Dear Dr. Mossman:
I am an adult psychiatrist practicing in a geographically isolated area. I am working with the family of 10-year-old “Bobby” who is struggling with attention problems. Top notch neuropsychologic testing recommends a stimulant trial, but the local pediatrician is too busy to give Bobby adequate follow-up and attention.
I am an experienced psychopharmacologist but have not prescribed medication to children since residency. My relationship with the family is excellent, and the local pediatrician said that she would supervise me. If I choose to treat Bobby, what are the possible liability issues I should be aware of, and how can I address them?—Submitted by “Dr. F”
Dr. F’s question raises issues that come up whenever patients need treatment for conditions outside the few with which you are highly familiar. Although you can’t be an expert on every aspect of every patient’s treatment, psychiatrists shouldn’t practice outside their area of competence.
Thus, the main liability-related issue that Dr. F should ask herself is, “Can I treat Bobby competently?” Of course, whenever you decide to treat any patient, you should be able to answer “yes” to this question. When thinking about potential liability related to treating Bobby, Dr. F might also ask, “If a lawsuit occurred, how would my treatment of Bobby appear?” This article discusses key issues that arise when general psychiatrists treat children and the steps general psychiatrists can take to show that they are practicing prudently.
Problem: Not enough clinicians
Child and adolescent psychiatrists (CAPs) are in short supply.1,2 In 2001 the United States had 8.67 CAPs per 100,000 youths and 1.6 CAPs for every 1,000 youths with severe mental disorders.1 Studies suggest that the United States needs nearly twice that many CAPs.3 The shortage is especially severe in rural areas, but approximately one-half of metropolitan counties with populations of >250,000 have no CAPs.1 In much of the nation, finding CAPs who are accepting new patients is difficult, and child and adolescent psychiatric treatment often is delivered by pediatricians, family practitioners, psychiatric nurse practitioners, and general adult psychiatrists.
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Children’s special medical issues
General psychiatrists know that children aren’t just little adults. CAPs develop skills and thinking styles during their 2 years of subspecialty fellowship training that are quite different from those used by their general psychiatric colleagues.
Communication. Children and adolescents who need psychiatric care often have limited verbal abilities. Working and communicating with these patients requires a different interactive style.
Information sources. CAPs learn to seek and assimilate clinically important information from many settings—especially a child’s home—where their patients interact with others.
Caution. Only a small subset of psychotropic medications that adult psychiatrists prescribe are FDA-approved for use in children (Table 1).4 Because we don’t know how psychotropic drugs affect brain development, CAPs sometimes are leery of giving kids the same medications that adult psychiatrists readily prescribe.
Table 1
FDA-approved drugs and dosages for ADHD in children and adults
| Brand name | Generic name | Drug class | Dosing forms (mg) | Dosage range | Age range |
|---|---|---|---|---|---|
| Adderall | Amphetamine-dextroamphetamine | IR stimulant | 5, 7.5, 10, 12.5, 15, 20, 30 | 5 to 40 mg | 3 to 18 years |
| Adderall XR | Amphetamine-dextroamphetamine | ER stimulant | 5, 10, 15, 20, 25, 30 | 5 to 30 mg | 3 years to adult |
| Concerta | Methylphenidate | ER stimulant | 18, 27, 36, 54 | 18 to 72 mg | 6 years to adult |
| Daytrana | Methylphenidate transdermal | Stimulant | 10, 15, 20, 30 (patch) | 10 to 30 mg | 6 to 18 years |
| Focalin | Dexmethylphenidate | IR stimulant | 2.5, 5, 10 | 2.5 to 10 mg bid | 6 to 17 years |
| Focalin XR | Dexmethylphenidate | ER stimulant | 5, 10, 15, 20 | 5 to 20 mg | 6 years to adult |
| Metadate CD | Methylphenidate | ER stimulant | 10, 20, 30, 50, 60 | 10 to 60 mg | 6 to 18 years |
| Ritalin | Methylphenidate | IR stimulant | 5, 10, 20 | 5 to 20 mg bid or tid | 6 to 18 years |
| Ritalin LA | Methylphenidate | ER stimulant | 10, 20, 30, 40 | 10 to 60 mg | 6 to 18 years |
| Strattera | Atomoxetine | SNRI | 10, 18, 25, 40, 60, 80, 100 | 10 to 100 mg | 6 years to adult |
| Vyvanse | Lisdexamfetamine dimesylate | ER stimulant (precursor) | 30, 50, 70 | 30 to 70 mg | 6 years to adult |
| LA: long acting; CD: controlled delivery; ER, XR: extended release; IR: immediate release; SNRI: selective norepinephrine reuptake inhibitor | |||||
| Source: Adapted from references 2,3 | |||||
Different drugs. Some medications commonly taken by children are not often prescribed for adults, although this is changing as attention-deficit/hyperactivity disorder (ADHD) is better recognized in adults.5,6