Kids, Complex Trauma, and Medication – The Great Debate Continued.
by Chuck Geddes, Ph.D.
This post will offer some thoughts on the use of psychotropic medications for children and youth with complex trauma histories. This post is a follow-up on my previous post on this topic https://www.complextrauma.ca/complex-trauma-medications/. I’ve had a chance to speak to some child psychiatrists and I have also been learning from a webinar series on Psychopharmacology and Trauma hosted by Dr. Bruce Perry and the Child Trauma Academy. Let’s see what implications we might find for our boy, David https://www.complextrauma.ca/complex-trauma-assessment/. You may wish to read each of these prior posts before beginning this one.
Let’s continue our look at one of the troubling outcomes of this typical assessment and diagnosis – the use of multiple psychotropic medications. I need to state that I am not a medical doctor and am not an expert in medications. I am simply offering my observations from many cases.
First, a correction. In response to my comment that antipsychotics haven’t been approved for use in children under age 16, one psychiatrist pointed out that “Abilify and Risperdal have both been studied in children w/ Autism and severe “irritability” (~aggressive outbursts) and are approved by the FDA (US) for use in this population in ages 6-17 (Abilify, 2009) and 5+ (Risperdal, 2006). However, while there have been studies in other populations of children (e.g. conduct disorder, aggression in kids w/ intellectual disabilities) they have not been approved for more general use in children outside of Autism.”
Psychiatrists connected with the Child Trauma Academy and Dr. Perry are clear that when they learn of a strong trauma history their starting point with medication is almost always the Alpha Agonists – anti-hypertensives like Clonidine or Intuniv. For these children, they see the primary explanation for externalizing and ADHD-like behaviours to be physiological hyperarousal. These psychiatrists also work hard to stick to one medication and not use polypharmacy as they believe that the interaction between different medications are not well understood.
I wrote about dramatic improvements I had observed when using Clonidine instead of stimulants. The week after my original post an 11-year-old boy under our care had his stimulant medications cut in half while adding Clonidine. This boy, who we’ll call Jeff, immediately began sleeping through the night when he had previously been awake until 2 or 4 am. Jeff was much more cooperative and less argumentative, and much less likely to be triggered into outbursts.
I asked another psychiatrist about boys like David or Jeff and the challenges in using medication. This psychiatrist said that by the time the child is referred to him, the child is often on multiple medications as prescribed by family doctors or pediatricians. He said that he’d like to remove all medications and start again but he realizes that this might create some difficulties for the caregivers as they got things sorted out. Since the caregivers are often already in crisis he’s reluctant to go that route and often adjusts and adds medication instead.
Another psychiatrist I contacted referred to a lack of evidence about a trauma-based understanding to medication. He was interested in the trauma perspective and how an elevated active stress response and hyperarousal might be key underlying features. At the same time, as soon as he heard of ADHD symptoms and an ADHD diagnosis he said that he would be obligated to start with evidence-based ADHD medications (mostly stimulants).
When ADHD is present, stimulants tend to be the most effective medication in reducing disruptive and aggressive behaviors and this finding has been fairly consistent across populations studied (including some w/ probable high levels of trauma). However, I still haven’t been able to find studies that look at whether/how trauma mediates or moderates the efficacy (or lack thereof) of stimulants.
David and Jeff are typical of many boys and girls cared for in our foster care system. Their behaviour is viewed as “out of control” and they can be aggressive, demanding, quickly lose their temper and have emotional “meltdowns.” In school, they are viewed as impulsive and distractible. Too many of these kids receive treatment that isn’t trauma-informed, resulting in assessments that reach questionable diagnostic conclusions. The diagnoses then lead to a confusing mix of medications – stimulants, anti-hypertensives, SSRIs, and antipsychotics – all of which is too often unhelpful and doesn’t address the child’s underlying issues. Even the physicians don’t necessarily understand (or have evidence for) the effects of this poly-medication – particularly on the child’s developing brain. We have little understanding of how these medications interact in these children, or what side effects they might be causing.
Don’t we have a moral obligation to do better than this? Can a trauma-focused understanding across our various services lead to more effective and less risky treatment?