Who holds the pills???

I still have a few connections at one of the local psych hospitals in my area, so I hear from time to time complaints and concerns from “the inside”.  One of the big questions that comes up is why kids have access to their medicine and, oftentimes, are given complete control of their medicine.  This is not just an issue for the inpatient world where they manage the kids who overdose on medicine they have control of,.  It is also an issue for my outpatient world.  In my area of treatment, the most common problem is not that they take too much of their medicine, but often not enough.  A frequent occurrence is the decompensating kid who, lo and behold, has not been taking their medicine.  The parents will come in and say that they knew the child was off their medicine because they were acting up. This begs the question . . . “who should hold the pills”.

Without a doubt, parents tend to manage their child’s mental health issues with a different level of intensity.  The level of supervision and oversight of a child’s medicine for asthma, seizures, or diabetes is far greater and taken more seriously.  It is far too common for parents to expect a minor child to “take responsibility” for their mental health issues and take their antidepressant or stimulant medicine on their own in a responsible fashion.  But isn’t the child with mental health issues by definition suspect in their judgement over major life issues?  The issues involved with depression are as potentially severe as those with the above medical issues, yet kids are often expected to take their pills as prescribed, and to let the parents know when they are running short so more can be ordered.  That sort of inattention with antidepressants can lead to increased risk of self harm either from worsening of depression when pills are not taken or an increase in antidepressant-mediated suicidal ideation which is worse in the period when the medicine is initiated (non-compliant kids who restart medicine essentially re-titrate the medicine over and over again).  Stimulant medicine can be used in a inconsistent fashion and still be beneficial, but non-compliance with the medicine will result in academic and behavior issues in some children who are not consistently taking them for school.  The other issue of huge concern is the potential for abuse with the stimulant medicine.  Stimulants that are not properly monitored can be taken inappropriately, or even sold to peers (yes, that does happen).

So . . . who should hold the pills?

It is my belief that the parents of any child under the age of 18 should be holding the pills and monitoring the administration of those pills in almost every case.  Once a level of trust is built up and there is a clear pattern of compliance and cooperation from the child, I can see moving to a system of using one of those Sunday-Saturday weekly pill dispenser/reminder things that the child can access and the parent can monitor DAILY to make sure that the proper medicine is taken.  But even that should be in a common area and not just handed over to the kid to take.  Any deviation from a pattern of compliance should result in the parents being more involved in the taking of the medicine.  The other issue that comes up is access to medicine for kids with suicidal ideation.  Since suicidal ideation can run the gamut from vague and fleeting to intense and persistent, this can be very tricky.  When in doubt, however, buy a lock box and put all of the family medicine (including over the counter medicines) in it for safe keeping.  Remember, one of the deadliest medicines out there is good old Tylenol–too much will destroy your liver.

As always, monitoring and good communication with your child is the best predictor of a good outcome when they are faced with any illness, be it medical or psychiatric.  Parents must be willing to step up to the plate and take control of the medicine–it is not about trust . . . it’s about being a good parent.  There are many areas in your child’s life where you can foster a sense of responsibility.  It does not . . . and should not . . . include their medical or psychiatric care.

–Dan Hartman, MD

7 comments to Who holds the pills???

  • I think it depends on the family and the patient. I went on Prozac not long before I turned 18. There’s probably a difference in the US, where financial constraints are likely to mean that the parents are necessarily more involved in a minor’s trip to the doctor. For me, it was entirely my decision to go to the doctor about my mental health problems; my parents knew I was taking medication, but really had no input into the situation. I think that would have been the case a couple of years before as well.

    At that point, my problems were as much about having to live in the horribly dysfunctional environment of my family as they were about bipolar disorder (which is my current diagnosis). I’d guess that this is the case for a significant proportion of kids with mental health issues. I was dealing with my problems in spite of my family, and with a fairly weird mix of support and disapproval. I have no doubt that had my father had the keys to a locked box holding my medication this would have caused arguments and made it much more difficult to maintain regular dosing.

    It’s an unfortunate fact that not all parents can be trusted to look after the best interests of their children. Things can get really complicated in some families.

  • AMF

    As the parent of two children who have mental health issues and the need for medication, I felt it most important to be the one who “held the pills”. As you noted, there are already questions of stability, a doctor who is (HOPEFULLY!) depending on the correct usage of the meds, factoring this into his treatment program, and the health/well-being of the child – perhaps even a teacher or two who is counting on that child’s medication being “on board” through a school day. Missing or playing with dosages does nothing to help the whole approach to healing. There were times when pills needed to be split, or liquids that needed to be measured. I cannot imagine leaving this to the repsonsibility of a child….no matter what degree of responsiblity is a goal. Thankfully, I did not have many problems with non-compliance in taking the meds until the “children” were no longer minors and chose to stop taking meds. Needless to say, this was the beginning of another struggle.
    I would strongly encourage parents to be responsible for this important task……….and remind them they are not alone in this, oftentimes painful, part of parenting.

  • The above comments nicely discuss two sides of this issue. Certainly as a treating physician, I expect the parents of a minor child to be responsible and helpful for their kid . . . not always the case, unfortunately. Successful treatment assumes a degree of reliability and communication between physician and patient (whether or not the ‘patient’ includes the family). The “best” treatment does include the family . . . meaning that the dysfunction of the family is addressed as well, hopefully to the betterment of the child and the child’s environment . . . not always the case, unfortunately. From a practical standpoint (and I am nothing if not practical), the parents are sometimes out of the equation. I then INSIST that the child maintain that degree of responsibility and communication that I would expect out of a parent. Complicating the situation in the good ole US of A is that mental health law is a “States rights issue” and is not regulated at the federal level. I am in Pennsylvania, but the laws of neighboring New Jersey and Delaware are different. This obviously will impact on the ability of a physician to treat a minor child.
    –DH MD

  • mike

    how do i contact the doc and post a ? about meds i am on. thankyou

  • Hey Mike!!!
    Hit the “comments” at the bottom of any entry and you will get a comment window. The one for this post now has “5 comments”. If your comment is more general, I will bring it up and write about it. Thanks for listening!

    –DH MD

  • I’m a therapist in the psych unit of a children’s hospital and just since the start of my rotation (August), I’ve probably seen a dozen adolescents admitted to our unit after overdosing on their own prescribed medication. Of course, the safe-keeping of medication wouldn’t solve the entire problem of their suicidal behavior but it would definitely be a start. It’s so frustrating to educate parents about this and then have the child or teenager to be admitted again following another overdose….or have them readmitted related to their behavior from not taking their medication.
    I’m really glad I found your blog-it’s a great supplement to my PhD classes and practicum experience.

  • Kara–
    I don’t know how much is denial . . . (my child could never do that! . . .) and how much is stupidity ( . . . common sense stupidity, not generalized smarts . . . ) Parents need to know that if their kid has an issue with depression, they need to go to Staples and buy a lock box. If your child is ingenious and a persistent type of kid, go Home Depot and get a lock box that attatches to studs on the wall. Then . . . use it. Get all of the medicines in the house and put them away. Leave a few tylenol around so that you can access them quickly (by a few, I mean four–they are very toxic) and even then keep an eye on them. Don’t make a big deal of it (for example don’t say . . . ” oh now we have to lock all our medicines away because I don’t trust you . . .” ). Just do it quietly. The kid doesn’t even need to know. Just do it. However hard and inconvenient, it is way more inconvenient to visit your kid in the hospital . . . or to plan a funeral.

    –DH MD