As the efficacy of psychotropic medications has been demonstrated by research and their use destigmatized, their prescription to children and adolescents has become commonplace. For example, when adolescents in the United States were recently surveyed, more than 6% reported using a psychotropic medication in the past month (Jonas et al. 2013). This relatively widespread use of psychotropic medications means that caregivers have come to expect primary care practitioners, not just mental health specialists, to consider prescribing medication for a child or an adolescent with a mental illness.
When should a psychotropic medication be prescribed? Not every child with depression, anxiety, or attention-deficit/hyperactivity disorder (ADHD) needs to receive a medication, regardless of whether it fits an approved or research-supported indication. Because psychiatric medications can cause adverse effects, you must, at a minimum, believe that the potential benefit of psychotropic medication exceeds the potential risks your patient may experience. For instance, if a child has a relatively mild case of depression, psychotherapy alone is usually sufficient to help, and its use does not introduce the risk of medical adverse effects. If a child or an adolescent’s depression is more severe or persistent, use of a selective serotonin reuptake inhibitor (SSRI) combined with psychotherapy makes better clinical sense to achieve a more rapid recovery (e.g., Emslie et al. 2010).
As a rule of thumb, if a child or an adolescent has a moderate to severe range of symptoms and an evidence-based psychotropic medication is available, we usually prescribe the medication at the same time we initiate the appropriate psychosocial interventions. For a child or an adolescent with milder symptoms, we generally recommend starting treatment with psychotherapy or environmental interventions alone. Those with mild symptoms but persistent dysfunction 276become stronger candidates for a medication treatment when nonmedication strategies prove to be ineffective.
When approaching the decision about what to prescribe, we advise following evidence-based principles. Although we appreciate the wisdom of experienced practitioners and the insights reported in case series, these are small, unstandardized accounts. Whenever possible, we base our prescribing decisions on evidence generated from controlled trials conducted among children and adolescents. For practitioners who frequently prescribe psychotropic medications to children and adolescents, we recommend reading the evidence-based systematic reviews published by the Cochrane Database of Systematic Reviews, the Practice Parameters published by the American Academy of Child and Adolescent Psychiatry, or one of the available textbooks (e.g., McVoy and Findling 2013; Preston et al. 2015).
When such evidence is unavailable, we find that adult mental health medication research is informative but in need of translation before we can use the medication for children and adolescents. Children and adolescents are not “little adults” who will respond to “little doses” in the same way that adults do. For example, tricyclic antidepressants are effective in the treatment of depression in adults, but controlled trials found that tricyclic antidepressants are no better than placebo in the treatment of depression in children and are of marginal utility for treating depression in adolescents (Hazell and Mirzaie 2013). A result from the adult mental health literature therefore must be replicated in children and adolescents before it can be reliably followed.
However, appropriate evidence-based care does not mean limiting your prescriptions to only those medications approved for children and adolescents by a regulatory agency such as the U.S. Food and Drug Administration (FDA). Pediatric approvals exist for only about half of all the medications used with children, such that nearly three-fourths of all hospital-delivered medications (both medical and psychiatric) lack an age-matched pediatric regulatory approval (Murthy et al. 2013). This regulatory discrepancy occurs largely because the process of obtaining an FDA approval is a long and expensive endeavor that requires a vested party (the manufacturer). Rigorous research may support the use of medication without such an approval.
Some of the key questions we ask ourselves before prescribing any medication include the following:
277• Diagnosis—does the child have an evidence-based medication indication?
• Age—how does the child’s age change your risk-benefit analysis?
• Severity—how rapid of a treatment response is needed?
• History—what has already been tried, and how effective was it?
• Preferences—are there strong patient or caregiver opinions about the use of medication?
Practitioners may feel pressured to use medications well outside of evidence-based indications when patients and caregivers are struggling. We prefer to resist these demands and limit the prescription of psychotropic medications to the indications for which sound evidence exists. For instance, prescribing methylphenidate for a child whose poor school performance is not due to ADHD but rather is due to a learning disability, anxiety, social distractions, or depression may be ineffective and delay the use of more appropriate interventions. Similarly, antipsychotics may reduce the severity of nonspecific aggression, but they are unlikely to address the underlying causes of youth aggression and may unnecessarily introduce major adverse effects.
Tables 16–1 to 16–5 include only those psychotropic medications with a randomized controlled trial evidence base for use with young people. The age ranges of the listed FDA approvals do not necessarily reflect the age ranges for which these medications are clinically appropriate or effective.
Older antipsychotic medications with long-standing FDA approvals for use in young people include haloperidol (≥3 years old) for severe aggression and Tourette’s disorder, pimozide (≥12 years old) for Tourette’s disorder, chlorpromazine (≥1 year old) for severe aggression, and thioridazine (≥2 years old) for schizophrenia. However, concern about adverse effects, chiefly movement disorders, limits contemporary use of these medications in children and adolescents.
When we prescribe a medication to a child or an adolescent, we take responsibility for monitoring for the development of known adverse effects. The tables in the following subsections are drawn from the published literature (Hilt 2012) and from adverse effect labeling from medication manufacturers (U.S. Food and Drug Administration 2015).
278TABLE 16–1. Attention-deficit/hyperactivity disorder: short-acting evidence-based stimulant medications
Drug name |
Stimulant class |
Duration (hours) |
Usual 6- to 10-year-old starting doses |
Available doses (mg tablets) |
FDA maximum daily dose (mg; approval ages) |
Editorial comments |
Methylphenidate (Ritalin, Methylin) |
Methylphenidate |
4–6 |
5 mg bid (2.5 mg if 3–5 years) |
5, 10, 20 |
60 (≥6) |
May have fewer side effects than dextroamphetamine; better evidence for very young children |
279Dexmethylphenidate (Focalin) |
Methylphenidate |
4–6 |
2.5 mg bid (1.25 mg if 3–5 years) |
2.5, 5, 10 |
20 (≥6) |
Racemic isomer, so has twice the mg:mg potency of methylphenidate |
Dextroamphetamine (Dexedrine, DextroStat) |
Dextroamphetamine |
4–6 |
2.5 mg bid (1.25 mg if 3–5 years) |
2.5, 5, 7.5, 10, 20, 30 |
40 (≥3) |
Tends to have longer duration than methylphenidate; slightly more side effects |
280Amphetamine salt combination (Adderall) |
Dextroamphetamine |
4–6 |
2.5 mg bid (1.25 mg if 3–5 years) |
5, 7.5, 10, 12.5, 15, 20, 30 |
40 (≥3) |
Tends to have longer duration than methylphenidate; slightly more side effects |
Note. bid=twice a day; FDA=U.S. Food and Drug Administration.
281TABLE 16–2. Attention-deficit/hyperactivity disorder: long-acting evidence-based stimulant medications
Drug name |
Stimulant class |
Duration (hours) |
Usual 6-to 10-year-old starting doses (mg) |
Available doses |
FDA maximum daily dose (mg; approval ages) |
Editorial comments |
Methylphenidate ER/SR (Metadate ER) |
Methylphenidate |
4–8 |
10 qam |
10, 20 mg tablets |
60 (≥6) |
Uses a wax matrix for delivery; variable duration of action |
OROS methylphenidate (Concerta) |
Methylphenidate |
10–12 |
18 qam |
18, 27, 36, 54 mg capsules |
72 (≥6) |
Osmotic release capsule; cannot be cut or crushed |
Methylphenidate XR oral suspension (Quillivant XR) |
Methylphenidate |
Up to 8 |
20 qam |
5 mg/mL liquid |
60 (≥6) |
Microsuspension yields an ER liquid |
282Methylphenidate XR; 30% IR, 70% ER (Metadate CD) |
Methylphenidate |
~8 |
10 qam |
10, 20, 30, 40, 50, 60 mg capsules |
60(≥6) |
Beads in capsule can be sprinkled on food |
Methylphenidate XR; 50% IR, 50% ER (Ritalin LA) |
Methylphenidate |
~8 |
10 qam |
10, 20, 30, 40 mg capsules |
60 (≥6) |
Beads in capsule can be sprinkled on food |
Dexmethylphenidate XR (Focalin XR) |
Methylphenidate |
10–12 |
5 qam |
5, 10, 15, 20 mg capsules |
30 (≥6) |
Beads in capsule are a racemic isomer of methylphenidate, so this medication has twice the mg potency |
283Methlylphenidate patch (Daytrana) |
Methylphenidate |
Until 3–5 hours after patch removal |
10 qam |
10, 15, 20, 30 mg patch |
30 (≥6) |
Site rash problems; slow morning startup of effects; works until removed |
Amphetamine salt combo-XR (Adderall XR) |
Dextroamphetamine |
8–12 |
5 qd |
5, 10, 15, 20, 25, 30 mg capsules |
30 (≥6) |
Generic available; beads in capsule can be sprinkled on food |
284Lisdexamfetamine (Vyvanse) |
Dextroamphetamine |
~10 |
30 qd |
20, 30, 40, 50, 60, 70 mg capsules |
70 (≥6) |
Conversion ratio from dextroamphetamine not well established; gastrointestinal bioactivation |
Dextroamphetamine ER (Dexedrine Spansule) |
Dextroamphetamine |
8–10 |
5 qam |
5, 10, 15 mg capsules |
40 (≥6) |
Beads in capsule can be sprinkled on food |
Note. bid=twice a day; ER=extended release; FDA=U.S. Food and Drug Administration; IR=immediate release; OROS=osmotic controlled-release oral delivery system; qam=every morning; qd=every day; SR=sustained release; XR= extended release.
TABLE 16–3. Attention-deficit/hyperactivity disorder (ADHD ): nonstimulant evidence-based medications
Drug name |
Half-life (hours) |
Medication type |
Usual starting, doses |
Available doses (mg) |
FDA maximum daily dose (approval ages) |
Editorial comments |
285Atomoxetine (Strattera) |
5 |
Norepinephrine reuptake inhibitor |
0.5 mg/kg once a day then 1.2 mg/kg/day after 1 week |
10, 18, 25, 40, 60, 80, 100 capsules |
100 mg or 1.4 mg/kg/day, whichever is less (≥6) |
Side effect risks same as with SSRIs (e.g., suicidality warning); cytochrome P450 2D6 metabolism; about 50% respond |
Clonidine (Catapres) |
12.5 |
Central-acting α2-agonist |
0.05 mg bid |
0.1, 0.2, 0.3, 0.4 tablets |
0.4 mg |
Dosing at bedtime may help manage sedation effects |
286Clonidine XR (Kapvay) |
12.5 |
Central-acting α2-agonist |
0.1 mg qd |
0.1, 0.2, 0.3, 0.4 tablets |
0.4 mg (≥6) |
Difference is a reduced peak blood level relative to IR form |
Guanfacine (Tenex) |
16 |
Central-acting α2-agonist |
1 mg qd |
1, 2, 3, 4 tablets |
4 mg |
Dosing at bedtime may help manage sedation effects |
Guanfacine XR (Intuniv) |
18 |
Central-acting α2-agonist |
1 mg qd |
0.1, 0.2, 0.3, 0.4 tablets |
7 mg (≥6) |
Difference is a reduced peak blood level relative to IR form |
Note. bid=twice a day; FDA=U.S. Food and Drug Administration; IR=immediate release; qd=every day; SSRIs=selective serotonin reuptake inhibitors; XR=extended release. Unlike stimulants, these medications may take up to a month to generate their full efficacy in the treatment of ADHD in children and adolescents. Stimulants are considered the first-line treatment option.
TABLE 16–4. Depressive and anxiety disorders: evidence-based medications
Drug name |
Half-life |
Usual teenage starting dose (mg) |
FDA maximum daily dose (approval ages) |
Available doses |
Conditions with RCT support |
Editorial comments |
287Fluoxetine (Prozac) |
4–6 days |
10 qam |
60 mg (≥7 OCD, 1 ≥8 MDD) |
10, 20, 40 mg capsules |
OCD, MDD, GAD, SAD, SOC |
First-line treatment for both depression and anxiety; long half-life reduces side effects from missed doses |
Sertraline (Zoloft) |
27 hours |
50 qam |
200 mg 2 (≥6 OCD) |
25, 50, 100 mg tablets |
OCD, MDD, GAD, SAD, SOC |
First-line treatment for anxiety; easy to use small doses (i.e., half of a 25 mg tab) |
Citalopram (Celexa) |
35 hours |
20 qam |
40 mg in adults 1 (not child approved) |
10, 20, 40 mg tablets |
MDD, OCD |
Very few drug-drug interactions |
288Escitalopram (Lexapro) |
29.5 hours |
10 qam |
20 mg (≥12 MDD) |
5, 10, 20 mg tablets |
MDD |
Racemic isomer of citalopram; very few drug-drug interactions |
Fluvoxamine (Luvox) |
16 hours |
25 qam |
300 mg (≥8 OCD) |
25, 50, 100 mg tablets |
OCD, GAD, SOC, SAD |
Often more side effects than other SSRIs; many drug-drug interactions; thus, not a first-line option |
Paroxetine (Paxil) |
18 hours |
20 qam |
40 mg in adults (not child approved) |
10, 20, 30, 40 mg tablets |
SOC |
Mixed evidence; not preferred for child depression |
289Clomipramine (Anafranil) |
32 hours |
25 mg |
200 mg or 3 mg/kg/day (≥10 OCD) |
25, 50, 75 mg ( capsules |
OCD |
Tricyclic, used for treatment-resistant OCD; not a first-line option because of greater adverse effects than with SSRIs |
Duloxetine (Cymbalta) |
12 hours |
30 qd |
120 mg (≥7 GAD) |
20, 30, 60 mg ( capsules |
GAD |
Serotonin-norepinephrine reuptake inhibitor; has more adverse effects than SSRIs |
Note. FDA=U.S. Food and Drug Administration; GAD=generalized anxiety disorder; MDD=major depressive disorder; OCD=obsessive-compulsive disorder; qam=every morning; qd=every day; RCT=randomized controlled trial; SAD=separation anxiety disorder; SOC=social phobia; SSRIs=selective serotonin reuptake inhibitors.
TABLE 16–5. Bipolar and psychotic disorders: evidence-based medications
Drug name |
Half-life (hours) |
Usual teenage starting dose (mg) |
FDA maximum daily dose (approval ages) |
Available doses (mg) |
Conditions with RCT support |
Editorial comments |
290Risperidone (Risperdal) |
17 |
0.5 qd |
6 mg (≥13 schizophrenia, ≥10 bipolar mania, ≥5 autism irritability) |
0.25, 0.5, 1, 2, 3, 4 tablets |
Schizophrenia, bipolar mania, autism, Tourette’s disorder |
Extensively studied in children; has relatively consistent and rapid effects; extra risk of prolactinemia |
Aripiprazole (Zoloft) |
75 |
2 qd |
30 mg (≥13 schizophrenia, ≥10 bipolar mania, ≥6 autism irritability, ≥6 Tourette’s disorder) |
2, 5, 10, 15, 20 tablets |
Schizophrenia, bipolar mania, autism, Tourette’s disorder |
Mixed agonist/antagonist at dopamine D2 receptor; may cause irritability; takes longer than others to see clinical changes |
291Quetiapine (Seroquel) |
7 |
25 bid |
800 mg (≥13 schizophrenia, ≥10 bipolar mania) |
25, 50, 100, 200, 300, 400 tablets |
Schizophrenia, bipolar mania |
Pills larger so might be harder to swallow; noted anxiolytic properties |
Ziprasidone (Geodon) |
7 |
10 qam |
160 mg/day in adults (not child approved) |
20, 40, 60, 80 capsules |
Schizophrenia, bipolar mania |
Greater risk of QT lengthening, so electrocardiogram monitoring is necessary; not a first-line option for children |
292Olanzapine (Zyprexa) |
30 |
25 qam |
20 mg (≥13 schizophrenia, ≥13 bipolar mania, ≥10 bipolar depression, with fluoxetine) |
2.5, 5, 7.5, 10, 15, 20 tablets |
Schizophrenia, bipolar mania, bipolar depression |
Has rapid benefits but greatest risk of weight gain and lipid changes in this group |
Paliperidone (Invega) |
23 |
3 qd |
12 mg (≥12 schizophrenia) |
1.5, 3, 6, 9 tablets |
Schizophrenia |
Major active metabolite of risperidone; similar risk of hyperprolactinemia |
Note. bid=twice a day; FDA=U.S. Food and Drug Administration; qd=every day.
Stimulants (i.e., methylphenidate, dextroamphetamine) are usually well tolerated, but they often cause decreased appetite and insomnia (Table 16–6). Dose and duration of action adjustments typically mitigate these problems. Tracking growth on a growth curve greatly helps with recognizing weight gain problems (Table 16–7). Sometimes stimulants cause irritability or dysphoria, which may resolve by switching to the other family of stimulant. Excessive doses can cause cognitive dulling. Stimulants often cause a very slight elevation in heart rate or blood pressure that is almost always clinically insignificant, but we screen for outlier responses via a vital signs check after initiation. A tic disorder is no longer considered a contraindication for stimulant use because tics are just as likely to increase or decrease temporarily during stimulant use (Pringsheim and Steeves 2011).
Common SSRI side effects include a change in appetite that can lead to weight gain or loss and a sleep change that may include dreams becoming more vivid (Table 16–8). Diminished sex drive is common, although this problem is less notable for adolescents than for adults. Because platelets use serotonin for aggregation signaling, easier bruising may occur. Very high SSRI doses or combining serotonin agents could result in serotonin syndrome, which includes agitation, ataxia, diarrhea, hyperreflexia, mental status changes, tremor, and hyperthermia. Manic symptoms occur rarely as an SSRI side effect; this occurrence is not proof that the child will develop bipolar disorder. SSRIs have a common risk of causing irritability or agitation, which, if added to significant anxiety or depression might be a reason why there is a reported twofold elevation of self harm thoughts early in treatment when youth use SSRIs versus a placebo. Prescribers need to discuss this black box suicidality warning with patients and caregivers when prescribing a SSRI, along with the need for early treatment monitoring. Safe SSRI use involves examining a patient for adverse effects at around 2 weeks and again at 4–6 weeks after initiation to screen for worsening mood or irritability (Table 16–9) (Bridge et al. 2007).
294TABLE 16–6. Highlights of stimulant adverse effects
Common
Decreased appetite
Nausea
Weight loss
Insomnia
Headaches
Stomachaches
Dry mouth
Less common
Irritability
Dysphoria
Cognitive dulling
Obsessiveness
Anxiety
Tics
Dizziness
Blood pressure and pulse rate elevation
Notable rare reactions
Seizure
Hallucinations
Mania
Loss of adult height potential
TABLE 16–7. Monitoring suggestions for stimulants
Record height and weight growth curve at baseline and at each follow-up, at least every 6 months.
Measure blood pressure and pulse rate at baseline and after initiation of medication.
Monitor refill dates to identify signs of drug diversion.
Repeat administration of attention-deficit/hyperactivity disorder symptom rating scale until remission is achieved.
TABLE 16–8. Highlights of selective serotonin reuptake inhibitor adverse effects
Common
Insomnia
Sedation
Appetite increase
Appetite decrease
Nausea
Dry mouth
Headache
Sexual dysfunction
Less common
Agitation
Restlessness
Impulsivity
Irritability
Silliness
Dizziness
Tremor
Constipation
Diarrhea
Notable rare reactions
Suicidal thoughts
Serotonin syndrome
Easy bleeding
Hyponatremia
Mania
Prolonged QT interval
TABLE 16–9. Monitoring suggestions for selective serotonin reuptake inhibitors
Record height and weight at baseline and at each follow-up, at least every 6 months.
Inquire about increased irritability or agitation at 2 weeks and at 4–6 weeks after initiation.
Inquire about new or worsened suicidal thoughts at 2 weeks and at 4–6 weeks after initiation.
Inquire about new bleeding or bruising at least once after initiation.
Repeat disorder-specific rating scale(s) until remission is achieved. Takes 4–6 weeks to see benefits from a given dose.
Antipsychotics for children and adolescents are typically initiated by mental health specialists, but primary care practitioners often find themselves in the role of providing refills or monitoring. Patients can experience fairly significant adverse effects from these medications (Table 16–10). Weight gain is the most common problem, with patients in some trials gaining an average of more than 10 pounds in just 3 months of medication use (Correll et al. 2009). Weight gain seems to occur more frequently in children than in adults—for instance, aripiprazole and risperidone have been found to cause equal degrees of weight gain in children, a finding that contradicts the adult literature (Correll et al. 2009). Muscle stiffness or dystonia may occur, particularly during initial use, for which practitioners can warn a family to keep diphenhydramine around as an antidote. Sedation is common, but this might be managed through bedtime dosing. A metabolic syndrome of elevated levels of blood glucose, cholesterol, and triglycerides may occur for which regular blood tests are needed. A physical sense of restlessness (akathisia) or agitation may occur without parents realizing that this can be a side effect. The opposite could occur as well: medication-induced parkinsonism causes decreased movement. One of the most worrisome but rare reactions is neuroleptic malignant syndrome, which is a severe febrile, systemic allergic reaction that may occur typically in the first few months of use (Neuhut et al. 2009). Families also must be warned about a small, but cumulative and dose-related, risk of tardive dyskinesia, which is a potentially permanent repetitive involuntary movement disorder caused by antipsychotics. Although rare, this possibility needs to be part of the ongoing risk-benefit analysis around use of these medications. Tardive dyskinesia monitoring (Table 16–11) usually involves biannual examinations with the Abnormal Involuntary Movement Scale (AIMS) for any new-onset abnormal involuntary movements (McClellan and Stock 2013).
297TABLE 16–10. Highlights of newer-generation antipsychotic adverse effects
Common
Weight gain
Muscle rigidity
Parkinsonism
Constipation
Dry mouth
Dizziness
Somnolence/fatigue
Less common
Tremors
Nausea or abdominal pain
Akathisia (restlessness)
Headache
Agitation
Orthostasis
Elevated glucose level
Elevated levels of cholesterol and triglycerides
Notable rare reactions
Tardive dyskinesia
Neuroleptic malignant syndrome
Lowered blood cell counts
Elevated liver enzymes
Prolonged QT interval
Tachycardia
TABLE 16–11. Suggestions for monitoring of newer-generation antipsychotics
Record height and weight growth curve at baseline and at each follow-up, at least every 6 months.
Measure blood pressure and pulse rate at baseline and after initiation of medication.
Monitor levels of fasting blood glucose, triglycerides, and cholesterol every 6 months.
Obtain complete blood cell count with differential once after initiation.
Inform family about home monitoring for neuroleptic malignant syndrome and tardive dyskinesia.
Administer Abnormal Involuntary Movement Scale (AIMS) every 6 months.
Adjust medication until remission is achieved.
Repeat the risk-benefit analysis every 6 months to wean off the medication when appropriate.
If a child or an adolescent experiences an adverse effect of a medication prescribed for the treatment of a mental disorder, DSM-5 provides direction on how to record this information in the medical record (American Psychiatric Association 2013, pp. 709–714). We include Table 16–12 as a shorthand list so that you can record a movement disorder or other adverse medication effect that is a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder. A condition listed in the table may be coded if it is a reason for the current visit or helps to explain the need for a test, procedure, or treatment. Conditions and problems from this list also may be included in the medical record as useful information on circumstances that may affect the patient’s care, regardless of their relevance to the current visit.
299TABLE 16–12. ICD-10-CM codes for adverse medication effects
ICD-10-CM code |
Disorder, condition, or problem |
G21.11 |
Neuroleptic-induced parkinsonism |
G21.19 |
Other medication-induced parkinsonism |
G21.0 |
Neuroleptic malignant syndrome |
G24.02 |
Medication-induced acute dystonia |
G25.71 |
Medication-induced acute akathisia |
G24.01 |
Tardive dyskinesia |
G24.09 |
Tardive dystonia |
G25.71 |
Tardive akathisia |
G25.1 |
Medication-induced postural tremor |
G25.79 |
Other medication-induced movement disorder |
T43.205A |
Antidepressant discontinuation syndrome: initial encounter |
T43.205D |
Antidepressant discontinuation syndrome: subsequent encounter |
T43.205S |
Antidepressant discontinuation syndrome: sequelae |
T50.905A |
Other adverse effect of medication: initial encounter |
T50.905D |
Other adverse effect of medication: subsequent encounter |
T50.905S |
Other adverse effect of medication: sequelae |
Source. World Health Organization 1992.300