Medication Management for Pediatric Mental Health in Primary Care

While primary care physicians (PCP) can evaluate and treat mild to moderate behavioral health conditions, including by prescribing medication, many pediatric primary care providers have knowledge gaps in this area and are reticent to prescribe. But with some foundational knowledge and general guidance — provided by Sandra Fritsch, MD, Medical Director of our Pediatric Mental Health Institute — PCPs can feel more comfortable managing medication for common pediatric mental health challenges.

Screening for children’s mental health conditions

Assessing for attentional challenges, mood symptoms and anxiety concerns can occur through routine socioemotional screening at annual well-child visits. Using a broadband screening tool such as the Pediatric Symptom Checklist can provide information for internalizing and externalizing difficulties. Further screening can occur with narrow band screening tools specific for attentional, mood and anxiety symptoms. For further support, consider using the Colorado Pediatric Psychiatry Consultation and Access Program’s (CoPPCAP) Colorado Care Guide on Assessment and Screening.

The three most common pediatric behavioral health concerns potentially amenable to medication treatments are attention deficit/hyperactivity disorder (ADHD), anxiety and depression.

Prior to starting any psychotropic medications, it’s important to have:

• Information and perspective from multiple people, such as the patient, caregivers and teachers, if feasible
• An assessment of the impact on the child’s level of function
• A specific, targeted, individual symptom checklist for monitoring response to treatments
• A sense of the effect size of medications for treatment of specific conditions to inform prescribing practices

Medication management for ADHD in children

There are three different categories of medications with FDA approval for treating ADHD in kids and teens:

• Stimulant medications
• Alpha-2 agonist medications
• Norepinephrine reuptake inhibitors

Stimulant medication for ADHD

Stimulant medications have the largest effect size — from 0.8 to 1.2 in school age youth and 0.94 in teens. There are only two major classes of stimulant medications — methylphenidates and mixed amphetamine salts — but they have several different names, brands, duration of effect and formulations, leading to potential confusion.

In addition to the robust effect size, another reason to consider stimulant medication is that the effect is almost immediate. It doesn’t need to “build up over time,” and effectiveness and side effects will be apparent almost immediately with use. One meta-analysis recommends methylphenidate products as first line treatment due to tolerability.

Common side effects include appetite suppression, nausea or stomach distress and headaches. Providers should also assess patients for underlying cardiac conditions or sudden unexpected death in family members if they’re considering prescribing stimulant medication. If present, they should consult a pediatric cardiologist. The ADHD Medication Guide created by Cohen Children’s Medical Center of Northwell Health is a visual resource and useful tool. This guide delineates how medications can be taken (pills, sprinkled, in liquid, etc.) and provides photos of the medications, helpful in identifying if patients or families can’t remember the name.

Alpha-2 agonist medications for ADHD

The extended-release alpha-2 agonist medications (clonidine/Kapvay and guanfacine/Intuniv) have a treatment effect size of 0.5 to 0.7 and can increase norepinephrine in the prefrontal cortex. Alpha-2 agonists are often effective when youth have significant overactivity and impulsivity, or comorbid trauma or anxiety and don’t tolerate stimulants. Providers can prescribe alpha-2 agonists in conjunction with stimulant medications with recent studies demonstrating improved outcomes with combining stimulant medications and extended release guanfacine (Intuniv). Of note, alpha-2 agonists were developed originally to treat adult hypertension, and abrupt discontinuation after a period of use can lead to rebound hypertension.

Norepinephrine reuptake inhibitors

Selective norepinephrine reuptake inhibitors (NRIs) increase serotonin and norepinephrine. There are two NRIs with FDA approval for treatment of childhood ADHD: atomoxetine (Strattera) and viloxazine (Qelbree).

The effect size for atomoxetine and viloxazine are 0.6 to 0.7 and these medications need to “build up” in the body — roughly 1 week for viloxazine and up to 3.5 weeks for atomoxetine. The SNRIs may be beneficial in youth with comorbid depression or anxiety and ADHD. Common side effects include fatigue, sleepiness, appetite suppression and headaches. NRIs have a black box warning of possible suicidal thinking.

For treating ADHD, be aware of treatment recommendations with respect to age. For preschoolers, the recommended first line treatment is parent management strategies, but providers can consider methylphenidate products for the first medication option as they have the fewest side effects.

For kids aged 6 to 11, treatment should include an FDA-approved medication, school supports and interventions, and possible behavioral interventions in the family.

For children 12 and older, treatment can include FDA-approved medication with youth assent, behavioral and executive function interventions and academic supports. Of note, providers should assess treatment adherence as studies have revealed up to 25% treatment non-adherence in teens.

Assessment and treatment of ADHD can be complex. Resources to support treatment include:

• CoPPCAP ADHD Colorado Care Guide
• American Academy of Child and Adolescent Psychiatry’s (AACAP) ADHD Resource Center
• American Academy of Pediatrics’ (AAP) ADHD Toolkit
• AACAP’s ADHD Parents’ Medication Guide
• AACAP’s ADHD Parents’ Medication Guide - Spanish
• AACAP’s ADHD in Youth with Autism Spectrum Disorder: Parents’ Medication Guide

Medication management for depression and anxiety in children

For youth presenting with mild to moderate depression and anxiety, providers should consider evidence-based psychotherapies including cognitive behavioral therapy, interpersonal therapy and dialectical behavior therapy. CoPPCAP’s Colorado Care Guides offer management and action plans for anxiety and depression that include a parent handout with recommendations factoring in evidence-based principles. If you’re considering medication, the recommendation is to begin medication trials of selective serotonin reuptake inhibitors (SSRI), as some of these medications have received FDA approval for youth.

SSRIs with FDA approval:

• Sertraline (Zoloft): Approved to age 6 for treatment of obsessive compulsive disorder (OCD)
• Fluoxetine (Prozac): Approved to age 7 for treatment of OCD, and age 8 and older for treatment of depression
• Escitalopram (Lexapro): Approved age 7 and older for anxiety and age 12 and older for depression
• Duloxetine (Cymbalta): Approved age 7 and older for generalized anxiety disorder

Fluoxetine’s effectiveness has been studied the most. Unfortunately, the effect size of antidepressants is only 0.5 to 0.6. The effect size of rigorous exercise is similar to antidepressant medications.

When recommending medications, it’s important to develop individualized target symptom checklists to monitor response to medications. Also, when working with the youth and families it’s important to let them know the length of time it may take to see effectiveness and that others around the youth may notice improvements before the youth sees improvement.

When prescribing, the provider should have a planned upward titration schedule to a target dose, then wait 4 or more weeks to determine effectiveness at the target dose. Providers should generally use medication trials first with two SSRIs before switching to a non-SSRI medication. All antidepressants carry the black box warning of the potential development of suicidal ideation. In addition to the CoPPCAP resources listed above, other materials to support primary care providers treating anxiety and depression in youth include the following:

• AACAP Anxiety Resource Center
• AACAP Depression Resource Center
• AACAP Anxiety Disorders: Parents’ Medication Guide - English
• AACAP Anxiety Disorders: Parents’ Medication Guide - Spanish
• AACAP Depression: Parents’ Medication Guide
• Clinical Practice Guideline for Assessment and Treatment of Depression
• Clinical Practice Guideline for Assessment and Treatment of Anxiety in Children and Adolescents

An emerging topic of interest when considering medication for treatment of behavioral health conditions is the potential value of pharmacogenomic testing. This testing has not been studied or normed for the continuously evolving pharmacokinetic system of children. This testing will not guarantee effectiveness to the testing site’s recommended medications. The testing can be helpful in determining how rapidly the patient might metabolize medications and considering drug-to-drug interactions.

From side effect questions to comorbidity to new patients already on complex psychopharmacologic regimens, medication management in primary care can be vary complex. But many programs provide peer-to-peer consultations around these complex questions. Pediatric Mental Health Care Access Programs (PMHCA) are funded in most states by Health Resource Services Administration grants.

CoPPCAP is the Colorado PMHCA. CoPPCAP provides same day peer-to-peer consultations, education with pediatric psychiatry ECHOs through ECHO Colorado, annual learning collaboratives, lunch and learns and other resources. All of CoPPCAP’s services are free and payor blind. The American Academy of Child & Adolescent Psychiatry has also created a Resources for Primary Care guide.