Ideally, both parents should be involved, Dr. Walkup advises. “If you are doing a major intervention, like starting an 8-year-old on a selective serotonin reuptake inhibitor (SSRI) or a 6-year-old on a stimulant, it is reasonable to expect the mother and father to show up.” Among other things, this often allows insight into parents’ attitudes toward medication and side effects that may help the clinician anticipate and address adherence problems.

A candid and detailed exploration of risks and benefits is optimal and should include discussion of controversial issues  (e.g., suicide risk associated with antidepressant use). “Emphasizing the benefits and minimizing the risks of pharmacologic treatment to enhance the chance that the family and patient will agree to a medication trial is not consistent with good clinical care,” and may undermine the provider-patient relationship if adverse effects are significant, according to the parameter.

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By the same token, the discussion should clarify the potential impact of inadequate treatment on the patient’s development, social and educational function, and safety. While important, the consent of the child to the regimen should be viewed in this context.

“With psychiatric disorders, it is amazing that parents often let children decide whether they will be treated with medication or not,” notes Dr. Walkup. “I do not think anyone would say that when treating leukemia.”  

The prescriber should explain that medication response may vary greatly from child to child and reassure parents that a “medication trial” is a test period after which ineffective or poorly tolerated drugs will be discontinued.

Implementing treatment

Whatever the disorder, the AACAP parameter stresses the importance of prescribing medication at a sufficient dose for a long enough time. “If primary-care clinicians make a mistake with psychotropics, it is usually in underdosing rather than overdosing,” says Dr. Walkup. “Make sure the trial is full and adequate.”

The definition of adequacy may depend on the disorder, the patient (an older child may require a larger dose of a stimulant than a younger one), and the agent (it takes up to eight weeks at the full dose to determine whether an antidepressant is effective, compared with days for a stimulant).

Falling short of full dosage and adequate length may seem conservative and safe, but this can put the child at risk by extending the period during which the disorder is untreated and resulting in less effective regimens or multiple medications when one would suffice.

Combination regimens have a legitimate role, but the rationale should be clear, according to the parameter authors. For example, multiple medications may be indicated to treat concurrent disorders (a psychostimulant and SSRI for a child who has ADHD and a high level of anxiety), or a drug may be added to address side effects of an effective medication (benztropine for extrapyramidal symptoms related to antipsychotic therapy).

When a child fails to respond to an adequate medication trial, reassessment is in order. It may be discovered that the initial diagnosis overlooked a comorbid condition or that psychosocial factors need more direct attention, perhaps with psychotherapy. Poor adherence must be ruled out.