Paeds · mental-behavioural-and-psychosomatic
Psychopharmacology and psychotropic medicines in children and adolescents
Also known as Paediatric psychopharmacology · Psychotropic medicines in children · Child and adolescent psychiatric medication · ADHD medication · Paediatric antidepressant prescribing · Antipsychotic use in youth
Fellowship guide to psychopharmacology in children and adolescents: developmental pharmacokinetics, the major drug classes (stimulants, non-stimulants, SSRIs, antipsychotics, mood stabilisers, melatonin), starting-dose and titration frameworks, the FDA black-box suicidality warning, antipsychotic metabolic monitoring, valproate teratogenicity, choice by indication and age with trial evidence, adverse effects, and exam pearls across ANZ, UK, US and Canada.
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Red flags
- Suicidal ideation or new agitation within the first 4 weeks of an SSRI — stop or reduce, safety-plan and arrange urgent mental-health review; never dismiss it as 'just the illness'
- Fever, rigidity, autonomic instability and confusion on an antipsychotic — neuroleptic malignant syndrome; stop the drug, cool, hydrate, escalate
- Agitation, tremor, hyperreflexia, clonus and fever on a serotonergic agent — serotonin syndrome; stop the drug and seek help
- Rapid weight gain, rising BMI or abnormal glucose/lipids on an antipsychotic — intensify metabolic monitoring and reconsider the agent; olanzapine carries the highest risk
- Syncope, exertional chest pain or family sudden death before or on a stimulant — complete cardiac review before continuing
- Pregnancy risk in an adolescent on valproate — stop or switch under specialist guidance; never prescribe without contraception and a pregnancy-prevention programme
- QTc prolongation on combination psychotropics — check interactions, electrolytes and cardiology input
- Lost scripts, escalating doses or sedation in an adolescent on a stimulant — diversion or misuse; reconsider formulation and supervision
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Clinical Pharmacology and Therapeutics
- Child and adolescent mental health
- Current 2026 PREP curriculum — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Adolescent medicine and youth-friendly care competencies
- Clinical Applications
- Mental health and prescribing safety
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- 5. Professional skills and knowledge: Health promotion and illness prevention
- 2. Professional skills and knowledge: Communication
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Neurodevelopmental and behavioural disorders
- Pharmacology and safe prescribing
- History
- Communication
- Clinical
- Developmental and behavioural assessment
- General Pediatrics Content Outline — Domain 15: Mental and Behavioral Health
- General Pediatrics Content Outline — Domain 4: Developmental and Behavioral Pediatrics
- General Pediatrics Content Outline — Domain 24: Patient Safety, Quality Improvement, and Research Methods
- General Pediatrics EPA: Manage common mental and behavioural health concerns with appropriate pharmacology and monitoring
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 1: Clinical Knowledge
- Systems-Based Practice 1: Patient Safety and Quality Improvement
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Medical Expert
- Communicator
- Collaborator
- Leader
- Pediatrics: Core EPA — Managing common developmental and behavioural problems
- Pediatrics: Core EPA — Safe and appropriate prescribing
Overview & Definition
Picture a 10-year-old who has just been started on methylphenidate and is suddenly eating almost nothing at lunch, a 15-year-old three weeks into fluoxetine who tells you she feels "wired and worse," and a 7-year-old with autism on risperidone whose weight has jumped two centiles in six months. Those three vignettes are the heart of paediatric psychopharmacology: the same drug that helps can also change appetite, mood, growth and metabolism in a developing child, and the clinician's job is to anticipate, detect and weigh that balance. [12] [21]
A psychotropic medicine is any drug that acts on the central nervous system to change mood, behaviour, cognition, arousal or sleep. In children and adolescents the practical classes are stimulants and non-stimulants (for ADHD), antidepressants (chiefly SSRIs, for depression, anxiety and OCD), antipsychotics (for psychosis, severe autism irritability and some aggression), mood stabilisers (for bipolar disorder), and melatonin and alpha-2 agonists (for sleep and arousal). [13]
Your role as a general paediatrician is rarely to start complex psychotropic polypharmacy; it is to prescribe the common, evidence-based agents well, to monitor the developmental and metabolic consequences that show up in your clinic, and to coordinate with child and adolescent mental-health services (CAMHS) for the complex and the resistant. [1] [21]
References24ShowHide
- [1]March J Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA, 2004.PMID 15315995
- [2]March JS The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. Archives of General Psychiatry, 2007.PMID 17909125
- [3]Emslie G Treatment for Adolescents with Depression Study (TADS): safety results. Journal of the American Academy of Child and Adolescent Psychiatry, 2006.PMID 17135989
- [4]Emslie GJ A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry, 1997.PMID 9366660
- [5]Walkup JT Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 2008.PMID 18974308
- [6]Pediatric OCD Treatment Study (POTS) Team Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA, 2004.PMID 15507582
- [7]Brent D Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA, 2008.PMID 18314433
- [8]Bridge JA Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA, 2007.PMID 17440145
- [9]Gibbons RD Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine. Archives of General Psychiatry, 2012.PMID 22309973
- [10]Le Noury J Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ, 2015.PMID 26376805
- [11]Cipriani A Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet, 2018.PMID 29477251
- [12]Storebø OJ Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database of Systematic Reviews, 2023.PMID 36971690
- [13]Cortese S Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry, 2018.PMID 30097390
- [14]Michelson D Once-daily atomoxetine treatment for children and adolescents with attention deficit hyperactivity disorder: a randomized, placebo-controlled study. American Journal of Psychiatry, 2002.PMID 12411225
- [15]Sallee FR Guanfacine extended release in children and adolescents with attention-deficit/hyperactivity disorder: a placebo-controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 2009.PMID 19106767
- [16]Cooper WO ADHD drugs and serious cardiovascular events in children and young adults. New England Journal of Medicine, 2011.PMID 22043968
- [17]Hennissen L Cardiovascular Effects of Stimulant and Non-Stimulant Medication for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis of Trials of Methylphenidate, Amphetamines and Atomoxetine. CNS Drugs, 2017.PMID 28236285
- [18]McCracken JT Risperidone in children with autism and serious behavioral problems. New England Journal of Medicine, 2002.PMID 12151468
- [19]Marcus RN A placebo-controlled, fixed-dose study of aripiprazole in children and adolescents with irritability associated with autistic disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 2009.PMID 19797985
- [20]Owen R Aripiprazole in the treatment of irritability in children and adolescents with autistic disorder. Pediatrics, 2009.PMID 19948625
- [21]Correll CU Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA, 2009.PMID 19861668
- [22]Ray WA Association of Antipsychotic Treatment With Risk of Unexpected Death Among Children and Youths. JAMA Psychiatry, 2019.PMID 30540347
- [23]Van der Heijden KB Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia. Journal of the American Academy of Child and Adolescent Psychiatry, 2007.PMID 17242627
- [24]Malow BA Sleep, Growth, and Puberty After 2 Years of Prolonged-Release Melatonin in Children With Autism Spectrum Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 2021.PMID 31982581