# 01 - Principles of prescribing practice in childho

# Principles of prescribing practice in childhood and adolescence

The Maudsley® Prescribing Guidelines in Psychiatry, Fifteenth Edition. David M. Taylor, 
Thomas R. E. Barnes and Allan H. Young. 
© 2025 David M. Taylor. Published 2025 by John Wiley & Sons Ltd.
Chapter 5
Principles of prescribing practice in childhood and adolescence
Diagnosis can be difficult in children and comorbidity is very common. Treatment 
should generally target key symptoms rather than specific conditions. While a working 
diagnosis is beneficial to frame expectations and help communication with patients 
and parents, it should be kept in mind that it could take some time for the illness to 
evolve.1
Differences in pharmacokinetics and pharmacodynamics compared with adults can 
explain the more pronounced or unforeseen adverse reactions to medication in the 
young, as well as the differences in ­dose–­effect relationships compared with those in 
adults.2
■
■Start low, go slow and monitor
Depending on the age, dose starts lower than in adults or may be calculated in mg/kg 
per day terms.1,2 Titration of dose should proceed slowly, aiming for the minimum 
dose that adequately controls symptoms and has minimum adverse reactions. Regular 
reviewing of efficacy and tolerability should guide if treatment is necessary and 
requires continuation.
■
■Polypharmacy in the severely ill
Monotherapy is ideal. However, childhood-­onset illness can be severe and may 
require treatment with psychosocial approaches in combination with more than one 
medication.1 Co-­prescribing of medication for different disorders or symptoms is 
common. This complicates the interpretation of efficacy of each medicine1 and 
requires care with drug interactions and dose adjustments.
■
■Adequate treatment duration
Children are generally relatively more ill than their adult counterparts and will often 
require longer periods of treatment before responding. An adequate trial of treatment 
for those who are admitted for in-­patient care may well be 8 weeks or more for 
depression or schizophrenia.
Prescribing in children 
and adolescents

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CHAPTER 5
■
■Change one drug at a time
Ideally changes should be made to one drug at a time and, if possible, remove a drug 
when adding a new one.
■
■Monitor outcome in more than one setting
For symptomatic treatments (such as stimulants for attention deficit hyperactivity or 
ADHD), bear in mind that the expression of problems may be different in different 
settings (e.g. home and school). For example, a dose titrated against parent reports 
may be too high for the daytime at school.
■
■Educate the child and parents on the treatment
For some, the need for medication will be life-­long. The first experiences with 
­medications are crucial to long-­term outcomes and adherence. Education regarding 
the target symptoms of the medication, likely adverse reactions and medication 
adherence should be addressed. Provide information on the monitoring required and 
how to identify adverse reactions. Patients and their guardians should be encouraged 
to ask for changes to their treatment regimen where they consider them ineffective or 
poorly tolerated.
■
■Review long-­term treatment
As children develop and grow through adolescence, dose changes may be required 
and adverse reactions may emerge or wane.
■
■Transition from paediatric to adult services
It is essential that continuity of care is not lost when moving from paediatric to adult 
services as this can be distressing and increase the risk of relapse. Planning and 
­co-­ordination should start at an early stage to achieve a smooth transition.3
■
■Technical aspects of paediatric prescribing
Most psychotropic drugs used in adults are not licensed for use in children or 
­adolescents.4 The Medicines Act 1968 and European legislation make provision for 
doctors to use medicines in an off-­label or out-­of-­licence capacity or to use unlicensed medicines. Where possible a licensed preparation should be prescribed 
(Table 5.1), however it is recognised that the informed use of unlicensed medicines, 
or of licensed medicines in an ‘off-­label’ way, is often necessary in paediatric 
­practice. Individual prescribers are always responsible for ensuring that there is 
adequate information to support the quality, efficacy, safety and intended use of a 
drug before prescribing it.5
When writing a prescription in most countries, inclusion of age is a legal requirement in the case of prescription-­only medicines for children under 12 years of age, 
but it is preferable to state the age for all prescriptions for children.

Prescribing in children and adolescents
CHAPTER 5
Table 5.1  Psychotropic medications approved by the UK Medicines and Healthcare products Regulatory Agency 
(MHRA), European Medicines Agency and the US Food and Drug Administration for children and adolescents 
(January 2024).­6–­9
Condition
UK MHRA 
approval only; 
age (years)
European Medicine 
Agency;* age (years)
US Food and Drug 
Administration; 
age (years)
ADHD
­Amfetamine–­dexamfetamine 
mixed salts
–­
–­
3+
­Amfetamine–­dexamfetamine 
mixed salts extended release
–­
–­
6+
Atomoxetine
6+
6+
6+
Clonidine extended release
–­
–­
­6–­17
Dexamfetamine
­6–­17
­6–­17
­3–­16
Dexamfetamine sustained release
–­
–­
­6–­16
Dexmethylphenidate
–­
–­
6+
Guanfacine extended release
­6–­17
­6–­17
­6–­17
Lisdexamfetamine
6+
6+
­6–­17
Methamfetamine
–­
–­
­6–­17
Methylphenidate
6+
6–18
6+
Viloxazine
–­
–­
6+
Anxiety disorders
Duloxetine
–­
–­
GAD 7+
Escitalopram
–­
–­
GAD 7+
Autism spectrum disorder 
(irritability)
Aripiprazole
–­
–­
­6–­17
Risperidone
–­
–­
­5–­17
Bipolar disorder (depressive 
episodes)
Lurasidone
–­
–­
10+
­Olanzapine–­fluoxetine combination
–­
–­
10+
Bipolar disorder (manic or 
mixed episodes)
Aripiprazole
Manic episodes 13+
Manic episodes 13+
Manic or mixed episodes 10+
Asenapine
–­
–­
10+
Lithium
–­
–­
7+
Lithium extended release
–
–
12+
Olanzapine
–­
–­
13+
Quetiapine extended release
–­
–­
10+
(Continued )

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CHAPTER 5
Condition
UK MHRA 
approval only; 
age (years)
European Medicine 
Agency;* age (years)
US Food and Drug 
Administration; 
age (years)
Risperidone
–­
–­
10+
Ziprasidone
–­
10+
–­
Conduct disorder
Risperidone
­5–­18
­5–­18
–­
Depressive disorder
Amitriptyline
–­
–­
12+
Escitalopram
–­
–­
12+
Fluoxetine
8+
8+
8+
Enuresis
Amitriptyline
­6–­17
­6–­17
–­
Imipramine
­6–­17
­5–­18
­6–­17
Insomnia (in autism spectrum disorder or Smith Magenis syndrome)
Melatonin extended release
­6–­17
­2–­18
–­
Insomnia (in ADHD)
Melatonin immediate release
­6–­17
–­
–­
Insomnia (short term)
Promethazine
5+
–­
–­
Obsessive compulsive disorder
Clomipramine
–­
–­
10+
Fluoxetine
–­
–­
7+
Fluvoxamine
8+
8+
8+
Sertraline
6+
6+
6+
Schizophrenia
Aripiprazole
15+
15+
13+
Brexpiprazole
–­
–­
13+
Lurasidone
13+
–­
13+
Olanzapine
–­
–­
13+
Paliperidone
15+
15+
12+
Quetiapine
–
–­
13+
Risperidone
–­
–­
13+
Sulpiride
14+
6+
–­
Tourette’s disorder
Aripiprazole
–­
–­
­6–­18
*Approvals may differ in individual countries.
GAD, generalised anxiety disorder.
Table 5.1  (Continued)