Does every outburst need medication?

Many of the prescriptions written for management of children’s behavioral/mental health issues stem from situations in which families, practitioners, or both feel that medication is the only practical solution to a child’s chronic or acute needs. Nonmedication-based solutions, however, are more practical than they may seem, said Lawrence Wissow, MD, MPH, professor of health, behavior, and society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Dr Wissow discussed how pediatricians can respond in these situations on Sunday, October 25, in a session on titled “Every tantrum does not need a tranquilizer.”

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“Frequently the family is in crisis, and the office can be in ‘crisis’ too with a waiting room full of patients. Prescribing medication may be the right thing to do in some situations, and when needed, there is a small set of psychotropic-related medications with a long track record that can be used effectively without significant safety concerns or monitoring burdens,” said Dr Wissow.  “Often, however, we can make things better with nonpharmacological intervention, and it would be hard to find a family who wouldn’t rather do something else besides use a psychotropic medication if they thought it would be effective.”

The first thing pediatricians need to do is establish a partnership with the family so that they can explore the nature of the problem and from that understanding, work with the family to find a good approach.  Identification of underlying situational issues that commonly are contributing factors provides a first target for intervention.

“Using a problem-focused approach to getting the history can often find the exact behavior or emotion driving the families’ concern, the situations when the problem occurs, and how family members respond,” Dr Wissow said. “With this in hand, the pediatrician can usually provide some useful brief advice along with a pledge to keep working with the family until things are better.”

Psychotherapy, such as cognitive behavioral therapy or interpersonal therapy, may also be appropriate and effective for some problems. Utilization, however, requires that pediatricians be knowledgeable about when these approaches are suitable and how to access the services.

Dr Wissow noted it may require a future visit to devote the extra time needed to obtain all the information needed and thoroughly discuss the alternatives. Before leaving the office, however, families should be given relevant informational materials and reassurance.

“Let them know that it may take a little time to think about and figure out what to do. However, tell the family you understand their concern, can be responsive, and are optimistic you can help,” he said.