The escalator

Abstract

My heart sinks. Sometimes we end up here. It's a tough place to be … standing between a desperate family and their imagined pharmacological salvation.

I feel an invisible push from behind.

Easy enough to start. To take that first step onto the psychopharmaceutical escalator.

Take care after that. Often harder to stop.

A fanciful mission to find the one true behavioural antiserum.

Professional triangulation. Drafted in, to paper over cracks in an educational system in which imposed demands can exceed a child's personal coping reserves.

As these anecdotes shout at me from the sidelines, I feel the tension rise.

Pressure for dosage increases.

Thinking about a second medication. A third…

A change to a different drug.

Something more powerful?

In response to the heat of such situations, are we at risk of ascending to the Overprescribing Level? None of us aspires to this. Hard, though, to know when you are there. No external signs, no warning lights.

I picture myself, with these patients and their families, on the escalator.

Am I, are we, caught up in an ill-defined pursuit of a pharmaceutically driven, unachievable ‘optimum’ state?

Impeccable behaviour, unbreakable concentration, unrealistic school marks, always-level emotions, perfect sleep…

STOP!

I hit the emergency button. I clamber down the escalator.

My private reflections become calmer.

To the families; please know that I am listening. I can see the struggle. I can sense your fear for your child's future.

How tricky for parents to know where to turn, when faced with so many phenomena and systems seemingly outside your locus of control.

I wish I could resolve every single one of your family aches and pains. Delete your trauma. Take away all of your discomfort.

I can empathise with the question; could a daily medicinal remedy make things better?

Yet … I cannot cosmetically shape pharmacological responses to every conceivable behavioural permutation.

I accept that the scope of my prescribing has limits.

Deep breath.

Having flirted with disillusionment, I move back to more constructive thoughts.

I reflect anew on my role in our joint venture, in which you, child and family, are the major stakeholders.

I reaffirm my commitment to the therapeutic partnership. To use my skills to help build capacity and relieve suffering … in a variety of ways. I do want to help!

Relationship-based care is the cornerstone. I have no interest in the purely transactional. Sitting behind a window at the Drive-Through Dispensary is not for me.

The prescribing of psychopharmaceuticals is a key competency for paediatricians, of course it is. Many of the children and families we see are facing off against some fearsome self-regulation dragons. At times, the taking up of pharmaceutical arms is a crucial part of the response, to see if we can reduce their power.

So I will continue to build my technical know-how. I have been entrusted to get this right.

Regular doses of ethical smelling salts will keep me grounded, I hope, and help me avoid prescribing excesses – too soon, too much, too many.

Our patient's voice must remain paramount.

In this area of our practice, we are chemically altering a child's emotions, reactions, performance.

A child who has a limited capacity to identify and describe unpleasant side effects.

A child who may internalise the belief that daily medication is a prerequisite for their acceptance by others.

A child who has no power to refuse.

The same child whose life chances just might be improved through judicious medication use, and the seizing of opportunities that better self-regulation provides.

This is no trivial undertaking.

As I contemplate addressing the challenge, I look into my toolbox, and find an array of blunt pharmacological instruments.

Also in the box is a handbook marked ‘Evidence’. There is some. Not as much as I'd like.

I close my eyes and visualise a Prescriber Bell Curve. At one extreme: too timid to be helpful. At the other: too gung-ho to be safe. Somewhere in the middle, then.

After all of this soul searching, if it is within my power to sensibly help, I can and will use my medication skills to address what I can.

In doing so, I will keep my eye on the prize. To aid in the fulfilment of strengths, through the lessening of bona fide executive function and mood regulation barriers.

To assess the impact of medication, I won't rely on the whims of episodic memory. I need data. I need collateral observations. This may seem cumbersome to some. So be it.

Evidence of positive impact will not beguile me into downplaying undeniable side effects.

I vow not to let my powerful desire to help cloud my judgement about therapeutic quality and safety.

If the need seems pressing, I will double-check my options. I won't blindly shoot medicinal arrows into the darkness, hoping to hit a target. Feelings of helplessness need to be stilled, lest they distort decision-making. I may phone a friend, to help sharpen my focus, as I look again from all angles.

I will stick to my process, and stay true to my prescribing principles.

If my timing is right, if I select my pharmacological tools wisely, if I keep my wits about me under pressure, I know I can do some good.

We can choose our moment to board the escalator.

I also recognise that an overly narrow view of intervention, dominated by prescribing, will keep us stuck on that escalator, tweaking and trialling indefinitely.

Prescribing psychotropics is not my only responsibility, not by a long shot.

Deep breath.

What else?

Zoom out.

There are other floors in our partnership building. Other ways to influence emotions and behaviour.

Optimising daily routines. Physical health essentials. The understanding and support of the school. Exploring interests. Finding one's tribe. Coaching the development of self-regulation skills. Individual counselling. Parental well-being.

I resolve not to ignore elephants. The family dynamics that no medication will fix. Shining a light here, where it is needed, may not be easy. In that case we may focus on the smallest increments, and slowly build upon those. Can we shift the needle towards more positive interactions?

Let's also discuss the enhancement of strengths, and maximising joy and meaning. This is a parallel enterprise, requiring a different approach. What a blessed relief it is to talk about what's going well, and could get even better!

A diversification of investments, to make that difference we are all seeking.

Let us work together, with a clear understanding of the role that psychotropic medication might (or might not) play for your child, and a commitment to explore other ways to help, that may not seem as obvious right now.

Repeatedly, I find myself in awe of parents and children who find a way through.

What will work for you? I look forward to the discovery.