The goals of pharmacologic treatment of mental and behavioral health disorders in children and adolescents include:
- Treatment of symptoms to remission
- Treatment for an adequate period so as to minimize likelihood of symptom relapse on discontinuation
- Minimize side effect burden and risk of adverse events associated with medications
- Complement and enhance other treatment modalities including psychotherapies, behavior management strategies, environmental changes or supports
Informed Consent and Assent in Psychopharmacology
Informed consent requires that a parent or guardian is competent to make decisions, has adequate knowledge and can decide freely.
- Adequate knowledge includes
- Understanding of the disorder and its effect on the child
- Risks, benefits and side effects of medication
- Alternative treatment options
- The child’s prognosis with and without the medication
Informed assent includes the same elements as consent, adjusted for the child’s development age. Assent includes the invitation to the child or adolescent to participate in treatment decisions and monitoring.
Adequacy of a Medication Trial
A common mistake is starting a medication at a low dose and titrating it so slowly that the patient sees no benefit and discontinues the medication.
Another common mistake is to overemphasize side effects in discussions with parents and patients and then discontinuing medication if any side effects emerge.
A better strategy is to start a medication at a low dose with stated plan to increase it if tolerated, aiming for a likely effective dose. Assess response and continue to increase until the response is achieved. Discontinue the medication only if unacceptable side effects occur or the child has not responded to a typically effective dose.
See individual medication classes for details.
Always maximize the utility of a single medication before adding another medication, particularly in the treatment of a single disorder.
For example, increase the dose of a stimulant, or add a booster dose of the same stimulant in the treatment of a patient with ADHD before adding a non-stimulant medication. See When to use a non-stimulant medication in your patient with ADHD.
Avoid prescribing more than one medication from the same class.
Common reasons for lack of adherence include lack of understanding of the duration of treatment, not knowing how or when to refill medications, believing that medications are to be taken only when symptomatic, stigma, trouble swallowing, trouble remembering, and ambivalence.
A helpful question: what do you notice if you forget to take your medication?
Children have proportionally more liver tissue adjusted for body weight than do adults. They may have more rapid metabolism and elimination of hepatically metabolized drugs.
Children may have a higher glomerular filtration rate than do adults and may have more rapid excretion of drugs that use renal pathways.
Gastrointestinal tract functioning continues to mature through childhood. Children may exhibit more variable absorption of orally administered drugs than do adolescents.
Psychoactive Medications and Your Practice
Pharmacologic treatment of common mental health disorders occurs over a longer time frame than does other pharmacologic treatment in pediatrics. This may require different follow-up schedules and protocols than are typical in pediatric practice.
Pharmacologic treatments of mental health disorders are effective in and of themselves, but their efficacy is enhanced in the treatment relationship. The treatment relationship in pediatric medicine is at a minimum triadic, involving the prescriber, the patient, and the parent or guardian.
Beliefs about the efficacy and safety of psychopharmacology, the meanings attached to taking medication to treat a given condition, as well as hope and expectation of symptomatic and functional recovery are all shaped in the treatment relationship.
Psychopharmacology for Pediatricians
The American Academy of Pediatrics recommends that pediatric clinicians be able to prescribe and manage selective serotonin reuptake inhibitors (SSRIs) in the treatment of pediatric anxiety and depression, and to prescribe and manage psychostimulants in the treatment of ADHD.
We encourage pediatricians to:
- Become familiar and comfortable with 2 or 3 of the SSRIs for which there is a good evidence base in the treatment of pediatric anxiety and depression (fluoxetine, sertraline and escitalopram)
- Become familiar and comfortable with common formulations of stimulant medications
- Become familiar with non-stimulant medications in the treatment of ADHD (atomoxetine and the alpha-agonists)
- Understand the indications for and side effects profiles of other psychotropic medications so that you can help monitor metabolic, neurologic or other adverse effects and partner with mental health specialists in maximizing your patient’s overall health and wellbeing