Here is a number that should change how you think about your future caseload: the United States has roughly 8,000 child and adolescent psychiatrists for about 70 million children. Do the math and you can see why most pediatric psychotropic prescriptions are written by primary care clinicians, and why adult-trained psychiatric providers get pulled into seeing kids whether they feel ready or not.
That is the opening reality in a piece by Dr. Anthony Charuvastra of NYU Langone, published October 1, 2026 in The Carlat Psychiatry Report under the title “Top 10 Prescribing Tips for Working with Teens and Kids.” It is written for the non-specialist. And if you are studying to become a PMHNP, you are about to be exactly that person: a well-trained clinician with a family-across-the-desk and a prescription pad, in a county that has no child psychiatrist within two hours.
So let’s walk through what Dr. Charuvastra says, and why it matters for your boards and for your first year of practice.
Why this isn’t “adult psychiatry, but smaller”
Your certification exam covers the lifespan, and pediatric questions tend to trip up students who studied adult pharmacology and assumed it scales down. It doesn’t. Children metabolize drugs differently, the approved-drug list is much shorter, and the person who consents to treatment is not the person who has to swallow the pill.
Dr. Charuvastra’s advice on dosing is refreshingly blunt: start low and go slow, and do not treat adult doses as a reliable guide. He also says to titrate by clinical response rather than by weight formulas or genetic tests. Read that last part twice. It is the kind of sentence that shows up, in one form or another, as a distractor on an exam question.
Before any of that, though, he makes a point that has nothing to do with pharmacology. Start the visit with the child’s strengths. Not the problem list, not the symptom checklist. A kid who has been dragged to an appointment because something is “wrong” with them will tell you far more if the first thing they hear is what is going right.
The approval list is shorter than you think
This is the board-exam gold. In the Carlat piece, the FDA-approved options by condition look like this:
- Pediatric GAD: only duloxetine and escitalopram carry FDA approval. SSRIs and CBT perform about equally from age 7. Avoid venlafaxine and benzodiazepines.
- Pediatric OCD: sertraline (age 6 and up), fluoxetine (7 and up), and fluvoxamine (8 and up).
- Adolescent depression: therapy first, then fluoxetine (approved from age 8), then escitalopram (12 and up). TMS is approved down to age 15. Avoid venlafaxine and paroxetine.
- Prepubertal depression: fluoxetine is the only FDA-approved medication, again for ages 8 and up.
Notice the pattern. Fluoxetine keeps showing up. If you are building flashcards, make one for “which antidepressant has the broadest pediatric footing” and put fluoxetine on the back. Then make a second one for the drugs to steer away from, because the same list names venlafaxine and paroxetine for adolescent depression and tells you to avoid benzodiazepines for anxiety and sleep.
Bipolar disorder and psychosis get a different instruction altogether: refer to a child psychiatrist. Lithium is FDA-approved from age 7, and Dr. Charuvastra notes it was linked to about 50% fewer suicide attempts than other mood stabilizers. Second-generation antipsychotics carry higher metabolic and neurologic risks in kids, so you need a clear rationale and close monitoring, and you need therapy and family work running alongside the medication. That connects directly to the monitoring content you are already memorizing for adult patients. It just matters more when the patient is eleven.
ADHD and sleep: the details that get tested
On ADHD, the article reminds us that medication beats behavioral treatment for core symptoms, while combined treatment gives the best functional outcomes. About 40% of kids respond equally well to amphetamines or methylphenidate. Methylphenidate is the preferred starting point under age 14, and if it fails, the next move is mixed amphetamine salts. That is a clean, testable sequence.
Sleep is where I see well-meaning clinicians get sloppy. The Carlat guidance starts with sleep hygiene and CBT-I and says to avoid benzodiazepines and Z-drugs in children. Melatonin up to 4 mg has short-term support, taken roughly 1.5 to 3 hours before bed for some kids, and up to 10 mg has been studied in autistic children. Clonidine IR starts at 0.05 to 0.1 mg thirty to sixty minutes before bed, titrated in 0.05 mg steps, with most children responding to 0.1 to 0.2 mg and a maximum of 0.4 mg. The article itself notes that you should verify dosing and age thresholds against current prescribing information, and I would say the same to you. Use this as a study frame, not a dosing chart.
The suicidality conversation you will have with parents
Every PMHNP student learns about the FDA boxed warning on antidepressants and suicidal thinking in young people. What you may not have been taught is how to talk about it with a frightened parent. Dr. Charuvastra gives you numbers to work with. SSRIs carry a small suicide-related risk, with a number needed to harm of roughly 110 to 140. For moderate-to-severe depression, the number needed to treat is about 10. For pediatric anxiety, the number needed to treat is 2 to 3 against a number needed to harm of 143.
Read those side by side. For anxiety, the odds of helping a child are dramatically better than the odds of harming one. A parent who has read an alarming headline deserves to hear both halves of that sentence, and you deserve to be the clinician who can say it calmly and accurately. This is also exactly the kind of risk-benefit reasoning that exam questions reward.
Consent first, then assent, then the whole family
Here is a piece that rarely gets its own flashcard but absolutely shapes real practice. Dr. Charuvastra says to get parental consent, then child assent. Meet the parents first, then the child. Avoid diagnostic labels and use plain language. Then ask the child, directly, whether they agree to the plan.
He also recommends interviewing parents and children separately, because kids will often tell you about side effects privately that they would never mention in front of a parent. And he says parents should supervise medications even in older teens. That is not about distrust. It is about the fact that a sixteen-year-old with a bottle of pills is still a sixteen-year-old.
If you have been through a clinical rotation with a family in the room, you already know how much of this job happens in the spaces between the prescription. The research backs it up. Talk therapy, especially CBT and family therapy, is almost always helpful across diagnoses, which is why the article treats medication as one part of a plan rather than the plan itself.
Timing, growth, and the long view
Two of the tips deal with time, and they are easy to skim past. First, kids change. Half of adult patients report that symptoms began in early adolescence, about 20% of children with ADHD go on to develop comorbid anxiety, and schizophrenia, bipolar disorder, and panic disorder tend to peak in the late teens. A diagnosis made at nine may need to be reconsidered at fifteen, and so may the dose. Bullying, substance use, and academic pressure can all change the picture.
Second, be thoughtful about when you make changes. Avoid starting or adjusting medication during semester transitions, vacations, or finals. A stable child should stay on medication for at least one full school year before you consider tapering. It is practical, it is humane, and it is the kind of detail that separates a clinician who has read the guidelines from one who has actually sat with a family in May while finals loom.
Knowing when to hand off
I want to be clear about something, because I think new prescribers hear “adult clinicians can treat kids” and take it as permission to go it alone. The article is more careful than that. It tells you to know the evidence and its limits, document your reasoning and the lack of specialist access, and check whether your malpractice carrier requires notification when you treat minors. It tells you to refer bipolar disorder and psychosis. And it points you toward regional child psychiatry consultation programs, which often provide phone or telehealth input and can reduce unnecessary referrals.
That last one is worth remembering. Part of being a safe, confident PMHNP is knowing the shape of your own competence and having a phone number to call when you reach the edge of it. That is not weakness. It is professional judgment, and it is precisely what licensing boards and employers hope to see.
The goal is function
Dr. Charuvastra closes with a tip that I find oddly comforting: be patient. Development continues into adulthood, and the goal is often good-enough symptom control that keeps a child functioning in school and in friendships, not necessarily full remission. For those of us who tend to want every patient fixed by the next visit, that is a useful reset.
What to do with this before test day
Turn the article into practice. Make a one-page table of the pediatric FDA approvals by condition and minimum age. Add a short list of drugs and drug classes to avoid in children for each condition. Write out the ADHD sequence from methylphenidate to mixed amphetamine salts. Memorize the structure of a good consent-and-assent conversation. Then practice saying the number needed to treat and number needed to harm for pediatric anxiety out loud, the way you would to a worried mother.
If you can do those five things, you will be ahead of many licensed clinicians who prescribe to children every day. And you will have started to build the instinct that this field asks for: precise knowledge, plain language, and patience.
One more thing. The research I leaned on here comes from The Carlat Psychiatry Report, an independent publication. Dr. Charuvastra reports no financial relationships with companies related to the material. When you are choosing what to study from, that kind of independence is worth caring about.
You are going to be the person a family trusts with their child. Study like it. And when you are ready to turn this kind of knowledge into a passing score, head over to PMHNPReview.org and keep building.