NEW YORK – Effectively managing children with refractory anxiety disorders isn’t easy – and decisions made during treatment can set the tone for a lifetime, according to Dr. John T. Walkup.
"It’s really hard to medicate kids," Dr. Walkup said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. "It takes a lot of work, a lot of time, and a lot of persuasion and convincing. Sometimes the family is resistant, so we just don’t put in the effort to make it happen. And these kids will sputter and not do very well."
Dr. John T. Walkup
That’s a shame, said Dr. Walkup, a child psychiatrist at New York Presbyterian Hospital, because pediatric anxiety can respond very well to the right treatment. But if children are left to flounder, the risk of long-term disengagement is very high.
"Many times adult psychiatric disorders start in childhood. If we fumble the first couple of attempts at treatment, this is a youngster who may grow into adulthood with no confidence in psychiatric care."
Dr. Walkup said he often sees patients labeled as refractory, who simply haven’t been appropriately treated. A common problem is having no real plan for reaching a goal. "I hear clinicians say, ‘Let’s just start at this dose and see how it goes.’ I guarantee if you don’t know where you’re going, you’re not going to go anywhere."
The "start low, go slow" method can be problematic if the dose never gets high enough.
"We want to be cautious, and we don’t want to do harm, but there’s a potential problem here. You can build treatment nihilism in the family. Because while you think you’re being prudent and thoughtful, the patient and family think: ‘I’m taking this thing and not getting better. Who is this person, and why should I trust him?’ "
Suicidality is a legitimate concern, but a very rare occurrence. According to the National Institutes of Health, Dr. Walkup said, the number needed to harm for suicidality is around 143. "If you examine that further, most of those are not deaths or attempts, but increased or new ideation."
Activation happens with some children on selective serotonin reuptake inhibitors. It’s extremely uncomfortable for patients and families, but usually occurs at low doses, is transient, and almost always has nothing to do with the long-term prognosis. Activation is sometimes misidentified as bipolar switching to mania, which is actually very rare. Of the 12% of treated children who experience activation, just 1% become manic.
When SSRIs are associated with activation severe enough to switch drugs, "I like mirtazapine," Dr. Walkup said. "It comes in an orally disintegrating tablet, which is good for kids who can’t swallow pills. It’s sedating, so it helps anxious kids sleep. And anxious undereaters who take it sometimes begin to chow down a little."
Switching to or adding another drug is a balancing act that, if not done carefully, can result in symptom resurgence. "The traditional switching strategy is to discontinue the first med and wait for it to clear and then start the second. During that period, children can have a return of symptoms, so this is not something you want to do when the kid is at summer camp, or over a winter holiday.
"I actually don’t do it that way any more," he added. "I prefer a cross-taper."
A common mistake in cross-tapering is, again, stopping the old medication too soon – before the second one has had a chance to kick in. "People get uncomfortable with having two drugs on board. It’s not for the faint of heart, but you have to keep on with the first one until you have a sense that the second one is going to work."
Sometimes luck kicks in, too. "I have experienced a few times – and sometimes hoped for– a kind of augmentation response. The child has an abrupt improvement with the addition of the new drug. When people see this, it can free them up to discontinue the old one, again too early. The problem here is that the old drug is the substrate that the new one is working on.
"If I have a patient who does get better like this, I just leave him on the two meds. Sometimes the improvement is very brisk, and it can really bring families into the fold with using medication."
Dr. Walkup said he had no relevant financial disclosures.
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