Pediatric Psychopharmacology for Primary Care

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 Pediatric
Psychopharmacology
FOR PRIMARY CARE

Mark A. Riddle, MD

CONTRIBUTING EDITORS

Jane Meschan Foy, MD, FAAP, Chair

Rebecca A. Baum, MD, FAAP
Susan dosReis, PhD
Stanley I. Fisch, MD, FAAP
Lynne C. Huffman, MD, FAAP
David B. Pruitt, MD
Gloria M. Reeves, MD
Lawrence S. Wissow, MD, MPH, FAAP

American Academy of Pediatrics

141 Northwest Point Blvd
Elk Grove Village, IL 60007-1019
www.aap.org

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 American Academy of Pediatrics Publishing Staff
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The recommendations in this publication do not indicate an exclusive course of treatment

or serve as a standard of medical care. Variations, taking into account individual circum-
stances, may be appropriate.
Statements and opinions expressed are those of the author and not necessarily those of the
American Academy of Pediatrics.
Every effort has been made to ensure that the drug selection and dosages set forth in
this text are in accordance with the current recommendations and practice at the time
of publication. It is the responsibility of the health care professional to check the package
insert of each drug for any change in indications and dosage and for added warnings and
precautions.
The inclusion of product names and photos in this publication is for informational pur-
poses only and does not imply endorsement by the American Academy of Pediatrics.
The American Academy of Pediatrics is not responsible for the content of the resources
mentioned in this publication. Web site addresses are as current as possible but may
change at any time.
This book has been developed by the American Academy of Pediatrics. The authors,
editors, and contributors are expert authorities in the field of pediatrics. No commercial
involvement of any kind has been solicited or accepted in the development of the content
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Copyright © 2016 American Academy of Pediatrics. All rights reserved. No part of this
publication may be reproduced, stored in a retrieval system, or transmitted in any form
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prior permission from the publisher. Printed in the United States of America.
9-351/1015
1 2 3 4 5 6 7 8 9 10

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 Contributors
Author
Mark A. Riddle, MD
Professor of Psychiatry and Pediatrics
Johns Hopkins University School of Medicine
Baltimore, MD
Contributing Editors
Jane Meschan Foy, MD, FAAP, Chair
Professor of Pediatrics
Wake Forest University School of Medicine
Winston-Salem, NC
Chair, AAP Task Force on Mental Health, 2004–2010
Member, AAP Mental Health Leadership Work Group, 2011–present
Rebecca A. Baum, MD, FAAP
Clinical Assistant Professor of Pediatrics
Nationwide Children’s Hospital
The Ohio State University
Columbus, OH
Susan dosReis, PhD
Associate Professor
University of Maryland School of Pharmacy
Baltimore, MD
Stanley I. Fisch, MD, FAAP
Primary Care Practice
Harlingen Pediatrics Associates
Harlingen, TX
Lynne C. Huffman, MD, FAAP
Associate Professor of Pediatrics
Stanford University School of Medicine
Stanford, CA
David B. Pruitt, MD
Professor of Psychiatry and Pediatrics
Director, Division Child and Adolescent Psychiatry
University of Maryland
Baltimore, MD
Gloria M. Reeves, MD
Associate Professor
Division of Child and Adolescent Psychiatry
University of Maryland School of Medicine
Baltimore, MD
Lawrence S. Wissow, MD, MPH, FAAP
Professor of Health, Behavior, and Society
Johns Hopkins School of Public Health
Baltimore, MD

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 What People Are Saying

“This clear and well-organized volume provides an excellent and useful

compendium of advice on the use of psychotropic medications in pediatric
primary care. Building on strong work by the AAP over the past 15 to 20
years to develop clinical practice guidelines for primary care management of
attention-deficit/hyperactivity disorder and the work of the AAP Task Force
on Mental Health, this book offers clear guidance on when to use psycho-
tropics, which to use, and what coexisting conditions and side effects the
clinician should monitor.”
James M. Perrin, MD, FAAP
John C. Robinson Chair in Pediatrics
MassGeneral Hospital for Children
President (2014), American Academy of Pediatrics

“This guide to pediatric psychopharmacology provides pediatric primary

care clinicians, and specialists working with them, with a practical clinical
resource that concisely integrates relevant current literature and significant
experience. Within a helpful framework that emphasizes safety and effi­
cacy, this book provides clear guidance on dosing, monitoring, and potential
adverse reactions. It makes access to and use of the information simple, yet
incredibly valuable, for the busy clinician.”
Christopher J. Kratochvil, MD
Professor of Psychiatry and Pediatrics
Anna O. Stake Professor of Child Psychiatry
Associate Vice Chancellor for Clinical Research,
University of Nebraska Medical Center
Vice President for Research, Nebraska Medicine
Chief Medical Officer, UNeHealth

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 Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Part 1—Conceptual Framework
Chapter 1—Conceptual Framework for Prescribing Psychotropic
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Rationale for Conceptual Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
General Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Group 1 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Group 2 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Group 3 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Group 1 Medications for ADHD, Anxiety, and Depression . . . . . . . . . . . . . 6
General Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Evidence Supporting Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Evidence Supporting Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specific Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
a2-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Norepinephrine Reuptake Inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Selective Serotonin Reuptake Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . 10
Group 2 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
General Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Specific Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antipsychotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Mood Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Group 3 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
General Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Specific Rationale for 10 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Part 2—Practical Guidance
Chapter 2—Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
General Clinical Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Prepare the Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Triage for Psychiatric and Social Emergencies . . . . . . . . . . . . . . . . . . . . . 19
Assess Symptom Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Emphasize Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Assess Sleep Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Identify Environmental Stressors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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 vi Contents

Screen for Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Differentiate New vs Exacerbation of Old or Chronic Problems . . . . . . 23
Inquire About Prior Evaluations and Prior or Current Treatments . . . 23
Overview of Assessment of Common Disorders . . . . . . . . . . . . . . . . . . . 24
Determine if Medication Is an Appropriate Treatment . . . . . . . . . . . . . . 25
Provide Initial Primary Care Intervention for Problems That Are
  Not Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Recognize Need for Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Assessment of the 3 Common Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 27
ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Major Depressive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Assessment of Common Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Disruptive Behavioral Problems and Disorders . . . . . . . . . . . . . . . . . . 38
Behavioral and Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Other Comorbid Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Assessment of Less Common Comorbidities . . . . . . . . . . . . . . . . . . . . . . 43
Formulation and Feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Emphasize Positive Attributes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Review Key Points of the History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Normalize the Feedback Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Develop a Basic Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Prioritize Problems and Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Discuss Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Emphasize the High Rate of Success of Available Treatments . . . . . . . . 45
Clarify Plans for Referral and Communicate With Other
  Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Approach Evaluation as a Continuously Evolving Process . . . . . . . . . . . 46
Chapter 3—Prescribing Medications: Getting Started . . . . . . . . . . . . . . . . . . . 49
Conditions for Safe and Effective Prescribing . . . . . . . . . . . . . . . . . . . . . . 49
Non-medication Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Clinical Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Pragmatic Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Evidence-Based Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Adherence and Persistence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Phases of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Off-label Prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

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 Pediatric Psychopharmacology for Primary Care vii

FDA Boxed Warnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

SSRIs and Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Stimulants and Cardiac Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Stimulants and Concerns About Abuse and Dependence . . . . . . . . . 59
Part 3—Group 1 Medications for Specific Diagnoses: ADHD,
Anxiety, and Depression
Chapter 4—Group 1 Medications for Attention-Deficit/
Hyperactivity Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
General Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
a2-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Norepinephrine Reuptake Inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Reminder About Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . . 66
Choosing a Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Adverse Effects: Boxed Warnings, Warning and Precautions,
   and Adverse Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Cost and Affordability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Information for Caregivers About Specific Medications . . . . . . . . . . . . . 68
Methylphenidate Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Available Methylphenidate Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Onset of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Duration of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Initial Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Dosage Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Monitoring Therapeutic Response During Dose Adjustments . . . . . . . 71
Safety Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Vital Signs, Physical Examination, and Laboratory Monitoring . . . . . . 73
Optimizing Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Medication Holidays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
What if a Methylphenidate Preparation Is Ineffective or
  Not Tolerated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Discontinuing Methylphenidate and Possible Withdrawal Adverse
  Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Switching From a Methylphenidate to an Amphetamine
  Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
When to Consult or Refer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

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 viii Contents

Amphetamine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Available Amphetamine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Onset of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Duration of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Initial Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Dosage Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Monitoring Therapeutic Response During Dose Adjustments . . . . . . . 77
Safety Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Vital Signs, Physical Examination, and Laboratory Monitoring . . . . . . 79
Optimizing Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Medication Holidays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
What if an Amphetamine Preparation Is Ineffective or Not
  Tolerated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Discontinuing Amphetamine and Possible Withdrawal
  Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Switching From an Amphetamine to a Methylphenidate
  Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
When to Consult or Refer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Guanfacine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Available Guanfacine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Onset of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Duration of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Initial Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Dosage Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Monitoring Therapeutic Response During Dose Adjustments . . . . . . . 84
Safety Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Vital Signs and Laboratory Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Optimizing Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
What if a Guanfacine Preparation Is Ineffective or Not Tolerated? . . . . 86
Discontinuing Guanfacine and Possible Withdrawal Adverse
  Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Switching From One to Another Guanfacine Preparation . . . . . . . . . . . 87
Adjunct Treatment to Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
When to Consult or Refer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Clonidine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Available Clonidine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Onset of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Duration of effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

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 Pediatric Psychopharmacology for Primary Care ix

Initial Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Dosage Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Monitoring Therapeutic Response During Dose Adjustments . . . . . . . 91
Safety Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Vital Signs and Laboratory Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Optimizing Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
What if a Clonidine Preparation Is Ineffective or Not Tolerated? . . . . . 94
Discontinuing Clonidine and Possible Withdrawal Adverse
  Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Switching From One to Another Clonidine Preparation . . . . . . . . . . . . . 94
Adjunct Treatment to Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
When to Consult or Refer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Atomoxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Available Atomoxetine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Onset of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Duration of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Initial Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Dosage Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Monitoring Therapeutic Response During Dose Adjustments . . . . . . . 96
Safety Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Vital Signs and Laboratory Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Optimizing Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
What if Atomoxetine Is Ineffective or Not Tolerated? . . . . . . . . . . . . . . . 98
Discontinuing Atomoxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Adjunct Treatment to Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
When to Consult or Refer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Chapter 5—Group 1 Medications for Anxiety and Depression
General Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Reminder About Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . 105
Choosing a Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Adverse Effects, Contraindications, and Drug Interactions . . . . . . . . . 105
Cost and Affordability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Information for Caregivers About Specific Medications . . . . . . . . . . . . 106
Group 1 Selective Serotonin Reuptake Inhibitors . . . . . . . . . . . . . . . . . . . . 106
Available SSRI Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Initial Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

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 x Contents

Onset of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Duration of Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Dosage Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Monitoring Therapeutic Response During Dose Adjustments . . . . . . 108
Safety Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Vital Signs and Laboratory Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Optimizing Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
What if the First SSRI Is Ineffective or Not Tolerated? . . . . . . . . . . . . . . 111
Discontinuing an SSRI and Possible Withdrawal Adverse Effects . . . . 111
Switching From One to Another SSRI . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
When to Consult or Refer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Part 4—Group 2 (FDA-Approved Antipsychotics and Mood Stabilizers)
and Group 3 (All Other) Medications
Chapter 6—Group 2 Medications: Antipsychotics and Mood Stabilizer . . . 115
Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Antipsychotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Effects, Indications, Ages, Equivalencies, and Dosages . . . . . . . . . . . . . 116
Adverse Effects and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Advanced Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Involuntary Movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Switching Second-Generation Antipsychotics . . . . . . . . . . . . . . . . . . 124
Comparing Second-Generation Antipsychotics . . . . . . . . . . . . . . . . . 124
The Mood Stabilizer Lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Chapter 7—Group 3 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Other Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Other Antipsychotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Other Mood Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Anxiolytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Sleep Aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Future Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Part 5—Advanced Topics
Chapter 8—What to Do When Treatment Is Not Successful . . . . . . . . . . . . 143
The Limits of Evidence-Based Treatments and Protocols . . . . . . . . . . . . . 143
Reassess Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Incomplete or Inaccurate Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Phenomenological or Nosologic Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

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 Pediatric Psychopharmacology for Primary Care xi

ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Reassess Non-diagnostic Issues and Concerns . . . . . . . . . . . . . . . . . . . . . . 146
Reconsider Psychotherapy(ies) or Therapist . . . . . . . . . . . . . . . . . . . . . . . . 146
Reconsider Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
When Medication Is Ineffective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
When the First Medication Is Partially Effective . . . . . . . . . . . . . . . . . . . 148
When Adverse Effects Lead to Discontinuation of a Medication . . . . . 148
When to Consider Group 2 Antipsychotics or Lithium . . . . . . . . . . . . . . . 148
When to Consider Group 3 Medications Without FDA Approval for
   Use in Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
When to Consider Drug Levels or Genetic Testing . . . . . . . . . . . . . . . . . . 150
When Is a Drug Level Test Indicated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
When Is Genotyping of CYP450 Isoenzymes Indicated? . . . . . . . . . . . 151
When to Consider Consultation or a Second Opinion . . . . . . . . . . . . . . . 151
When to Consider Referral for All or Part of the Patient’s Ongoing
   Behavioral Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Appendixes
Appendix A—Assessment and Symptom Monitoring Tools . . . . . . . . . . . . . 157
Appendix B—Resources for Clinicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Appendix C—Training Resources for Clinicians . . . . . . . . . . . . . . . . . . . . . . . 179
Appendix D—Quality Ratings for Psychotherapies and Efficacy Data for
  Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Appendix E—Resources for Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Appendix F—Diagnostic and Statistical Manual of Mental Disorders,
  Fifth Edition, Complete Criteria of Select Diagnoses . . . . . . . . . . . . . . . 189
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

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 Introduction

What Is This Book?

This book is designed to provide primary care clinicians with a practical and
coherent approach to prescription and management of psychotropic medica-
tions for children and adolescents.
The book covers 4 main concepts.
■■ Conceptual framework
■■ Guiding clinical principles
■■ Clinical guidance about specific diagnoses and medications
■■ Next steps when difficulties persist
The Contents provides a detailed outline of each part. Each chapter is
designed to “stand alone” so that, depending on the reader’s knowledge,
skills, and experience, relevant chapters and sections may be specifically uti-
lized. Additionally, numerous resources are included in the appendixes, with
an emphasis on access to electronic content from the American Academy of
Pediatrics (AAP).

Target Audience
The primary audience for this book is pediatric primary care clinicians (pe-
diatric PCCs) who care for children and adolescents with common psychi-
atric disorders and mental health or behavioral problems in their outpatient
practices and who prescribe and monitor medications, including
■■ Primary care pediatricians
■■ Family physicians
■■ Pediatric physician assistants
■■ Pediatric, psychiatric, and family nurse practitioners
Secondary audiences include specialists who provide consultation to primary
care clinicians in performing those roles, including
■■ Developmental-behavioral pediatricians
■■ Specialists in neurodevelopmental disabilities
■■ Child and adolescent psychiatrists

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 xiv Introduction

■■ Specialists in adolescent medicine

■■ Pediatric neurologists
■■ Some adult psychiatrists with training in adolescent care
Another secondary audience is allied mental health professionals, who col-
laborate with medication prescribers and who can provide evidence-based
psychotherapies and other care for children and adolescents, including
■■ Psychologists
■■ Social workers
■■ Nurses
■■ Counselors
And, finally, another important audience is those who want to understand
how clinicians strategize about medication for children and adolescents,
including
■■ Parents, guardians, and caregivers
■■ Families
■■ Youth
■■ Advocates
■■ Policy makers

Why Now?
The need for a conceptual framework with practical guidance for pediatric
psychopharmacology is critical.
■■ At least 8 million US youth (10%) have an impairing psychiatric disorder.1
■■ A persistent critical shortage of mental health specialists, especially child
and adolescent psychiatrists (<8,000 practicing), hinders ability to meet
the needs of these youth.
Pediatric PCCs are ideally suited to meet this need because of their knowl-
edge of child development, their long-term relationships with patients and
families, and the frequency with which they encounter children and teens.
There are many—about 170,000—US pediatric PCCs.
■■ Approximately 60,000 primary care pediatricians (Ken Shaw, AAP,
communication, October 29, 2014)
■■ Greater than 80,000 family physicians2
■■ Approximately 2,000 pediatric physician assistants3

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 Pediatric Psychopharmacology for Primary Care xv

■■ Approximately 14,000 pediatric nurse practitioners4

■■ Approximately 12,000 youth-dedicated family nurse practitioners5
The AAP6 recommends that primary care pediatricians achieve compe-
tence in initiating care for children and adolescents with attention-deficit/
hyperactivity disorder (ADHD), anxiety, depression, and substance use and
abuse. This raises important considerations.
■■ Treatment of 3 of these conditions—attention-deficit/hyperactivity dis-
order, anxiety, and depression—may, under certain conditions, include
medication.
■■ Many pediatric PCCs report having insufficient knowledge, skills, and
training to prescribe safe and effective psychotropic medications to youth
with these conditions.
■■ Continuing medical education courses in pediatric psychopharmacology
targeted to pediatric PCCs are rare; maintenance of certification courses
are even rarer.
■■ Pediatric residency training in psychiatric assessment and psychophar-
macology is limited, and requirements are minimal.7
■■ Child psychiatry consultation programs are forming in many parts of
the country to fill these gaps by providing real-time clinical guidance to
pediatric PCCs8; it is critical that consultants in these programs apply a
framework that recognizes realities of the primary care setting.
Because of limited time and resources for obtaining new knowledge and
skills, pediatric PCCs and those who train or consult with them need an
approach to pediatric psychopharmacology that is coherent, practical, and
sufficiently simple to meet their needs.

Basic Principles
A few basic principles provide the foundation for all recommendations in
this book, as follows:
■■ Evaluation and diagnosis of ADHD, common anxiety disorders, and
depression in children and adolescents can be relatively simple and
straightforward when a few basic guidelines are followed.
■■ Whenever possible, psychotropic medications should be prescribed
concomitantly with, or following inadequate response to, evidence-based
psychotherapies and evidence-informed pragmatic supports.
■■ Medications that have US Food and Drug Administration approval for
the patient’s diagnosis (or a similar diagnosis) are recommended, when-
ever possible, because these medications have met a formal standard for

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 xvi Introduction

efficacy and safety and generally have more available information regard-
ing use in youth.
■■ There are only a few classes of medications (eg, stimulants, 2-adrenergic
agonists, and selective serotonin reuptake inhibitors) that need to be mas-
tered to effectively treat most presentations of ADHD, common anxiety
disorders, and depression.
■■ Providing clinical, in addition to medicolegal, informed consent and
assent can strengthen and help sustain a therapeutic alliance with the
patient and caregivers.
■■ Prescribing as few psychotropic medications as possible simplifies the
task of monitoring efficacy and safety.
■■ Sequential, not simultaneous, changes in medication or dosage are rec-
ommended, whenever possible.
■■ Monitoring for safety is as important as monitoring for effectiveness.
■■ Use of pragmatic supports can improve efficiency and effectiveness.
Resources included in this book are derived from the US Food and Drug
Administration as well as national organizations such as the American
Academy of Pediatrics and the American Academy of Child and Adoles-
cent Psychiatry.
■■ As an important component of the continuum of mental health care,
pediatric PCCs will encounter children for whom additional specialty
care is required. Consultative and collaborative relationships with mental
health professionals are thus important.

What About the Future?

■■ The conceptual framework and treatment strategies in this book are
designed to prepare pediatric PCCs for future developments. Fortunately,
new information about the safety and efficacy of existing psychopharma-
cologic agents will accrue, and safer and more effective medications for
children and adolescents will be developed and disseminated. Based on
its recent emphasis on pediatric mental health, we can anticipate that the
American Academy of Pediatrics (and other professional organizations)
will provide ongoing and up-to-date educational and training opportu-
nities for interested clinicians (see Appendix C, Training Resources for
Clinicians).
■■ As US health care systems continue to evolve under the Affordable Care
Act,9 emphasis on value-based medicine will continue to grow. Account-
able Care Organizations and similar entities that incentivize cost reduc-

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 Pediatric Psychopharmacology for Primary Care xvii

tion while maximizing quality will be responsible for providing care to

specific populations within a fixed total budget. Financial benefit of safe
and effective medication prescribing is a key component in the effort to
secure funds for necessary evidence-based mental health treatments.
■■ Treatment strategies suggested in this book emphasize use of generic
medications, when appropriate, and de-emphasize use of multiple med-
ications, which can lead to added adverse effects and cost, unless clearly
needed. These strategies can have the additional benefit of reducing costs
while maintaining quality.

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 xviii Introduction

References
1. US Department of Health and Human Services. Mental Health: Culture, Race, and
Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville,
MD: US Department of Health and Human Services; 2001.
http://www.surgeongeneral.gov/library/reports. Accessed May 21, 2015
2. US Department of Health and Human Services, Agency for Healthcare Research and
Quality. The number of practicing primary care physicians in the United States: primary
care workforce facts and stats no. 1.
http://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html.
Publication No. 12-P001-2-EF. Reviewed October 2014. Accessed May 21, 2015
3. Freed GL, Dunham KM, Moote MJ, Lamarand KE; American Board of Pediatrics
Research Advisory Committee. Pediatric physician assistants: distribution and scope of
practice. Pediatrics. 2010;126(5):851–855
4. National Association of Nurse Practitioners. Membership.
http://www.napnap.org/membership. Accessed May 21, 2015
5. Freed GL, Dunham KM, Loveland-Cherry CJ, Martyn KK; American Board of Pediat-
rics Research Advisory Committee. Family nurse practitioners: roles and scope of prac-
tice in the care of pediatric patients. Pediatrics. 2010;126(5):861–864
6. American Academy of Child and Adolescent Psychiatry Committee on Health Care
Access and Economics Task Force on Mental Health. Improving mental health services
in primary care: reducing administrative and financial barriers to access and collabora-
tion. Pediatrics. 2009;123(4):1248–1251
7. Caspary G, Horwitz S, Singh M, et al. Graduating pediatric residents’ training and
attitudes vary across mental health problems. Paper presented at: Pediatric Academic
Societies Annual Meeting; 2008; Elk Grove Village, IL. http://www.aap.org/en-us
/professional-resources/Research/Pages/Graduating-Pediatric-Residents-Training-and
-Attitudes-Vary-Across-Mental-Health-Problems.aspx. Accessed May 21, 2015
8. Gabel S, Sarvet B. Public-academic partnerships: public-academic partnerships
to address the need for child and adolescent psychiatric services. Psychiatr Serv.
2011;62(8):827–829
9. Mechanic D. Seizing opportunities under the affordable care act for transforming the
mental and behavioral health system. Health Affairs. 2012;31(2)376–382

00b_Psychopharmacology_FM.indd 18 9/11/15 2:06 PM

 Part 1—Conceptual Framework

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01_Psychopharmacology_CH01.indd 2 9/11/15 9:16 AM
 CHAPTER 1

Conceptual Framework for

Prescribing Psychotropic Medications

Background
The American Academy of Pediatrics recommends that pediatric pri-
mary care clinicians (pediatric PCCs) achieve competence in initiating care
of children and adolescents with attention-deficit/hyperactivity disorder
(ADHD), anxiety, depression, and substance use and abuse. Treatment of 3
of these conditions—ADHD, anxiety, and depression—may, under certain
conditions, include medication. The primary purpose of this book is to offer
guidance that will assist pediatric PCCs in their decision-making about the
use and monitoring of psychotropic medications.

Rationale for the Conceptual Framework

General Rationale
The goal of this chapter is to offer a clear, rational, and evidenced-based
framework for using psychotropic medications in youth with psychiatric
diagnoses. This is critical because, while many clinicians are already using
these medications, there remains a wide range of comfort with, confidence
in, and knowledge about how these drugs are initiated, titrated, and mon-
itored across care settings. In addition, the large number of psychotropic
medications can be overwhelming, even for experienced mental health
specialists. According to an expert task force comprising representatives
from major international and regional (ie, American, Asian, and European)
organizations, led by the European College of Neuropsychopharmacology,
108 psychotropic medications are available for prescribing (the app
NbNomenclature is available at https://play.google.com/store/apps
/details?id=il.co.inmanage.nbnomenclature&hl=en and https://itunes.apple
.com/us/app/nbn-neuroscience-based-nomenclature/id927272449?mt=8).

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 4 Chapter 1—Conceptual Framework for Prescribing Psychotropic Medications

Most of these drugs are Food and Drug Administration (FDA) approved for
adults in the United States.
This chapter offers a unifying approach, grounded in the most up-to-date
research, for the prescribing of psychotropic medications by pediatric PCCs.
The intention is not to dictate practice specifics but to offer a methodological
approach that can best serve a wide range of clinicians who, after completing
a thorough diagnostic assessment in which medication-responsive illness is
identified, must then make decisions regarding medication treatment options
for youth and families. The conceptual framework is designed to simplify
and organize the medications into 3 manageable and targeted groups, in
accordance with the American Academy of Pediatrics mental health compe-
tencies policy statement.1 Following is a brief description of each of the 3
groups.

Group 1 Medications
Group 1, the most important group of psychotropic medications for pedi-
atric PCCs, includes medications for the common psychiatric disorders:
ADHD, major depressive disorder, and anxiety disorders. The best epide-
miologic data indicate that greater than 80% of psychotropic medications
prescribed to youth are for ADHD, anxiety, and depressive disorders.2
Group 1 includes all FDA-approved medications for ADHD in youth: 2
stimulants (methylphenidate and amphetamine), 2 α2-adrenergic agonists
(guanfacine and clonidine), and a norepinephrine reuptake inhibitor
(atomoxetine). It also includes all FDA-approved medications for depression
in youth: the 2 selective serotonin reuptake inhibitors (SSRIs), fluoxetine
and escitalopram. There are no FDA-approved medications for youth with
anxiety. This is, in large part, because of a discrepancy between FDA rules
regarding anxiety disorder indications and efficacy studies that have been
conducted in children and adolescents with anxiety (see Evidence Support-
ing Efficacy later in the chapter for details). Thus, for anxiety in youth,
3 SSRIs are included—fluoxetine, fluvoxamine, and sertraline—that all have
one high-quality, positive, safety and efficacy study for common anxiety
disorders and FDA approval for obsessive-compulsive disorder (OCD),
an anxiety-related condition.
Nine medications are in Group 1 (Table 1.1). It is important to emphasize
that these are not a formulary or restricted list of possible medications.
However, as described in greater detail in Appendix D, they are the only
medications with high-quality scientific evidence supporting their efficacy.

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 Pediatric Psychopharmacology for Primary Care 5

Table 1.1. Group 1 Medicationsa

US FDA Approval
Drug and Approved
(Mode of Action) Indicationb Age, years
ADHD
Methylphenidate (stimulant) ADHD Yes; ≥6
Amphetamine (stimulant)c ADHD Yes; ≥6
Guanfacine (α2-adrenergic agonist) ADHD Yes; ≥6
Clonidine (α2-adrenergic agonist) ADHD Yes; ≥6
Atomoxetine (NRI) ADHD Yes; ≥6
CERTAIN ANXIETY DISORDERSd AND OCD
Fluoxetine (SSRI) (Anxiety) No
OCD Yes; ≥7
MDD Yes; ≥8
Sertraline (SSRI) (Anxiety) No
OCD Yes; ≥6
Fluvoxamine (SSRI) (Anxiety) No
OCD Yes; >10
MAJOR DEPRESSIVE DISORDER
Fluoxetine (SSRI) MDD Yes; ≥8
Escitalopram (SSRI) MDD Yes; ≥12
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; FDA, Food and Drug Administration; MDD,
major depressive disorder; NRI, norepinephrine reuptake inhibitor; OCD, obsessive-compulsive disorder;
SSRI, selective serotonin reuptake inhibitor.
a
E vidence of efficacy, favorable adverse effect profile, and management of disorder within primary care
competencies; for a detailed discussion on pediatric mental health competencies for primary care, see
Committee on Psychosocial Aspects of Child and Family Health: Task Force on Mental Health, 2009.1
b
Each of these disorders also has evidence-based psychosocial interventions. See Evidence-Based Child
and Adolescent Psychosocial Interventions at https://www.aap.org/en-us/Documents/resilience_anxiety
_interventions.pdf.
c
Approved down to age 3, “grandfathered in.”
d
Generalized anxiety disorder, social anxiety disorder, separation anxiety disorder.

Also, these medications are relatively safe; thus, pediatric PCCs should be
comfortable prescribing them and monitoring their use.

Group 2 Medications
The second group of medications (Group 2) includes all FDA-approved med-
ications for youth with other disorders (ie, not ADHD, anxiety, or

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