Paediatric psychopharmacology — SSRI, ADHD and antipsychotic safety (MEQ)

(i) Consent/capacity and black-box. Assess developmental (Gillick) competence: understanding of depression, proposed fluoxetine, benefits, risks, alternatives, and voluntary choice. Involve parents as usual; see youth alone and together. Explain confidentiality limits (safety overrides secrecy). Black-box: small absolute increase in suicidal ideation/behaviour signals on antidepressants vs placebo in short paediatric trials — implies early monitoring and safety planning, not automatic ban on indicated treatment. Invite questions; document shared decision. Do not invent Mental Health Act section numbers.[1][7]

(ii) Fluoxetine plan. Continue CBT elements. Example: fluoxetine 10 mg orally daily then 20 mg daily as tolerated; early reviews (often within first week if higher risk, then frequent through month one) for activation, insomnia, agitation, akathisia, suicidality; carer means restriction; crisis contacts; adequate 4–6 week trial at therapeutic dose before declaring failure. TADS supports fluoxetine/combination signals acutely.[2][7]

(iii) ADHD sibling. Confirm multi-setting diagnosis and psychoeducation. Prefer carefully titrated stimulant (methylphenidate or amphetamine class), long-acting coverage for school when suitable. Baseline height/weight, BP/HR, cardiac history; plot growth; counsel appetite/sleep/mood; diversion awareness. Serious CV events uncommon but screen and act on chest pain/syncope. MTA supports carefully managed medication for core symptoms.[5][8]

(iv) SGA / autism irritability. Risperidone can reduce severe tantrums/aggression/self-injury (RUPP) — treats target behaviours, not core autism. Behavioural interventions remain foundational. Correll: first SGA exposure can drive rapid weight/metabolic change — baseline and serial weight/BMI, glucose, lipids, BP. TEOSS: comparable efficacy framing with olanzapine weight liability — avoid casual olanzapine first-line. Start low (e.g. risperidone 0.25–0.5 mg oral daily in smaller children, titrate to function), monotherapy, frequent review of need.[3][4][6]

(v) Pitfalls. (1) Undertreating moderate–severe depression solely from black-box fear. (2) Antipsychotics for generic behaviour without formulation/metabolic plan. (3) Declaring stimulant failure without adequate dose, duration, or school data; or promising absolute confidentiality despite risk.[1][3][7]