Children who have experienced maltreatment and those in foster care are among youths most likely to be treated with psychotropic medications for mental health disorders. Often, they are treated with multiple psychotropic medications at the same time.
Stable home environments, nurturing caregivers and evidence-based therapy are the highest priority for these children. However, pediatricians may be called on to adjust or maintain medication for these youths.
There has been little trauma-informed guidance on how pediatricians should approach youths who have experienced maltreatment and are on multiple psychiatric medications, including the appropriate discontinuation of psychotropic medications. A new AAP clinical report helps fill that gap.
Why are multiple medications prescribed?
Maltreated youths are at increased risk for symptoms of traumatic stress, including but not limited to post-traumatic stress disorder (PTSD). While there is no evidence for pharmacotherapy for PTSD in children, it is well-established that trauma symptoms can mimic commonly identified mental health disorders in youths.
In addition, maltreated youths may have a diagnosis, such as sleep difficulty, anxiety, depression, attention-deficit/hyperactivity disorder or aggression, that warrants consideration of medication.
Since children who have experienced maltreatment are more likely to see multiple providers and be diagnosed with multiple disorders over time, it is easy to see how children and adolescents can end up on several medications. However, it can be challenging for pediatricians to piece together knowledge about traumatic exposures or rationale for previous treatment approaches due to placement changes, involvement in multiple systems and limited access to records from various health care professionals.
How to deprescribe
The AAP clinical report Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication (https://doi.org/10.1542/peds.2019-3751) reviews the evaluation, psychotherapeutic recommendations and pharmacotherapeutic response to children with diagnoses common to those who have experienced maltreatment traumas.
The report highlights the approach to common diagnoses in this population and areas of diagnostic overlap. Some pharmacotherapeutic agents have demonstrated benefit when they are part of a treatment response that includes psychosocial supports. Often, the conundrum is figuring out how to safely stop psychotropic medications.
One approach in caring for youths on several psychotropic medications is to consider deprescribing. Initially used in geriatrics, deprescribing has been adopted by numerous fields of medicine that struggle with stopping medications once they have been started. Deprescribing is not simply ceasing medication, but rather identifying and tapering off medications that no longer are indicated or when the existing or potential risks outweigh the existing or potential benefits.
This process can be daunting for pediatric providers. Thus, the report recommends taking the following steps:
- Ascertain the patient’s complete medication history.
- Consider the risk and adverse effect profile of current medications.
- Assess each prescribed medication in light of the comprehensive assessment.
- Prioritize each medication to be decreased or discontinued.
- Implement the plan.
- Monitor the patient response and reassess.
When choosing which medications to decrease, consider:
- those with no clear indication,
- those that are part of a prescribing cascade in which an adverse effect of a medication is the basis of another diagnosis, such as insomnia, and a new medication is added,
- those that may be causing more harm than good,
- those that are redundant or no longer needed,
- those that are prophylactic in nature,
- those that impose an unacceptable treatment burden on children and families.
Lack of Food and Drug Administration approval of a medication for children (“off label” use) is not a reason alone to discontinue a medication. Instead, providers should consider the level of evidence or support for the medication’s use for the specific condition as well as documented response to treatment. Medications with the least evidence, least documented improvement and/or most adverse effects should be stopped first.
Furthermore, medications prescribed at supratherapeutic doses without clear justification or subtherapeutic doses without clear effectiveness should be considered for discontinuation.
In general, only one medication should be tackled at a time so any symptom return or adverse effect can be clearly attributed and addressed.
If child psychiatrists are available, collaborating with them can be an effective way to address diagnostic uncertainty and plan approaches to discontinue medications as part of a comprehensive treatment plan.
Dr. Keeshin is a liaison from the American Academy of Child and Adolescent Psychiatry to the AAP Council on Child Abuse and Neglect Executive Committee. Dr. Forkey is a member of the AAP Council on Foster Care, Adoption and Kinship Care Executive Committee.
