While educators have been focused on the ever-changing academic demands of our high-tech society, psychiatrists and school health personnel have been busy with another challenge facing students: the increasing use of psychiatric medications. Often these medications need to be administered during the school day. In its 2012 guide for community agencies serving children and adolescents, the American Academy of Child and Adolescent Psychiatry reported that the increased use of these medications over the past 20 years has produced a body of evidence “to support its effectiveness when used appropriately.”
Physicians such as Dr. Adrienne Allen, a pediatric psychiatrist with the R.H. Hutchings Psychiatric Center in Syracuse, work hard to ensure that medications are prescribed and managed appropriately within a comprehensive care plan. Family Times spoke with Allen, who also serves as a consultant with Upstate Medical University, about the challenges of balancing psychiatric care and academic continuity. (This interview has been edited and condensed.)
Family Times: Many students now take medication for conditions such as ADHD. How common is this?
Adrienne Allen: It is a pretty common diagnosis, and we choose to use medication when we see that ADHD symptoms are interfering with functioning. There are lots of kids who will struggle with paying attention or sitting still in certain circumstances, but if it’s not across the board and in multiple settings, and it’s not interfering with function, we’re not as likely to recommend medication. I think the dysfunction that we see the most in terms of inattentiveness and hyperactivity at school is when it’s interfering with their learning, or the learning of others.
We do see children who have these symptoms in one location, but not the others. When those situations occur, we look at what else is going on. Sometimes, if a child is struggling primarily at school, and at home parents are like, “What are they talking about?,” perhaps that child has a learning disability or their learning style isn’t conducive to a large classroom. Perhaps that child is being bullied.
FT: What other conditions require students to take medications during school hours?
AA: Well, anxiety, depression, post-traumatic stress disorder—any kind of trauma, kids on the autism spectrum, kids that have problems regulating their mood and emotions in general, OCD. There are a myriad of different conditions. Many children with these conditions can be treated with medications before or after school, but not all.
FT: And then there are the possible side effects.
AA: That tends to be a little bit easier to deal with. It’s harder to come up with the right strategy for treatment in the first place—because it’s not just medication. It’s other supports. Disorganization is a core symptom of ADHD. Medication alone isn’t going to solve that, so there needs to be a multipronged approach to managing symptoms. People often look for a quick fix, and medication isn’t a quick fix.
We want to be able to teach kids longer-term strategies that will work when they are older so hopefully, they will not need medication or the same amount of medication, and they will be able to function adequately as adults. They need to learn organization, time management, using a planner, a calendar, a smartphone.
FT: Is there a finite list of medications being used—in order to assist schools with educating staff?
AA: I wish! (laughs) Our arsenal of medications keeps getting bigger. There are some very common stimulant medications such as Ritalin, Concerta, Vyvanse—those tend to be the typical first- line treatments for ADHD. Psychiatrists and neurologists are prescribing more combinations for kids with more complex problems. The pediatricians and family doctors tend to stick with prescribing one medication at a time. More complicated patients are sent to specialists.
FT: What kinds of side effects are students experiencing while taking these medications?
AA: With our stimulant medications, the most common side effect is loss of appetite. We’ve got lots of kids who are not very hungry at lunchtime but hungrier at other times during the day, which disrupts the school schedule. With some stimulant medications, if someone takes it too late, they may have trouble falling asleep at night. Then they come to school the next day and they are tired. There are many reasons why children aren’t sleeping well, and medication can exacerbate that—as can lifestyle choices and how a family functions. You have to understand everything that’s going on with these families.
I’ve got children that are woken up every night at 11 or 11:30 p.m. when a parent gets done with work, so that they can go from a sitter back home. Life is just so hard for some of our kids.
Some kids are getting medication at school because they need a middle-of-the-day dose. Others are getting medication in the morning at school because families are struggling with organization at home and can’t consistently give them the medication. There is just general chaos when you’re working two or three jobs and have three or four children. Everybody’s going in different directions.
FT: So this is a real collaborative effort between the families and doctors.
AA: Very much so. Here at Hutchings, I have social workers and psychologists who can bridge some of the gaps for me. But sometimes we go directly to families to get feedback. Nurses and teachers become our eyes and ears to tell us if we are not addressing some need. It makes things challenging for teachers. I think our teachers are seeing children with far more needs than when they first did their training—just as we are seeing in our offices.
AA: I think our society has gotten much more complex. Relationships and family units have changed. The boundaries in society with the media have changed. We no longer have natural boundaries like stores being closed on Sundays. Gone are the days where the TV just went off the air at 11:30 at night. Those of us that were raised in the 1960s and 1970s had boundaries. We had four TV channels. Grocery stores closed at 10 p.m. Now, we have 24/7 everything. If I want a pizza in the middle of the night or a book or some music, I can get it. There is no end point to anything anymore. I think that’s a hard way to live for all of us.
FT: Is this process a fairly smooth one for patients? Some parents may be reluctant to surrender to it.
AA: I think it is difficult. You want to take care of your own child. You know best. It’s hard for a parent to make that decision to put their child on medication to begin with; it’s a big deal. To let others help in monitoring that takes a certain amount of fortitude. Nobody knows your child like you do, so assessing when there is a problem or when there is a particular response . . . it’s hard.
FT: What concerns do parents typically have when faced with the decision to use medication in a child’s treatment plan?
AA: The biggest concerns are side effects, particularly long-term side effects on growth. There are concerns about how long they are going to need the medication. When people see some of the advertisements on TV that mention side effects, that really gets them concerned. In order to have those medications advertised, the drug companies have to list all the potential side effects. That raises a lot of concern, as it should. There is no medication that is without side effects—including Tylenol or Motrin.
We’re looking at other ways to manage students’ behaviors besides having to expose them to challenging medications. So, if I have a child that is hyperactive, aggressive or overstimulated in a classroom of 25 children, maybe they would do better in a class of 12 children with a teacher and an aide. That’s where my push is. If I can get a child to do better in a smaller setting, as opposed to exposing them to medication, that would be my ideal. If I can avoid putting a child on big-deal mood stabilizing medication, I will.
FT: What improvements need to be made to maximize treatment and positive outcomes for young patients?
AA: I think we are heading in the right direction, but it comes down to resources. There is more we can do, certainly. It’s not fair to a child to be medicated throughout the day because they can’t be in a smaller setting. Some families just need more supports in general.
There are systems issues. There are families who don’t have transportation and require a Medicaid cab to get to appointments. The students miss an entire day of school because the cab isn’t permitted to take them back to school. They can’t go pick up a parent, go to school and pick up the child, then reverse that. These systems issues are bigger than all of us. I think it is important not to medicate according to the constraints of the system, but to push where we can to get other supports that might allow us to minimize the use of medication.