What You'll Learn
- Why might your child’s doctor prescribe more than one medication?
- Is it safe for a child to be on more than one medication?
- What are some guidelines for adding a new medication?
There are a few reasons a doctor would put your child on more than one medication. The child might have several mental health problems that can’t be treated with the same medication. They might have one problem, but one medication isn’t helping enough by itself. Or your child might be having bad side effects. In that case, a doctor might lower the dose of that medicine and add a second one to help. Or they might use a second medicine to treat the side effect.
There isn’t much research on combining medications in kids. If your doctor recommends this, it’s important that they have training and experience prescribing for children. Combining medications can cause worse side effects than one on its own. Before adding a second medication, you and your doctor should talk through all other treatment options.
Make sure only one person is prescribing for your child. If there need to be two doctors, one of them should take the lead and they should work together. If a doctor wants to add a new medication, they should explain why. Here are some things to ask the doctor: What do they expect it to do? What side effects should you watch for? How will you know if your kid is having a bad reaction?
If a medicine doesn’t work, that can be a sign that your child might have a different issue than their doctor first thought. A doctor should not start or change more than one medication at the same time. If you’re worried about your doctor prescribing too many meds, ask for a second opinion.
It’s important to only start or change medications when other things in your child’s life are stable — not during a school vacation or a big move. Keep everyone who takes care of your child in the loop, like teachers and babysitters. If your child has a reaction when you’re not there, you want to hear about it.
Making decisions about medication for a child with emotional or behavioral problems can be daunting and fraught with worry, especially when more than one medication is involved. Studies show that the number of children taking several psychoactive medications is soaring. Here are some guidelines to help you understand why your doctor might recommend multiple medications for your child, and whether you should have concerns about this treatment.
There are several reasons why a psychiatrist or pediatrician might prescribe more than one medication for a child’s emotional or behavioral issues
- Some children have more than one disorder, and there is no single medication that helps with all of them. But they can be treated separately with different medications, in the same way that you might take two medications if you have both high blood pressure and high cholesterol. For instance, it’s quite common for a child who has ADHD to also have anxiety or depression. If your child has both, a doctor treating them might prescribe stimulant medication such as Ritalin (methylphenidate) or Adderall (amphetamine) and an antidepressant like Zoloft (sertraline) or Prozac (fluoxetine).
- Sometimes a child might have just one disorder, but the medication recommended for treating it doesn’t help them enough at an appropriate dosage. They might be showing some improvement, but they’re still struggling. Your doctor might propose adding a second medication to boost the effect of the first. For example, if they have ADHD and haven’t improved enough on a stimulant medication, your doctor might want to try adding a nonstimulant medication that helps with ADHD symptoms like Strattera (atomoxetine).
- Another possibility is that your child does respond well to the first medication your doctor prescribes—it successfully alleviates their symptoms—but they experience side effects that are unpleasant or harmful. Your doctor might want to lower the dose of the medication to the point where the side effects are not a problem, and then add a different medication to give them a little more help with their symptoms. For instance, if your child with ADHD can’t tolerate an effective dose of a stimulant without serious sleep or eating problems, your doctor might lower the dose and add a prescription of a nonstimulant medication like Tenex (guanfacine).
- Sometimes medications are added to counteract the side effects of the first medication without lowering the dosage of that medication. For instance, if your child with ADHD has sleep problems as a side effect of stimulant medication, your doctor might prescribe medications like Catapres (clonidine) to counteract the insomnia. In most cases, it’s preferable to reduce the dosage of the first medication, or change meds, to minimize the side effects, but in some cases this combination might be preferred.
Is it safe for a child to take more than one psychotropic medication?
There is very little scientific evidence about the safety and effectiveness of multiple medications in children. Clinical evidence suggests that medication “cocktails” can be safe and effective when prescribed by a doctor who is very well informed about the medications and has extensive experience prescribing them and monitoring the responses of children to them. That’s because children, whose nervous systems are still maturing, don’t always respond to medication the same way adults do.
But adding medications shouldn’t be done in lieu of safer behavioral treatments that have been shown to be effective for kids with many issues, including ADHD, anxiety and depression. The combination of a single medication and behavioral treatment should be carefully considered before more meds are added.
What can go wrong with multiple medications?
The risk in combining medications is that they may interact in a way that increases uncomfortable or harmful side effects. For instance, explains Ron Steingard, MD, a child and adolescent psychiatrist, you can get overlapping side effects. If one medication causes mild sedation and the second does the same thing, the result can be so much sedation that the child isn’t herself and can’t stay awake.
There’s another type of interaction that can be problematic, Dr. Steingard adds: If two medications use the same metabolic pathway—the mechanism in the body that breaks them down and delivers them to the target—they can overwhelm that pathway and create a buildup of medication, causing the kind of side effects you’d see with a much higher dose of one of the meds.
Things to look out for if your doctor is proposing multiple medications
- Your clinician should have specific training and substantial experience with the medications that are being prescribed in children, not just adults.
- Medications for your child should not be prescribed by two different doctors, unless they are coordinating their care and communicating with each other closely. If there are two doctors on your child’s treatment team, one should take the lead in your child’s care, and the other act as consultant.
- Whenever a medication is introduced, you doctor should explain clearly what symptoms it is expected to treat, and how you will measure whether the medication is helping.
- With any new medication, your doctor should explain what side effects to watch for, as well as anything in the child’s mood or behavior that might indicate that they’re having a bad reaction.
- If the first medication isn’t working, or is barely helping, it can also be a sign that the disorder has been wrongly diagnosed. It’s important that your doctor reevaluate the diagnosis, and the treatment, before adding other medications.
- Before a child begins taking a second medication, other supports should be explored that might have lower risks and more benefit. For instance, research has shown that stimulant medications can be effective at lower doses when they are combined with behavioral treatments.
- If your child is experiencing side effects from one medication, it’s advisable to explore either cutting back on the dose or switching medications before adding another med to treat side effects.
Guidelines for adding a medication
- A child should not begin taking two or more medications at the same time. Meds should be introduced one at a time, enabling you and your doctor to monitor any side effects that occur, and to measure the effects on his mood and behavior.
- If your child is taking more than one medication, dosages should be changed one at a time. It’s impossible to evaluate the effect of each change if more than one is altered.
- New medications should be added and dosage changes made when your child’s life and routine are as stable as possible. You want to avoid times like the start of a new school year, vacation, a move to a new home, or a medical illness.
- When you change or add medications, it’s important to let everyone on your child’s team know—including their teachers and other caregivers—and check in with them to find out how the child is doing.
- When you evaluate the effects of a medication, it’s important to not assume that any change, for better or worse, is a result of the medication. Pay attention to other changes in your child’s life at home and at school that might affect their emotions and behavior.
What should you do if you are concerned that your child may be on too many meds?
Dr. Steingard recommends that your first step should be to go to your prescribing doctor with your concerns, and talk about getting a second opinion. It’s your right, and it’s common in other areas of medicine. A good doctor will be supportive, and may be able to help you find another clinician to review your child’s case.
How much is too much?
The children most at risk for taking multiple medications that could be harmful are those with disruptive or dangerous behavior. When kids are unmanageable at home and at school, a primary care physician or psychiatrist is, understandably, likely to try whatever pharmaceutical tools are available to help them. If one medication helps a little, but not enough, doctors may add medications to try to get a better outcome. And another. And so on.
Dr. Steingard, who’s seen children on as many as a dozen meds, recommends a cautious and thoughtful approach to medication. Behavioral supports should be explored fully before multiple medications are used. If a child has a learning or attention disorder and is frustrated at school, they should have supports there. If they are out of control at home, parent training can be very helpful. Anxiety and depression, which might also be causing aggression, both respond well to behavioral treatments. Thinking beyond medication is an important part of the solution to complex problems that’s often overlooked.