Principles of psychotropic use in children

There is limited evidence for the efficacy and safety of psychotropics in children—most trials have small sample sizes and are of short duration, and few are placebo controlled. Consequently, many psychotropics do not have approval from the Australian Therapeutic Goods Administration (TGA) for use in children (see Off-label prescribing for psychiatric disorders).

Data on psychotropic use in adults cannot necessarily be extrapolated to children because of age-related differences in drug metabolism and effect. It is also not known how psychotropics may affect long-term neurodevelopment.

In children who are obese, it may be necessary to use ideal body weight to calculate the appropriate drug dose.

Note: Use psychotropics cautiously in children—nonpharmacological treatment is usually preferred.

Nonpharmacological treatment is usually preferred in children with psychiatric disorders. If psychotropics are required, they should ideally be started, and reviewed at least 6-monthly, by a clinician with expertise in using psychotropics in children. Depending on the disorder and the availability of services, oversight can be provided by a child or youth psychiatrist, a paediatrician, a physician with expertise in paediatric psychopharmacology, or an age-appropriate mental health service.

Set clear, measurable goals for pharmacotherapy. Use symptom checklists, screening questionnaires, or structured clinical interviews to establish the child’s baseline, and repeat the same assessment periodically to determine efficacy and adverse effects. Children often require more frequent review than adults.

Avoid polypharmacy in children unless there is a good rationale for combining drugs, such as using drugs with different mechanisms to target different symptoms or disorders—document the target symptoms of each drug. If polypharmacy is necessary, consult a clinician with expertise in paediatric psychopharmacology.

When using a psychotropic in an older child, obtain informed consent from the child as well as their family or carers. Agreement to treatment should also be sought from younger children.