AACAP Official Action
Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents

https://doi.org/10.1097/CHI.0b013e3181ae0a08Get rights and content

Abstract

The purpose of this practice parameter is to promote the appropriate and safe use of psychotropic medications in children and adolescents with psychiatric disorders by emphasizing the best practice principles that underlie medication pre scribing. The evidence base supporting the use of psychotropic medication for children and adolescents with psychiatric disorders has increased for the past 15 to 20 years, as has their use. It is hoped that clinicians who implement the principles outlined in this parameter will be more likely to use medications with the potential for pharmacological benefit in children safely and to reduce the use of ineffective and inappropriate medications or medication combinations. The best practice principles covered in this parameter include completing a psychiatric and medical evaluation, developing a treatment and monitoring plan, educating the patient and family regarding the child's disorder and the treatment and monitoring plan, completing and documenting assent of the child and consent of the parent, conducting an adequate medication treatment trial, managing the patient who does not respond as expected, establishing procedures to implement before using medication combinations, and following principles for the discontinuation of medication.

Section snippets

Methodology

A literature review of relevant articles pertaining to psychopharmacology in children and adults was completed using the PubMed database. In addition, textbooks on pediatric psychopharmacology were reviewed as were their reference lists. In addition, a PubMed search on quality medical care and the overuse of medical testing (e.g., routine laboratory or radiological testing), other medical procedures considered to be used excessively (e.g., cesarean section), and other medical conditions that

General Background

The increased use of psychotropic medications3, 4 and psychotropic medication combinations14, 15 to treat childhood psychiatric disorders reflects a deservedly larger role for medication treatment of childhood psychiatric disorders. A number of factors have likely influenced this increased use including increased support for the biological basis of some childhood psychiatric disorders, a developing evidence base demonstrating the efficacy of psychotropic medications in children and adolescents,

Assessment

Principle 1. Before Initiating Pharmacotherapy, a Psychiatric Evaluation Is Completed. The psychiatric evaluation7 is comprehensive enough to identify symptoms best addressed pharmacologically and best addressed with psychosocial treatments and to identify psychosocial factors that may impede an adequate and safe medication trial or confound the assessment of outcome. A comprehensive evaluation increases the likelihood that medication interventions will be well conceptualized and hopefully

Parameter Limitations

The AACAP practice parameters are developed to assist clinicians in psychiatric decision making. These parameters are not intended to define the standard of care, nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results. The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all of the circumstances presented by the patient and his or her family, the

References (65)

  • H Abikoff et al.

    Sequential pharmacotherapy for children with comorbid attention-deficit/hyperactivity and anxiety disorders

    J Am Acad Child Adolesc Psychiatry

    (2005)
  • DA Brent et al.

    Treatment-resistant depression in adolescents: recognition and management

    Child Adolesc Psychiatr Clin N Am

    (2006)
  • TE Wilens et al.

    Combined pharmacotherapy: an emerging trend in pediatric psychopharmacology

    J Am Acad Child Adolesc Psychiatry

    (1995)
  • JM Swanson et al.

    Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment

    J Am Acad Child Adolesc Psychiatry

    (2001)
  • JF Leckman

    Phenomenology of tics and natural history of tic disorders

    Brain Dev

    (2003)
  • J Curry et al.

    Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS)

    J Am Acad Child Adolesc Psychiatry

    (2006)
  • RL Findling et al.

    Combination lithium and divalproex sodium in pediatric bipolarity

    J Am Acad Child Adolesc Psychiatry

    (2003)
  • JR Weisz et al.

    Youth psychotherapy outcome research: a review and critique of the evidence base

    Annu Rev Psychol

    (2005)
  • D Satcher

    Office of the Surgeon General. Report of the Surgeon General's conference on children's mental health: a national action agenda

  • JM Zito et al.

    Psychotropic practice patterns for youth: a 10-year perspective

    Arch Pediatr Adolesc Med

    (2003)
  • J Rosack

    New data show declines in antidepressant prescribing

    Psychiatr News

    (2005)
  • BE Hamilton et al.

    Annual summary of vital statistics: 2005

    Pediatrics

    (2007)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameters for the psychiatric assessment of children and adolescents

    J Am Acad Child Adolesc Psychiatry

    (1997)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder

    J Am Acad Child Adolesc Psychiatry

    (2007)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder

    J Am Acad Child Adolesc Psychiatry

    (1998)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders

    J Am Acad Child Adolesc Psychiatry

    (2007)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameter for the assessment and treatment of children and adolescents with depressive disorders

    J Am Acad Child Adolesc Psychiatry

    (2007)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameter for the assessment and treatment of children and adolescents with schizophrenia

    J Am Acad Child Adolesc Psychiatry

    (2001)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder

    J Am Acad Child Adolesc Psychiatry

    (2007)
  • J Guevara et al.

    Psychotropic medication use in a population of children who have attention-deficit/hyperactivity disorder

    Pediatrics

    (2002)
  • A Martin et al.

    Multiple psychotropic pharmacotherapy among children and adolescent enrollees in Connecticut Medicaid managed care

    Psychiatr Serv

    (2003)
  • PS Jensen et al.

    Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers

    J Dev Behav Pediatr

    (2001)
  • Cited by (0)

    This parameter was developed by John Walkup, M.D., principal author, and the Work Group on Quality Issues: William Bernet, M.D., Oscar Bukstein, M.D., M.P.H., and Heather Walter, M.D., M.P.H., Co-Chairs, and Valerie Arnold, M.D., R. Scott Benson, M.D., Joseph Beitchman, M.D., Allan Chrisman, M.D., Tiffany R. Farchione, M.D., John Hamilton, M.D., Helene Keable, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., Ulrich Schoettle, M.D., Jon Shaw, M.D., Matthew Siegel, M.D., and Saundra Stock, M.D. American Academy of Child and Adolescent Psychiatry (AACAP) Staff: Kristin Kroeger Ptakowski and Jennifer Medicus.

    AACAP practice parameters are developed by the AACAP Work Group on Quality Issues (WGQI) in accordance with American Medical Association policy. Parameter development is an iterative process between the primary author(s), the WGQI, topic experts, and representatives from multiple constituent groups, including the AACAP membership, relevant AACAP components, the AACAP Assembly of Regional Organizations, and the AACAP Council. Details of the parameter development process can be accessed on the AACAP Web site. Responsibility for parameter content and review rests with the author(s), the WGQI, the WGQI Consensus Group, and the AACAP Council.

    The AACAP develops both patient-oriented and clinician-oriented practice parameters. Patient-oriented parameters provide recommendations to guide clinicians toward best treatment practices. Recommendations are based on empirical evidence (when available) and clinical consensus (when not) and are graded according to the strength of the empirical and clinical support. Clinician-oriented parameters provide clinicians with the information (stated as principles) needed to develop practice-based skills. Although empirical evidence may be available to support certain principles, principles are primarily based on expert opinion derived from clinical experience. This parameter is a clinician-oriented parameter.

    The primary intended audience for the AACAP practice parameters is child and adolescent psychiatrists; however, the information contained therein may also be useful for other mental health clinicians. The author acknowledges the following experts for their contributions to this parameter: Daniel S. Pine, M.D., Laurence L. Greenhill, M.D., Christopher Kratochvil, M.D., Aradhana Bela Sood, M.D., Mark Riddle, M.D., Timothy Wilens, M.D., and Charles H. Zeanah, Jr., M.D. This parameter was reviewed at the Member Forum at the AACAP Annual Meeting in October 2005.

    From September 2006 to December 2007, this parameter was reviewed by a Consensus Group convened by the WGQI. Consensus Group members and their constituent groups were as follows: WGQI (Oscar Bukstein, M.D., Chair, Allan Chrisman, M.D., and Saundra Stock, M.D., Members); Topic Experts (Daniel S. Pine, M.D., and Timothy Wilens, M.D.); AACAP Assembly of Regional Organizations (Susan Daily, M.D.); and AACAP Council (Aradhana Bela Sood, M.D., and Charles Zeanah, Jr., M.D.).

    Disclosures of potential conflicts of interest for authors and WGQI chairs are provided at the end of the parameter. Disclosures of potential conflicts of interest for all other individuals named above are provided on the AACAP Web site on the Practice Information page.

    This practice parameter was approved by the AACAP Council on March 18, 2009. This practice parameter is available on the Internet (www.aacap.org). Reprint requests to the AACAP Communications Department, 3615 Wisconsin Avenue, NW, Washington, DC 20016.

    View full text