Part 2 of 2. Editor’s Note: Read Part 1 of this essay, “Supporting Children and Parents to Withdraw from Psychiatric Medication,” here.
Reasons Parents and Children May Consider Medication Withdrawal
There are many reasons parents and children may desire to reduce or eliminate the child’s prescribed medication(s). The most common reason, in my experience, is that the child is experiencing significant negative side effects. Problematic physical side effects often include weight gain, blood sugar dysregulation, appetite problems, fatigue, and sleeping too much or too little. On the mental health side of things, it is very common for families to report side effects such as foggy thinking and poor focus, increased anxiety, worse mood, suicidality (often not present prior), hyperactivity, and irritability. These immediate side effects are very worrisome to both parents and patients, especially when no real solution is provided beyond adding more medications to address these side effects.
Another fairly common concern related to continued use of psychiatric medication is that the child is not improving on the drugs. This can be the case whether or not negative side effects are present. Most parents are not enthusiastic about their child being on these medications in the first place, and don’t wish to continue them if improvement is minimal or nonexistent. Even when there is benefit, some parents view these medications as a temporary Band-Aid and desire to use other non-drug approaches to treat the root of their child’s struggles.
Many parents also have concerns about the potential long-term side effects of their children taking these medications. Because there have been no studies of any class of psychiatric medication over the long term when initiated in childhood, parents are right to be concerned. Some parents worry about the potential for addiction to medications, particularly if there is family history of addiction issues.
Steps for Safe and Appropriate Medication Reduction
The process of helping children reduce or fully withdraw from psychiatric medications often requires an individualized approach and should occur in collaboration with the child’s prescriber(s). As a psychologist, this is not something I address with families without the direct involvement and oversight of their prescriber and other medical providers. Parents and children should never stop taking medications suddenly without provider instructions, as this can be dangerous. It is also necessary to have a prescriber involved in this process because some prescriptions may need to be altered in dose, formula, or delivery as the withdrawal plan is implemented.
Many prescribers approach psychiatric medication reduction in a cookie-cutter way by cutting the dose in half every one to two weeks, with full weaning done over a four-to-eight-week period. It’s important to recognize that this one-size-fits-all plan is not helpful or appropriate for all children. Some tolerate a faster wean, while others need to reduce in very small increments over a longer period of time. Factors to consider include the number and type of medications, length of time on medications, physical health status, level of family support, and other effective treatments in place.
It’s also important to note that different classes of medications work differently in the body and may lend themselves to a faster or slower taper. Most of these medications, such as SSRIs and antipsychotics, build up in the body over time to reach a target dose, which means they may need to be more slowly weaned for safety and comfort. Stimulant medications like Ritalin, however, act quickly and leave the body over the course of a few hours or by the end of the day. This means they can often be discontinued more quickly, depending on how large a dose the child has been taking.
While individual needs and responses vary, there are many general principles and strategies I have seen work well over my years of supporting families through this process. Here is an overview of the steps I take in my practice:
- Clarify parent and child concerns and goals – Talk with the child and family to determine their motivation for weaning medications, as well as their ideal end goal. Some families have a goal of completely eliminating medications, while others are seeking to reduce the number of prescriptions or the dosing level.
- Perform a thorough assessment of underlying issues and treatment needs – I find it best to determine what underlying physiological issues may be creating or exacerbating symptoms and start implementing a plan to support those issues before initiating the medication weaning process. This can include uncovering and addressing such things as nutrient deficiencies, sleep disorders, hormone imbalances, blood sugar dysregulation, allergies, and many more potential medical issues It is also important to identify any unaddressed environmental or emotional issues, such as inappropriate school environment, peer challenges, abuse, family trauma, and a wide array of other problems that may not have been addressed prior. Getting the right types of counseling and other therapies and types of support in place is key to success. If the child is already in some type of counseling or psycho-social treatment and it is not yielding a benefit, then changes should be made to ensure the best possible fit in terms of personality and approach so the child can progress.
- Educate the family about potential benefits and risks – I provide parents and children with a thorough education about how the medication weaning process will be implemented and the potential benefits and challenges that may come up. I find it very helpful to share experiences of other patients with similar challenges so they have an idea of what they might expect. This is also a time to discuss the importance of ongoing communication and monitoring, and what exactly this will look like.
Families do need to understand that withdrawing from these drugs can bring some temporary discomfort and increases in symptoms. Having this information from the outset puts them in a much better position to navigate the process with less distress.
- Get the entire team on board – At this point, the family or I will initiate a discussion with prescriber(s) and other members of the provider team to hear their perspective and determine their willingness to support and participate in working toward the family’s goal of medication reduction. Typically, parents attempt this discussion first, but I will make a follow-up contact if they feel there is confusion or lack of support on the part of the prescriber.
If the child’s prescriber is unwilling to support the family’s goals with medication reduction, it is appropriate for the family to seek out a practitioner who is willing to be supportive and collaborate on an appropriate plan.
It’s also important to ensure that all caregivers (usually both parents) are on the same page about medication plans. Everyone needs to be willing to implement the plan consistently and be supportive of the child in the process. If parents have very different views on this, there should be continued discussion and education during appointments with the child’s providers in order to come to an agreement on what everyone is willing to support.
- Make a plan and start implementation – Often the prescriber communicates their plan to start the weaning process, and we may have some discussion about altering that plan due to the specific history and needs of the child. The majority of the time the weaning process is done fairly slowly, without major dosing changes in a short period of time.
Some general principles that I’ve found work well include:
- Start reducing one medication at a time (if the child is on more than one prescription). If the child is on multiple medications, start with the one most recently initiated and work toward eliminating the ones they have been on the longest. This is just a general guideline, as there can be very compelling reasons to wean in a different order, especially when specific side effects like major weight gain or sleep issues are present.
Reduce the dose by one-quarter every two to four weeks as tolerated. Back up and reduce more slowly if the child is experiencing significant withdrawal symptoms. Specific withdrawal symptoms to watch for include: dizziness, nausea/vomiting, headaches, fatigue, appetite changes, repetitive motor movements, feeling of skin crawling, increased irritability and agitation, increased anxiety, more problematic behavior, increased sleep issues, or just about anything else that seems markedly worse after reducing the dose.
These are not necessarily indications that the medication is needed, but that the brain needs more time to adjust between dosing changes. Parents should be given a plan at the outset of the withdrawal process for what to do in these situations, which typically includes contacting the provider right away to share observations and concerns, and returning to the previous higher dose until symptoms stabilize again.
- Set a schedule and plan for regular communication with the prescriber, therapist, and any other pertinent members of the treatment team. This includes regularly scheduled appointments, as well as written or phone communication between appointments to share observations, progress, and concerns.
- Continue the process by slowly reducing the dose as tolerated. At various times it may be necessary to go back to a previous higher dose and then decrease again more slowly if larger reductions are not well tolerated.
- Wait at least two weeks (if not longer) between dose changes to ensure tolerance and reduce the likelihood of overloading the system with too many changes. I have found that most children and young adults I treat can tolerate dosing changes every two to four weeks, but have had patients who needed eight weeks or more for their brain and body to adjust to a reduction before proceeding.
- Wait at least four weeks after coming off one medication entirely before starting a reduction of the next one. This allows for a new baseline of symptoms and functioning to be established, and for any rebound withdrawal issues to be identified. Again, this is just a general guideline, as some children benefit from a longer waiting period between fully discontinuing one medication and starting to wean the next, while others can proceed more quickly without problems.
- Provide consistent and ongoing therapy and support – Children need consistent support during this time to help them become aware of their experience and communicate about it with their parents and providers. They also need instruction and practice with implementing healthy coping skills if the process becomes challenging. Parents need consistent support during this time as well to help them observe, track, and communicate about the child’s withdrawal process. They also benefit from skills development and emotional support to handle challenges that can arise during the withdrawal process. Some of the therapies and strategies I find are most helpful to children and parents during this time are specific nutrient supports, parent education, stress-reduction and mindfulness training, neurofeedback, and movement-based therapies.
Keys to Safety: Patience and Communication
The pace at which medications can be reduced varies greatly from one child to the next, and it’s important to move through the process at a rate that keeps everyone comfortable. This is not a race, and it’s not worth quickly reducing medications if it leads to problems. If challenges arise and the child regresses with behavior or other symptoms, communicate that to the appropriate provider and discuss options. Sometimes, after a few days, the withdrawal symptoms will subside and behavior improves again. Other times, the symptoms may worsen or stay troublesome for a longer period of time, in which case the plan should be altered to provide more support. It’s critical that parents not make reactive changes to dosing if the child experiences distress or things become more challenging. Communication goes a long way in reducing stress and ensuring that the plan is adjusted to maintain safety for all involved.
Also, it is important not to complicate the medication-weaning process by starting new prescription medications, over-the-counter medications, nutritional supplements, or other treatment options during this time. Though some of these things may ultimately be helpful, it’s always best to talk with the prescriber and team of providers first, as each of these options also carries a risk of adverse effects. During the withdrawal process, the goal is to simplify the picture so it’s easier to tell whether the reduction in medication is beneficial or problematic.
Timing Considerations
In light of the current coronavirus pandemic, this could be an ideal opportunity for some families to consider medication reduction, and for others it may be an inappropriate time to do so. Important considerations include parent stress level, child stress level (some are much less stressed being out of school, while others may experience increased stress due to routine changes), and access to healthcare.
Another thing to consider in terms of timing: Is the child currently stable and functioning well? If not, has s/he become increasingly unstable since adding or changing medications? If the child’s symptoms have been reduced for a significant period of time, and they are functioning fairly well, it may be appropriate to consider reducing medications to see how they manage well without them.
If the child’s medication regime has remained unchanged but s/he is experiencing significant disturbance such as episodes of apparent psychosis, suicidality, self-injurious behavior, or severe aggression toward others, it is often best to delay medication withdrawal until whatever issues seemed to trigger these acute and potentially dangerous behaviors have been stabilized and a new normal has been established. For example, are there significant acute stressors right now in the child’s or family’s life? This could include physical health issues such as the flu, recent surgery, or other medical issues. Family-related acute stressors could include a recent family change such as the birth of a child, moving houses, divorce, or death. Significant school-related stressors or changes should also be considered. However, it can sometimes be the case that these severe symptoms are being caused by the initiation of, or a change in, medications. In this case, it would be not only appropriate but necessary to initiate the reduction or elimination of these drugs.
In either case, in this type of scenario, it will be necessary for parents to have a strong support system in place, including a plan for what to do should the situation.
The Bottom Line
Every child deserves the opportunity to feel and function well, and to receive the safest and most effective treatment available, aligned with their family’s values. Reducing and potentially eliminating psychiatric medication is a journey – one that can take time, but often leads to improvement when undertaken in a safe and supportive way. In my experience, the vast majority of children and parents discover that improved functioning is possible on lower doses of medication than they have been taking, or without these drugs altogether.
As an integrative practitioner, I believe that medications should not be a first-line approach to symptoms in children and that they should receive the benefit of thorough assessment and targeted treatment with other treatments before considering psychiatric drugs.
While parenting a child who has developmental or mental health problems can feel incredibly challenging, there are many reasons to have hope. Regardless of whether a child has symptoms currently, is on one or many prescriptions, or has never taken medications, many things can be done to improve symptoms and functioning. Parents need to know that it is entirely possible, and I would argue necessary, to safely get kids off medications that aren’t providing clear benefit. Finding the right professionals to collaborate with, engaging in consistent communication, and patiently sticking with the plan help children safely reduce or eliminate prescription psychiatric medications, and experience improved functioning and quality of life as a result.
Editor’s Note: Dr. Beurkens will address her experience with non-drug interventions in a future blog. For information on scientifically validated alternatives to medication for children and youth, visit the following MIA pages:
Non-Drug Therapies for Depression
Non-Drug Therapies for Psychosis, Bipolar, and More
