One of the first questions parents typically ask when I suggest medication is to inquire how long their child will need to be on it. While many of the conditions we treat in child and adolescent psychiatry are very chronic, most parents intuitively sense that “less is more” when it comes to medication. We’d like to think that medication can be a temporary tool to help kids through a rough patch of development. Sometimes that’s true. Sometimes it’s not. Some key determinants of how long we use medication include…
- The chronicity of the condition
- The extent to which the child’s environment affects the expression of the condition
- The availability of effective, non-medical treatments for the condition
- The ability of the child/teen to develop compensatory strategies to manage the condition
- Potential or actual side effects from medication
Let’s look at how the question may be answered differently, depending upon the condition we’re treating.
I would tend to view ADHD as a condition in which the need for treatment is highly dependent upon the demands of the child’s educational and home environments. The need for medication is typically greatest during middle school and high school when the demands for academic productivity overwhelm the organizational skills of kids with the condition. Motivation is a big factor. When kids are interested in the subject being taught-because of an especially engaging teacher or because the material is engaging-they typically do well. For this reason, many of my kids with ADHD generally need less medication after they settle in at college. Unlike high school, kids get to pick a “major” at college…presumably, a majority of their classes are in a subject area in which they profess to have interest and have some relevancy to future career plans.
About half of the kids who are diagnosed with ADHD continue to meet the diagnostic criteria for the condition as adults. In general, difficulties with impulse control and hyperactivity tend to resolve over time as the brain’s prefrontal cortex fully develops, resulting in less need for medication for those particular target symptoms. Adults are also at an advantage compared to kids because they’re free to choose work environments that suit the way their brains process information. In our practice, we have lots of kids with ADHD who have parents with ADHD-most are untreated, and many are very successful. Three observations about our untreated parents who are functioning well…
- A disproportionate number of them are entrepreneurs or senior leaders at their companies…they’re good at big picture stuff and don’t like detail work or others telling them what to do.
- A much higher proportion of them find jobs where they travel a lot. They get bored sitting in an office, seeing the same people every day.
- Many are very successful in sales jobs where financial incentives and competition help them to maintain their motivation.
I tell parents of kids I treat for ADHD that it’s highly unlikely I’d ever hire their children to do my taxes. Persons with ADHD are more likely to need medication if they’re in jobs that require a high degree of organizational skills, demand lots of paperwork and impose lots of deadlines.
Depression is one of the least chronic conditions we treat in kids. While there aren’t specific guidelines describing an ideal duration of treatment for kids and teens with depression, assuming kids we’re treating for depression don’t have another chronic condition (OCD), most clinicians will typically treat with medication for a year and then offer the child/family an opportunity for a trial off medication. In the FDA trials of kids who responded positively for depression, approximately 70% were able to remain medication-free for one year after they were weaned off medication. On the other hand, depression tends to recur, and an examination of the data on the frequency with which antidepressants are prescribed to adults in the U.S. suggests that kids treated for depression will very likely require medication for the condition at frequent intervals during adulthood.
Anxiety tends to be a more chronic condition as opposed to depression, and tends to manifest in different ways at different times during development…i.e., the six year old with separation anxiety is often the the 11 year-old with panic attacks and the teenager with social anxiety. We typically treat with the same medications we use in depression-SSRIs. The greater the severity of anxiety symptoms and the more chronic the condition, the greater the likelihood the child/teen will need medication long-term, although we don’t have good data on the impact that good cognitive-behavioral therapy may have on the long-term need for medication. OCD is one condition that tends to be especially chronic. In the discontinuation studies performed for the FDA, relapse rates for kids who responded positively to medication for OCD were in the range of 90%.
Bipolar disorder is generally considered to be a condition requiring lifelong treatment with medication, assuming the child/teen has been accurately diagnosed. The presence of cyclical mood symptoms may predispose patients to more frequent and more severe mood cycles as they grow older. The biggest question with long-term medication use has more to do with whether we can encourage the child and their parents to continue to take effective medication. A one-year follow up study of kids and teens in short-term FDA studies of medication for bipolar disorder completed at the University of Cincinnati reported that only 35% of patients were considered to be “adherent” to medication-defined by taking 75% or more of prescribed medication for their condition. 42% were “partially adherent”, taking 25-75% of their medication, while 23% stopped medication completely…and we’re talking about families who, for the most part, had sufficient capacity for follow-through to enroll in and complete a FDA-sanctioned clinical trial!
Treatment for any given child or family is highly individualized, and as a clinician, I would much rather have a child on less or no medication as opposed to more. Unfortunately, many of the conditions we treat in child and adolescent psychiatry are quite chronic in nature, and as a general rule, the more chronic the condition and the less available good non-medical treatments are for the condition, the greater the likelihood is that kids may require medication long-term.
Dr. Steve Grcevich is a physician specializing in child and adolescent psychiatry who serves as President and Founder of Key Ministry. He blogs at church4everychild.org and may be reached at steve@keyministry.org."
