Psychotropic drugs should be neither the first choice nor the last choice in treatment for the behavioural and emotional disorders in children. The physician needs to keep in mind that the child is a developing individual, whose subjective symptoms may not indicate mental illness as clearly as adults’ symptoms may. As a result, the physician’s decisions about treatment are usually based on the assessment of the ecological system of the child (home, school, neighbourhood).
Taking the History
Behaviour data, either in narrative form or using numerically validated scales (e.g., Conner’s scales), can be obtained from parents, guardians, siblings, peers, and teachers. The physician must be wary that medication may be sought as a simple solution for complex problems, such as family stress or parental emotional illness, inappropriate teaching situations, or inadequate child care. The physician must therefore explore the psychosocial history and educational background adequately and should also determine the availability of psychotherapy, behavioural therapy, family therapy, and remedial education.
Before initiating treatment the physician needs to determine any history of physical problems, especially drug hypersensitivity; previous history of seizures (which is not necessarily a contra-indication); and liver, kidney, or visual dysfunction. Any gross neurological abnormalities, especially incoordination, gait disturbance, tremors, or tics, should be noted.
Certain drugs may require additional tests. A complete blood cell and differential count is required before prescribing methylphenidate or thioridazine; a platelet count is also necessary before prescribing methylphenidate. Patients treated with imipramine should have dexamethasone testing, an electrocardiogram before and during treatment, frequent blood samples to assess the serum level of imipramine, and reassessment after a two-week withdrawal period when treatment is discontinued. Thioridazine therapy requires liver function tests at least once every month.
Attitude Toward Drugs
The attitude of the child, family, or guardians to medication should also be carefully assessed. Do they regard the child as unco-operative or manipulative and the medication as a means of control? Does the child or guardian expect the medication to cure the disorder? Is there undue pressure or resistance to the use of medication? The physician must also be aware of his or her own desire to offer a “quick fix,” for the sake of time or lack of awareness of other therapeutic interventions.
Klaus Minde has encapsulated, in two doctor-patient exchanges, the major communication required about the role of psychotropic medications in a child’s ecological system:
Doctor A. (to the parents):
I would like John to stay with these pills and take them twice daily, seven days a week at exactly 8 a.m. and 12 noon. Don’t let him forget them. Watch that he really takes them and don’t leave it up to him to remember. He is obviously doing much better and we want to keep it that way.
Doctor B. (to the child):
Paul, don’t forget that these tablets are simply some kind of crutch-like a crutch you need when you break a leg. Always remember, however, that a crutch can only help you with your walking, but can never do the walking for you, because that you have to do yourself.
Dr. B. has avoided enhancing powerlessness in the child and has stressed the importance of Paul’s effecting change. Minde stresses the “demedicalization” of this transaction. Although it is tempting to use the placebo effect of any medication, particularly in suggestible children or parents, Minde cautions against the resulting loss of autonomy and responsibility for the patient’s own actions.