There are only around 8,000 child psychiatrists for 70 million children in the US. Primary care providers handle most pediatric psychotropics, and adult-trained psychiatric clinicians are increasingly asked to see kids despite not being pediatric experts (Olfson M et al, JAMA Psychiatry 2014;71(1):81–90). These clinical pearls will help adult psychiatrists care for children and teens when families cannot access specialized care and when the clinical presentation is not too complex. One principle that cuts across all diagnoses is that talk therapy is almost always helpful, especially cognitive behavioral therapy (CBT) and family therapy. Psychiatric clinicians have a deep understanding of how therapy works and are well positioned to explain its role to families.

1. Start on a positive note
“What brings you here?” might work with adults, but kids don’t warm up to openers like these. I spend the first few minutes on strengths instead. Try: “Before we talk about what’s been hard, tell me something you’re really good at.” Once you have a better picture of the child, pivot naturally: “Great—now let’s talk about what isn’t going so well.” This approach builds rapport quickly and gives you clinically useful context (Schlechter AD et al, Child Adolesc Psychiatric Clin N Am 2019;28(2):157–169).

2. Know the evidence and its limits
Landmark studies confirm that medication works for ADHD, anxiety, and adolescent depression, and that combining psychotherapy with medication tends to yield the best results. Before treating kids, you should review the latest treatment guidelines so you are up to date on developmental considerations and the current evidence base. In your medical record, document your review of treatment guidelines and your clinical rationale for accepting the patient, including the lack of available CAP providers and the risk of no treatment. Also check with your malpractice carrier, as some policies may require you to notify them if you start treating minors.

What follows is a high-level summary. For complex presentations (especially bipolar disorder and psychosis), these tips can be a starting point while you help the family access a child psychiatrist.

Anxiety
SSRIs and CBT are equally effective for children ages 7+. SSRIs have a larger effect size for pediatric anxiety than for adolescent depression. Fluoxetine, sertraline, and escitalopram have strong evidence, though only duloxetine and escitalopram are FDA approved for GAD in children 7+. Therapy is always part of the plan, and I do not use venlafaxine in kids because of the risk of withdrawal reactions. For pediatric OCD, the FDA has approved sertraline (ages 6+), fluoxetine (ages 7+), and fluvoxamine (ages 8+). Do not use benzodiazepines in kids.

Adolescent depression
Therapy is first line, especially CBT. Among medications, fluoxetine has the strongest evidence base (FDA approved for ages 8+), followed by escitalopram (FDA approved for ages 12+). I have seen many depressed teens who have not responded to other SSRIs do well with fluoxetine. Transcranial magnetic stimulation, a newer modality, is approved down to age 15. I avoid venlafaxine and paroxetine in teens due to concerns about agitation, withdrawal reactions due to missing doses, and suicidal ideation (Thapar A et al, Lancet 2022;400(10352):617–631; Cipriani A et al, Lancet 2016;388(10047):881–890).

Prepubertal depression
Two placebo-controlled studies support fluoxetine for children 8+, the only FDA-approved medication for this age group (Cipriani et al, 2016). Especially in this group, therapy is essential, and there is often a role for family therapy.

ADHD
Medication alone outperforms behavioral interventions for core symptoms, but combination therapy yields the best functional outcomes. About 40% of kids respond equally to amphetamines or methylphenidate; I find methylphenidate better tolerated in younger children and will start with it in kids under age 14. If response or tolerance to methylphenidate is poor, it is important to also do a trial with a mixed dextroamphetamine/amphetamine salt.

Sleep
I prioritize sleep hygiene first. Many families have poor sleep habits and have never been told basic facts about sleep. For persistent insomnia, CBT-insomnia is a powerful intervention if you can help families find a trained clinician to implement the protocol. Do not use benzodiazepines or Z-hypnotics in children. Melatonin (up to 4 mg) has evidence for short-term use, with higher doses (up to 10 mg) studied in autistic children. Some kids will respond to melatonin quickly, while others do better taking it 1.5–3 hours before bedtime. I also use clonidine, particularly for children with ADHD and sleep-onset difficulties. Start with 0.05–0.1 mg of immediate-release clonidine, 30–60 minutes before bedtime. Titrate by 0.05 mg increments every few days as needed. Most children respond to 0.1–0.2 mg at bedtime, and the maximum dose is 0.4 mg at bedtime (Bruno S et al, Sleep Med Rev 2025;84:102158).

Bipolar and psychosis
These are complex—I recommend consultation with a child psychiatrist. Lithium (FDA approved for ages 7+) shows significantly better long-term outcomes, including 50% fewer suicide attempts, than other mood stabilizers.

Second-generation antipsychotics (SGAs)
SGAs carry higher metabolic and neurologic risks in children than in adults. I make sure I have a clear rationale before prescribing and monitor rigorously. It is also essential to make sure that patients are receiving multimodal therapy for the underlying condition they have (eg, psychosis, mood disorder, autism).

Suicide risk and SSRIs
SSRIs carry a small risk of increased suicidal ideation (NNH = 110–140), but for FDA-approved options in moderate to severe depression, the benefits (NNT = 10) outweigh those risks—especially when medication is paired with therapy (Miller L and Campo JV, NEJM 2021;385(5):445–449). For pediatric anxiety, the benefit-risk profile is even more pronounced: NNT = 2–3 versus NNH = 143 (Kowalchuk A et al, Am Fam Physician 2022;106(6):657–664).

3. Set expectations about therapy and medication
Many families arrive hoping to start with talk therapy and avoid medication, and this is a valid preference. Explain how therapy works, the different types indicated for the child’s condition, and what a realistic treatment course looks like: how often, how long, and what to expect. When therapy isn’t accessible, help families understand that medication alone can be a viable and evidence-based alternative, not a shortcut: “Ideally, we’d do both at once, but there is good evidence that medication alone will help. When there is an opportunity to add therapy in later, we can do that.”

4. Get consent from parents, assent from kids
Working with children takes more time than adult visits; plan for it. Start by meeting with parents alone to address their concerns and obtain legal consent. Then speak with the child, either privately or with the parents, depending on the child’s comfort level. When you’re ready to discuss the plan with the child, avoid diagnostic labels: Instead of saying, “You have major depression,” try: “This medicine helps you have more control over bad feelings.” Plain, non-alarming language makes it easier for the child to engage rather than shut down. Once the child knows their parents are on board, ask for the child’s assent—their willing agreement to participate. I will say: “I want to make sure that you want to try this medicine; it is important to me that you have a say in this.” That moment of being asked, rather than told, builds the therapeutic alliance from the start.

5. Work with the family

Interview both parents and kids
Kids are imperfect self-reporters. You need parent input for an accurate diagnosis, but always interview the child privately too—symptoms and side effects they’d never mention in front of a parent often surface in a one-on-one conversation.

Supervise medications
Parents must oversee medication use, even with older teens. Adult adherence is often poor, so expecting teenagers to manage medications independently is just setting them up to fail.

Coach the parents
The parent-child dynamic is frequently a primary stressor. Use parent meetings not just for updates, but to offer practical guidance on managing a child with mood or attentional problems. This can include coaching on responsive caregiving (listening to the child and supporting their agency in shared problem solving) and acceptance of the child as they are in the process of treatment.

6. Adjust your dosing expectations
“Start low and go slow.” Children metabolize medications differently than adults—faster in some age groups, slower in others—and clinical response varies widely. Adult doses are not a reliable guide. Schedule frequent follow-ups and titrate based on what you see clinically, not on weight-based formulas or genetic tests.

7. Revisit diagnosis and dosing as kids grow

Intervene early
Half of adult psychiatric patients report that their symptoms began in early adolescence. Early detection changes trajectories.

Adjust doses over time
As children grow, revisit medication doses and watch for new stressors. Bullying, substance use, relationships, and academic pressure can shift the clinical picture.

Expect diagnoses to evolve
Prepubertal anxiety often precedes postpubertal depression, and 20% of children with ADHD will develop a comorbid anxiety disorder. Schizophrenia, bipolar, and panic disorder all have their peak onset in the late teens. Build reassessment into every visit; don’t treat the original diagnosis as fixed.

8. Time medication changes carefully
Children’s lives are always in flux. Avoid starting or adjusting medications during major transitions: the beginning or end of semesters, vacation weeks, or finals. Once a child is stable, keep them on medication for at least one full school year before attempting a taper.

9. Know when and how to refer
When a case is beyond your scope, call a child psychiatrist. Regional consultation programs make this easier. Many offer phone or telemedicine consults that get you specialist input without transferring care. These programs increase provider confidence and reduce unnecessary referrals (Stein BD et al, J Am Acad Child Adolesc Psychiatry 2019;58(10):1016–1019).

10. Be patient
Time is a treatment. A child’s brain is continuously developing stronger capacity for emotional regulation, reasoning, and socialization. The goal isn’t always remission. It’s good-enough symptom control so the child can stay engaged in school, family, and social life while their brain matures.

CARLAT VERDICT
Adult clinicians can be effective working with kids, especially if they slow down, loop in families, and recalibrate their expectations. Get up to date on the most recent treatment guidelines, and consult with specialist colleagues when needed. Start low, go slow, and aim for function: keeping the child engaged in life while development does its work.