Complete Guide to Multiple Medications

Making decisions about medication for a child with emotional or behavioral problems can be daunting, especially when more than one medication is involved.

When children have complex psychiatric symptoms, or aren’t responding adequately to a medication they are taking, doctors often recommend adding another medication.

Taking multiple psychoactive medications is called “polypharmacy.” And studies show that the number of children taking more than one medication is soaring.

Combining medications can be effective when they’re prescribed and monitored carefully by a doctor who is an expert in using them with children. But it’s important for parents to be informed about the risks inherent in adding medications, and signs that you should be concerned about what a doctor is recommending.

These are the most common reasons why a doctor might recommend adding a medication:

• In the same way that you might take two medications if you have both high blood pressure and high cholesterol, some kids take multiple meds because they have more than one disorder. For instance, it’s common for a child who has ADHD to also have anxiety or depression, and both can be treated with medication.

• When a medication isn’t helping enough, your doctor might propose adding a second prescription to boost the effect of the first. For example, if your child has ADHD and hasn’t improved enough on a stimulant medication, the doctor might want to try adding a non-stimulant medication that also helps with ADHD symptoms.

• When a medication is helping but has troubling side effects, your doctor might be able to avoid them by lowering the dose. Then he might add a second medication to treat remaining symptoms. For instance, if your child can’t tolerate an effective dose of a stimulant medication, your doctor might lower the dose and add a prescription for a non-stimulant.

• Sometimes medications are added to counteract the side effects of the first prescription without lowering its dosage. For instance, if your child with ADHD has sleep problems as a side effect, your doctor might prescribe something to counteract the insomnia. In most cases, it’s preferable to reduce dosage or change meds, but in some cases this option is preferred.

There is very little scientific evidence about the safety and effectiveness of multiple medications in children. But 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 treating children with them.

Experience with treating adults is not enough to guide treatment of children, because kids, whose nervous systems are still maturing, don’t always respond to medication the same way adults do.

But adding medications should not be done in lieu of behavioral treatments that have been shown to be effective for kids with many issues, including ADHD, anxiety, depression and disruptive behavior. The combination of a single medication and behavioral treatment should be carefully considered before adding more medication.

The risk in combining medications is that they may interact in a way that increases uncomfortable or harmful side effects. For instance, explains Dr. Ron Steingard, a child and adolescent psychiatrist at the Child Mind Institute, 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.

Another type of interaction that can be problematic, Dr. Steingard adds, can occur if two medications use the same metabolic pathway — the mechanism in the body that breaks them down and delivers them to the target. If that pathway is overwhelmed, it can create a buildup of medication, causing the kind of side effects you’d see with a much higher dose of one of the meds.

1. Your clinician should have specific training and experience with the medications that are being prescribed in children, not just adults.
2. 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.
3. Whenever a medication is introduced, you doctor should clearly explain what it is. She should also identify the symptoms it is expected to treat, and how you will measure whether the medication is helping your child.
4. With any new medication, your doctor should explain what side effects to watch for, as well as anything that might indicate that your child is having a bad reaction.
5. If a 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.
6. Before a child begins taking a second medication, other supports should be explored. For instance, research has shown that stimulant medications for ADHD can be effective at lower doses when they are combined with behavioral treatments.
7. 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.

1. 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.
2. 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.
3. 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.
4. When you change or add medications, it’s important to let everyone on your child’s team know — including her teachers and other caregivers — and check in to find out how she is doing.
5. When you evaluate the effects of a medication, it’s important to note other changes in your child’s life at home and at school that might affect her emotions and behavior. Don’t assume that any change is a result of the medication.

If you are worried that your child is on too many different medications, or your child is not doing well on them, Dr. Steingard recommends that your first step should be to go to your prescribing doctor with your concerns. Tell your doctor that you’d like to get 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.

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, doctors generally try whatever pharmaceutical tools are available to help them. If one medication helps a little, but not enough, doctors may add more 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 exploring behavioral supports before using multiple medications.

If a child has a learning or attention disorder and is frustrated at school, she should have supports there. If she is 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.