Are you a foster or adoptive parent whose child is taking mood altering medications or medications to help them sleep? You will learn a lot about these medications and what you can do to make them as effective as possible. We talk with Dr. Adam Langenfeld, a Developmental Pediatrician at Children's Minnesota hospital. He also has a Ph.D. in chemistry.
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Welcome everyone to creating a family talk about adoption and foster care. I am Dawn Davenport. I am the host of the show as well as the director of the nonprofit, creating a family.org. Today we're going to be talking about understanding psychotropic medications. We will be talking with Dr. Adam Langenfeld. He is a developmental pediatrician at Children's Minnesota hospital. He is also has his PhD in chemistry. Let me start by saying that children in foster care are significantly more likely to be on psychotropic medications, as compared to the general population. There was a study several years ago, that found that one in every three kids in foster care on one psychotropic medications, and those are designed to alter their mental state or mood status or mood. And they compare this and in order to find out whether they were significantly higher to a similar demographic of children, they compare them to other children who were also on Medicaid. And they found that about 8% of the children not in foster care who were on Medicaid, received psychotropic medications, compared to 35% of those who were in foster care. When research was presented at the 2021, at the American Academy of Pediatrics national conference, that showed that the prevalence of psychotropic medication use in the foster care population is anywhere from two to 27 times higher, depending on which classes or psychotropic medication we're talking about. So having said all that with with that intro, thank you for being here, Dr. Langenfeld. And I would like to start obviously, with the ad getting everybody on the same page, not everybody will know what psychotropic medications mean. So can you tell us what are psychotropic medications and then go through the classes of these medications?
Sure. So psychotropic medications, kind of broadly speaking, are medications that can alter mood, perceptions or behavior, the National Institutes of Health, Mental Health has a nice summary of the different classes of medications. And really, these are medications that are used to help with mental health conditions. There are six major classes that are discussed, some of them we had in our outline, but they are medications that include things like anti psychotic medications, these are medications that are typically used for people who have psychiatric disorders, but can also be used for aggressive behaviors. And then antidepressant medications, which as as sort of stated in the in the title are medications that are used to treat depression, there are anxiety, Medic medications, and these are medications that are used to treat symptoms of anxiety, either acutely, as they kind of come up in more acute phases, or more chronically for kids and adults who have more long standing anxiety in different situations, there are hypnotic medications or what can be classified also as sedative hypnotic medications. These are medications that are typically used to help with sleep, or again, sort of with behaviors. And I'll talk a little bit more about that. There are mood stabilizing medications. Most commonly, these are medications that are used to treat symptoms of mental health conditions, such as bipolar disorder. And then finally, there are stimulant medications. And those are medications that are used in a lot of cases to treat the symptoms of ADHD or Attention Deficit Hyperactivity Disorder.
Okay. And I realize there are many medications under each of these classes that you have just given us. Could you name a few of the common ones that people may have heard of? Under each of them?
Yes, I will do my best. And
what is this not a full? We're not even trying there. But just so that we know what when people when they often know names, but don't really know, they wouldn't know the class that it might fit in?
Absolutely. And the the caveat I will give to you to start out with is that there actually are a lot of overlaps. So some medications that are sort of in one category can be used to treat symptoms from a different category. So I agree with you, this will not be an exhaustive list, but I'll try my best to kind of help give some common choices. So the going down the list in order I did previously antipsychotic medications, ones that I see typically, are typically the second generation antipsychotics, there were medications that were used previously that had more side effects. And more recently, medications were developed that had fewer side effects and better response. So better treatment of symptoms. Ones that people may have heard of are Abilify or aripiprazole Risperdal or Risperidone. And I'm using the brand name first and then the common name Okay. Zyprexa, which is also called olanzapine and Seroquel or QuickTips. So these are all second generation anti psychotic medications. Antidepressants are probably medications that people have heard of most frequently along with stimulants. These are a lot of medications in this category are in the selective serotonin reuptake inhibitor or SSRI category. And those are ones like fluoxetine or Prozac, which a lot of people have heard of. There's also Zoloft, which is also called sertraline, and Lexapro, which is also called as citalopram and there are a number of other medications. This is just a brief list. There are also other types of medications in the antidepressant category that we don't use quite as often in children. Those include tri cyclic, antidepressants, and Ma Li inhibitors or Mao eyes. Again, I'm not one that typically would use those because as working with pediatric population, the SSRIs are the most commonly used ones that we see anxiety. oolitic medications, again, wants to treat anxiety. SSRIs fall into that category as well. So we do treat anxiety with SSRIs like Prozac, but there are also medications that can be used in the short term. These include anti histamine medications, such as Benadryl or hydroxyzine Alpha agonists, which are medications such as clonidine or guanfacine. And then medications we don't use quite as frequently in pediatric population, which are called benzodiazepines. And these are ones like Ativan or Xanax that people might have heard of before. Hypnotic medications, again, a lot of overlap with different things with some of the ones I just mentioned it the anti histamine medications, Benadryl, hydroxyzine, the benzos or benzodiazepines, Ativan, or Lorazepam. And then also medications such as melatonin, which are commonly purchased over the counter to help with sleep, mood, stabilizing medications, the sort of common one that people will think of is lithium, this one that will be given for bipolar disorder, but then also medications that can be used for seizures called anticonvulsant, Medic medications and these are medications such as Trileptal or valproic acid. And then finally, Stimulant medications, again, are probably pretty commonly known in the general population. The two big classes are methylphenidate, this is a your Ritalin also has other brand names including Concerta meditate. And then amphetamine medications, which are a mixture of different types of amphetamines. And those are things like Adderall is the most common one. So a lot of different medications and like I said, a lot of overlap between those classes.
So what are some of the mental health issues that these medications are prescribed for?
Sure. So the big ones that that I would see as a pediatrician or a developmental pediatrician, anxiety and depression are very common anxiety more in the younger population, but you do see depression as well. And these are situations where we would use an SSRI like fluoxetine or sertraline, ADHD is an extremely common one these days where we will treat with a stimulant medication, usually as a first line. And after that, if we do have trouble, there are other medications that are non stimulant that can also be used for sleep problems, including difficulty falling asleep, and difficulty staying asleep are very common situations where we use these medications. And then, for, for me, you know, some of the more behavioral issues that can come up in certain children. I do see a lot of children who have autism spectrum disorder and sometimes in these cases, they will have behavioral issues that are not responsive to behavior intervention. So if they have trouble with being aggressive, or was having self injurious behaviors or self harming behaviors, not intentionally, but just have difficulty controlling them, will sometimes use a medication like clonidine and guanfacine, or if needed an antipsychotic medication, like Abilify or Risperdal.
So, what are some of the symptoms that you would see of anxiety and then and then give them for depression in children because I suspect that children display anxiety and depression in different in different ways than when an adult?
Sure. So in children who have anxiety, especially younger children, one of the biggest concerns or things that we see is a really difficult time being able to join in sort of typical situation. So a child may be having a very hard time going to the store or going to school, separating from parents, they might have some challenges with separation from parents. In situations where they get to school, they might have a hard time interacting with other children or they might have difficulty being able to engage with learning in the school setting. And that could be because they're worried about something that could be happening. As they get older. Again, depending on the situation they may have trouble with social interactions. They may have trouble with novels. situations where they get very upset or worried about things that could happen. Sometimes they'll display something called rumination. And that's just really thinking about one thing very constantly, very consistently not being able to get it out of their head. So a child may be worried that there's an upcoming exam and have a very hard time being able to think about anything but that exam. Children who are depressed again, younger children are a little harder to tease out if they have depression symptoms, but you know, having less desire to participate in previously enjoyed activities. So if say they're on the basketball team, or they're playing a musical instrument, and just having no interest in being able to participate in that activity anymore, changes in sleep patterns are a very common one. So either being much more sleepy than normal, or having less interest in sleep as another one. And, you know, just not having sort of the same kind of reaction you would typically expect, you know, kids might get a little bit more sulky or solid or less interested in interacting with other people. When we have concern about anxiety or depression, there are checklists that we can use to help kind of tease out what's the symptoms are so there's a checklist for anxiety called the scared, I'm gonna look up the acronyms I can tell it to you accurately. And then another for depression, it's the childhood Depression Inventory. So we do have scales that we can use to further tease those out. So if a parent comes in with a concern, we can actually do some evaluation with the parents and with the child to be able to determine whether or not those symptoms are truly anxiety or depression or if they're maybe just experiencing something more transiently. So a change in school, a change in home life COVID For example, that's impacting a lot of kids. And the the scared acronym is screen for child anxiety related disorders.
Um, I must say that is a good acronym. Yeah. Yeah. Hats off to the to the ones who had to work on that when I'm sure. Yeah, well, let me you bring up a question that I have, and we're talking about children in foster care are any adopted children as well as children who have are in kinship care? And it seems to me that many of these children are in situations that are anxiety producing and depressing. And so how do we know the difference between situational anxiety or depression and chronic anxiety and depression? And, and when to use medication for these? When in fact, anxiety and depression might be a very healthy response to a situation? That is anxiety producing a depressant?
Yes, I'm nodding very vigorously. It's a good question. And, you know, when we, when we conceptualize symptoms of these mental health issues, one of the things that we try to take into account is the situation around the symptom. So not just the symptoms in in isolation, but also the entire situation around around the child or around the adolescent or the adult who's experiencing these symptoms. So when we, when we imagine a child who comes in with, say, anxiety symptoms, one of the things that we start with is a thorough history. So we talk about the history, the present concerns that the caregivers would have, and also us caregivers, because it may or be parents or maybe kinship care, or foster or adoptive care, their current concerns and then what the history of symptoms is. So has has the have these symptoms been going on recently, have they been occurring for a long period of time? What makes them better? What makes them worse? Are there any factors that could potentially be impacting the symptoms development, so for example, if they did have a recent placement in the new environment, or if they had experienced trauma in the form of neglect or abuse, and then identifying other potential factors, and that can include, you know, doing a medical exam to identify any other potential reasons why they could be experiencing symptoms, especially if they have maybe a co occurring condition that might not have been identified previously. So we try to really be thorough about what has gone on prior to visiting us in clinic so we know what potential factors could be impacting those behaviors. When When kids come in and they have experienced trauma relatively recently, one of the things we can sort of with one of the ways we can conceptualize it is that they are experiencing an adjustment reaction. So they're saying so appropriately risk responding to a change in a way that presents with some of these symptoms, but doesn't necessarily mean that it's a lifelong condition. And one way that I like to think about it is, once you have been established in a supportive environment, where you have stable caregiving, you don't have a lot of transitions and change, do these symptoms persist? In that case, then they may be be worthwhile to do a little bit more exploration, possibly medication management.
We have 12 free courses for you available to listen to their courses on parenting. And thank you jockey Bing family for providing us with the opportunity to offer you these, you can find these toll free courses at our online Parent Training Center. You can get there by going to Bitly slash JBS support. That's bi T dot L y slash JBf. Support. How do psychotropic medications work? And I do realize that what I'm asking is, is probably multiple graduate level courses of information. But can you give us a basic overview of psych pharmacology? Do? Do we know how they work? Maybe that's a better question.
Yeah. So the general answer is we know what mechanisms they follow, and how they produce the outside results. It's fairly clear that this sort of broad brushstrokes view on psychotropic medications is that they work by impacting and changing the neurotransmitters in the brain. And sort of buzzword neurotransmitters when you're when you're preparing for these, like pharmacology exams, are things like serotonin, norepinephrine, dopamine, and GABA, or gamma, amino butyric acid, those are sort of the main neurotransmitters that we think about.
And there'll be effected by the medications directly on them.
Exactly. They're being affected in different ways. And I'm wanting to be broad with this, because there are different mechanisms for that as well. So when when the brain when neurons in the brain are firing are working, what they do is they pass these neurotransmitters between different cells. So they have a synapse, which is a spot in which two neuron cells interact with each other. And they will take these neurotransmitters and transmit them from one side to the other. So they go from the first one to the second one in this little, you can look up diagrams of this, but it's like a little space in between where they move across. And psychotropic medications affect how these neurotransmitters are metabolized. So how they're taken up and broken down, how they're transported, and whether or not they are taken up back into the cells right away, or if they stay in there longer. So as an example, the SSRIs or selective serotonin reuptake inhibitors, it gives you the mechanism in the name so it stops the reuptake or putting back into the cell of serotonin molecules. And for people who have anxiety and depression that tends to help having more serotonin available in that that space between the two cells actually sends to help with those symptoms. Another example, there's a related class of medication called serotonin, norepinephrine reuptake inhibitors, similar mechanism, they don't, they help to keep more of those neurotransmitters in the in that part of the neuron, but they affect both serotonin and norepinephrine. Third example stimulant medications they aren't particularly labeled, is being like neurotransmitter in inhibitors. But in stimulants, they affect dopamine and norepinephrine. But instead of affecting how the transmitters are transmitted or transported, or like seeing in the in the synapse, they actually compete for the transporters of these Medicaid of these neurotransmitters, the short version is to say, they take the spot of dopamine and norepinephrine so that there can be more dopamine and norepinephrine in the in the synapse. So all of this is to say, if you take if you kind of take the broad brushstroke is that these medications affect how the neurotransmitters are moved around in the brain. And when we do that, in a lot of patients, they do produce a positive effect and reduce the symptoms of these mental health conditions that they're feeling.
So how are these medications administered? And I realized we've got six classes to talk about. So yeah, first of all, are they all pills? And if so, you know, how are they administered as far as timing a day, an empty stomach, full stomach, that type of thing?
Yeah, and again, I will I will be broad and perhaps give some specific examples. For the most part, all of these medications are available in multiple forms, you are genuinely looking at giving them by mouth just in different ways. So there are liquid formulations so you can go to pharmacies and have them either compound which means take the medication itself and break it down and put it into a liquid that a person can take. There are tablet forms and their capsule forms and capsule would be your little medication capsule that has little pellets of the medication inside of it. Some medications, especially the anti psychotic medications do also come in injectable forms. And those are ones that we typically wouldn't use. In the outpatient setting or in the clinics. We usually prefer to do medications by mouth if we can As far as how they're given, you know, the liquid medications are typically good for younger children, for children who have a hard time swallowing pills, or for children who have like a G tube or a gastrostomy tube, where they need to get their nutrition through their stomach, as opposed to through their mouth. So kids who have trouble swallowing, so those can be given more easily that way, the sort of trade off is that a lot of them don't taste very good in the liquid form. Unfortunately, the tablet forms not every medication is like this, but the tablet forms can often be crushed down and put into something that's like a liquid or spoonful of applesauce or yogurt. And that's something the caveat I would give to that is that it's important to know which medication you're taking, because there are some that actually are designed to be broken down to the stomach as a whole pill. Right? Yeah, you wouldn't want to do that for those pills. So that's sort of case by case basis.
This is Ask your pharmacist before you
ask your pharmacist astir. Ask your pediatrician or physician to or Advanced Care Practice provider to talk about that before you you do that, for the most part, it's okay, but it's important to know just in case, and then the capsule forms. The nice thing about those is they can be swallowed whole, but they can also be opened like pulled apart and and the contents can be poured onto a spoonful of applesauce or yogurt or ice cream or whatever the patient is able to take. So there are ways to get around kids who have trouble swallowing pills, or kids who have adults who have trouble with certain tastes of certain medications. So we often can play around with that when we're prescribing these medications to find something that works for the patient. As far as timing goes, again, it really depends on the medication in question. There are some medications that are geared towards helping people fall asleep. So again, your melatonin means your hydroxyzine or Bennett drills. Your clonidine means these medications are typically given at night because they can be sedating. And that's one reason why we have to pay attention to side effects. Because with those medications, for some people, they if they are more sedating, it can be challenging during the daytime. So we typically would say keep those at night. On the other hand, there are medications that are kind of more activating, we meaning that they make the person more aware and more awake. Those are medications, we would typically say, give them in the morning, so they don't interrupt sleep. And also, you know, for depending on the medication, you may want to target a certain time of day because you are trying to treat those symptoms during that timeframe. The best example I can give is the stimulant medications, which are typically given during the daytime to help with focus in school or job settings. And they can be disruptive to sleep. So you wouldn't want necessarily to give those at nighttime because they could potentially be disruptive, as far as food is concerned. But for the most part, most medications are actually okay to take with food in these different classes, I would again, refer to a pharmacist or your your healthcare provider to discuss that further, because there are some that necessarily that they would be less, they would work not quite as well. But it's important to know kind of what side effects they have. Because a medication like a stimulant, for example, can reduce appetite. And in that case, giving it around a mealtime can be very important too, because you may not be hungry for a good chunk of the day when on that medication. So most times, I would tell a family that it's okay to give it with food or around the time of food, barring any specific reasons that we wouldn't be able to do that.
You've mentioned melatonin a couple of times how effective is melatonin?
Generally, it's pretty effective. It really depends on on the person in question. Some children I've seen in the past and others have seen in my practice have had children who have been more activated by melatonin for whatever reason. It's a hormone that's produced in the brain to help maintain those sleep and wake cycles. And the reason that we prescribe it in a lot of cases is because children and adolescents and young adults just have a hard time regulating the sleep cycles internally with their own endogenous or in their hormones that they produce. So most children who have sort of your average sleep challenges will respond really well to a fairly small dose in the one to three milligram range. For some children who have a very hard time falling asleep, especially children who have neurodevelopmental disabilities, or differences such as autism, it may require a very significant amount. So what I would always suggest is, it's a medication that can be tried pretty easily without significant side effects. So a family can definitely if you're having a child say who recently moved in and from a new foster placement, who was having some trouble sleeping, trying a low dose of over the counter melatonin, one to three milligram range, it's is appropriate to give a try and see how they respond to it if they haven't used it before.
Is it more effective? This doesn't always work with children, but to let it dissolve under their tongue rather than give it to them as a pill that they will then by debt be digested in their stomach,
that would depend on the formulation, there are formulations that are chewable, in which case that may produce some increased efficacy and might help it work a little faster, because the space under the tongue is more absorbent, essentially. So it can help the medications absorb a little bit faster. The pill forms, I wouldn't necessarily say chewing them was a good idea, especially because they're going to taste really
good. They taste terrible. Yeah. And that would be the reason one wouldn't want to do that. That's right. All right, you mentioned side effects. And I think that is a really important topic, because these medications, depending on which ones can have significant side effects, and they can also have significant can also do significant good. But let's talk about some of the side effects that are common side side effects for the commonly prescribed drugs in each of these classes.
Absolutely. And, you know, again, it really does depend on which medication were concerned about or thinking about taking. So it's really important to have a conversation with your healthcare provider about that. And there are really nice handouts and and information online, they typically will provide all of the side effects or all of the major side effects. So it can be a little bit daunting, especially if you're concerned about side effects with these medications. When they report side effects, they report anything that has happened, which means that there are some side effects that happen only very rarely. But there are others that are more common. Generally, the side effects that I think about when starting any medication in any of these categories, it has to do with the head and the stomach. So having headaches impacts on sleep either increased or decreased sleep, nausea, some people will have vomiting with it as well. So upset stomach, and then changes in their mood and their behaviors. So, you know, we were targeting behaviors and mood in a lot of cases with these medications. But sometimes you have effects that are not expected. And then, you know, depending on the medication again, it really it really will be sort of specific based on what type of medication are you using. So I want to go through my list in the right order here. So when we talked about the anti psychotic medications, for example, those ones like Abilify, or Risperidone, the really big side effect that we discuss with families is appetite. And and actually, with these medications, we tend to have an increase in appetite. That's pretty significant. So some children and young adults who who take these medications can have really significant weight gain and impacts on their sort of metabolism, that can have a cause a really hard time for them. For some children and young adults who take these medications, we monitor closely, their metabolic labs, so how their liver and kidneys are working. And sometimes we actually work on weight management with them as well, because we have a pretty significant concern for those side effects. Those Medications also can have what are called extra pyramidal side effects. And these are ones that we see in the anti side kind of classes in general where you have sort of abnormal movements, abnormal behaviors that are not what is expected under normal circumstances. And those are ones that were more common in the earlier anti-psychotics, but they're ones that we want to watch very closely for because they can cause problems and we would want to know if there was something going on with that. Antidepressant medications, your SSRIs your your fluoxetine, sertraline, citalopram, they have a lot of the common side effects like I talked about, so headaches, upset stomach, trouble with sleeping. But you can also have some kids who get very again, activated by these and then what we see is that they become more irritable or hyperactive, they might also be more emotional, so they just are very reactive to situations. And we do see that in some kids. These ones can also have sexual side effects, especially in adolescents and young adults, some are not as effective don't cause as many effects as others. So we tend to try to target those symptoms, or those those medications based on their ages. So we try to use the ones that have fewer side effects in that regard, especially as they get older. And then you can also see in SSRI, something called serotonin syndrome, that is a buzzword that would come around and this is one where you have an excess of the serotonin neurotransmitter and that can cause like the anti-psychotics, a typical behaviors movement, kind of trouble maintaining normal homeostasis in the body, so sort of normal body function. So that's when we were very careful about and we want to make sure that families are aware of and pay attention to the anxiety, lytic medications and the hypnotic medications all put together. The biggest side effect that we see with these medications is sedation, which is why we use them to to help calm things down and to help fall asleep in a lot of cases. So we actually take advantage of that, especially for the medications like hydroxyzine or Benadryl and clonidine and guanfacine, which are ones that we would typically use to treat sleep. There are actually some medications that fall into multiple categories like You can antidepressant and a hypnotic medication because one of their side effects is fatigue and sedation. So that's when we are taking advantage of that side effect. But they do, they can potentially have have challenges as well. The mood stabilizers, again, typically aren't, are not medications that I use frequently. But there are ones lithium, I'll speak specifically to because it is one that's commonly used, can have also impacts on weight can also impact the kidney and the thyroid gland. So they can impact sort of how the body's normal homeostasis is maintained. So it's very important to keep a close eye on any side effects as well as like monitor for changes in those functions of kidney and whatnot. The other anticonvulsant medications that go in this category, same kind of thing, just really monitoring for weight gain, and then impact on the organs in the body. And then finally, the stimulant medications, the big side effect that we talked about is decreased appetite. So you kind of have the opposite as you would have for the anti psychotic medication. So kids who take stimulants are oftentimes very have very suppressed appetites during the day while the medication is available within their bodies. So we do see some kids who have pretty significant weight loss, it does happen from time to time. So we really want to pay close attention to appetite and make sure that if they are having a decreased appetite that we're trying to optimize the other times of day, so they have a chance to eat a meal at breakfast time, maybe not eat very much for lunch. And then usually by the time dinner rolls around, they're they're hungry again. The only other challenge I've seen with that in some kids is that they can kind of overcorrect at the end of the day once the medication wears off. And that can impact their weight gain as well.
Okay, that mean they're going timing would be so important. I have a question about sleep and medication. I totally appreciate that when a child is not sleeping, that that becomes a significant problem for the child. And for the parents. I totally appreciate that. But do sleep medications, particularly when used frequently interfere with the the restfulness of sleep, the natural sleep cycle of going into the different stages of sleep, which is the restorative aspect of sleep?
Yeah. Typically, no. Typically, they do kind of help to get into those more restorative sleep cycles. But it also depends on the medication in question. So there are some medications that are very, very good for getting into sleep being able to fall asleep. And so they're more geared towards those early stages of sleep in the night. So you're having fewer fewer of those like deep sleep episodes where you get into the rapid eye movement or REM sleep, there are other medications that are much better at maintaining sleep overnight. And in those typically what I found is that most children who who require those medications, when they do get started, tend to have more restorative sleep. And for a lot of kids, it actually helps to improve behaviors as well. Sure as they are sleeping better. Yes.
Because, yeah, we do see better behaviors and all of us. And when we hear when we are rested, yes, yeah, absolutely. If you are getting something out of today's podcast, please let others know about it. That's how people find out about podcasts. That's how they choose what they listen to. So if it's been helpful to you in any way, spread it around, tell your friends who are in the adoption, foster or kinship world or, or tell those in your life who you want to understand more about your life where it's going, what's happening, the more ways we can spread the word about the existence of this podcast, the better. So please let others know. And if you're not subscribing, make sure you have subscribed to to the creating a family.org podcast. There is a lot of talk in the media now popular books coming out. Talking about the role of the potential role. I think this is all still experimental, of using psychedelics to impact mental health issues, mental health, mental illness, I am assuming that this would not be appropriate for certainly for children, but I would assume that they have I don't know, is it appropriate ever for children? Our youth are young adults?
That's a very good question. And I would defer to the people studying that to give a good idea of what impact it's had. Typically, what I would say offer as as general advice is that if there is a question about a particular substance or medication, to have a conversation with your healthcare provider, and to just understand that for a lot of these, there's not regulation to help determine safety and efficacy. That's
really data. I mean, really, exactly. We don't have we don't know yet. It's not to say 10 years from now, we might know. Hopefully, we will know but yeah,
yeah. And, you know, that's the real challenge with any sort of sort of off label or non regulated substance, whether it's a supplement or a psychedelic Like medication is that we don't have that information. And it's really tough to say, to make a recommendation without good data to support to use. The sort of substance that gets asked about a fair amount is CBD, so marijuana, CBD or THC. And the same thing it has some has some information around it. But there's not enough from my understanding to make a strong recommendation that it was helpful or harmful. And it's not regulated the same way as other medications. So there have been families who have used it and had good benefit. And that's great. But there are other families who have tried it and not really had any sort of benefit. So in any case, I'd say, communicating with your healthcare provider about that is probably the most important thing to make sure that you're doing any sort of trial and error in a safe way.
So maybe this is the $64 million question. Why are children in foster care? Do you think more likely to be on psychotropic medications than children outside? In same socio economic same general demographic outside of foster care?
It's a, it is a $64 million question or the $64,000 question. I remember I think that was that was the was the $64,000? Because 1000
Okay, there, I think it's inflation going on? I'm just going to increase it. Yeah,
we might as well at this point, as well. Yeah, so it's a very good question. And my sense is that it's a very much a multifactorial question or answer to that question. Children who are in foster care, experience a lot of different environments and have a lot of different backgrounds as far as what, what brought
them to that situation? And almost always they've experienced a lot of trauma.
Exactly. So traumas is it impacting factor for sure. But also, you know, their their family background? Is there a family history of mental health concerns that could be contributing to their placement in foster care, for example. So you could make an argument that there are certain factors in their history from both their personal environmental exposures and experience to their genetics that could make them more likely to have these these diagnoses and require these medications. But at the same time, again, you know, one, one important factor that I would consider is when they're in a stable environment does do things change, too. And that's sometimes where we get into a little bit of a not jumping the gun, but being more reactive to what we're seeing right in front of us then then understand then thinking about sort of the whole picture. An example that I have is there was a young lady I saw I worked with an adoption medicine Provider A few years ago. And there was a young lady that I saw who was coming in for an evaluation because she had been adopted, and she had a diagnosis of autism, and Global Developmental Delay, meaning that all of her developmental progress was delayed compared to other kids her age. And when she came into clinic, she was smiling. She was talking to me, she was reaching out to parents for support, she was very much what I would call a neurotypical child. And I said, What is going on here. And it turned out that she, we learned later that she had experienced significant neglect significant trauma, and was essentially crib bound for years, so that she just did not have the opportunity to develop. And once she was in that stable home environment, she thrived. And we sent her back for reevaluation because she we said she could still have had autism. But her symptoms were much less severe than what was recorded on paper. And if we had thought of her as being autistic and delayed and thought, Oh, well, she's engaging in these behaviors, we need to start treating her with medications without taking into account her history might have sort of over, over treated her. So it's very important to, you know, take what you have in front of you at the time, but also to remember that there are certain parts of the of the history that may help you guide you to what kinds of resources you should take advantage of in addition to medications, and it could be that you still need them. But these kids just have so many different things going on that it can be hard to tease out how much of that is inherent to them. And how much of that is because of their experience.
Yeah, I agree with you. And I would also suggest a couple of other potential factors and like to get your input on that. One is the continuity of care issue. Very often. The kids are dropped off at our homes and with a bag of medication and nobody has gone through and nobody it's sometimes the the first doctor who prescribed has never been gone back to them. Every time they move. They're continuing. Nobody is taking the medications off, and we're just piling them on. If, and if the child is not going to be in your home for a particularly long time, and of course, often time in foster care, we don't know, you're not the one who has to make these decisions or the foster parent to the county or the parish or wherever has the responsibility. So it's just that a, just the just the, who's responsible? Where does the buck stop, so to speak?
Yeah, that's a it's a very good question. And one of the challenges that you're highlighting is that it can be difficult to maintain that continuity across different providers. You know, in Minnesota, we have different health systems that interact fairly well. But that doesn't necessarily mean we have all of the information all the time. So you may if especially if you're moving between households who may have different primary care providers, or if they have a specialist, they may not see the same specialist. So it's really important to aim for the goal of having a medical home or somebody who can remain consistent across different living situations, if possible. And that can ease the burden of having to make all of these changes. And the other piece too, depending on sort of level of responsibility, if if the foster parent is able to being able to have a conversation with that, that healthcare provider and to say, you know, this person, this, this child, or this, this adolescent came in with all of these medications, and I'm not sure what they actually need, you know, can we talk about it, a knowledgeable provider should be able to at least have a conversation about that, so that as the child moves through the system, and is hopefully able to find a stable environment, at least that conversation has been had. So they can be thoughtful about how they, they approach these medications after they're stably placed.
Well, and that that raises my second point, which would be the lack of an advocate. I mean, so often, these children in an ideal situation, they're placed in a stable foster home or with a stable grandparent or other kin. And even while their parents hopefully are getting their act together so that they can reunify there is and that's an ideal situation, and that person then becomes the child's advocate. And when somebody says, Well, you know, let's put them on this medication, they could stop and say, Well, what are our other alternatives? What else can we do? What are the side effects? What are the, but these kids often don't have the ideal, they're moved, hopefully, they're moved into a kinship situation where there will be set, but very often they're not. And it feels to me that the lack of everybody needs an advocate in this world. And we especially needed anytime we're interfacing with the medical professions, no offense, but we need that. And I think these children lack that. So yeah,
yeah. And I will say to that, having a place that can act as a medical home, it's such a benefit when it is available in the primary care office can be that having a specialist who specializes in adoption medicine, or working with children who have been in foster care or adoption is is it's a rare event. But when it's available, I would highly encourage people, I couldn't
agree with you more. It's a goldmine if you can get some, there are a few. There are in many states there. Unfortunately, they're usually centrally located at the in the major city where there is a teaching hospital are a so it's, you know, so it's not ideal, and it certainly isn't, they can't It can't end up functioning as a home unless your child lives in that county, your medical home. I mean,
yeah, and the very nice thing, if we can take anything positive away from from the last couple of years is that there is has been an increased in accessibility through telehealth so that there is an opportunity to take advantage of those resources if they are available in your state. And unfortunately, the waitlist is still going to be quite long. But if you do have that option available, I would I would highly suggest taking advantage of it.
So do the use of psychotropic medications in childhood, especially the prolonged use throughout childhood increase the likelihood of substance abuse in adolescents or adults?
Generally, the answer is no. The real challenge with that question is that a lot of these mental health conditions do raise the risk of substance use and abuse. And there are medications in these different categories that can be abused. So you have sort of a double edged sword there where we're trying to treat these conditions to reduce that possibility, but some of the medications can be can be abused. There is information. I'll speak specifically to ADHD, there is information to show that children and adolescents who are treated appropriately with ADHD medications tend to have less substance abuse as they get older. And I would say the way I'd interpret that is that with adequate treatment, some of those more impulsive behaviors that can lead to substance abuse among other sorts More dangerous behaviors, if those are well treated, then you're less likely to engage in them to begin with,
wouldn't it also also play that, again speaking to ADHD, if you are well controlled through medication, some of the secondary impacts of not fitting in socially, or not just the impulsivity, but the not being that square peg in a round hole. And so you start self medicating looking for something that makes you feel better to make you fit in. So I would think that would also have some impact as well.
Yeah, being being more comfortable with social situations and, and having, you know, sort of stable, stable support people and being able to access them, you know, whenever we have mental health issues, knowing who's around and who's available to be supportive, and being able to take advantage of the supports can definitely help reduce the likelihood of those more dangerous behaviors being started in the first place. So I would absolutely agree with that.
So what can parents do? They the child arrives in their home, and there is a ziploc full of bottles of medication? So what can parents do, first of all, to help these medications be as effective as possible?
Sure. And again, with with the caveat of knowing sometimes it's not always clear what the reasoning is, or why why we're doing all these medications. You know,
we're going to talk about that in a minute. But let's start with start. Okay, at the beginning, before, while we're getting the child stabilized at what do we do to make sure that we're using these as effectively as possible,
of course, the main thing I'd say is consistency, making sure that if we do have medications that are prescribed to be given that certain times a day that they are given consistently, that they're not missed doses as much as possible, some meds are okay are more okay with than others, but making sure we're just giving them at the time they're prescribed and the same time every day as much as possible, when the child is placed in his in the household just monitoring for any sort of symptoms or concerns that you have behaviors that are not what you would expect. So if they are having some of those side effects that we talked about earlier, or noticing that maybe they're not eating anything at dinnertime, or they're having trouble with getting homework done, or anything that that is outside of the realm of what you would normally expect for a child that age, you know, as much as you're able to identify that, just to make sure that we're not seeing a medication causing a problem rather than solving a problem. The other thing I would say too, like we talked about is being an advocate for your child to put their health with their medication. So being able to talk to the different people involved, the stakeholders involved, whether that's other case managers, or other health care providers, teachers, so that they know that these medications are being given. And these are the reasons as much as I understand these are the reasons why. And then the other thing too, I think, especially for older kids, it's like getting them involved with medication management, because it's their, it's their health. So that as you're able to being able to say, you know, hey, I understand that you're on these medications, are these ones that you take yourself? Are you managing them? Do you need help with it? Some kids, again, with worries about maybe misusing the medications, making sure that they're in a safe space, so that if they are, do have potential for abuse, making sure that they're safely distributed as needed, but then also allowing the child to have some say in how their and when they're being prescribed or when they're being given so that they can have more ownership over their?
Absolutely. Especially, ultimately, that is our role as parents, with our teens? Is there going to be doing this and they need to understand what what this medication is doing for them? Do they like the way it feels? Do they recognize the need, and so that they can identify I am feeling x, and this is how my body works. This medication does this. That is why I'm taking it. These are the ways I need to I mean, we can't be at some point. They're not going to be with us running after them in the morning saying have you taken your medication, they're going to have to be so shifting that. I want to thank one of our longest partners hopscotch adoption, they have been around, maybe not from the beginning of the podcast, but for a very long time. They truly do support our mission in every way possible. Hopscotch adoptions is a Hague accredited international adoption agency placing kiddos from Armenia, Bulgaria, Croatia, Georgia, Ghana, Kiana, Morocco, Pakistan, Serbia and Ukraine. They specialize in the placement of kids with Down Syndrome and other special needs. And they also do a lot of kinship adoptions. They place children throughout the US and offer home study services as well as post adoption services to residents of North Carolina and New York. Thanks, hopscotch. So my next two questions are kind of a are intertwined. And that is, how do we know when a child should taper down or get off of psychotropic medications? And what do you do? If you look at all these, you see the child taking four or five, or just maybe even one or two, and you're thinking, Gosh, I don't know that this kid needs all of this stuff. And I, I wonder if some of the behaviors we're seeing are not the symptoms, side effects. So how do you figure all that out?
It's a very good question. And I do think those two are are intertwined. And really, what it comes down to is having a good conversation with a health care provider, somebody who is prescribing these medications to talk about what your concerns are. So again, advocating for the child by saying, they came in here with a lot of different medications. And I'm not sure what the benefit is, at this point, there does seem to be a lot of polypharmacy using multiple medications going on. And a lot of children and I have a selection bias in my case, because I see kids who are medically complex, but but there is reason to consider whether or not medications are necessary each time you meet with your health care provider. Typically what I would say and I'll use I'll use the antidepressants as an example. So an SSRI, for example, let's say a kid's coming in, and they have a pretty good dose of, of, I'm gonna say, Prozac or fluoxetine, and they've been on it for a long time, like more than a year, and they're doing really well. That's a good indication to talk about whether or not you think it's still needed. And typically, in those situations, where you have a really good solid support system, you're doing really well from a mood standpoint, having a trial where you wean it down and see how the child responds is very appropriate. Because these medications generally are used for a couple of years at a time. And at which point, if things are going well, you can think about weaning them down. Other medications like stimulant medications, same kind of thing, it really depends on what what benefits we're seeing our symptoms resolved, are fairly well controlled. And what are the side effects if a kid is really responsive to medication, but they are not eating and they're not gaining weight? That's an indicator to, to think about making change or weaning down if possible. Some kids do take meds for a very, very long time and into adulthood to so for life. Yeah, exactly. So there's not necessarily an indication that we that says we have to stop that at age 18, or whenever, whatever age, but it's a conversation that's ongoing with your healthcare provider for every every medication. So for some kids, they, they definitely need that combination, and it works very well for them. But for other kids, you might find that you've been doing something for quite a few years, and you're not seeing any changes good or bad. And that could be an indication that it's time to to make a change.
And conversely, it could also be, especially as our children's are growing and gaining weight, and their body mass is increasing that we may have to consider it, do we still have the right dosage? I mean, so that children are ever changing. And so that's the nature of the beast. So, yeah, so any final words to say for parents who are in the position of trying and now having to start administering and understanding that the use of psychotropic medications?
Yeah, so I'll say that we covered a lot of ground for, for a podcast and having, like you said, like lectures worth of material to go through. So it is definitely understandable if it's overwhelming. And I think having a good conversation with somebody who's knowledgeable in this area is really key. So if you do have a foster child, or an adopted child comes in with multiple medications, communicating with their healthcare provider, and even just asking and saying, Hey, this child came in with all these medications, what are they for? What am I what am I treating with them? What are the things I need to be concerned about with them? We are happy to answer those questions and to talk about it. And it's really helpful because then it gives you the the knowledge to understand what the medications are being used for and what concerns you should have about them. The other sort of takeaway that I would have with any of these medications is that our goal in general and this is true for pretty much all, pediatricians, developmental pediatrician, psychiatrist, anybody who prescribes medications is to try to get the most out of the least number and dose of medications as possible. So we don't, we try to do as much as we can, with as little as we can as possible. That's not always possible. But when it is, you know, we do try to aim towards that. So really trying to optimize everything else in the child's environment to help them be successful, you know, a stable caregiving environment, having different therapeutic supports, school based supports, county based supports, all of those things play a really important role in helping the child to be successful. And the more that we can do that the better off we'll be, in general,
perfectly hinting words. Thank you so much. Dr. Adam Langan fell for being with us today. I truly appreciate it.
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