Problems of mental health and behaviour in children are multidisciplinary in nature and optimal treatment is often multimodal. This article focuses on aspects of psychopharmacology that has special relevance in children and adolescents, especially the recent controversies. In general, this article provides information about classes of medication and not detailed information about specific medicines. Treatment recommendations of the specific disorders have been dealt within the appropriate chapters.

The use of psychotropic medication in children is higher in the United States than in many other countries, and polypharmacy is common. About 1 per cent of overall medical consultations visits by children and adolescents in 2003-2004 in the US resulted in a second-generation antipsychotic (SGA) prescription. The majority of the visits involving antipsychotics were by Caucasian boys aged over nine years, visiting specialists, without private insurance, with a diagnosis of bipolar disorder, psychosis, depression, disruptive disorder, or anxiety.⁽¹⁾

Pre-school (2 to 4 year olds) psychotropic medication use, between 1995 and 2001 increased across the US for stimulants, antipsychotics, and antidepressants, while the use of anxiolytics, sedatives, hypnotics and anticonvulsants remained stable across these years, suggesting non-psychiatric medical usage.⁽²⁾ Ethnicity may influence differential prescription rates; for example, as compared to Caucasian youths, African-American youths are less likely to be prescribed psychotropic medications especially methylphenidate.⁽³⁾

Apart from a thorough diagnostic assessment, a full medical history including present, recent, and past prescribed and over-the-counter medication, response to treatment, and attitude towards interventions play a major role in deciding treatment. History of substance misuse needs to be elicited to ascertain potential medicationmisuse liability and because certain medication significantly interact with illicit drugs. A family history of mental illness, suicide, substance abuse, neurological or medical conditions, especially early onset coronary artery disease, hyperlipidemias and diabetes, and specifically the response of family members to psychotropic medication are all important.

Disorders that have an extended course, where emergence of new problems is common, require continuous, dynamic treatment planning and monitoring to ensure effectiveness of the current treatment. The treatment should stress multi-modal intervention and address co-morbid psychiatric disorders. Treatment plans
should be individualized according to the pattern of target symptoms and strengths identified in the evaluation. A thorough functional analysis of problems or symptoms is central to pharmacological decision-making. Treatment should target situations in which symptoms cause the most impairment. Custom-designed target symptom scales or daily behavioural report cards are useful in monitoring treatment progress.

One way to conceptualize paediatric psychopharmacotherapy is the ‘Symptom-based Approach’ for core symptoms as follows:

Psychosocial interventions may be required to address either primary or secondary relationship problems associated with the core deficits or to deal with co-morbidity.

Pharmacological interventions do not necessarily work exclusively because of their ‘neurochemical’ effects. Response to medication also includes the inherent ‘placebo response’ or ‘expectancy effect’ that prescribing can induce, as well as the effect of the ‘therapeutic concordance’ achieved through getting the agreement and acceptance of why the medication is being prescribed and also what is the expected response.

Parents as well as patients respond better when they feel understood, accept why treatment is necessary and are in agreement with the prescriber regarding the need for treatment. Simple strategies help this process: collaborating with parents, patients, school and care providers; giving a clear explanation of diagnoses, of why medication (with or without psychosocial interventions) is necessary; setting realistic expectations (for example, aiming for a 40-60 per cent reduction in anxiety symptoms in a child with multiple co-morbidity); keeping track of the larger systems of care at school and home; providing clear, appropriate information sheets, websites etc to obtain further information if needed; prioritizing and tracking target symptoms; asking them to ‘opt in’ to treatment after having weighed all the pros and cons, as opposed to them perceiving that they are being ‘told’ that they ‘have to’ start medication; using short telephone-based medication monitoring during the stabilization phase in order to pick up emerging side-effects and monitoring dosage accordingly; initiating medication using small doses and titrating it up over a period of 4 to 6 weeks, to identify the minimum effective dose (MED), which is the minimum dose with which ‘acceptable’ improvement with minimal side-effects is achieved; involving school in monitoring symptoms regularly even if it means maintaining a school-home dairy; and willingness to change treatment if the expected outcome has not been achieved.

Domains that each therapy focusses on should be clearly documented and periodically evaluated. The designation of a case manager is essential for chronically disabled individuals to coordinate the wide range of services necessary for their care and to ensure periodic diagnostic reassessments.

Stimulants have been used for decades and good research evidence exists for their short-term use in ADHD. More recently, various stimulant delivery systems have been developed (the osmotic controlled-release system (OROS) – Concerta XL^®; the wax-matrixbased beaded system – Metadate CD^®; the patch release system – Daytrana^®; etc) resulting in long-acting preparations which makes it possible to avoid medication needing to be administered in school. This once daily dosing schedule possibly reduces stigmatization and embarrassment. The release systems and preparation of stimulants (immediate release / slow release ratios) allow the tailoring of the long-acting preparations to suit the need of individual children.⁽¹²⁾