# Lecture 9: Child and Adolescent Psychiatry ## Unit 2.6: Psychiatry --- ## Learning Objectives By the end of this lecture, students will be able to: 1. Describe the developmental approach to child psychiatric assessment 2. Explain attention-deficit/hyperactivity disorder and its treatment 3. Describe autism spectrum disorder and related conditions 4. Explain disruptive behavior disorders and their management 5. Describe pediatric mood and anxiety disorders 6. Explain special considerations in pediatric psychopharmacology --- ## Lecture Outline ### I. Developmental Approach to Assessment Child psychiatric assessment must be understood through a developmental lens that considers what constitutes normal behavior at each developmental stage. Age-appropriate behavior varies significantly across development, and behaviors that would be pathological in an adolescent may be entirely normal in a toddler. Developmental milestones in language, motor skills, and social functioning provide the framework for identifying delays or deviations. Context is essential, as behavior occurs within the ecology of family, school, and peer relationships. Multiple informants including the child, parents, and teachers provide complementary perspectives that together form a comprehensive picture. The assessment components in child psychiatry include the clinical interview, which should involve both child and parent separately and together to observe the dyadic interaction. Developmental history encompasses pregnancy, birth, early milestones, and the trajectory of symptom development. School information including report cards, standardized testing, and teacher observations is often essential for diagnosing conditions like ADHD and learning disorders. Behavioral observations during the interview capture affect, relatedness, activity level, and play quality. Psychological testing may be indicated when questions about cognitive functioning, learning disabilities, or specific diagnostic clarification arise. Normal developmental milestones provide the reference points against which concerning behaviors are evaluated. By age two years, children typically use two-word phrases and engage in parallel play alongside other children. By age three, children speak in three-word sentences and engage in interactive play with peers. Ages four to five bring complex sentences and imaginative play. School-age children (six to twelve) develop concrete operational thinking and form meaningful peer relationships. Adolescence brings abstract thinking, identity formation, and increasing autonomy. Red flags that warrant further evaluation include no words by sixteen months suggesting language delay, no pretend play by eighteen months concerning for autism spectrum disorder, any regression or loss of previously acquired skills, social disinterest or failure to respond to name suggesting autism spectrum concerns, and severe aggression beyond typical developmental boundaries. Early identification of these concerns allows for earlier intervention. Panel A displays a developmental milestones timeline from birth through adolescence, showing language milestones (cooing, babbling, words, sentences, abstract language), social milestones (social smile, stranger anxiety, parallel play, interactive play, peer relationships), and cognitive milestones (sensorimotor, preoperational, concrete, formal operations). Panel B illustrates the multi-informant approach showing the child at center with arrows connecting to parents, teachers, and clinician, each providing unique observational perspectives. Panel C presents red flags for referral: no words by 16 months (language concern), no pretend play by 18 months (ASD concern), regression (any loss of skills—immediate evaluation), social disinterest (ASD concern), severe aggression (disruptive behavior concern). Panel D shows assessment components: clinical interview (child, parent, dyadic), developmental history, school information, behavioral observations, and psychological testing when indicated. --- ### II. Attention-Deficit/Hyperactivity Disorder Overview Attention-deficit/hyperactivity disorder is a neurodevelopmental disorder characterized by developmentally inappropriate levels of inattention and/or hyperactivity-impulsivity that interfere with functioning. DSM-5 Criterion A requires at least six symptoms of inattention and/or at least six symptoms of hyperactivity-impulsivity that have persisted for at least six months to a degree that is inconsistent with developmental level and negatively impacts functioning. For individuals seventeen years and older, only five symptoms are required. Additional diagnostic criteria specify the context and timing of symptoms. Criterion B requires that several symptoms were present prior to age twelve years. Criterion C requires that several symptoms are present in two or more settings such as home, school, work, with friends, or in other activities. Criterion D requires clear evidence that symptoms interfere with or reduce quality of social, academic, or occupational functioning. Criterion E specifies that symptoms are not better explained by another mental disorder. Inattention symptoms span difficulties with sustained focus and organization. Individuals often fail to give close attention to details or make careless mistakes. They have difficulty sustaining attention in tasks or play. They often do not seem to listen when spoken to directly. They frequently do not follow through on instructions and fail to finish tasks. They have difficulty organizing tasks and activities. They often avoid or are reluctant to engage in tasks requiring sustained mental effort. They frequently lose things necessary for tasks. They are easily distracted by extraneous stimuli and are often forgetful in daily activities. Hyperactivity-impulsivity symptoms reflect difficulties with motor control and waiting. Hyperactivity includes often fidgeting or squirming, leaving seat when remaining seated is expected, running or climbing in inappropriate situations, being unable to play quietly, being "on the go" as if driven by a motor, and talking excessively. Impulsivity includes blurting out answers before questions are completed, having difficulty waiting turn, and interrupting or intruding on others. Panel A presents the DSM-5 diagnostic criteria structure: Criterion A (6+ symptoms of inattention and/or 6+ hyperactivity-impulsivity for 6+ months), Criterion B (onset before age 12), Criterion C (present in 2+ settings), Criterion D (functional impairment), Criterion E (not better explained by another disorder). Panel B displays inattention symptoms as icons: careless mistakes, difficulty sustaining attention, doesn't listen, doesn't follow through, difficulty organizing, avoids mental effort, loses things, easily distracted, forgetful. Panel C shows hyperactivity-impulsivity symptoms: fidgets/squirms, leaves seat, runs/climbs inappropriately, can't play quietly, "on the go," talks excessively (hyperactivity), blurts out, can't wait turn, interrupts/intrudes (impulsivity). Panel D presents the three presentations: combined (both domains), predominantly inattentive (often missed, previously called ADD), predominantly hyperactive-impulsive (less common). --- ### III. ADHD Epidemiology and Neurobiology The epidemiology of ADHD reveals prevalence of approximately five to seven percent in children, making it one of the most common neurodevelopmental disorders. The condition persists into adulthood in approximately fifty percent of cases, though presentation may shift from hyperactivity to more subtle executive function difficulties. The sex ratio shows boys are diagnosed approximately two to one compared to girls in clinical samples, though community samples suggest the ratio is closer to equal, indicating that girls, particularly those with predominantly inattentive presentation, are underdiagnosed. Comorbidity is common, with learning disorders, oppositional defiant disorder, anxiety disorders, and mood disorders frequently co-occurring. The neurobiology of ADHD involves dysfunction in prefrontal-striatal circuits that subserve executive functions including attention, working memory, impulse control, and planning. Neuroimaging studies demonstrate hypofunction of the prefrontal cortex during tasks requiring sustained attention and response inhibition. Dopamine and norepinephrine signaling are deficient, explaining the efficacy of stimulant and non-stimulant medications that enhance catecholaminergic transmission. Brain volume is slightly smaller overall, and maturation of the cortex, particularly prefrontal regions, is delayed by approximately two to three years. Heritability is approximately seventy-five percent, indicating strong genetic contribution. Several assessment tools facilitate diagnosis and treatment monitoring. Conners rating scales include parent and teacher versions that assess core ADHD symptoms and related behaviors. Vanderbilt scales are free, widely used, and include DSM-based symptom assessment along with screening for comorbid conditions. SNAP-IV is a DSM-based rating scale often used in research and clinical settings. Continuous performance tests provide objective measures of attention and impulsivity but should not be used alone for diagnosis. The differential diagnosis of ADHD includes several conditions that can mimic or co-occur with ADHD. Anxiety disorders can cause restlessness and concentration difficulties, but focus typically improves when the child is calm and not anxious. Learning disorders cause specific academic difficulties in reading, math, or written expression that may be confused with inattention. Sleep disorders including sleep apnea and insufficient sleep cause daytime fatigue and inattention. Thyroid dysfunction should be excluded through appropriate laboratory testing. Trauma and abuse history may produce hypervigilance and concentration problems resembling ADHD. Panel A presents epidemiological data: 5-7% prevalence in children, persistence into adulthood in 50%, sex ratio 2:1 boys in clinical samples but closer to equal in community (girls underdiagnosed), and common comorbidities (learning disorders, ODD, anxiety, mood). Panel B illustrates neurobiology with brain diagram showing prefrontal cortex hypofunction, striatal involvement, dopamine and norepinephrine deficiency, 2-3 year maturation delay, and 75% heritability. Panel C displays assessment tools: Conners scales (parent, teacher), Vanderbilt (free, widely used), SNAP-IV (DSM-based), continuous performance tests (objective but not diagnostic alone). Panel D shows differential diagnosis comparison: anxiety (restlessness but focuses when calm), learning disorders (specific academic difficulties), sleep disorders (fatigue causing inattention), thyroid (medical workup), trauma (hypervigilance, history). --- ### IV. ADHD Treatment Stimulant medications represent first-line pharmacotherapy for ADHD and are among the most effective treatments in psychiatry. Methylphenidate-based preparations include immediate-release, intermediate-release, and long-acting formulations, with trade names including Ritalin, Concerta, and others. Duration of action ranges from three to four hours for immediate-release to twelve hours for long-acting preparations. Amphetamine-based preparations include mixed amphetamine salts and lisdexamfetamine. Lisdexamfetamine is a prodrug requiring enzymatic conversion to active d-amphetamine, conferring smoother onset and reduced abuse potential. Selection between methylphenidate and amphetamine classes is often based on individual response and tolerability. Non-stimulant medications provide alternatives when stimulants are ineffective, poorly tolerated, or contraindicated. Atomoxetine is a selective norepinephrine reuptake inhibitor with a slower onset of action requiring several weeks for full effect. Guanfacine extended-release and clonidine extended-release are alpha-2 adrenergic agonists that may be used alone or as adjuncts to stimulants, particularly helpful for hyperactivity and aggression. Viloxazine, a norepinephrine reuptake inhibitor, was recently approved for ADHD. Stimulant side effects require monitoring and management. Decreased appetite is common and can be managed by giving medication after meals or offering high-calorie snacks in the evening. Sleep problems may be addressed through earlier dosing or switching to shorter-acting formulations. Growth suppression is controversial, with some studies showing minimal long-term impact, and drug holidays are sometimes used though evidence for benefit is limited. Tics may emerge or worsen in susceptible individuals, warranting consideration of non-stimulant alternatives. Cardiovascular effects require baseline screening for cardiac history and ongoing monitoring of heart rate and blood pressure. Behavioral interventions are essential components of comprehensive ADHD treatment. Parent training teaches behavior management strategies including clear expectations, consistent consequences, and positive reinforcement. Classroom accommodations may include preferential seating, breaks, extended time on tests, and modified assignments. Organizational skills training helps children develop strategies for managing materials, time, and tasks. Social skills groups address peer interaction difficulties that commonly accompany ADHD. Panel A presents stimulant medications organized by class: methylphenidate-based (immediate, intermediate, long-acting with durations) and amphetamine-based (mixed salts, lisdexamfetamine as prodrug with reduced abuse potential), with selection based on individual response. Panel B displays non-stimulant options: atomoxetine (NRI, slower onset), guanfacine ER and clonidine ER (alpha-2 agonists, helpful for hyperactivity and aggression), viloxazine (NRI, recently approved). Panel C shows side effect management: decreased appetite (give after meals, evening snacks), sleep problems (earlier dosing, shorter-acting), growth (monitor height, controversial drug holidays), tics (consider alternatives), cardiovascular (screen history, monitor HR and BP). Panel D illustrates behavioral interventions: parent training (behavior management, consistent consequences), classroom accommodations (seating, breaks, extended time), organizational skills training, social skills groups. --- ### V. Autism Spectrum Disorder Autism spectrum disorder is a neurodevelopmental condition characterized by persistent deficits in social communication and social interaction across multiple contexts, along with restricted, repetitive patterns of behavior, interests, or activities. DSM-5 consolidates previous separate diagnoses including autistic disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified into a single autism spectrum disorder diagnosis with severity specifiers. The social communication criterion requires deficits in all three areas. Social-emotional reciprocity includes deficits in back-and-forth conversation, reduced sharing of interests and emotions, and failure to initiate or respond to social interactions. Nonverbal communicative behaviors include poorly integrated verbal and nonverbal communication, abnormalities in eye contact and body language, and deficits in understanding and use of gestures and facial expressions. Developing, maintaining, and understanding relationships includes difficulties adjusting behavior to social contexts, sharing imaginative play, and developing friendships. The restricted and repetitive behavior criterion requires at least two of four types of behaviors. Stereotyped or repetitive motor movements, use of objects, or speech includes simple motor stereotypies, lining up toys, echolalia, and idiosyncratic phrases. Insistence on sameness, inflexible adherence to routines, or ritualized patterns includes extreme distress at small changes, difficulties with transitions, and rigid thinking patterns. Highly restricted, fixated interests that are abnormal in intensity or focus include strong attachment to unusual objects or excessively circumscribed or perseverative interests. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment includes apparent indifference to pain or temperature, adverse response to specific sounds or textures, excessive smelling or touching, and visual fascination with lights or movement. Severity levels describe the amount of support required. Level 1, requiring support, describes individuals with noticeable impairments but who can function with minimal support. Level 2, requiring substantial support, describes individuals with marked deficits requiring notable supports. Level 3, requiring very substantial support, describes individuals with severe deficits requiring extensive supports. Severity is specified separately for social communication and restricted, repetitive behaviors. Panel A presents the two diagnostic domains: A (social communication deficits in all three: social-emotional reciprocity, nonverbal communication, relationships) and B (restricted/repetitive behaviors, at least 2 of 4: stereotyped movements/speech, insistence on sameness, restricted interests, sensory reactivity). Panel B illustrates social communication deficits with examples: reduced eye contact, difficulty with back-and-forth conversation, limited sharing of interests, difficulty understanding nonverbal cues, challenges developing friendships. Panel C shows restricted/repetitive behaviors: stereotypies (hand flapping, spinning), insistence on sameness (distress with changes, rigid routines), restricted interests (intense focus on specific topics), sensory differences (hyper- or hypo-reactivity). Panel D displays severity levels as a spectrum: Level 1 (requiring support, noticeable impairments), Level 2 (requiring substantial support, marked deficits), Level 3 (requiring very substantial support, severe deficits), with separate ratings for social communication and restricted behaviors. --- ### VI. ASD Assessment and Treatment Early identification of autism spectrum disorder is essential for accessing early intervention. Screening is recommended at eighteen and twenty-four months using the Modified Checklist for Autism in Toddlers (M-CHAT-R/F). Positive screens warrant comprehensive evaluation. The gold-standard diagnostic assessment includes the Autism Diagnostic Observation Schedule, Second Edition, a structured observation that probes social communication and restricted behaviors. The Autism Diagnostic Interview-Revised is a structured parent interview providing developmental history. Comprehensive evaluation should also include developmental testing of cognitive and language abilities. Early signs that may prompt referral include reduced eye contact by six months, no babbling by twelve months, no pointing or other gestures by twelve months, no single words by sixteen months, no two-word spontaneous phrases by twenty-four months, and any loss of previously acquired language or social skills at any age. Parents often express early concerns about their child's development, and these concerns should be taken seriously. Treatment approaches for ASD focus on building skills and addressing associated symptoms. Applied Behavior Analysis is an intensive behavioral intervention with the strongest evidence base, particularly when started early. ABA uses structured teaching, reinforcement, and shaping to develop communication, social, and adaptive skills. Speech and language therapy addresses both verbal and nonverbal communication. Occupational therapy addresses sensory processing, motor skills, and activities of daily living. Social skills training may be delivered individually or in groups. Special education services with individualized education programs provide appropriate educational supports. Pharmacotherapy for ASD targets associated symptoms rather than core features. No medication treats the core social communication deficits or restricted behaviors of autism. Risperidone and aripiprazole are FDA-approved for irritability associated with autism in children. Stimulants and atomoxetine may address comorbid ADHD symptoms, which are common. SSRIs may help with anxiety, which also frequently co-occurs. Melatonin is commonly used for sleep difficulties. Panel A presents screening and diagnostic tools: M-CHAT-R/F for screening at 18 and 24 months, ADOS-2 as gold-standard diagnostic observation, ADI-R as structured parent interview, and developmental assessment of cognition and language. Panel B displays early warning signs: no eye contact by 6 months, no babbling by 12 months, no pointing by 12 months, no words by 16 months, no 2-word phrases by 24 months, any regression at any age. Panel C shows treatment modalities: ABA (intensive behavioral, strongest evidence, early start important), speech therapy, occupational therapy, social skills training, special education with IEP. Panel D presents pharmacotherapy targets: irritability (risperidone, aripiprazole FDA-approved), ADHD symptoms (stimulants, atomoxetine), anxiety (SSRIs), sleep (melatonin), with note that no medication treats core ASD symptoms. --- ### VII. Disruptive Behavior Disorders Oppositional defiant disorder is characterized by a pattern of angry and irritable mood, argumentative and defiant behavior, or vindictiveness lasting at least six months. The angry and irritable mood cluster includes often losing temper, often being touchy or easily annoyed, and often being angry and resentful. The argumentative and defiant cluster includes often arguing with authority figures, often actively defying or refusing to comply with requests or rules, often deliberately annoying others, and often blaming others for mistakes or misbehavior. Vindictiveness requires being spiteful or vindictive at least twice within the past six months. Most symptoms must occur at least weekly. Conduct disorder represents a more severe pattern involving violation of the rights of others or major societal norms. The diagnostic criteria require at least three criteria from four categories present in the past twelve months, with at least one present in the past six months. Aggression toward people and animals includes bullying, initiating fights, using weapons, cruelty to people or animals, and forced sexual activity. Destruction of property includes fire-setting or other deliberate destruction. Deceitfulness or theft includes breaking and entering, lying, and stealing. Serious violations of rules include staying out at night, running away, and truancy. Conduct disorder specifiers describe onset and associated features. Childhood-onset specifies at least one criterion prior to age ten years and carries worse prognosis. Adolescent-onset specifies no criteria before age ten. The with limited prosocial emotions specifier, indicating callous-unemotional traits, is associated with more severe course and poorer treatment response. These traits include lack of remorse or guilt, callous lack of empathy, unconcern about performance, and shallow or deficient affect. The developmental relationship between these disorders and antisocial personality disorder is important. Oppositional defiant disorder may precede conduct disorder in some cases. Conduct disorder before age fifteen is required for the diagnosis of antisocial personality disorder in adults. However, many children with ODD do not progress to CD, and many adolescents with CD do not develop ASPD, particularly those with later onset and without callous-unemotional traits. Panel A presents ODD diagnostic criteria organized by symptom clusters: angry/irritable mood (loses temper, touchy, angry/resentful), argumentative/defiant (argues, defies, annoys, blames others), and vindictiveness (spiteful twice in 6 months), requiring at least 4 symptoms for at least 6 months, most occurring weekly. Panel B shows conduct disorder categories with examples: aggression (bullying, fighting, weapons, cruelty, sexual coercion), destruction (fire-setting, vandalism), deceit/theft (breaking in, lying, stealing), rule violations (staying out, running away, truancy), requiring 3 criteria in 12 months with 1 in past 6 months. Panel C displays CD specifiers: childhood-onset (before age 10, worse prognosis), adolescent-onset (no criteria before 10), with limited prosocial emotions (callous-unemotional traits: no remorse, callous, unconcerned, shallow affect). Panel D illustrates developmental trajectory: ODD may precede CD, CD before 15 required for adult ASPD, but many do not progress (not all ODD → CD, not all CD → ASPD), with better outcomes for later onset and without callous traits. --- ### VIII. Treatment of Disruptive Behavior Parent management training represents the first-line evidence-based treatment for disruptive behavior disorders. Core components include increasing positive reinforcement for appropriate behavior, establishing clear expectations and consistent consequences, using effective commands and following through, reducing coercive parent-child interactions that maintain problem behaviors, and implementing structured discipline approaches. Specific programs with strong evidence include Parent-Child Interaction Therapy, which involves live coaching of parent-child interaction, and the Incredible Years parenting program. School-based interventions address behavior in the academic setting where children spend substantial time. Behavior plans establish clear expectations, consistent consequences, and reinforcement for appropriate behavior. Functional behavior assessment identifies the antecedents and consequences maintaining problem behavior, allowing for targeted intervention. Check-in/check-out programs provide daily monitoring with adult contact at the beginning and end of each day. Social problem-solving training teaches cognitive approaches to managing conflicts and frustrations. Pharmacotherapy plays a limited role in treating disruptive behavior disorders, with psychosocial intervention as the primary approach. Risperidone is FDA-approved for irritability associated with autism and has evidence for reducing aggression in children with conduct problems. When ADHD is comorbid, which is common, treating the ADHD with stimulants often improves behavioral symptoms as well. Mood stabilizers have limited evidence and are not considered first-line. Overall, medication should supplement rather than replace behavioral intervention. Prognostic factors influence outcomes across disruptive behavior disorders. Better outcomes are associated with ODD without progression to conduct disorder, adolescent onset rather than childhood onset of conduct symptoms, milder severity, and absence of callous-unemotional traits. Family engagement in treatment is critical for outcomes, as parent management training requires active parental participation. Comorbid ADHD should be identified and treated, as untreated ADHD worsens prognosis for disruptive behavior. Panel A presents parent management training components: positive reinforcement (catch them being good), clear expectations and consistent consequences, effective commands with follow-through, reducing coercive cycles, and specific programs (PCIT with live coaching, Incredible Years). Panel B displays school interventions: behavior plans (expectations, consequences, reinforcement), functional behavior assessment (identify antecedents and consequences), check-in/check-out (daily monitoring), social problem-solving (cognitive approaches to conflict). Panel C shows pharmacotherapy role: limited, psychosocial treatment first, risperidone for aggression (FDA-approved for autism irritability), stimulants when ADHD comorbid (often helps behavior), mood stabilizers limited evidence. Panel D illustrates prognostic factors: better outcomes with ODD only (vs CD), later onset (vs childhood), mild severity, no callous-unemotional traits, family engagement, and treated ADHD comorbidity. --- ### IX. Pediatric Mood and Anxiety Disorders Pediatric depression differs from adult depression in presentation and treatment considerations. Prevalence is approximately two percent in children and eight percent in adolescents, increasing substantially around puberty. Presentation may emphasize irritability more than sad mood, and somatic complaints are common. The course involves high recurrence risk, with most youth who experience one episode experiencing additional episodes. Comorbidity with anxiety and ADHD is frequent. Treatment of pediatric depression follows a stepped care approach. Cognitive-behavioral therapy is first-line for mild to moderate depression and has strong evidence in youth. Fluoxetine is FDA-approved for depression in children aged eight and older. Escitalopram is FDA-approved for adolescents aged twelve and older. The Treatment for Adolescents with Depression Study demonstrated that combination treatment with fluoxetine plus CBT produced the best outcomes. All antidepressants carry a black box warning regarding increased suicidality risk in children and adolescents, requiring close monitoring particularly in the first weeks of treatment. Disruptive mood dysregulation disorder was introduced in DSM-5 to address concerns about overdiagnosis of pediatric bipolar disorder. DMDD is characterized by severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation, occurring on average three or more times per week. The mood between outbursts is persistently irritable or angry most of the day, nearly every day. Symptoms must be present for twelve or more months. DMDD cannot be diagnosed with bipolar disorder, and the diagnosis is made rather than bipolar when children present with chronic, non-episodic irritability. Treatment typically involves CBT, parent training, and sometimes SSRIs or stimulants if ADHD is comorbid. Pediatric anxiety disorders are among the most common childhood psychiatric conditions. Separation anxiety disorder features developmentally inappropriate excessive anxiety concerning separation from attachment figures. Social anxiety disorder involves marked fear of social or performance situations. Generalized anxiety disorder presents with excessive worry about multiple domains. Selective mutism features consistent failure to speak in specific social situations despite speaking normally in others. CBT is first-line treatment, and SSRIs including sertraline and fluoxetine are effective and commonly used off-label. Panel A presents pediatric depression features: 2% children/8% adolescents prevalence, irritability may predominate over sadness, somatic complaints common, high recurrence risk, comorbidity with anxiety and ADHD. Panel B displays treatment: CBT first-line for mild-moderate, fluoxetine FDA-approved age 8+, escitalopram FDA-approved age 12+, TADS showed combination best, black box warning requiring monitoring. Panel C shows DMDD diagnostic features: severe temper outbursts 3+/week, out of proportion to situation, persistently irritable/angry mood between outbursts, 12+ month duration, introduced to address bipolar overdiagnosis, treatment with CBT, parent training, sometimes SSRIs. Panel D presents pediatric anxiety disorders: separation anxiety (excessive about attachment figures), social anxiety (fear of social situations), GAD (excessive worry), selective mutism (doesn't speak in specific settings), treatment with CBT first-line and SSRIs off-label. --- ### X. Pediatric Psychopharmacology Principles General principles guide medication use in children and adolescents. Start low and go slow, using lower starting doses and slower titration than in adults due to developmental differences in pharmacokinetics and pharmacodynamics. Psychotherapy should be first-line for many conditions, with medication added when psychotherapy is insufficient. Growth monitoring including height and weight should occur regularly, as some medications affect growth. Informed consent must be obtained from parents, with developmentally appropriate assent from the child. Off-label use is common in pediatric psychopharmacology, as many medications are not specifically FDA-approved for use in children. FDA-approved medications for specific pediatric indications include stimulants, atomoxetine, and alpha-agonists for ADHD, with various age minimums depending on the specific medication. Fluoxetine is approved for depression in children eight and older, and escitalopram for adolescents twelve and older. For OCD, fluoxetine, sertraline, fluvoxamine, and clomipramine have pediatric approval. No medications are specifically approved for pediatric anxiety, though SSRIs are commonly used off-label. For bipolar disorder, lithium is approved for children twelve and older, and several atypical antipsychotics are approved for pediatric mania. Risperidone and aripiprazole are approved for irritability associated with autism at ages five and six, respectively. Monitoring requirements vary by medication class. Stimulants require monitoring of height, weight, heart rate, and blood pressure. SSRIs require monitoring for suicidality and activation, particularly in the first weeks of treatment. Antipsychotics require metabolic monitoring including weight, glucose, and lipids, as well as monitoring for prolactin elevation and extrapyramidal symptoms. Lithium requires monitoring of serum levels, renal function, and thyroid function. Special considerations in pediatric practice include managing medication refusal by exploring the child's concerns and involving them in treatment decisions. School medication administration requires appropriate documentation including 504 plans and coordination with school nursing. Transition to adult care should be planned and gradual. Polypharmacy should be avoided when possible, and when multiple medications are used, each should have a clear indication. Panel A presents general principles: start low, go slow (developmental pharmacokinetics), psychotherapy often first-line, monitor growth (height, weight), informed consent from parents with assent from child, off-label use common. Panel B displays FDA-approved pediatric medications by indication: ADHD (stimulants, atomoxetine, alpha-agonists), depression (fluoxetine 8+, escitalopram 12+), OCD (fluoxetine, sertraline, fluvoxamine, clomipramine), bipolar (lithium 12+, atypical antipsychotics), autism irritability (risperidone 5+, aripiprazole 6+), anxiety (none approved, SSRIs off-label). Panel C shows monitoring requirements by class: stimulants (height, weight, HR, BP), SSRIs (suicidality, activation), antipsychotics (metabolic, prolactin, EPS), lithium (levels, renal, thyroid). Panel D presents special considerations: medication refusal (explore concerns, involve child), school administration (504 plans, nurse coordination), transition to adult care (planned, gradual), polypharmacy (avoid, each medication needs clear indication). --- ## Summary - Developmental assessment considers age-appropriate behavior, uses multiple informants, and identifies red flags warranting referral - ADHD requires at least six inattention and/or hyperactivity-impulsivity symptoms before age twelve, present in at least two settings with functional impairment; stimulants are first-line pharmacotherapy - ASD features social communication deficits across all three domains (reciprocity, nonverbal, relationships) plus at least two restricted/repetitive behavior types; early intervention is critical - ODD involves angry/irritable, argumentative/defiant, or vindictive patterns; parent management training is first-line treatment - Conduct disorder involves violation of others' rights or societal norms; childhood onset and callous-unemotional traits confer worse prognosis - Pediatric depression may present as irritability; fluoxetine and escitalopram are FDA-approved with required suicidality monitoring - DMDD was introduced to address pediatric bipolar overdiagnosis, featuring severe temper outbursts with chronic irritable mood - Pediatric anxiety disorders are common; CBT is first-line with SSRIs used off-label - Pediatric psychopharmacology principles include starting low, going slow, prioritizing psychotherapy, monitoring growth, and avoiding unnecessary polypharmacy --- ## Key Terms | Term | Definition | |------|------------| | ADHD | Neurodevelopmental disorder with inattention and/or hyperactivity-impulsivity causing functional impairment | | Autism spectrum disorder | Neurodevelopmental disorder with social communication deficits and restricted, repetitive behaviors | | Oppositional defiant disorder | Pattern of angry, argumentative, and defiant behavior toward authority figures | | Conduct disorder | Pattern of behavior violating the rights of others or major societal norms | | Disruptive mood dysregulation disorder | Severe temper outbursts with chronic irritability, alternative to pediatric bipolar diagnosis | | Parent management training | Evidence-based behavioral intervention teaching parents strategies to manage child behavior | | Black box warning | FDA warning about increased suicidality risk with antidepressants in children and adolescents | | Applied behavior analysis | Intensive behavioral intervention with strongest evidence for autism spectrum disorder | --- *This content is subject to the [MIT License](https://opensource.org/licenses/MIT). © 2024–2026 Hibbert School of Medicine.*