Preparing for an evaluation

Dr. Jacqueline Amato

Many families who make an appointment with a psychiatrist for evaluation and treatment of their child are unsure of what to expect or how to prepare ahead of time.

In this issue we will cover the information the doctor needs from the parents or caregiver and what can be expected during the appointment, followed by a brief overview of medication treatment options.

The first recommendation is to do a bit of homework before you actually arrive for the appointment. This information helps to guide the doctor toward future recommendations and avoids repeating past failures.

Preparing Ahead of Time
Compile information in the following areas, if available:

• Child’s medical history, including previous evaluations and previous usage of medication
• Current medication list
• Family medical history
• Behavior concerns, frequency and duration
• Sleeping and eating patterns
• Event that prompted making the appointment

Making lists of questions and concerns before the appointment enables you to listen more attentively during the appointment. Besides, your questions and concerns help focus the discussion with the doctor.

The Appointment
Once you have entered the doctor’s office, it is crucial to LISTEN to what the doctor is asking and think about your answers before responding. At times family history is unclear and may need to be deferred until you can clarify with other relatives about certain symptoms in distant relatives. Not all mental disorders were as well defined in the past as they are today, which complicates the situation. For example, a quirky bachelor uncle would perhaps today be diagnosed with Asperger Syndrome, but in his day he was merely thought to be “odd.” Therefore, further investigation into the family tree may become necessary to gather more data.

One of the most difficult things to do when being presented with new information is to keep focused and not let your mind run away with all of the questions that keep popping up. Try to listen carefully when the doctor asks questions and delivers treatment options. Effective listening for some means taking notes and writing down questions to ask after the doctor has finished his or her explanations.

Now that data have been collected and analyzed, it is time to make decisions about treatment. With any psychiatric disorder, the options for treatment are many. This column will focus primarily on medication, which is only one arm of a complete treatment approach. For example, a patient with obsessive compulsive disorder may benefit from cognitive therapy in conjunction with medication. In other cases, therapy alone would be most beneficial.

Medication recommendations will vary depending on the presenting symptoms. There are multiple classes of medications that each can be effective when used for the “right” reason with the individual child. These medication classes, known as psychotropics, include, but are not limited to, antidepressants, anxiolytics, antipsychotics, stimulants, etc.

The “right” reason is the tricky part. Few psychotropic medications are indicated, or even studied, for use in children and adolescents under 18 years of age. “Indicated” means the Federal Drug Administration (FDA) has received, reviewed and approved of at least two placebo-controlled studies that have shown sufficient efficacy to improve the condition at hand.

The unfortunate truth is that there is only one medication formally indicated for the treatment of autism or any other autism spectrum disorder: Risperidol, which belongs to the class of medications labeled antipsychotics. Risperidol has been approved by the FDA for the treatment of irritability associated with autistic disorder, aggression toward others, self-injurious behavior, temper tantrums and quickly changing moods in patients 5 to 16 years old. It is backed by the most research of an antipsychotic medication, 53 studies known as of this writing.

As with any medication, there are both advantages and disadvantages associated with Risperidol. As for any medication, each individual reacts differently to it. While by no means the only ones, the most common side effects from Risperidol include increased appetite and weight gain.

Quite frequently doctors recommend medications that are not indicated for children/adolescents because all other resources have been exhausted. The use in this case is considered “off-label.” Often the use of medications off-label is necessary, as there are other issues to consider in the risk-versus-benefit ratio. For example, if you have a child suffering from self-injurious behavior and all other interventions have failed to rectify the situation, the risk of weight gain or some other side effect may be well worth it.

Doctors choose medications based on clinical evidence and must be flexible if a specific medication causes intolerable side effects. At the moment, it is not possible to predict which patient will have which side effects. Further research is very much needed. For now we are forced to consider exploration of the unknowns in the hope of a brighter future.

Dr. Jacqueline “Jake” Amato is board certified in psychiatry and child and adolescent psychiatry and practices at Peacehealth Medical Group in Oregon. In her rare free time, “Jake” enjoys running, swimming, and walking on the beach with her beloved golden retriever, “Parker Grace.”

Courtesy of AAPC

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