Ask An Expert / Medication

Our granddaughter is severely anxious, but an antidepressant had too many side effects. Should we try a natural medication?

What to do when the first medication doesn't work

Steven G. Dickstein, MD

Our 10-year-old granddaughter, who has been diagnosed with severe anxiety disorder and possibly selective mutism, has been having issues with aggressive behavior and about two weeks ago has started to wet the bed as well as herself. Although her anxiety has been evident for some time, the aggressive behavior and wetting may be associated with a change in counselors at the service she is with. It takes a long time for Rachel to warm up to someone enough to feel comfortable with. Her pediatrician has prescribed Celexa, but since a child psychiatrist had earlier put her on Prozac, with devastating side effects, we are very uncomfortable with any type of psychiatric medication. We thought about a natural medication called KOK Kiddee Calmer, but don't really want to waste time because we feel the sooner she starts any medication treatment, the better. Do you have any recommendations?

Clearly, you’re very worried about your granddaughter: She’s going through a lot of different things and she’s had a bad response to one medication she was given. You ask a very good question: When the first treatment doesn’t work, what do you do next?

Many people are attracted by the idea of using something that’s natural, or homeopathic — for one thing you want to make sure you’re not harming your child. But in most cases, homeopathic or natural products really have no data other than anecdotal evidence to show that they’re actually helpful. Someone may say that a product is helpful, but as far as scientifically based data, it’s generally not available.

For children with anxiety, the medications that have been shown to be most effective are the type of anti-depressants you mention, called SSRIs. There is very strong evidence for SSRIs working with children like your granddaughter. Still, not all children respond to the first medication they try. When medication isn’t effective, or has unacceptable side effects, you want to consider several things.

First, you want to make sure that the dosage has been right; it needs to be high enough to be effective, but “devastating” side effects can mean the dose is too high. Second, it’s helpful to try a different SSRI, since children respond differently to different medications. And if a child doesn’t respond to the first or second antidepressant, you have to look carefully at the diagnosis, to make sure it’s correct, and to think about what alternative treatments there are.

It’s important to keep in mind that 10-year-olds are still growing, and symptoms that present at one age may develop into something different later. It may be difficult to find a precise diagnosis at age 10, which is why you want to make sure you are working with a physician who is knowledgeable about psychiatric disorders, and experienced enough to feel comfortable, if the first treatment doesn’t work, knowing what to do next. Also, does the explanation that she’s giving for the symptoms fit with how you see them? It’s certainly reasonable to get a second opinion.

You also mentioned that your granddaughter has gone through a transition of counselors, which can be a big stressor. In any kind of transition stage, it’s important to ask, what is the counseling trying to address? What specifically are they working on, and does the method or the person seem reasonably able to address these issues?