Bipolar disorder treatment algorithm for children and adolescents

Ramelteon is a melatonin receptor agonist with no data in pediatric patients. 

May be effective and safe for use in performance anxiety, particularly when the sedating or cognitive side effects of benzos could interfere with an individual’s performance, but there are no data in kids.

Although there are only minimal data, consider prazosin for PTSD in kids, especially for PTSD-associated sleep disturbances and nightmares, but monitor BP.

Benzodiazepines are generally only appropriate for use before procedures. Lorazepam probably has less risk of misuse than others. Lorazepam is also the first-line, but off-label, treatment for catatonia.

Due to the lack of large randomized controlled data to support its use and the potential for side effects, clonazepam should be avoided. If you decide to use it, keep it very short term and deploy it adjunctively in kids who exhibit only partial response to first-line therapies (SSRI, SNRI) or have severe anxiety.

Despite the lack of large randomized controlled data to support first-line use, buspirone may be used adjunctively in kids who exhibit partial response to first-line therapies for anxiety (SSRI, SNRI), without the sedation and abuse potential burden of benzodiazepines.

Antihistamines can be effective sleepers for some kids and are the most prescribed by pediatricians, although some patients may experience too much grogginess (“hangover”) in the morning or a paradoxical excitation.

Anxiety treatment algorithm for children and adolescents

Anxiety is perhaps the most frequent symptom for which child psychiatrists are consulted.