NAPNAP 2012: Pediatric Psychotropic Medication… Can We Talk?

There are several factors that determine whether children with psychiatric disorders and their families decide to use psychotropic drugs as part of treatment. The patient-provider relationship is a key factor in promoting treatment adherence in this patient population, and there are several strategies that providers can use to improve this relationship and help ensure successful treatment.

For many pediatric mental health conditions, psychotropic medications can elicit dramatic improvements. For example, 80-90% of youth with ADHD respond well to stimulants. Between 1994 and 2001, prescriptions written for psychotropic medications for adolescents between the ages of 14 and 18 years more than doubled. This trend has been attributed to an enhanced knowledge base, changes in insurance reimbursement practices, the introduction of additional and more desirable medication options, and providers’ greater acceptance of these medications as effective treatment options. Yet, the literature shows an adherence rate of about only 50% for psychotropic medications among children.

During her session Thursday at the 2012 NAPNAP annual meeting, Vanya Hamrin, MSN, RN, APRN, PMHCS, associate professor, Vanderbilt University School of Nursing, reviewed a number of interventions that can help improve treatment adherence among pediatric patients, including establishing a healthy relationship between family and provider, offering reward programs, utilizing motivational interviewing techniques, reducing multiple daily dosing of medications, addressing social stigma associated with mental health conditions and the medication used to treat them, and offering patient and caregiver education.

After covering several factors that influence families’ decisions to initiate, sustain, or discontinue treatment with psychotropic medications, Hamrin talked about the benefits and costs of the drugs, as reported by children and parents. Addressing problems with adherence requires an understanding of children’s and their parent’s perceptions about medication treatment, she told the audience. In addition to making medical assessments, practitioners must collaborate with families in the decision-making process.

Hamrin emphasized the need for providers to form a trusting alliance and open dialogue with their families. According to her, relationship between the patient (and the patient’s family) and the health care provider is probably the “most important factor” in medication adherence. Studies have found that a good family-provider relationship can help minimize stigma associated with childhood mental health treatments, improve medication adherence, and influence decisions about continuation of treatment.

“The more family members are involved in the decision, the more ideas are generated and the greater the family’s investment in the outcome,” she explained.

Motivational interviewing helps patients recognize the pros and cons of change and openly discuss ambivalence to treatment. Hamrin told the audience about the Hamrin Medication Questionnaire, an useful tool she helped develop for qualitatively assessing reasons for nonadherence. Hamrin suggested that providers should select questions from this comprehensive list that are most relevant to their practice and to the individual patient. Questions may be asked at initiation of treatment, at follow up, or when nonadherence is suspected. She said that asking these questions will create an open forum to discuss family concerns.

When treatment is not producing adequate progress, providers need to explore how best to improve the treatment plan. The Hamrin Medication Questionnaire can be a useful resource in this endeavor. “Mental health has come a long way in the last thirty years, but it still has a long way to go,” said Hamrin. “We don’t ever want to get into a situation where we are blaming the family; we have to come up with new solutions.”

Hamrin’s presentation slides are available here. http://www.napnap.org/Docs/2012%20Conference/Handouts/119_Hamrin.pdf