What Teachers Should Know About the Medications Their Students are Taking

Joseph B. Ryan, Ph.D. Clemson University Concerns Regarding Psychotropic Medications 1. Increase use of Meds among Students

2. Potential for Adverse Side Effects

3. Use of “Off Label” Medications with Children

4. Increased Use of Adjunctive Therapy

5. Lack of Monitoring Procedures

6. Lack of Teacher Knowledge

7. Disproportionate Levels of Care Why are Medications Prescribed to Children? • ADHD • Autistic Spectrum Disorder • Anxiety Disorders • ODD • Conduct Disorder • Depression • Bipolar Disorder • Eating Disorders • Psychotic Disorders • Substance Use Disorders Prevalence of Psychotropic Medications • 20% students 9 - 17 have mental disorders resulting in at least a mild functional impairment (Center for Health and Healthcare in Schools, 2007).

• Estimated 8 million children taking psychotropic medications (Morris & Stone, 2011).

• 2% to 3% of all youth prescribed some type of psychotropic medication (NIMH, 2003).

• Prevalence rates increase to 15% to 20% when dealing with special ed. students

• Prevalence rates range from 50% -76, especially among students with ADHD, Autism, and Emotional Disturbance (Ryan , Reid, Gallagher & Ellis, 2008). Advantages of Psychotropic Medications • Assists with biologically-based disorders

• Decreases negative symptoms

• Increases functioning

• Increases effectiveness of other Behavioral & Academic Interventions

• Fast acting

• Cost-effective Potential Dangers of Psychotropic Medications • All medications have a potential for adverse side effects that may range from mild to life threatening.

– "Sleepwalking, and eating or driving while not fully awake, with amnesia for the event, have been reported."

• Medications can also produce adverse side effects when taken with other medications (Adjunctive Therapy). Limited Teacher Monitoring of Medications – 1982: 9% of SPED teachers communicate directly with physician (Gadow , 1982)

– 1990: 49% of EBD teachers said their school had no drug policy (Singh, Epstein, Luebke & Singh, 1990)

– 1996: 68% of EBD teachers helped monitor med effectiveness (Runnheim, Frankenberger & Hazelkorn,1996)

– 2003: 51% of Regular & SPED teachers monitored medication effectiveness (Snider, Busch, & Arrowood, 2003)

– 2008: 49% of EBD teachers did not believe they were properly informed / involved in medication process of their students. (Ryan, Reid & Ellis, 2008) Lack of Teacher Knowledge

• 1975: Only 21% of Sped teachers were adequately trained (Wiethorn & Ross, 1975)

– 1990: 95% of EBD teachers desired additional training (Singh, Epstein & Singh, 1990) – 1991: 85% of LD teachers desired additional training (Epstein, Singh, Luebke, & Strout, 1991)

– 2003: Most Regular & Sped teachers were unaware of side effects of stimulants (Snider, Busch, & Arrowood, 2003)

– 2008: 92% of EBD teachers expressed a desire to increase their knowledge of medications (Ryan, Reid & Ellis, 2008). Potential Disparity of Care

• 1987: Caucasians (7.7%) Minority (3.0%) (Cullinan, Gadow, & Epstein, 1987)

• 1997: AA 2.5 times less likely to receive methylphenidate (Zito et. al., 1997)

• 2000: Caucasian /African American 5 : 1

• 2000: Caucasian / Hispanic 3 : 1 (Safer & Malever, 2000) Understanding How Psychotropic Medications Work NEURONS & NEUROTRANSMITTERS

• Chemical molecules that regulate brain function by relaying messages from nerve to nerve both within and outside the brain.

• Neurotransmitters are used all over the body to transmit information and signals. They are manufactured and used by neurons (nerve cells) and are released into synaptic clefts between the neurons.

• Also relay messages from nerve to muscle, lungs, and intestinal tracts.

• They can accentuate emotion, thought processes, joy, elation and also fear, anxiety, insomnia and that terrible urge to over indulge in food, alcohol, drugs, etc. Developing Neurons & Synapsis

• Most neurons are formed & survivors selected by the end of the 2nd trimester.

• Up to 90% of neurons commit “apoptotic suicide” before birth.

• Neuronal Arborization: Develop more synapsis by age 6 than any time in our lives. Next 5-10 years half of connections removed through “synaptic pruning”

• Mature brain contains 100 billion neurons with 100 trillion synapsis. Over 50 Neurotransmitters Identified (100 Estimated) Classic 6 Neurotransmitters 1. Epinephrine: – Major stress neurotransmitter (Related to blood pressure, heart rate). 2. Norepinephrine: – Stress neurotransmitter. High levels seen in states of anxiety and insomnia. – Released in response to perceived threat. 3. Dopamine: – Modulates effect of excitatory hormones. Necessary for states of relaxation & mental alertness. 4. Acetylcholine – 1st neurotransmitter identified. Rather than engaging in direct synaptic transmission between neurons, is a neuromodulators acting on a variety of neurons throughout the nervous system. Plays a role in attention and arousal. 5. Serotonin: – Master neurotransmitter found all over the body. Helps modulate levels of stress hormones. 6. GABA (gamma-aminobutyric acid) – Foremost inhibitory neurotransmitter involved with insomnia, anxiety & depression. How Neurons Communicate with Neurotransmitters Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) How Neurons Communicate with Neurotransmitters Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) How do Medications Work? Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) How do Medications Work? Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) How do Medications Work? Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

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Nerve to Nerve Connection

(Wilens, 2004) How Neurotransmitters are Linked to Mental Health Disorders Neurotransmitter Amount of Associated Neurotransmitter Psychological Disorders Dopamine Too much Schizophrenia

Serotonin Too little Depression / OCD Norepinephrine Too little Depression How do Medications Work?

• Direct Acting Medications

• Indirect-Acting Medications – Increased release of NT – Decreased re-uptake of NT – Decreased metabolism of NT Several Mechanisms Psychotropic Medications Use to Assist or Deter the Transmission of Neurotransmitters Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal

Nerve Signal Receptors

Reuptake Transporter

Nerve to Nerve Connection Categories of Psychotropic Medications

1. Antidepressants 2. Adrenergic Agonists 3. New & Atypical Antipsychotics 4. Anxiolytics 5. Beta-blockers 6. Mood Stabilizers 7. Selective Serotonin Reuptake Inhibitors (SSRI) 8. Antiepileptics 9. Stimulants Antidepressants Why are Antidepressants Being Prescribed to Children?

Child Statistics • Up to 2.5 percent of children in the United States suffers from depression. • Up to 8.3 percent of adolescents in the United States suffers from depression. • Girls entering puberty are twice as likely than boys to experience depression. • Only 2 out of 3 patients with depression will respond to any given antidepressant (Stahl, 2000) Treatment for Adolescents with Depression (TADS) • 12 week treatment study • 439 Adolescents (12-17 years) with Depression • Group 1: Combination 71% Response – Prozac + Cognitive Behavioral Therapy (CBT)

• Group 2:Prozac 61% Response

• Group 3: CBT 43% Response

• Group 4: Placebo 35% Response Selective Serotonin Reuptake Inhibitors (SSRIs) • fluoxetine (Prozac) • fluvoxamine (Luvox) • paroxetine (Paxil) • sertraline (Zoloft) • citalopram (Celexa) • escitalopram (Lexapro)

Used to treat: • Major Depressive Disorder • Enuresis • ADHD • Anxiety disorders – (e.g., school phobia, separation anxiety, panic disorder, and obsessive-compulsive disorder) • Sleep disorders (night terror) • Some cases of self-injury in individuals with developmental disabilities How Do Antidepressants Work?

Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) How Long Do SSRIs Take to Work?

 SSRIs prevent the reabsorption of serotonin into the releasing neuron and increase its availability to the next neuron downstream.

• Must be taken for 3-4 weeks to reduce or alleviate symptoms of depression

• Typically used for a minimum period of 9 to 12 months SSRI Side Effects Common Less Common Serious Nausea Weight Loss or  Rash Diarrhea Gain Hives Headache Increased activity Seizure Anxiety Heatstroke Restlessness Dizziness Fatigue Tremor Sexual Dysfunction (This is NOT a complete list of side effects) SSRI Cautions • Possibility of an increased risk for suicidal behavior in adolescents who are being treated with antidepressant medications, especially at the beginning of treatment or when doses are changed.

• FDA Black Box Warning – Antidepressants increase risk of suicidal thinking and behavior – Patients should be observed closely – Family members must be advised

• Interaction with anticonvulsants also can affect seizure threshold. Atypical Antidepressants • bupropion (Wellbutrin) • venlafaxine (Effexor) • mirtazapine (Remeron) • trazodone (Desyrel) • nefazodone (Serzone)

• These medications may be tried when other antidepressants (e.g., SSRIs) are not effective or have problematic side effects.

• These antidepressant medications do not fit well into any of the other medication categories. How Long for Atypical Antidepressants to Take Effect?  Majority of these medications may take up to 12 weeks to begin working.

 Hence, the ‘Titration process’ of identifying the proper dosage for a child can be time consuming process. Atypical Antidepressant Side Effects Common Less Common Serious

Dry mouth Agitation Liver problems Constipation (Duloxetine) Urinary retention Confusion Blurred vision Heart palpitations Nasal congestion Nervousness Fatigue Seizures Confusion Anxiety (Buproprion) Abnormal (Buproprion) Dreams (This is NOT a complete list of side effects) Cautions

• FDA issued advisory to closely monitor children taking antidepressants for warning sides of suicide, especially at the beginning of treatment or when doses are changed.

• FDA Black Box Warning – Antidepressants increase risk of suicidal thinking and behavior – Patients should be observed closely – Family members must be advised Tricyclic Antidepressants (TCAs)

• Used for depression, also for panic, obsessive-compulsive, and anxiety disorders, as well as ADHD and sedation.

• Older tricyclic antidepressants (TCAs) are more commonly suggested only as a second-line choice. How Long for TCAs to Take Effect?

 TCAs work by raising the levels of serotonin and norepinephrine in the brain by slowing the rate of reuptake, or reabsorption of neurotransmitters into the releasing neuron.

 May take several weeks to see desired results. Tricyclics work by blocking the Reuptake of norepinephrine & serotonin reuptake sites Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) Side Effects Common Less Common Serious

Dry mouth Nausea Increased heartbeat

Delayed urination Fatigue Irregular heart rhythms (very rare) Sexual dysfunction Weight gain

Constipation

Lightheadedness (This is NOT a complete list of side effects) Cautions

• TCAs are the leading cause of death by drug overdose in the United States.

• Due to possibility of causing serious cardiac complications, TCAs can be lethal if misused at high doses.

• Because people with major depressive disorder may be contemplating suicide, the danger of overdosing is a serious concern, and should be considered when these medications are prescribed. Adrenergic Agonists What are Adrenergic Agonists prescribed for?

• clonidine hydrochlorid (Catapres, Kapvay) • guafacine hydrochloride (Tenex, Intuniv)

Primarily used to treat: • ADHD • Tics and Tourette Syndrome • Behavior disorders with severe agitation, self-injury, or aggression • Adjunctive treatment of schizophrenia and mania Adrenergic Agonists Side Effects Common Less Common Serious

Constipation • Depression Anxiety • Swelling of Difficulty legs/feet breathing Hallucinations Irritability Dizziness Headache Nausea

(This is NOT a complete list of side effects) New & Atypical Antipsychotics (Neuroleptics) What are Antipsychotics prescribed for? • risperidone (Risperdal) • olanzapine (Zyprexa) • quetiapine (Seroquel) • ziprasidone (Geodon) • aripiprazole (Abilify)

 Typically used to treat:  Psychotic disorders (including schizophrenia - exacerbations and maintenance  Mania (in conjunction with a mood stabilizer)  Bipolar Disorder  Irritability in autism  Dyskinetic movement disorders (e.g., Tourette Syndrome)  Behavior disorders with severe agitation. Antipsychotics Block Receptors for dopamine & serotonin neurotransmitters Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) Side Effects Common Less Common Serious Dry mouth Restlessness Decreased Fatigue Stiffness of number of blood cells Constipation tongue, jaw, back or legs Liver damage Blurred vision Shaking of hands Extreme stiffness Dizziness Heatstroke of movement Drooling Seizures Inability to Sexual breath or swallow dysfunction Itchy skin (This is NOT a complete list of side effects) Cautions • Serious side effects are possible, especially with longer term use, including tardive dyskinesia (abnormal, involuntary movement of the arms, legs, and head) and Parkinsonism (symptoms resembling Parkinson's disease, such as muscle stiffness, stooped posture, and drooling).

• Approximately 5% of patients will develop TD each year.

• Relapse occurs at 10% per month

• Therapeutic dose is very close to a toxic dose of medication. Anxiolytics (Antianxiety) Medications Who are some Students Being Prescribed Antianxiety Medications? • Separation Anxiety Disorder – Ages 7 -11 (4.1-4.7% ) – Ages 12-14 (3.9%) – Ages 14-16 (1.3%)

• 5% of school-aged children are identified as school refusers.

• PTSD – 15% to 43% of girls and 14% to 43% of boys have experienced at least one traumatic event in their lifetime. – Of those children and adolescents who have experienced a trauma, 3% to 15% of girls and 1% to 6% of boys could be diagnosed with PTSD. – Following sexual abuse 21% to 55% – Much higher risk of the disorder for children in at-risk homes.

• GAD Child Anxiety Multimodal Study (CAMS)

• 12 week treatment study • 439 Adolescents (7 – 12 years) with General Anxiety Disorder (GAD) • Zoloft & CBT Group: 81% Response

• CBT Group: 60% Response

• Zoloft Group: 55% Response

• Placebo Group: 24% Response Pediatric OCD Treatment Study (POTS) • 12 week treatment study • 112 Adolescents (7 – 17 years) with Obsessive Compulsive Disorder (OCD) • Zoloft & CBT Group: 54% Response

• CBT Group: 39% Response

• Zoloft Group 21% Response

• Placebo Group 4% Response What are Anxiolytics prescribed for? Benzodiazepines • alprazolam (Xanax) • diazepam (Valium) • lorazepam (Ativan)

Atypical anxiolytics • buspirone (BuSpar)

Antihistamines • diphenhydramine (Benadryl) • hydroxyzine (Atarax)

• Most often used for anxiety disorders, seizure control, night terrors and sleepwalking, acute management of severe agitation, adjunct treatment in mania and refractory psychosis, and Tourette Syndrome How Anxiloytics do they work?

• Majority of antianxiety agents increase the inhibitory neurotransmitter, GABA which slows the firing rates of all neurons in the region.

• Overactivity of norepinephrine neurons is associated with anxiety

• The effect of these agents is to reduce the individual’s awareness of environmental stress and disrupt memory of the events.

• Buspirone attempts to decrease the effect of environmental events on aggression through interference with serotonin activity in the memory processing regions (hippocampal/amygdala) of the brain. Anxiolytics Slow Down the Firing Rates of Neurotransmitters

Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) Side Effects Common Less Common Serious

Sleepiness Paradoxical effect Dependency Short term resulting in: memory loss  Irritability  Excitement Muscle relaxation  Anger  Uncontrollable behavior

(This is NOT a complete list of side effects) Cautions • Should not be stopped suddenly due to common withdrawal symptoms that may include anxiety, muscle cramps, and vomiting.

• Hallucinations and potentially lethal seizures are a risk if large doses are stopped suddenly.

• Must not be combined with alcohol which greatly increases their sedating properties and can result in unconsciousness, slowing or stopping breathing. Beta Blockers What are Beta-blockers prescribed for?

• propranolol (Inderal)

Prescribed for: • Performance anxiety disorder • Disruptive behavior disorders (especially those manifesting explosive and violent behavior) • Self-injury and aggression in intellectual disability • Aggression and panic in autism Beta Block Receptors for sympathetic nervous system by blocking Beta receptors

Presynaptic Neuron Postsynaptic Neuron Cleft

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Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection Mood Stabilizers

Happy Lab Depressed Lab Anxious Lab Mood Stabilizers  Eskalith CR / Lithonate (LITHIUM)  Lithium stabilizes nerve cells in the brain  Lithium only effective for 40% - 50% of patients.

Prescribed for:  Manic episodes of bipolar disorder

 Unipolar Depression/adjunct treatment in major depressive disorder

 Behavior disorders with extreme agitation or aggression Side Effects of Lithium Common Less Common Serious Weight gain Low thyroid Seizures Diarrhea function Vomiting (exhaustions) Increased thirst Severe dizziness Acne Increased urination Irregular Rashes Tiredness heartbeats Hair loss Headache and Blurred vision dizziness Irritability. Muscle twitches Unconsciousness

(This is NOT a complete list of side effects) Cautions Lithium

• Overdose of Lithium may be fatal.

• Some patients with bipolar disorder may become manic more often if lithium is stopped suddenly.

• Only about half of patients will respond to treatment. Selective Norepinephrine Reuptake Inhibitors (SNRIs) Selective Norepinephrine Reuptake Inhibitors (SNRIs)

• Strattera (atomoxetine) • Edronax (rebxetine)

 SNRIs are an older form of antidepressant, more commonly prescribed today for dealing with motivation and concentration issues associated with ADHD. How Do SNRIs Work?

Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) Side Effects Common Less Common Serious

Constipation Depression Unknown at this Dry mouth Tremor time Nausea Early awakening Dizziness Problems sleeping Problems urinating

(This is NOT a complete list of side effects) Cautions

• Possibility of an increased risk for suicidal behavior in adolescents who are being treated with antidepressant medications, especially at the beginning of treatment or when doses are changed Antielpileptic Drugs (AEDs) What are Antiepileptic Drugs (AED) prescribed for?

• carbamazepine (Tegretol) • ethosuximide (Zarontin) • sodium valproate (Depakote) • oxcarbazepine (Trileptal) • topiramate (Topamax) • gabapentin (Neurontin) • lamotrigine (Lamictal)

• Commonly used for treatment of Bipolar Disorder or mood stability (most evidence for Depakote and Lamictal), adjunct treatment in Major Depressive Disorder, severe behavior problems, and seizure control Antiepileptic Drugs (AEDs)

Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors

Reuptake Transporter

Nerve to Nerve Connection Side Effects for AED Common Less Common Serious Sedation  Weight gain Congenital Fatigue malformations and cognitive Dizziness  Irreversible visual defects deficits of Coordination newborns when Disturbances mothers treated Tremor with antiepileptic Cognitive deficits drugs during Sexual disorders pregnancy

(This is NOT a complete list of side effects) Stimulants Why are Psychostimulants Commonly Prescribed?

• 3% – 5% of Children Demonstrate Characteristics of ADHD

– C.H.A.D.D. estimates 3.5 million children

• Bender (1997) claims children more Likely to be: – Physically Abused – Suspended / Expelled – Higher Rates of Psychiatric Disorders – Parenting Stress Significantly Higher – Difficulties Establishing Relationships – 50% of Children Develop Bx Problems of an Oppositional Nature (Hinshaw, 1987) Multimodal Treatment Study of ADHD (MTA) • 14 month randomized clinical trial • 579 children (7-9.9 years) with ADHD combined type • Sponsored by NIMH and Dept of Education

Combination of Meds & Behavior Group 68% Response

Medication Management Only Group 56% Response

Behavioral Treatment Only Group 34% Response Standard Community Care 25% Response Clinical Relevance of MTA

• Following 24 months: – Effect size for medication and combined treatment groups deteriorated 50% from the end of treatment at 14 months (ES: 0.6) to the follow-up at 24 months (ES: ~0.3).

– Therefore, some children in medication management and the combined treatment group lost some of the initial benefits (14 months), when seen in follow up (24 months).

– Behavioral treatment group & community care group did not show deterioration. Stimulants • methylphenidate (Ritalin, Methylin, Metadate, Concerta, Daytrana Quillivant) • dexmethylphenidate (Focalin) • mixed amphetamine salts products (Adderall) • lisdexamfetamine dimesylate (Vyvanse) • dextroamphetamine (Dexedrine, Dextrostat)

Prescribed primarily for: • Attention Deficit Hyperactivity Disorder • ADHD with comorbid disorders – including mental retardation, Fragile X Syndrome, Tourette Syndrome • Hyperactivity in Developmental Disorders • Narcolepsy • Adjunctive treatment in refractory depression How Do Stimulants Work? Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal Problem with

Reuptake receptors activating Receptors

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) How Do Stimulants Work? Synapse Presynaptic Neuron Postsynaptic Neuron Cleft

Nerve Signal Nerve Signal

Reuptake Receptors Direct Acting Medication

Reuptake Transporter

Nerve to Nerve Connection

(Wilens, 2004) Side Effects Common Less Common Serious

Lack of appetite Rebounding Motor or vocal Insomnia Slowing of tics Headaches and growth Sadness stomachaches Nervous habits. Hallucinations Irritability (auditory, visual, tactile) Loss of interest in friends Staring into space Rapid pulse rate. Medication Frequency Peak Duration Effect of Effect Dexedrine (d- 2 or 3 times per 1 – 3 hours 5 hours amphetamine) day Adderall 2 or 3 times per 1 – 3 hours 5 hours day Dexedrine Spansules Once in morning 1 – 4 hours 6 – 9 hours Adderall XR Once in morning 1 – 4 hours 9 hours Ritalin 3 times per day 1 – 3 hours 2 – 4 hours Focalin 2 times per day 1 – 4 hours 2 – 5 hours Ritalin SR 1 or 2 times per 3 hours 5 hours day Metadate CD Once in morning 5 hours 8 hours Once in morning 8 hours 12 hours Overview • Parents are less likely to leave childhood emotional and behavioral problems untreated.

• Since many medications are prescribed Off Label “trial & error” will tell what works best for each student

• Many drug interactions are unknown at this time.

• Parents & children “Should Expect Side Effects” since no medication comes(Wilens, without 2004) them. Legal Requirements • IDEA and Section 504 of Rehab Act of 1973 require medications be administered by schools whenever it is deemed necessary for the child to have access to educational services.

• Educational personnel are prohibited from requiring parents to obtain a prescription medication for child with or suspected of having a disability as a condition for a. attending school b. receiving an evaluation, or c. receiving any type of special education or related services [Section 612 (a) (25) (A)].

• School personnel may consult or share classroom-based observations with parents regarding a student's academic and functional performance, or behavior, or the need for an evaluation [Section 612 (a) (25) (B)]. Recommendations for Schools

• Established Policy for Monitoring Medication Effectiveness. • Ensure schools provide feedback to prescribing physicians. • Monitor students prior to medications and after beginning new medications or changing dosage. • Provide teachers training in psychotropic medications. – Professional Preparation – Staff Development SCHOOL CHECKLIST FOR ADMINISTERING PSYCHOTROPIC MEDICATIONS

Step 1 Roles and responsibilities of adults involved in administration (e.g., parents, nurse, unlicensed personnel) should be clearly defined.

Step 2 Medications should be delivered to school in the original container by the parent with the insert containing medication guidelines included

Step 3 Medications should be stored in a locked cabinet

Step 4 School nurse or physician should review medication orders to ensure that the medication is appropriate for the student and dosages are within recommended ranges

Step 5 Team should establish procedures to ensure student receives medication as prescribed (e.g., one pill at 8 am and noon).

Step 6 Procedures should be in place in the event of a medication incident (e.g., accidental overdose, missed dose, child given the wrong medication). SCHOOL CHECKLIST FOR ADMINISTERING PSYCHOTROPIC MEDICATIONS

Step 7 Personnel responsible for administering medication should maintain a log of all medication dispensed

Step 8 Establish procedures for notifying parents when it is time to renew supplies of medication

Step 9 List of precautions to take while administering the various types of medications (e.g., do not crush capsules).

Step 10 Off-site (e.g., field trip) administration procedures.

Step 11 Procedures for dealing with student refusal. Physician Monitoring Guidelines • Weeks 1-4 (once per week) • Weeks 5-8 (every other week) • Week 12: face to face visit • After week 12: as clinically indicated

Monitor for suicidality, worsening of symptoms, behavioral changes (physician med guide @ www.aacap.org) Future Research Needed

• Survey Teacher Training Programs & School Systems to Determine Level of Training Provided on Psychotropic Medications.

• What should the Priority & Level of Training be?

• Monitor Physician Prescription Practices for Children & Adolescents with EBD.

• Investigate Efficacy of Monitoring & Feedback Procedures used by Schools.

• Investigate Use of Polypharmacy Across Placement Settings.

Parting Thoughts

• “In selected cases behavioral therapy can be as effective as psychotropic medications, and its therapeutic effects may last longer after discontinuance of treatment” (Stahl, 2000). Common Treatments for Oppositional Defiant Disorder (ODD) an Conduct Disorder (CD)

Psychosocial: • Behavioral Interventions focusing on reinforcing appropriate behavior and timeout for inappropriate behaviors.

Psychopharmacological • Mainly used for comorbid disorders with ADHD, depression. Common Treatments for ADHD

Psychosocial: • Behavioral Interventions & parent consultations with emphasis on home-school collaboration.

Psychopharmacological • Stimulants (e.g., Ritalin) 1st line of treatment. For non-responders SNRIs (e.g., Straterra). Common Treatments for Depression

Psychosocial: • Cognitive behavioral to assist child in monitoring & developing coping skills.

Psychopharmacological • SSRIs (e.g., Prozac, Zoloft). Atypical & tricyclics for non-responders. • For bipolar disorder Lithium or Depakote as primary meds. Common Treatments for Anxiety Disorders (GAD, OCD, PTSD, SAD)

Psychosocial: • Cognitive behavioral therapy and learning ways to self control and responding in a more adaptive fashion

Psychopharmacological • Some SSRIs (e.g., Luvox, Zoloft). • For nonresponders atypical antidepressants (e.g., Effexor) or anxiolytics (e.g., Ativan, Buspar) Common Treatments for Schizophrenia

Psychosocial: • Behavioral & social skills training to assist child in coping.

Psychopharmacological • Atypical antipsychotics (e.g., Risperdal, Zyprexa) with traditional neuroleptics (e.g., Haldol) for non-responders. Common Treatments for Autism Spectrum Disorder (ASD) Psychosocial: • Behavioral & psychoeducational approaches that focus on language development & socialization.

Psychopharmacological • Increasingly prescribed combinations of medications not for ASD, but for overactive, anxious and aggressive behaviors, including antidepressants, stimulants, and antipsychotic medications (e.g., Risperidal) References A-Z Health Guide from WebMD Retrieved on http://www.webmd.com/drugs/index- drugs.aspx

Dulcan, M.K., (2007). Helping parents, youth, and teachers understand medications for behavioral and emotional problems. American Psychiatric Press, Inc.

Forness, D.R., Walker, H.M. & Kavale, K.A. (2004). Psychiatric disorders and their treatment: A primer for school professionals. Emotional & Behavioral Disorders in Youth, 4, 3-7.

Mental Health Disabilities Technical Assistance Guide on Psychotropic Medications. Retrieved on http://www.jobcorpshealth.com/mhdisabilities/html/meds.htm.

Nissen, D. (2004). Mosby’s 2004 Drug Guide. Mosby Inc.

Psychotropic Medication Guide Retrieved on February 7, 2008 from http://allpsych.com/meds.html

Practice Parameters for Use of Stimulants in the Treatment of Children, Adolescents and Adults www.aacap.org

Ryan, J.B., Ellis, C. & Katsiyannis, A. (2015). Increasing role of medication therapy for managing student behavior. Beyond Behavior, 24(3), 31-37. References

Ryan, J.B., Katsiyannis, A. & Hughes, E. (2011). Medication treatment for Attention Deficit Hyperactivity Disorder. Theory into Practice. 50(1), 1-9.

Ryan, J. B. & Katsiyannis, A. (2009). Helping schools ensure medication therapy is conducted in a safe and efficacious manner. Teaching Exceptional Children Plus, 6(2), 1-12.

Ryan, J. B., Reid, R., & Ellis, C. (2008). A survey of special educator knowledge regarding psychotropic interventions for students with emotional and behavioral disorders. Remedial & Special Education, 29(5), 269-279

Ryan, J.B., Katsiyannis, Losinski, M., A., Reid, R., & Ellis, C. (2013). Review of state medication policies/guidelines regarding psychotropic medications in public schools. Journal of Child and Family Studies,

Ryan, J. B., Reid, R., Gallagher, K. & Ellis, C. (2008). Prevalence rates of psychotropic medications for students placed in residential care. Behavioral Disorders, 33(2), 99-107.

Stahl, S.M. (2012). Essential Psychopharmacology: Neuroscientific Basis and Practical Application. Cambridge University Press. For additional Information

Joseph B. Ryan, Ph.D. Clemson University (864) 656-1531 [email protected]

Caution about Side Effects