What are the recommended medications for child and adolescent psychiatric disorders, including attention deficit hyperactivity disorder (ADHD), anxiety disorders, depressive disorders, and psychotic disorders?

Recommended Medications for Child and Adolescent Psychiatric Disorders

For ADHD, stimulants (methylphenidate or lisdexamfetamine) are first-line pharmacotherapy with the strongest evidence, while for depression and anxiety SSRIs (fluoxetine, sertraline) are preferred, and for psychotic disorders atypical antipsychotics (risperidone, aripiprazole) should be used over older agents. 1

ADHD Treatment by Age Group

Preschool Children (Ages 4-5)

• Behavioral therapy (parent/teacher-administered) is the mandatory first-line treatment 1, 2
• Methylphenidate should only be prescribed if behavioral interventions fail AND there is moderate-to-severe functional impairment 1, 2
• Pharmacotherapy in this age group has lower efficacy and higher adverse event rates than in school-age children 1

Elementary School Children (Ages 6-11)

• FDA-approved stimulant medications are first-line treatment, preferably combined with behavioral therapy 1, 2
• Evidence hierarchy: stimulants (strongest, effect size ~1.0) > atomoxetine (effect size ~0.7) > extended-release guanfacine > extended-release clonidine 1, 2
• Methylphenidate may improve teacher-rated ADHD symptoms by approximately 10.6 points on the ADHD Rating Scale (0-72 scale), exceeding the minimal clinically relevant difference of 6.6 points 3

Adolescents (Ages 12-18)

• Prescribe FDA-approved stimulant medications with the adolescent's assent as primary treatment 1, 2
• Behavioral therapy may be added but has weaker evidence in this age group compared to medication 1

ADHD Medication Specifics

Stimulants (First-Line)

• Methylphenidate and lisdexamfetamine have the largest effect sizes for reducing ADHD core symptoms 1
• Start methylphenidate at 5 mg or amphetamine at 2.5 mg, titrating weekly in 5-10 mg increments (methylphenidate) or 2.5-5 mg increments (amphetamines) 4
• Maximum methylphenidate dose: 60 mg daily (expert consensus often limits to 40 mg) 4
• Maximum amphetamine dose: 40 mg daily 4
• Long-acting formulations provide superior adherence and consistent symptom control 1, 4
• Monitor: height, weight, pulse, blood pressure 1
• Common adverse effects: decreased appetite, sleep disturbances, increased blood pressure/pulse, headaches 1

Non-Stimulants (Second-Line)

• Atomoxetine: "around-the-clock" effects, requires 6-12 weeks for full effect, smaller effect size than stimulants 1

  • Monitor for suicidality (FDA black box warning) 1, 4
  • Consider as first-line in comorbid substance use disorders, disruptive behavior disorders, or tic/Tourette's disorder 1

• Extended-release guanfacine and clonidine: 2-4 weeks until effects observed, effect size ~0.7 1, 2

  • Monitor pulse and blood pressure 1
  • Common adverse effects: somnolence/sedation, fatigue, hypotension, irritability 1
  • Must taper gradually to avoid rebound hypertension 2
  • Consider as first-line in comorbid sleep disorders, substance use disorders, or disruptive behavior disorders 1

Treatment Algorithm

• If methylphenidate fails at adequate dosage/duration, switch to lisdexamfetamine before trying non-stimulants 1
• Long-term methylphenidate use (>1 year) is associated with decreased risk of depression (HR 0.70) and conduct disorders (HR 0.52) compared to short-term use 5

Depression and Anxiety Disorders

First-Line Treatment

• SSRIs are the treatment of choice: fluoxetine (first choice) and sertraline (second choice) 1, 6
• Escitalopram and citalopram may be used as second-choice alternatives 6
• SSRIs remain weight-neutral with long-term use 4

Monitoring Requirements

• Monitor for suicidality and clinical worsening, particularly during the first few months or at dose changes 4, 2
• No significant drug-drug interactions between SSRIs and stimulants, making combination therapy safe for comorbid ADHD 4

Alternative Agents

• Alpha-2 agonists (clonidine, guanfacine) and beta-blockers are sometimes used for anxiety, but lack trial evidence in children 1
• Benzodiazepines are NOT recommended for chronic anxiety due to heightened sensitivity to behavioral side effects (disinhibition) 1
• Tricyclic antidepressants may be helpful but adverse effects limit use 7
• Buspirone is effective for anxiety disorders 7

Psychotic Disorders and Mania

Psychotic Disorders

• Atypical antipsychotics (risperidone, aripiprazole) are preferred over first-generation antipsychotics (haloperidol) 1, 7
• Children with intellectual disability may have increased sensitivity to extrapyramidal symptoms, making atypical antipsychotics particularly important 1
• Risperidone is the most commonly prescribed antipsychotic in pediatric populations 8

Bipolar Disorder

• Mood stabilizers (valproic acid, lithium) are the primary treatment 1
• Treatment approach is similar to adults with bipolar disorder 1

Obsessive-Compulsive Disorder (OCD)

Treatment Algorithm for Comorbid OCD and ADHD

• Begin with CBT for OCD while simultaneously initiating stimulant medication for ADHD 4
• If OCD symptoms are severe, begin with SSRI plus supportive therapy before initiating CBT 4
• If ADHD improves with stimulants but OCD persists, add an SSRI to the stimulant regimen 4
• Stimulants do not worsen OCD symptoms and may improve obsessive-compulsive symptoms when ADHD is adequately treated 4

Medication Options

• Clomipramine (tricyclic) is effective for childhood OCD 7
• SSRIs are also useful for OCD 7

Sleep Disorders

• Melatonin is effective for improving sleep in adolescents 1
• Long-term use of benzodiazepine hypnotics and antihistamines should be approached cautiously due to potential disinhibition 1

Critical Pre-Treatment Requirements

Diagnostic Confirmation

• Confirm DSM-5 criteria with documentation of symptoms and impairment in more than one setting 2
• Obtain information from multiple sources: parents/guardians, teachers, school personnel, mental health clinicians 2

Comorbidity Screening

• Screen for emotional/behavioral conditions (anxiety, depression, ODD, conduct disorders, substance use), developmental conditions (learning disorders, language disorders, autism), and physical conditions (tics, sleep apnea) 1, 2

Cardiac Evaluation

• Obtain personal and family cardiac history before initiating ADHD medication 2
• Perform baseline ECG if cardiac risk factors are present, particularly before starting non-stimulants 2

Monitoring Protocol

• Conduct weekly follow-up during titration phase to assess efficacy and safety 2
• Use standardized parent and teacher rating scales at each visit during titration 4
• Once response is achieved, continue monitoring at monthly intervals during maintenance 4

Critical Pitfalls to Avoid

• Do NOT use MAO inhibitors concurrently with stimulants or SSRIs due to risk of hypertensive crisis 4
• Do NOT delay ADHD treatment while waiting for other conditions to improve—both can and should be treated simultaneously 4
• Do NOT underdose stimulants—titrate to optimal effect within safe limits 4
• Do NOT prescribe medication for behavioral problems (aggression, self-injury) without first diagnosing a DSM-5 psychiatric disorder 1
• Medication should not substitute for appropriate educational services (IEP, 504 plans) 2

Chronic Disease Management Approach

• Recognize ADHD and other psychiatric disorders as chronic conditions requiring medical home principles 1, 4, 2
• Establish collaborative communication systems with schools and mental health professionals 2
• Multimodal management including psychoeducation, CBT, and family therapy should complement medication 2