https://www.thecarlatreport.com/newsletters/4/issues/473

When treating kids and teens with psychiatric disorders, it’s easy to feel overwhelmed by treatment options. This guide walks you through what works best, based on the evidence, for the most common conditions in child and adolescent psychiatry.

First things first
Give yourself adequate time to complete an initial assessment. Children and teens typically come in with multiple conditions, so developmental, social, and family history (including medication responses) will guide your care.

ADHD: Stimulants reign supreme
Stimulants remain the most effective treatment for ADHD, with effect sizes between 0.8 and 1.0—some of the highest in medicine (Pliszka S et al, J Am Acad Child Adolesc Psychiatry 2007;46(7):894–921).

Start with behavioral support
Start with parent and school-based behavioral interventions, regardless of medication use. Younger kids often respond well to behavioral treatment and may have more side effects from medications.

First-line meds: Methylphenidate
Try a methylphenidate-based stimulant first. These tend to cause fewer side effects than amphetamines in kids. If the first one doesn’t work or causes problems, try a different formulation. If two trials fail, move to an amphetamine-based stimulant. They can be more effective but have more side effects (eg, appetite suppression, insomnia, irritability).

Second-line options
If stimulants aren’t effective or preferred, consider:

• SNRIs (atomoxetine and viloxazine): Atomoxetine had an effect size of 0.6–0.7 in some research studies, but is less effective in clinical settings. Viloxazine is still rather new. Start low and titrate slowly. Watch for blood pressure elevation and, rarely, suicidal thoughts.
• Alpha agonists (guanfacine XR or clonidine XR): These medications have an effect size of 0.4–0.7. They are less effective for core symptoms but helpful for aggression, tics, or sleep problems. Use them alone or to augment stimulants.

Watch for comorbidities
Treat co-occurring issues like anxiety or depression. These may need their own interventions beyond ADHD meds.

Anxiety: Start with cognitive behavioral therapy (CBT)
Anxiety disorders are the most common psychiatric conditions in kids. Many respond well to therapy alone.

First line: CBT
CBT is your best first step, even in moderate cases. For mild anxiety, CBT alone may be enough. Effect size is around 0.6–0.7 (Walter JH et al, J Am Acad Child Adolesc Psychiatry 2020;59(10):1107–1124).

Second line: SSRIs
If CBT isn’t available or symptoms are severe, add an SSRI. No SSRI clearly outperforms the others, though escitalopram is FDA approved for pediatric generalized anxiety disorder (GAD). Start low and go slow. Monitor for activation and suicidal thoughts, especially in the first month.

Third line: SNRIs
If the first SSRI doesn’t work, try another SSRI. Only consider an SNRI like duloxetine after at least two failed SSRIs. Duloxetine is FDA approved for GAD and has an effect size of 0.5, but its side effect burden is higher (Strawn JR et al, J Am Acad Child Adolesc Psychiatry 2015;54(4):283–293).

Avoid benzodiazepines (BZDs)
There’s little evidence for BZDs in children, with risks usually outweighing any benefit.

OCD: Use exposure and response prevention (ERP), then add SSRIs
First line: CBT with ERP
For kids with mild or moderate OCD, start with CBT that includes ERP.

Second line: SSRIs
If ERP isn’t available or symptoms are severe, add an SSRI. No SSRI is superior to another for OCD, but fluoxetine, sertraline, and fluvoxamine are FDA approved for pediatric OCD. Effect sizes for SSRIs are modest (0.3–0.4; Cohen SE et al, J Am Acad Child Adolesc Psychiatry 2025;64(7):775–785; see RU "SSRIs Help Modestly With Pediatric OCD"). Higher dosages are typically necessary for OCD. If monotherapy isn’t enough, combine medication and therapy.

Third line: Clomipramine
If 2 robust trials of SSRIs fail after an adequate duration (typically 12 weeks), consider clomipramine. It’s more effective (effect size ~0.6) but carries more side effects, notably anticholinergic burden and cardiac risks (Watson HJ and Rees CS, J Child Psychol Psychiatry 2008;49(5):489–498).

Depression: Therapy first
Mild to moderate: Start with therapy
Use CBT or interpersonal therapy. Both have effect sizes around 0.6 (Walter HJ et al, JAACAP 2023;62(5):479–502; Arnberg A and Ost LG, Cogn Behav Ther 2014;43(4):275–288).

Severe or treatment resistant: Add an SSRI
If symptoms are severe, or if there’s no improvement after 8–12 weeks of therapy, start medication. Antidepressant effect sizes hover around 0.5, slightly lower than psychotherapy (Walter et al, 2023). Fluoxetine has the best evidence and FDA approval. If it fails, try escitalopram, then sertraline. Data for antidepressants with younger kids are sparse, and some evidence points to no benefit at all (Wagner KD et al, J Am Acad Child Adolesc Psychiatry 2006;45(3):280–288).

Avoid SNRIs in youth depression; they have more side effects and little evidence of benefit (see CCPR Oct/Nov/Dec 2025).

Monitor closely
Check for new suicidal thoughts throughout treatment. The risk is low (~1%) but highest in the first few weeks.

Bipolar disorder: Match the phase
Pediatric bipolar disorder is rare. Choose meds based on the phase: depression, maintenance, or, uncommonly, mania.

• Acute mania or mixed states: Stabilize with antipsychotics, then try to decrease/discontinue them. Risperidone and aripiprazole have the best data (effect sizes 1.2 and 0.6). Quetiapine and olanzapine are also FDA approved (effect sizes 0.8 and 0.6; Vita G et al, J Am Acad Child Adolesc Psychiatry 2025;64(2):143–157). If partial response, add lithium, which is preferred over valproate in adolescents due to fewer metabolic and reproductive side effects.
• Bipolar depression: Try lurasidone or the olanzapine/fluoxetine combo—both FDA approved with effect sizes around 0.5.
• Maintenance: Use lithium if possible. It prevents relapse, has the strongest long-term data, and is preferred over valproate, especially in teens. For more, see box below.
• Add psychosocial support: Medication isn’t enough. Use family-focused therapy and school coordination to reduce relapse and improve adherence.

Schizophrenia: Focus on engagement and side effects
First line: Atypical antipsychotics
For childhood-onset schizophrenia, start with risperidone (effect size ~0.8). Aripiprazole and olanzapine also have strong support (effect sizes ~0.6–0.7). Aripiprazole, risperidone, olanzapine, quetiapine, paliperidone, and lurasidone all have FDA approval. If two antipsychotics fail, try clozapine. Monitor closely due to risks of neutropenia, seizures, and weight gain.

Monitor side effects
Adjust doses slowly. Discuss and closely track weight, glucose, lipids, and neurological effects, including use of the Abnormal Involuntary Movement Scale (AIMS).

Psychosocial care is key
Help families with communication and psychoeducation. Support school engagement and social functioning early.

Autism: Treat co-occurring conditions
No medication treats the core symptoms of autism, and these patients are more sensitive to side effects.

Developmental relationship-based or naturalistic, parent-mediated approaches should be first line for irritability and aggression. Focus on co-regulation and connection. Next, try complementary treatments (eg, omega-3s, melatonin). Then try alpha agonists, stimulants, SSRIs, or propranolol. If symptoms are severe and persistent, try risperidone (effect size ~0.9) or aripiprazole (effect size ~0.6). Both are FDA approved for irritability in autism (Choi H et al, Mol Autism 2024;15(1):7).

Effective care: Beyond algorithms
Few kids fit neatly into the categories above. The list of other factors to consider in both assessment and treatment planning is long but includes family conflict, trauma, or stress; sleep, diet, and exercise; peer relationships and bullying; and cultural and familial views on mental health.

CARLAT VERDICT
Use nonpharmacologic approaches first whenever possible. When medications are needed, stick with those that have the strongest evidence. Always personalize care to the child and family’s needs and values—and taper when appropriate.