropion Safety and effectiveness has not been established in children. Extended release forms are contraindicated in patients with seizure disorder, bulimia, or anorexia nervosa. Blood pressure should be monitored before and during treatment. Bupropion has been associated with the risk of seizures and increased restlessness, agitation, anxiety, and insomnia, especially shortly after initiation of treatment. Zyban is used for smoking cessation. Desyrel trazodone Trazodone is an antidepressant unrelated to other known antidepressant. It carries the same boxed warning about increased suicidal thoughts and behavior. Protection and Safety & Juvenile Services New Worker Training

M A N A G I N G P S Y C H O T R O P I C M E D I C A T I O N Anxiety Medication A treatment approach for children and adolescents with anxiety disorders should consider education of the parents and child and coordination with school personnel and primary care physicians. Cognitive behavioral therapy (CBT) is effective with many children and parentchild and family interventions should be considered. When symptoms are severe or impairment makes psychotherapy difficult, antidepressant therapy (SSRIs) has been shown to be effective. Benzodiazepines, used in adults for the short term treatment of anxiety, have little usefulness in children and carry many risks including addiction. Key Considerations for Protection and Safety Workers CBT is effective. Cognitive Behavioral Therapy (CBT) is an effective therapy for children with anxiety disorders including separation anxiety or school phobia.. In children with specific phobias, desensitization has been also shown to be effective. SSRIs are effective for OCD (Obsessive Compulsive. Disorder). OCD is currently considered an anxiety disorder, but the DSM-V draft is proposing to separate OCD into its own category. Regardless of how OCD is classified, the SSRI medications can often safely result in dramatic improvement. Ask questions. Because benzodiazepines are still used in for anxiety in adults but have serious drawbacks and are seldom recommended for children, parents and parent substitutes should ask questions to assure that the risks are worth the potential benefit before giving informed consent for these medications.. Important Benzodiazepine Adverse Reactions With benzodiazepines, psychiatric and paradoxical reactions are more likely to occur in children. These include stimulation, restlessness, acute hyperexcited states, anxiety, agitation, aggressiveness, irritability, rage, hallucinations, psychoses, delusions, increased muscle spasticity, insomnia, sleep disturbances, and nightmares. Inappropriate behavior and other adverse behavioral effects have been reported when using benzodiazepines. Central nervous system effects can include confusion, depression, dysarthria, headache, slurred speech, tremor, vertigoshould these occur, use of the drug should be discontinued. Abuse and dependence of benzodiazepines has been reported. Once physical dependence to benzodiazepines has developed, termination of treatment will be accompanied by withdrawal symptoms. The risk is more pronounced in patients on long-term therapy. Withdrawal symptoms, similar in character to those noted with barbiturates and alcohol have occurred following abrupt discontinuance of benzodiazepines. TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

Benzodiazepines These are addictive drugs that may be useful for the short term (less than 4 months) treatment of anxiety in some adults. Use for longer periods has not been shown effective and increases the chance of dependency. These drugs have little use in the treatment of anxiety or behavior problems in children. Psychiatric and paradoxical reactions are more likely to occur in children. These drugs start working quickly. Klonopin clonazepam Clonazepam is used to treat some types of seizures and has a long halflife. Do not confuse Klonopin with clonidine, a central stimulant used for ADHD. Valium diazepam Used by injection for the acute treatment of seizures. Diazepam is long acting and it can take up to two days to reduce the blood level by half. Xanax alprazolam Shorter acting but still with risk of dependence. Serax oxazepam Also shorter acting and with risk of dependence. Librium chlordiazepoxide Like diazepam, this drug is long acting. It is not recommended in young children. Ativan lorazepam Also shorter acting and with risk of dependence. Dalmane flurazepam Used for insomnia in adults. Not recommended in children. Other Anti-Anxiety Agents Buspirone is unrelated to the benzodiazepines, has less sedative effects, and does not result in dependence. Unlike benzodiazepines, it takes several weeks to begin working. It has not been studied in long term (more than 3 to 4 weeks) use. It has recently been studied as a treatment for ADHD. Buspar buspirone Grapefruit juice may interfere with the metabolism of buspirone. Buspirone does not have addiction potential. Protection and Safety & Juvenile Services New Worker Training

S E Q U O I A C L U B Page 15 TRAINEE Required In-Service Developed for DHHS - DCFS by DHHS - HRD and UNL - CCFL

Prepared by Gregg F. Wright, M.D., M.Ed University of Nebraska, Lincoln Center on Children, Families, and the Law for Children and Family Services Nebraska Department of Health and Human Services February 2013 Protection and Safety & Juvenile Services New Worker Training