• Patients should receive regular metabolic monitoring, including lab work, both before and during treatment (Recommendations 11-13).
These are rigorous guidelines that challenge even those who regularly assess and treat children with serious psychiatric disorders. The clinical and legal implications of prescribing antipsychotic medications without adhering to these guidelines will, and probably should, give many physicians pause. Further, the specific point about the need for a thorough psychiatric evaluation underlies the commonly heard recommendation that this class of medicines generally should be avoided by primary care physicians. At the same time, many pediatricians are acutely aware of how dire the clinical situation often is for these families. At this point, it can easily begin to feel very much like a “no-win” situation.
Here are some thoughts that may be useful to consider in these moments:
• Remember that many non-MD mental health professionals can offer a lot of help. Although they can’t do the prescribing themselves, referral to a psychologist or another type of therapist can be useful in getting information about a patient’s diagnosis and the degree to which nonpharmacologic options have been exhausted. If the patient is already seeing a therapist, it is certainly worthwhile to seek their advice as to whether or not antipsychotic medications are now reasonable to consider.
• Look for opportunities to talk “curbside” to a child psychiatrist. Most of us are keenly aware of how inadequate access is to child psychiatry and want to help. Indeed, many states now have specific brief consultation programs in place.
• Get the lab work. A recent study in Pediatrics reported that a baseline glucose was obtained in only 11% of youth receiving antipsychotic medication treatment (Pediatrics 2014;134:e1308-14). In addition to providing important information, this step signals to everyone involved that the decision to use these medications is not something to be taken lightly.
Case follow-up
Cody’s pediatrician decides to get a diagnostic evaluation from a psychologist, who confirms the ADHD diagnosis without associated conditions such as bipolar disorder. The psychologist recommends a course of therapy to build regulatory skills for Cody and provide the mother with some parent behavioral guidance about how to best manage Cody’s challenges and encourage health-promoting behaviors such as physical activity, reading, and a regular sleep routine. The pediatrician decides to try a second line ADHD medication, guanfacine, and the school also begins to institute an incentive plan to reinforce positive behavior. In combination, these efforts significantly reduce the level of aggression and dysregulated behavior.
Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych.