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 Reuptake Transporter 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.,