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On SSRIs, Young Children & the Importance of Getting Second Opinions

On SSRIs, Young Children & the Importance of Second Opinions

By Amalah

Hi Amy,

I’m looking for some advice or perspective on selective serotonin reuptake inhibitors (SSRIs) in preschool aged kids. I recently received some troubling (to me) advice from our pediatrician and I wonder if you or your readers can offer any insights.

Here’s our situation: My three year old son has always been a bit of a..ahem..challenging kid. He’s amazing and smart and funny and sweet, but he is intense, deeply sensitive, and fairly anxious. He’s always been, always “on.” As an infant he was an up-every-hour-to-nurse-nurse-nurse-baby, he was irritable, always moving and fidgeting, and even then, acutely aware and observant. As a toddler, he was very sensitive to his surroundings, things like typical toddler-aged chaos in his daycare classroom and it caused him distress. About this time, he was also developing his fondness for order and cleanliness in his surroundings. He wasn’t quite rigidly lining up toys, but he liked for things to be in their place and he needed his hands to be cleaned if the food he was eating was messy or sticky. He bit a LOT at daycare before he was really able to express himself in words. In the two year old classroom, he got bored very easily and would start to act out – biting again (still), hitting, misbehaving, never seeming content or integrated when other kids in the class were perfectly happy and engaging in activities together. He had nasty tantrums at home – long, hard tantrums. But at the same time, he was usually responsive to me and his teachers. I got reports of him being a “good helper” and “following directions” and he was the same at home. He developed a love for puzzles, and he learned all his colors, letters, and numbers really quickly. He essentially self-lead the potty training process before he was three and his vocabulary, problem solving skills and inventiveness are all quite high. At daycare he was moved up into the next class group (3-4 year olds) early to try to curb some frustration issues he was having with the “babies” in the 2-year-old room. It seemed to work.

But now he is three. And starting a few months ago, I began to receive more and more and worse and worse bad behavior reports from school. Hitting, biting, scratching. Unprovoked. Acting out toward teachers. At home we were still seeing tantrum after tantrum. These long, intense, rage-y tantrums. Hitting, kicking and throwing (stuffed animals) at ME. Overall, I would sum it up by saying LIFE just seems HARDER for him. While he’s a great kid and sweet and affectionate, everything is just too much. Things must be ordered and routine, or he could blow at any moment. We’re walking on egg shells.

I knew we needed to intervene so I started to do a lot of research about what we could do at home. We have cut out TV altogether. We locked down a firm and to-the-minute scripted bedtime routine (which had gotten out of hand – requiring us to read with him for up to an hour, plus additional time when we inevitably had to lay down with him until he fell asleep). We started eating dinner together as a family instead of feeding my son and his 17 month old sister when we got home from work (both full time). We’ve seen marked improvements at school. Cut down on the frequency (though not the intensity or duration) of tantrums at home. Two additional measures – I called his pediatrician for a behavioral consult and agreed with his daycare to set up an observation by a service provided by our state to help identify children with spectrum disorders, behavioral and/or emotional disorders.

My husband and I met with the pediatrician, to whom we described all of the above in great detail, and who nodded and agreed and could predict with crazy accuracy some of the behaviors we’re seeing before we could even say them. She drew diagrams and explained the entire chemistry of the brain. And was obviously very comfortable and knowledgeable about what she was pinpointing as an anxiety disorder. And then said SSRI prescription. End of story. Oh, so, like, coupled with behavioral therapy? Nope. Not needed.

We have not yet had the state observation, but I’m feeling so uneasy about a pediatrician recommending treatment with a drug that she explained “rewires the brain” without at least complementing it with some kind of behavioral therapy. I thought the obvious answer was that we should try behavioral therapy FIRST and kind of exhaust that as an option before resorting to drugs. And especially given the gains we’ve already seen from the actions we’ve taken in the past month (which I described to her). We’re dealing with a different animal here than what your family has been through, but I’ve read about your (and others’) positive experience with behavioral therapies COUPLED with medicinal treatments. I’ve read about the real effects of parenting style on child behavior.

So, even with the state observation still coming up, should I seek a second medical opinion on this matter? Do you or your readers have any experiences with SSRIs in pre-school aged kids?

Thanks so much for any advice.

Oh sweet lord in heaven get a second opinion. I do not know what your pediatrician is thinking, but I do not like it.

Look, I can’t dispense any sort of advice on SSRIs and young children at all. That’s…way way out of my (and this website’s) wheelhouse of experience, knowledge and general comfort zone. But I can absolutely spot the need for a more thorough evaluation and definitive diagnosis from many miles away. So picture me on the horizon, frantically waving a couple BIG RED FLAGS at you right now.

Actually, make that three red flags. Specifically:

  1. Pediatricians are usually not the first line for prescribing SSRIs. I know yours sounded very comfortable and knowledgeable about the subject, but the actual final decision and prescribing is really best left to a child psychiatrist who specializes in this stuff and works with it literally every day, rather than just occasionally. (There’s a reason that ADHD medications got their reputation as being over-prescribed, because tons of pediatricians will write the script without insisting parents make the extra effort to be seen by a child psychiatrist [who might have a long waiting list or not accept insurance, etc.]. Our regular pediatrician is not involved in prescribing or managing our son’s ADHD medication; we have regular visits and check-ins with a wonderful and deeply-experienced child psych instead.) Like, I want someone who lives and breathes this stuff making decisions about my child’s brain; someone who is immersed in the latest research and medication options and side effects because that’s all they doHere is a good overview on doctors, what they do (and don’t) and the differences in their schooling and training.
  2. Your unease is completely backed up by evidence-based research shows that a full psychological evaluation, followed by Cognitive Behavioral Therapy (CBT) PLUS medication is the most effective for treating anxiety and other mental health issues in children. Medication alone is not enough. Here is some of that research. Here is more. And some more! Your doctor is directly going against all this well-known, not-exactly-difficult-to-track-down research and I cannot for the life of me understand why.
  3. AND FURTHERMORE! TOO! Prescribing medication before an evaluation makes no sense. It will skew any results or insight to be gleaned from that evaluation. The evaluation should be done to establish a “baseline” for your child against which future progress (be it through meds or CBT or both) can be measured. He should be seen by a specialist “as-is” and un-medicated.

You have a state evaluation coming up, which is good. Personally, I would also seek the opinion of a private child psychiatrist, if it’s at all possible. Yes, they are often hard to get appointments with and can be out-of-network for your insurance, but when you’re dealing with stuff like this, their input and opinions can be both helpful and reassuring. Like, you know you’re doing the right thing, whatever that thing (or more than one thing! or all of the things!) ends up being.

Photo source: Stocksy/Julia Forsman

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Amalah
About the Author

Amy Corbett Storch

Amalah

Amalah is a pseudonym of Amy Corbett Storch. She is the author of the Advice Smackdown and Bounce Back. You can follow Amy’s daily mothering adventures at Ama...

Amalah is a pseudonym of Amy Corbett Storch. She is the author of the Advice Smackdown and Bounce Back. You can follow Amy’s daily mothering adventures at Amalah. Also, it’s pronounced AIM-ah-lah.

If there is a question you would like answered on the Advice Smackdown, please submit it to amyadvice@gmail.com.

Amy also documented her second pregnancy (with Ezra) in our wildly popular Weekly Pregnancy Calendar, Zero to Forty.

Amy is mother to rising first-grader Noah, preschooler Ezra, and toddler Ike.

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Comments

  • Oh my, I wish the OP and I could meet for coffee because I think we’d quickly be best friends! My oldest child is VERY VERY similar (he’s now 6 years old, but his behavior issues started around 18 months. He’s amazing, but it has been a VERY intense number of years, complete with all that eggshell walking!). I started looking for outside resources (therapy? Psychologist? Parent training? Anything?) when he was 3, and I got a lot of resistance from the providers themselves (I called the behavioral health center for our insurance, and they acted like what I was asking was unheard of. “Therapy for a 3 year old or their struggling parents? WHY do you want this? Um, okay, I guess I can send a message . . . “). We got started in the process, then we had a winter of non-stop illnesses and then I got pregnant and he seemed to be doing better so I let it slide . . . fast forward to when he started kindergarten this year and while he is academically WAY above grade level, his behaviors have been really problematic and hard for his overwhelmed teacher to handle 🙁 This time when I called the behavioral health center to say, “HELP!” they were wonderful and now he goes every 2 weeks to therapy with an MFT and just finished a round of evaluations by a child Psychologist (still waiting to find out what happens next!). In any case, I have found the therapy process to be IMMENSELY helpful for identifying what the biggest problem areas are and setting goals and plans to work on those things. For the first time in years I feel like I have a plan instead of just floundering (and pre-kids I was a behavioral therapist and worked with kids on the Autism spectrum. So if anyone SHOULD have been well-equipped to set up a behavior plan for my son, it was me! And yet NOTHING WAS WORKING and I had no idea what to do next!). My son still is a handful for his teachers and we’re still dealing with behaviors at home, but it’s been so great for the whole family to have help figuring out how to deal with things. I really wish we would have continued to pursue therapy when he was younger instead of waiting until things got so bad at school, so regardless of whether you pursue medication or not or what the state evaluator recommends, I would highly recommend you look into therapy. It is so much better to “get in the door” and established with someone before you have a crisis on your hands (because then if you DO need immediate help, you have someone you can call or email directly instead of having to wait months for an appointment). And for the record, I’m not necessarily anti-medication at any age (my family has a LOOOONG history or mood disorders, and I haven’t ruled it out as an intervention that my son might need before too long) but I do think that is a decision that should be made after working with a child psychiatrist and exploring all the options available to you. Trust your gut, mama, and never feel like you can’t seek help or a second opinion from an alternate source!

    • Shannon Maltese

      Carolyn, OP here, and thank you for this comment. Yes, we are kind of amazingly in the same boat here! This is so helpful to hear, though I’m sorry that you are also experiencing this situation. I think I’m going to start researching behavioral therapy/psych options in our area, because I think what you say here is so smart – getting established with someone who can help before a crisis arises, so you have support if it does! Thank you for responding, I haven’t yet found any articles, anecdotal stories that seem to jibe so closely with our life at the moment.

      • That part is so isolating : Even people who are really supportive don’t always understand what life is like when everything revolves around what kind of day your child is having (I knew of one person whose kiddo was similar as a child, and that was my light at the end of the tunnel. My kiddo wasn’t following any of the other trajectories I’d seen, but at least one was out there and somehow still hanging in there!). So you’re totally not alone! Apparently lots of us commenters have also had challenging kiddo issues to work through. It certainly doesn’t solve the problem, but I hope it’s comforting to know your child isn’t the first to walk this path, and we all understand how hard it is to navigate the journey! Good luck!

  • Amy

    I would also really suggest removing all artificial dyes from your child’s diet. Include toothpaste, shampoo, fingerpaints, anything that comes into contact with your child that has dye in it. Trying this won’t hurt (except that it is shocking how much stuff has dye in it) and could really help your son regulate his behavior.

  • Erica Beth Armstrong

    Please please please get yourself a copy of Raising the Spirited Child!!! And then find another pediatrician!!!
    We. Are. This. We struggled so much, but I was fortunate enough to have a pediatrician that backed me, corroborated with a totally normal OT eval, and moved to a fantastic Montessori school where there was lots of space, quiet, and reduction of excessive stimulation. My boy will be 5 in a month and he has blossomed! He is wicked smart and still Spirited, always, but healthy and comfortable and growing in a positive, supportive environment! And not medicated!

    • Shannon Maltese

      OP here. Thank you for the reco – I think I have more homework cut out for me. I was also recommended “How to talk so your kid will listen and listen so your kid will talk.” I tend to steer clear of these kinds of books after reading a few in the early baby days and finding them either too specific or too general (duh), but coming from someone who has/is going through a similar situation is good enough proof in the pudding for me. Really appreciate the comment.

      • Erica Beth Armstrong

        Please also look at Parent Talk by Chic Moorman. He and it are so, so incredible ❤

  • Caroline Bowman

    Our neurological paed – qualified to do a full assessment for these kinds of issues, not a child psychiatrist but certified specifically with neurological matters in children is very, very clear on two points; first, medicating a child under 5-6 at the earliest UNLESS it is a severe psychiatric disturbance of epic proportions (i.e. not your kid at all). Many issues genuinely do either dial right down or go away completely with proper behaviour management, OT and various other things that are onerous and seem a bit unrewarding for a while, but which ultimately provide coping tools he or she can carry forever through life.

    THEN second, when the child has been thoroughly evaluated at 5-6, as a second tool, medication can be tried. It generally does work very well immediately IF it’s going to work. His view is that you will know within 2-3 days if it’s effective and then it’s a question of getting dosages correct, which is usually not that complicated.

    There is no way a 3 year old who probably has a few sensory issues and may even ultimately have ADD (far, far too young to tell) or whatever, should just be given strong psychiatric drugs without a comprehensive behavioural / emotional therapy plan being implemented after a very thorough assessment, possibly even over a couple of sessions. The road is long, it seems like it anyway, but the results are worth it. By the time he’s 6-7, he will be so much happier, more centred and you will all know how to handle / cope. And yes, it may well include medication, but that is way, way down the road.

    • Shannon Maltese

      Hi Caroline, OP here. Thank you for sharing the info from your doc. It’s a very helpful opinion because it (obviously) does not coincide with what I’m being told by our pediatrician. And sounds so much more in line with what my gut tells me is right here. To say literally, “Meds will handle it”?! It seems like a wildly cavalier attitude with a very young child’s mind! **For the record! I do want to clarify that our doc was not ready to send me home with a scrip that very day – she said we would need to set up an appointment for her to see our son in person. However, it honestly didn’t sound much more in depth than that.** I had no idea that general pediatricians are not usually the ones to prescribed these types of medications so regardless, that fact alone gives me far enough pause and reason to SEEK ADDITIONAL OPINIONS! Thank you, thank you again.

  • Becky Siegel

    Reading this was so strange, it was as if you observed my kid 5-6 years ago and wrote it all down! My now almost 9 year old son was EXACTLY like this – so “on”, aware and observant, obviously “smart”, but also intense, tantrums, biting, very particular, struggled a lot with transitions. Everything was turned to 11, he is incredibly sensitive and caring and loving and kind, but also can get incredibly mad and wail and “freak out.”
    We made it through years 2-5 kind of just figuring out what tripped him up and then very proactively planning for and/or avoiding those things. Basically eggshells. And routine, rountine, routine.

    Then we got to elementary school, still had some behavior issues, but also resources. He was tested and observed, and ultimately identified as gifted. Which we’ve learned is far more than “really smart.” His brain works differently, albeit at a very advanced level, but it’s different. He has an IEP to receive outside of the classroom challenges, as well as to accommodate and work around some of those brain quirks in the classroom.

    Once we really started to understand what that all meant and how his entire thought process and approach to the world was different than most kids (and adults!) around him, it made such a difference. Still sometimes eggshells and melt downs, even years later, and very much still routine, routine, routine. But understanding why that works and that it’s what he needs makes it easier/less frustrating/less feeling constantly like I’m about to step on a behavior based IED.

    I also highly recommend Raising the Spirited Child, also Parenting the Strong-Willed Child. And for anyone that has a spirited/strong willed kid who is also gifted, “On the Social and Emotional Lives of Gifted Children” is good too. We’ve also attended a parenting round-table group by our local SENG group (Supporting the Emotional Needs of the Gifted) and it was so helpful and affirming to know we’re not alone, and neither is our kid.

  • JL

    Clinical Psychologist here!!! Please please see a pediatric psychologist. Only in very rare circumstances should a child this age be put on meds.

    I support all other posters telling you to get another opinion. This is a tough thing to navigate in a managed care world and you’ll have to be your child’s advocate.

    I hope you find a supportive person who can help you design interventions for your child.

  • Emily

    I just want to second the point made by Amy that (as far as I’ve ever known), ADHD medications (and other metal illness meds like anti-anxiety, depression, bi-polar, etc) would never be prescribed by the pediatrician. They would only be prescribed by a therapist. My younger brother has ADHD and Aspergers and still to this day as an adult needs to have regular visits with a therapist who handles all of his medication prescriptions. It makes sense – over the years his needs have changed and so have his medications and a general physician who only sees him annually wouldn’t be able to make that call. He also had a behavioral therapist growing up. I definitely feel your pediatrician is overstepping and I personally wouldn’t give any medications without a therapist’s evaluation.
    Good luck with your son! On the bright side, diagnosis’s, treatments and accommodations have come SO FAR and I really think its so great for your son that you’re getting him the all the help he needs so early on.

  • loloeleven

    In addition to all that Amy and commenters are adding- you may consider an occupational therapy evaluation and services to support his self-regulation and sensory processing skills. It is most definitely not the complete answer to this situation, but can be a big help– especially with the sensory side of it! I am happy to I’ve more info (I am a pediatric OT) if you’d like.

    Best of luck and bravo for working so hard for your kiddo!!

    • Do you have any recommendations on where to go for something like that? (I’m very well versed with how to get evaluations for speech therapy now, but have no idea who I’d call for an OT evaluation. The school district? Our pediatrician? Or do I have to find a clinic nearby and pay out of pocket?)

      • loloeleven

        Your pediatrician (or given your post above, a new dr). They should be able to recommend someone. Otherwise if you have other professionals or friends to get a recommendation. The doctor will have to write a prescription/referral but it is covered to some degree by most insurances. In my area (CA) most OT are in private clinics. School based OT is mich harder to get approved and is much more limited in scope. I’d recommend starting with private OT (medically based services).

        If you have a nearby clinic you know of, oftentimes you can just call ped dr and request a referral/prescription to get started. Then the OT will do an eval and submit to insurance. *usually*. Good luck!!

  • Jillian

    Hi! Fellow parent of an awesome, difficult boy here. I can offer some observations from a few years down the road from you. First is that I agree with Amy, I would never, never take a brain-chemistry prescription from a pediatrician. We have, in our time, seen a psychiatric nurse practitioner, a developmental pediatrician and a pediatric psychiatrist. Of course levels of competence and wonderfulness will vary by doctor, but no one has held a candle to our pediatric psychiatrist in terms of detailed drug knowledge and how to apply it to our situation. Now I would not consider getting meds from anyone else. Second, the first thing she did was critical. She ordered Genesight testing (a genetic test developed by major pediatric hospital research groups) to narrow down the best drugs for my son’s particular brain biology. If anyone else had done that it would have saved us two years of ineffective SSRIs because my son can’t process them well enough to be helped by them. The test indicated another, less common drug and the positive effect it had was immediate. So I strongly recommend you ask for it before you do anything else (Caveat: It can cost a few hundred dollars and may show that your son is fully chemically typical and have no special advice for you.) Third, even though I trust our doc fully, I never give my kid a complex medication (or change the medication) without talking to the pharmacist. No one, no doctor even, knows drugs like a pharmacist and it’s always good to get that additional feedback about possible side effects, interactions, etc. And finally, you’re doing awesome, mom, and your son sounds great!

    • Shannon Maltese

      OP here – wanted to thank you for your comment. Someone said it earlier in the comments thread but it feels very isolating to go through this while your friends look at you with a concerned nod, but really have way to empathize. It’s been eye opening for me, hearing others’ experience and to find that the pediatrician is not the first line of defense (and like I said, it gave me HUGE pause that she went straight to meds). Appreciate your advice and support.

      • Katie

        Can I suggest that you remove your full name from these comments? Your child will probably not like that you have discussed his personal medical issues.

  • First, there is NO WAY I would put a 3 year old (or any kid) on an SSRI as a first step. Definitely get a second opinion. I’d be seriously pissed at the pediatrician for even suggesting that with no referral to a child psychologist or psychiatrist first. The pediatrician should NOT be doling that stuff out to kids.

    I have LOTS of experience with the SSRI/children question. My daughter has terrible anxiety, She did CBT with 4 different child psychologists between the ages of 5-10. Each helped a little, but not enough. I finally decided to get her evaluated by a child psychiatrist. She is now on Zoloft and it has made a WORLD of difference. But, it was our last step, not our first.

    • Shannon Maltese

      Hi Cheryl, OP here. Thank you for sharing your experience. You have no idea what a comfort it has been to have others share similar stories. No one that we’re personally acquainted with seems to have anything remotely similar going on. I truly appreciate the response and based on your and other posters’ feedback, am now researching child psychologists in our area.