Practice guidelines usually focus on specific conditions, but the Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents from the American Academy of Child & Adolescent Psychiatry (AACAP) has a broader goal: to provide “decision-making principles that underlie optimal psychopharmacological practice” across diagnostic categories.
“If people adhere to these principles, more kids who would benefit from medication will get them,” says John Walkup, MD, director of child and adolescent psychiatry at Weill Cornell Medical College in New York City and principal author of the parameter.
Evaluation and treatment planning
The practice parameter recommends that a thorough medical history and evaluation be done before prescribing to rule out medical problems that could account for psychiatric manifestations and ensure that a medication trial will not entail undue risk. Before initiating some drugs, targeted testing may be appropriate to establish a baseline against which to measure adverse effects (e.g., height and weight measurement for stimulants; height, weight, and lipid assessment for antipsychotics).
The evaluation should guide treatment by differentiating biological, psychological, and social causes of symptoms. “I see a tendency for primary-care clinicians to discount psychopathology when symptoms can be attributed to environmental or developmental factors,” Dr. Walkup says. “If a kid is hyperactive or has anxious symptoms, there’s the assumption that he or she will grow out of it.”
The AACAP parameter points out that while tradition favors psychosocial interventions over pharmacotherapy as first-line treatment for children, substantial data now provide a better basis for choice: Evidence supports medication as initial treatment for most patients with attention-deficit hyperactivity disorder (ADHD), for example, and cognitive behavioral therapy, alone or with medication, for obsessive compulsive disorder.
Psychoeducation and consent
Information for the patient and family should cover the nature of the child’s problems, the treatment being offered, and the pros and cons of alternatives. The parameter describes this as an ongoing discussion that is particularly important when treatment is initiated or regimens are changed, when management enters the maintenance phase, and around discontinuation.
The informed-consent process should be documented and include a notation in the patient’s record stipulating that all concerned parties were provided the opportunity to ask questions and understood the risks, benefits, and goals of treatment.