TCPR: Adult psychiatrists are increasingly seeing children and adolescents. When is it appropriate for a general psychiatrist to take that on?
Dr. Rettew: In many cases, it’s quite appropriate. All psychiatrists receive some child and adolescent training, though the amount varies. One model that works well is to gradually extend the age range downward as you gain confidence—16 and older, then 14, and so on. We have to be honest about the workforce reality: Child and adolescent psychiatrists are scarce, and if general psychiatrists aren’t filling the gap, people with even less specialized training will. For clinicians who are motivated to learn, expanding into adolescent care is feasible and can be very rewarding, particularly if they take the time to do some additional learning in areas like ADHD, autism, and child development.

TCPR: Which conditions are adult psychiatrists best able to handle?
Dr. Rettew: Adult psychiatrists are well prepared for early psychosis and bipolar disorder, both of which frequently first present in adolescence. The more challenging areas are autism spectrum disorder and ADHD, and these conditions are also presenting more often in adults. Anxiety and depressive disorders are very common in both adulthood and adolescence and should be something most adult psychiatrists can handle pretty well. The most challenging cases may be those who present with high levels of both mental health and developmental/cognitive disorders. These patients benefit by referral to a child psychiatrist or a developmental/behavioral pediatrician.

TCPR: What does a good assessment look like?
Dr. Rettew: Maybe the biggest difference from typical adult psychiatry practice is the role of collateral information. In adult psychiatry, the patient is often the sole data source. In child psychiatry, it’s quite different—we routinely speak with parents, teachers, and pediatricians, and we’re taught to expect meaningful disagreement between informants. Ratings of the same child by different adults correlate at only about 0.3, which is quite modest (Althoff RR et al, Psychiatry Res 2010;178(3):550–555). That spread tells us something clinically. When a child looks very different at school versus home, that difference itself becomes a target for intervention. What’s happening in the school environment that isn’t happening at home? That question often opens a therapeutic door.

TCPR: How do you tell what is normal in children?
Dr. Rettew: With youth, that boundary is a moving target. The clinician needs to have a good sense of how, for example, the typical attention span of a 6-year-old boy is different from a 15-year-old girl. This takes time and experience. Rating scales that are normed by age can also help quite a bit.

TCPR: How important is the developmental history?
Dr. Rettew: It’s indispensable and often underutilized. A standard psychiatric history asks about pregnancy complications and developmental milestones: When did they first walk (typically 15–18 months), use words (typically by 12 months), and have a social smile (typically 1–3 months)? Those are the basics, and I try to go further. What was this child like temperamentally at age 3? What did they enjoy? What was the family environment? For ADHD, you need evidence of symptoms before age 12, and pediatric records are often the best source of that historical documentation—behavioral concerns noted by a pediatrician, parents raising questions, early observations from teachers. With our current EMR systems, those records are often accessible electronically. I also ask about prenatal substance exposure, which is increasingly relevant given rising cannabis use in pregnancy, including use for nausea in pregnancy. It doesn’t always change the treatment plan, but it adds important context (Avalos LA et al, JAMA Netw Open 2024;7(10):e2440295).

TCPR: What should general psychiatrists know about assessing autism?
Dr. Rettew: The first thing is to dive in a little bit rather than just reflexively referring. Unlike most psychiatric diagnoses, an autism diagnosis can feel as though it requires the use of formal testing with tools like the Autism Diagnostic Observation Schedule. But we don’t require that for diagnoses like PTSD or major depression. My view is that a psychiatrist with good training can often make a confident clinical judgment. Where formal testing becomes more valuable is in ambiguous cases—particularly teens or young adults who self-refer with concerns about autism, which has become much more common in the past decade. In those cases, collateral history from a parent who knew the child in early life can be especially useful. Ask about social smile, reciprocal play, pointing to objects, and whether the child showed the “serve and return” quality typical of early social development.

TCPR: We’re seeing a wave of young adults and teens who come in self-diagnosing autism. How do you approach that?
Dr. Rettew: We have seen an increase in autism diagnoses—from 1 in 150 in 2020 to 1 in 36 today. The increase is in milder cases. The rate of profound autism with intellectual disability hasn’t gone up that much (Salkić A et al, Psychiatry Res 2026;363:117246). I’d resist the urge to dismiss it as a fad. The right response is to take it seriously and do a careful assessment. Ask what led them to this conclusion, reserve judgment, and follow the data. Sometimes the self-referral turns out to be accurate. In other cases, the patient doesn’t meet criteria for autism but does meet criteria for something else—an anxiety disorder, ADHD, PTSD—that has gone unrecognized for years. There are also cases where the patient is genuinely well, and part of what we’re seeing is reduced stigma around neurodevelopmental labels among younger cohorts. When that’s the case, I try to offer that reassurance directly, while being honest that not everyone who struggles meets criteria for a formal disorder.

TCPR: Are there screening tools you recommend for autism?
Dr. Rettew: The Modified Checklist for Autism in Toddlers (M-CHAT) is a free, widely used screening tool for younger children. The Social Responsiveness Scale (SRS) is more comprehensive but proprietary. I often find that simply asking the relevant questions directly is as informative as a rating scale. On the genetic side, chromosomal microarray and whole-exome sequencing are increasingly considered standard of care for children with more significant autism presentations—what some now call profound autism, typically those with limited language and lower IQ (Rodan LH et al, Pediatrics 2025;156(1):e2025072219). For higher-functioning individuals, the yield is lower, but it isn’t negligible. Identifying a specific genetic variant can alert you to associated conditions—cardiac, metabolic, or others—that matter for monitoring and medication safety. It’s also important to screen for major risks and protective factors: things like food insecurity, bullying, exercise, and screen time.

TCPR: What are the most important psychopharmacology principles for children?
Dr. Rettew: It’s critical to have a balanced treatment plan that includes therapy, parent guidance, and health promotion. If medications are needed, start with half of the lowest available dose and go slowly. Rushing tends to produce side effects that scare patients off the medication, and then you’re cycling through four drugs in six weeks trying to find something that sticks—that’s a bad foundation. Prepubertal children can be especially sensitive to stimulants and SSRIs. I’ve seen young kids get diagnosed with bipolar disorder when what they were experiencing was SSRI-induced activation. For adolescents, you may start low but still aim for adult doses. I frequently see referrals for treatment nonresponse where the teen has been on 25 mg of sertraline for a couple of years. Also, remember that most of the conditions we treat run in families, so directing treatment at parents and caregivers when appropriate can sometimes reduce or even eliminate the need for medications in the identified youth.

“If general psychiatrists aren’t filling the gap, people with even less specialized training will.” - David Rettew, MD

TCPR: How do you tell SSRI activation apart from mania?
Dr. Rettew: In theory, activation is less cyclic. It’s tied to the medication start or dose increase rather than occurring spontaneously. In practice, I find cyclicity hard to assess reliably in children, so I rely more heavily on the temporal relationship: Did this emerge when we started the SSRI or raised the dose? Does it resolve when we stop it? If yes, that points to activation. I use the bipolar diagnosis cautiously in children, and I want to rule out SSRI activation first.

TCPR: What about antipsychotics?
Dr. Rettew: The two scenarios I worry most about are antipsychotics used as sleep aids and antipsychotics used for oppositional or irritable behavior when safer approaches haven’t been tried. I do use antipsychotics when there’s a genuine safety concern—physical aggression, imminent risk of placement disruption—and in those cases, the risk-benefit ratio makes sense. I don’t think they should be used for developmentally expected tantrums, or as the first intervention for disruptive behavior, without any behavioral therapy trial. Children have a greater risk of metabolic side effects, so the bar for starting is higher, as is the motivation for stopping when appropriate (Libowitz MR and Nurmi EL, Front Psychiatry 2021;12:623681).

TCPR: What is the role of prevention in child psychiatry?
Dr. Rettew: This is a passion of mine. I think we’re past the point where we can wait for a full-blown psychiatric disorder to develop before intervening. The science increasingly supports early identification and attention to what I’d call mental health promotion: parenting support, physical activity, sleep, screen time regulation, and social determinants of health. These aren’t outside our lane—they should be part of how we think about psychiatry. Partnering with primary care is one of the most underutilized levers we have. Pediatricians see families when children are young and can identify risk factors years before a psychiatric crisis emerges. There’s a lot of work to be done here, although when I’m doing lifestyle counseling with families, I try not to overwhelm them. Instead, I help them identify one domain where they’re already motivated and build from there.

TCPR: Final thoughts?
Dr. Rettew: Two things. First, hold prior diagnoses lightly. Kids with trauma, dysregulation, and anxiety often come in carrying one of several labels—oppositional defiant disorder, disruptive mood dysregulation disorder, bipolar disorder—that reflect real impairment but aren’t always biologically distinct entities. It’s okay to revisit those diagnoses and think dimensionally rather than categorically. Second, think about gene–environment interaction when you talk to families. Framing such as “Your child has a genetic predisposition that tends to evoke certain responses from the environment, which then feeds back on the child” is far less blaming than “Here’s what you are doing wrong.” It’s accurate, it reduces defensiveness, and it usually opens families up to change rather than shutting them down (Rutter M et al, J Child Psychol Psychiatry 2006;47(3–4):226–261).

TCPR: Thank you for your time, Dr. Rettew.