1

COURSE
NNNC6042 PSIKOFARMAKOLOGI DALAM PENGAMALAN KLINIKAL
SEMESTER 2 2023/2024

TITLE
ASSIGNMENT 4: GROUP TASK

COURSE COORDINATOR
DR. NOH AMIT

NAME
PUI WEI ZHE (P137440)
REBECCA SOH MAE YIN (P137452)
SHIRLYN LEE MING HUI (P137448)
TEH YONG XIN (P137439)

SUBMISSION DATE
28 JUNE 2024
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THE USE OF PSYCHOPHARMACOTHERAPY WITH CHILDREN AND

ADOLESCENTS
INTRODUCTION
Globally, approximately one in seven children and adolescents experience mental health
conditions (World Health Organization [WHO] 2021). In Malaysia, about 424,000 children were
identified as having mental health issues (Institute for Public Health [IPH] 2020). Among these
children, peer problems were the most prevalent at 42.9%, followed by conduct issues at 15.9%,
emotional problems at 8.3%, and hyperactivity at 2.3% (IPH 2020). In terms of
neurodevelopmental disorders, autism spectrum disorder (ASD), attention-deficit/hyperactivity
disorder (ADHD), and learning disabilities are recognised as significant concerns. Globally,
ADHD prevalence rates range widely, with studies suggesting about 5-11% of children affected
(Francés et al. 2022). For ASD, prevalence rates generally range between 0.70-3% in children
(Francés et al. 2022). The prevalence of ASD in Malaysia is estimated to be between one to two
per 1,000 children 18 months to three years of age (CodeBlue 2022). This indicates a significant
impact on the population, with diagnoses rising steadily over the past decade. In 2021, 589
children under 18 were diagnosed with ASD, reflecting a consistent increase from previous
years, where 99 and 562 children were diagnosed with ASD in 2010 and 2020, respectively
(CodeBlue 2022). On the other hand, the prevalence of ADHD in Malaysia is estimated to range
from 1.6% to 4.6%, with boys being diagnosed three to four times more frequently than girls
(Dzulkifli 2023).
Given the substantial prevalence of mental health and neurodevelopmental disorders
among children in Malaysia, as well as globally, it is crucial for clinicians to understand these
conditions thoroughly to inform effective paediatric psychopharmacology practices. Paediatric
psychopharmacology involves the use of psychotropic medications in children and adolescents.
Clinicians who prescribe these medications must understand developmental psychopathology
and how drugs interact with the developing body alongside general psychopharmacology
principles (McVoy et al. 2023). Extrapolating adult data to children is insufficient for guiding
treatment. Differences in how children’s bodies process drugs (pharmacokinetics), how their
brains react to them (pharmacodynamics), and how psychopathology manifests during
development significantly impact the efficacy and safety of these medications.

PHARMACOKINETICS
Pharmacokinetics, which includes absorption, distribution, metabolism, and excretion,
determines the drug's availability at the action site, influencing its pharmacological activity
(Smits et al. 2022). Understanding a drug’s pharmacokinetics is essential for determining
appropriate dosage and administration frequency, especially in children. Children, having smaller
body sizes but higher proportions of liver and kidney tissues, exhibit different pharmacokinetics
compared to adults. They have more body water, less fat, and lower plasma albumin levels,
affecting drug distribution, metabolism, and elimination (McVoy et al. 2023). Simply reducing
adult doses based on child weight can lead to undertreatment (McVoy et al. 2023). On the other
hand, adolescence brings significant growth and body composition changes, with gender
differences influencing pharmacokinetics where males typically have higher serum
concentrations of certain drugs, like risperidone, compared to females (Calarge & Miller 2011).

PHARMACODYNAMICS
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Psychotropics mainly interact with neurotransmitters like dopamine, serotonin, and

norepinephrine, whose receptors change significantly during development (Rho & Storey 2001).
Receptor density peaks between ages three and six, and then declines to adult levels by late
adolescence (Chugani et al. 2001). Recent research shows antidepressants may act by binding to
the tropomyosin receptor kinase B (TrkB) receptor, which is crucial for neuronal plasticity and is
also developmentally regulated (Casarotto et al. 2021). Developmental changes may impact drug
efficacy and safety, as seen with amphetamines and antipsychotics affecting children and adults
differently (Correll et al. 2009). Brain imaging studies suggest medications like quetiapine can
normalise brain connectivity in adolescents who have bipolar disorder (Li et al. 2022). Moreover,
mechanism-targeted medications are promising as neuroscience reveals disorder pathogenesis,
allowing for modifying specific biological targets. This approach is feasible for conditions like
Fragile X syndrome, Down syndrome, and Rett syndrome, offering a model for new targeted
treatments (Vitiello 2020).

SYMPTOM MANAGEMENT
Understanding the pharmacokinetics and pharmacodynamics of medications is crucial for
optimising their use in symptom management among children and adolescents, ensuring
effective treatment while minimising potential risks. Medications could alleviate severe
symptoms of mental health disorders in this population and enhance their ability to engage in
daily activities, academic pursuits, and social interactions. For instance, stimulant medications
such as methylphenidate and amphetamines have been shown to reduce core symptoms like
inattention and hyperactivity in ADHD, leading to improved academic performance and social
functioning (Correll et al. 2021). Similarly, selective serotonin reuptake inhibitors (SSRIs) are
effective in treating obsessive-compulsive disorder (OCD), which can markedly improve a
child’s quality of life by alleviating debilitating compulsive behaviours (Pediatric OCD
Treatment Study [POTS] Team 2004).
For conditions like bipolar disorder or severe depression, medications play a crucial role
in mood stabilisation and preventing risky behaviours. Mood stabilisers such as lithium and
atypical antipsychotics like quetiapine are commonly used to manage bipolar disorder in
adolescents. These medications help stabilise mood swings, thereby reducing the risk of manic or
depressive episodes that may lead to harmful behaviours (Correll et al. 2009; Li et al. 2022). In
severe depression, antidepressants like fluoxetine have been found to effectively reduce
depressive symptoms and prevent suicide attempts, which are critical for ensuring the safety and
well-being of affected adolescents (March et al. 2004). Some medications show consistent
efficacy from childhood to adulthood, like SSRIs for OCD, stimulants for ADHD, and clozapine
for schizophrenia (Correll et al. 2021). However, tricyclic antidepressants (TCAs) have yet to
show efficacy in children, and among SSRIs, only fluoxetine and escitalopram have consistently
outperformed placebo (Zhou et al. 2020).
That said, not all mental health conditions in children and adolescents necessitate
medication, especially when symptoms are mild and do not significantly disrupt daily life. In
such cases, psychotherapy can serve as a valuable alternative or initial treatment. Therapeutic
methods like applied behaviour analysis (ABA) can assist young individuals in developing
coping mechanisms, enhancing emotional regulation, and managing behavioural challenges
without relying on medication. For example, research has demonstrated ABA’s efficacy in
treating ASD and ADHD among children (Rad et al. 2019). For more severe conditions, a
combined approach involving both psychotherapy and medication may prove most beneficial
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(Correll et al. 2021). Beginning with psychotherapy can also help gauge the need and optimal
timing for introducing medication, ensuring a well-rounded treatment plan.

INTERVIEW
To explore the use of psychopharmacotherapy in therapy with children and adolescents,
we interviewed a consultant child and adolescent psychiatrist, Dr Fairuz, who is the Head of the
Child and Adolescent Psychiatric Unit at UKM Children’s Specialist Hospital. She provides
support for parents, particularly in developmental disorders, children in residential homes, abuse
and infant mental health. Before the interview, the students conducted preliminary research
online and developed a list of questions. The interview was held virtually via the Google Meet
platform and lasted about an hour. We included semi-structured interview questions such as
“What are the most prescribed psychotropic medications for children and adolescents, and what
conditions are these medications typically used to treat?” “What are some of the common
concerns or challenges you encounter when prescribing psychotropic medications to children and
adolescents?” and “Can Traditional and Complementary Medicine (T&CM) be integrated with
psychopharmacotherapy for a more holistic approach? If so, how?”. The students then
transcribed the interview and analysed the data, integrating the information into the write-up and
presentation content.

ISSUES WITH THE USE OF PSYCHOPHARMACOLOGY IN MENTAL HEALTH

Costs of medication. Children and adolescents with psychiatric disorders often require
additional healthcare and interventions, such as speech therapy, occupational therapy, and
psychotherapy, in addition to drugs. These special needs increase the economic strain on
families. This is particularly concerning as research conducted in Malaysia showed that the
parents of 83.5% of adolescents with Major Depression Disorder (MDD) and 63.6% of those
with Generalized Anxiety Disorder (GAD) have an income below RM1,000 (Mohd Rocky
2023). To address these difficulties, parents can register their children with Jabatan Kebajikan
Masyarakat (JKM) as Orang Kurang Upaya (OKU) to be eligible for RM150 per month of
financial aid. However, despite this assistance, the amount is still insufficient for families to
afford comprehensive care and interventions necessary to support their children’s needs
(Chandran 2016).
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During the interview, Dr. Fairuz highlighted the significant burden of the cost of common
drugs used in psychiatry. For instance, Ritalin, a commonly prescribed medication for ADHD,
costs approximately RM60 per month, which is substantial for low-income families.
Antidepressants range from RM100 to RM200, while antipsychotic medications, particularly
injectable non-formulary options, can cost around RM300. Financial strain might limit parents’
ability to opt for more expensive formulary drugs to treat their children, even if they are charged
the same price across hospitals, as noted by Dr. Fairuz. Hence, the overall cost of these
medications remains a critical concern for families needing long-term treatment for their
children.
Myths and misconceptions. Social stigma and widespread misconceptions surrounding
these medications could influence the use of psychopharmacological treatments. Many
individuals are reluctant to seek treatment due to the stigma associated with mental illness and
the use of psychiatric drugs, leading to the underdiagnosis and undertreatment of mental health
conditions, particularly in communities with low mental health awareness (Ahad et al. 2023).
Common misconceptions include beliefs that these medications are addictive, indicate personal
weakness, or can fundamentally alter one’s personality (Aloe Mind Malaysia 2024).
These misconceptions can have severe implications for medication adherence. A
systematic review by Kalaman and colleagues (2023) highlighted that parents’ perceptions and
attitudes toward medication or treatment significantly influence medication adherence in children
and adolescents. Positive parental attitudes can shape the child’s or adolescent’s views on
medication, thereby promoting adherence. Conversely, psychiatric disorders are often
stigmatised, which can lead parents to downplay the severity of their child’s symptoms and lack
motivation to ensure proper medication adherence. The stigma associated with psychiatric
medications is positively correlated with perceived costs and resistance to their use, directly
discouraging adherence in children (Kalaman et al. 2023).
However, there are strategies to combat these negative perceptions. For example, Atzori
and colleagues (2009) found that when psychiatrists approved parental requests for weekend
drug holidays as part of a well-planned treatment strategy, it significantly improved medication
adherence and gradually reduced stigma and negative attitudes toward psychotropic medications.
Parents play a crucial role in administering prescribed medication correctly and reporting any
adverse effects that may arise from the treatment (Kalaman et al. 2023; McVoy et al. 2023). The
negative impact of stigma and misconceptions highlights the importance of the clinical
psychologist’s role in providing psychoeducation to parents (Findling 2008; Malaysian Health
Technology Assessment Section [MaHTAS] 2020). Educating parents about disorder-related
information, treatment approaches and their effectiveness, side effects of the medications, as well
as other relevant components can empower them to support their child’s treatment more
effectively, reduce the stigma and misconceptions surrounding psychopharmacological therapies
and improve medication adherence (MaHTAS 2020).
Other considerations. Dr Fairuz pointed out that prescribing suitable medication in
child-friendly forms, such as syrups, small-sized tablets, or easy-to-swallow options, directly
relates to ethical considerations in child psychiatry practice. This approach ensures that treatment
is effective but also accessible and manageable for young patients. This practice is in the child’s
best interests as it ensures that medications are accessible for children to take, minimising
distress and improving treatment adherence, which is crucial for their well-being. Besides,
child-friendly medication forms reduce the risk of choking or other complications, adhering to
the ethical principle of non-maleficence, which emphasises avoiding harm to the patient. While
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children cannot provide legal consent, they should be involved in their care to the extent
possible. Offering medication in a form that is easier for them to take respects their comfort and
autonomy, making them more willing participants in their treatment.
While psychopharmacological treatments can be highly effective for many mental health
conditions, there are concerns regarding their efficacy and side effects (Altuwairqi 2024). The
effectiveness of these medications can vary significantly from patient to patient. Finding the right
drug and dosage involves a trial-and-error process, which can be time-consuming and frustrating
for both child patients and their families (Findling 2008). Moreover, Coghill and colleagues
(2017) found that psychopharmacological treatments can have side effects that impact the child’s
or adolescent’s quality of life (QOL) and their functional abilities. For instance, antidepressants
may cause weight gain, sleep disturbances, sedation, etc., has been long established (Brown et al.
1994), while antipsychotics can lead to metabolic issues and other serious health problems
related to weight gain (Libowitz & Nurmi 2021). Besides, stimulants, such as methylphenidate
and amphetamines, are commonly prescribed for ADHD among children (Altuwairqi 2024),
which might cause side effects such as decreased appetite and insomnia (Khajehpiri et al. 2014;
MaHTAS 2020; Ogundele & Yemula 2022; Phillips 2014).
Clinical psychologists come into play by addressing the side effects that the child or
adolescent experiences. For instance, a behavioural management strategy to help address appetite
issues is to work with the client and parents to establish mealtime routines that encourage regular
meal and snack times (Phillips 2014). Besides, parents could collaborate with the clinical
psychologist to provide ideas for nutritious snacks that are easy to consume, such as nuts and
cheese (Phillips 2014). It is also essential to use positive reinforcement to encourage eating
during meals, making mealtimes enjoyable and stress-free. On the other hand, managing
insomnia or sleep-related issues can involve teaching good sleep hygiene practices, such as
maintaining a consistent bedtime routine, creating a comfortable sleep environment, and limiting
screen time before bed (Ogundele & Yemula 2022).
The above idea sheds light on the importance of combining pharmacotherapy and
psychotherapy (CBT) in treating children and adolescents with psychiatric disorders (Findling
2008). For instance, a meta-analysis conducted by Teng and colleagues (2022) proposed that it
may be necessary to combine antidepressants with CBT, a treatment that showed effectiveness in
the Treatment for Adolescents with Depression Study (TADS) to improve QOL in paediatric
MDD (March et al. 2004). Similarly, CBT is also encouraged as a practical approach to
managing pediatric insomnia in children with ADHD (Ogundele & Yemula 2022) and OCD
(Findling 2008; POTS Team 2004). Clinical psychologists can minimise distress in children and
adolescents by taking these significant measures. To illustrate, CBT teaches children and
adolescents effective coping strategies for dealing with the side effects of medication and the
stress or anxiety related to their condition. These strategies can include relaxation techniques,
mindfulness, and cognitive restructuring to address negative thoughts. Furthermore, CBT helps
young patients understand their condition and the role of medication in managing their
symptoms. When they comprehend how medication helps them, they are more likely to adhere to
the treatment plan.

INTERVENTION AND REHABILITATION

Pre-intervention in healthcare involves Shared Decision Making (SDM), a model
outlined by Elwyn and colleagues (2012). It promotes collaboration between healthcare
providers and users, specifically for children and adolescents under 18, where the
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decision-making process must involve their families (Elwyn et al. 2012). This process is
essential for achieving better health outcomes and service satisfaction (Granados-Santiago et al.
2020; Milky & Thomas Iii 2020). SDM has strong backing from 86 randomised trials,
demonstrating that it leads to patients gaining knowledge, feeling more confident in their
decisions, actively participating in their healthcare choices, and often opting for more
conservative treatment approaches when well-informed (Stacey et al. 2011). According to SDM,
deliberation is the critical process in which patients become aware of their choices. It gives
patients and families the time and support to consider their options thoroughly. It can also be
understood by the transition from initial preference to informed preference. The initial preference
is when a person first finds their treatment options based on what they already know, their
beliefs, past experiences, and sometimes just initial gut feelings. Incomplete information,
misconceptions, or emotional reactions often influence it. At this stage, the decision might not be
fully informed or based on a thorough understanding of all the relevant factors.
The transition stage involves gathering and discussing more information with a
healthcare provider. Here, the person learns about the medical facts, the pros and cons of
different treatments, and how each option aligns with their personal values and circumstances.
This process begins with choice talk, where patients and their families are informed that a choice
needs to be made regarding treatment options. Next is option talk, involving detailed
discussions about each treatment’s benefits, risks, and suitability for the child’s condition.
Finally, decision talk helps patients explore what matters most to them, leading to informed
preferences that align with their values and circumstances. This phase benefits moving from an
initial inclination to a more informed decision. After going through the transition stage, the
person arrives at an informed preference. This choice is well-considered, considering all the
information gathered, discussions held, and the person’s own values and concerns. It is a more
stable decision that reflects a deeper understanding of the implications of each treatment option.
In this phase, a ‘shared mind’ is formed between the patients and the family to be involved in
decision-making (Epstein & Street 2011). Dr Fairuz also emphasises delivering these important
messages while respecting the family’s choices.
Medication adherence, misuse and overdose. During the intervention phase, one
crucial aspect to address is the issue of medication adherence, especially in children. Strategies
such as simplified drug regimens, pleasant-tasting medicines, liquid formulations, and regular
contact between parents and healthcare providers can significantly improve adherence (Gardiner
& Dvorkin 2006). Additionally, reminders, self-management plans, and individualised
supervision or attention are effective methods (Gibson et al. 1996; Renders et al. 1996; Toelle &
Ram 2004). Healthcare providers can enhance adherence by providing clear explanations and
patient information sheets detailing medication names, dosages, schedules, durations, common
side effects, and coping strategies. For example, a study by Frush and colleagues (2004) showed
that a colour-coding chart and medication dispenser will help reduce dosing errors. Healthcare
providers should take further action to assist parents in administering medications.
Moreover, according to Dr Fairuz, persistent monitoring during the intervention phase to
ensure timely medication intake, assess effectiveness, and monitor for potential side effects or
misuse is important. For example, benzodiazepines and sleeping pills, commonly misused due to
their addictive nature, require careful management. Hypnotics are less commonly misused and
are not typically prescribed routinely to children and adolescents unless they exhibit severe
aggression in clinical settings. It is important to ensure that the medication is administered
correctly, often by a responsible caregiver and ensure that there are no family members with
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substance abuse issues in the home. Additionally, healthcare providers must educate caregivers
about the potential for misuse and the importance of time management in administering
medications (Reinhard et al. 2008). By closely monitoring these aspects, the intervention phase
aims to minimise the risk of misuse and overdose, ensuring the safety and well-being of the
patient.
Follow-up issues. After the intervention, follow-up is important to evaluate the
effectiveness of the treatment and manage any ongoing issues. However, the post-intervention
phase often faces challenges, such as family dissatisfaction with the treatment outcomes.
The level of dissatisfaction may vary; however, there is a significant relationship between
parental satisfaction and children’s medical care (Jokinen-Gordon & Quadagno 2013). Hence,
healthcare providers must discuss alternative options with the family to address their concerns.
This phase involves continuous engagement with the patient and their family, exploring other
options, and ensuring the treatment is adapted as needed to achieve the best possible outcomes
for the child or adolescent. The post-intervention phase aims to provide comprehensive support
and adjust the treatment plan to meet the patient’s and their family’s needs by addressing these
issues and maintaining open communication.
Another issue that may arise is patients not returning for follow-up appointments. Leong
and colleagues (2006) demonstrated that Malaysia had a notably high rate of missed
appointments, at 48.1%, compared to Australia, the United States (US), the United Kingdom
(UK), and Canada. The primary causes for missing appointments included forgetting the dates
(32.9%), feeling unwell (12.3%), administrative mistakes (19.1%), and work or family
responsibilities (8.2%) (Zailinawati et al. 2006). Most people preferred reminders via phone
(71.4%), with letters being the second choice (41.3%). In summary, addressing these identified
reasons could lead to effective interventions to reduce missed appointments. The UKM
Children’s Specialist Hospital practice aligns with the study, wherein healthcare providers will
contact parents for a follow-up appointment if the patient’s condition is life-threatening.

THE USE OF TRADITIONAL AND COMPLEMENTARY MEDICINE (T&CM)

In Malaysia, Traditional and Complementary Medicine (T&CM) is increasingly being
integrated into healthcare practices, including psychological approaches for children. The
regulation and institutionalisation of T&CM in Malaysia have evolved significantly with the
enactment of the Traditional and Complementary Medicine (T&CM) Act 2016 [Act 775], which
aims to provide for the establishment of the T&CM Council to regulate the T&CM services in
Malaysia and to provide for matters connected in addition to that (MOH 2024). Moreover, MOH
(2017) also established initiatives like the Traditional and Complementary Medicine Blueprint
2018-2027 (MOH 2017). These efforts aim to integrate T&CM into mainstream healthcare,
ensuring quality and safety through stringent regulations and mandatory practitioner certification
(Park et al. 2022).
Shirodhara is a type of traditional Indian medicine called Ayurvedic therapy that is
currently practised in Malaysian hospitals as one of the alternative treatments for mental
disorders among children and adolescents (MOH 2024). It involves pouring a continuous stream
of warm medicated oil over the forehead, specifically the "third eye" area. This treatment is used
to address various mental disorders in children and adolescents, including insomnia, stress,
anxiety, and mild depression. Shirodhara is shown to improve sleep quality by calming the
central nervous system and promoting relaxation, helping to regulate the sleep-wake cycle,
making it easier for individuals to fall asleep and stay asleep (Vinjamury et al. 2014). For
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anxiety, Shirodhara helps in soothing the mind and reducing hyperactivity in the brain. The
treatment promotes the release of serotonin and dopamine, neurotransmitters associated with
mood regulation and happiness (Gayatri et al. 2023). By balancing these chemicals, Shirodhara
can significantly decrease anxiety levels, providing a non-invasive and natural method to manage
anxiety in young individuals.
In terms of traditional Malay Medicine (TMM), One of the primary components of TMM
involves using herbal remedies. Herbs such as “Tongkat Ali” and “Kacip Fatimah” are
traditionally used for their calming and mood-stabilizing effects (Rehman et al. 2016). For
children and adolescents, specific formulations are used to treat anxiety, depression, and stress.
These herbs are often administered in forms like teas or capsules and are regulated to ensure
appropriate dosages and safety​. Besides,
For children, particularly those with mental health issues, traditional Chinese Medicine
(TCM) also offers several therapeutic options. These include acupuncture, herbal medicine,
dietary therapy, and exercises like tai chi and qigong. TCM practices emphasise holistic care,
focusing on the balance of mind and body, which can be particularly beneficial in managing
psychological conditions (Park et al. 2022). The holistic approach of TCM can help address
underlying imbalances that contribute to mental health issues in children, providing a
complementary option to conventional psychological treatments​ (Aung et al. 2013). Some
applications of specific TCM practices for treating mental illness in children include:
Herbal medicine in TCM uses various plant-based formulas to address psychological
conditions. For instance, the “NingShen” (calming) pill, also known as “Dimu Ningshen”, is a
TCM used in Malaysia to treat children with ADHD, particularly those diagnosed with the
“kidney yin deficient and Liver yang excess” syndrome (Quoquab et al. 2023). This condition,
according to TCM principles, contributes to the hyperactive and inattentive symptoms of ADHD,
and it is believed that the “NingShen” pill is composed of various traditional herbs that are
believed to have calming and mood-stabilizing effects.
In Malaysia, the use of acupuncture and acupressure for children’s mental health is
integrated into some hospital practices as part of TCM therapies (MOH 2024). These techniques
aim to restore the balance of ‘Qi’ (energy flow) within the body, which is believed to influence
mental well-being (Aung et al. 2013). Acupuncture involves inserting thin needles into specific
points on the body to restore the balance of ‘Qi’. Acupressure uses the same principles but
applies pressure instead of needles. These techniques are believed to stimulate the body's natural
healing processes and reduce symptoms of mental distress. For children, acupuncture is effective
in reducing anxiety, improving mood, and enhancing cognitive function by modulating brain
activity and promoting relaxation (Aung et al. 2013).
Dietary therapy in T&CM customises food intake to support mental health, emphasising
foods that nourish the brain and calm the mind. For example, foods rich in omega-3 fatty acids,
such as fish and walnuts, are recommended to improve cognitive function and reduce symptoms
of ADHD (Ni et al. 2014). Additionally, foods that are considered to have a calming effect, like
lotus seeds and jujube dates, are incorporated to help alleviate anxiety and improve sleep​ (Ni et
al. 2014).
Exercise and Mind-Body Practices: Exercises such as tai chi and qigong are integral to
TCM, combining physical movement with mental focus and deep breathing. These practices
promote physical fitness, reduce stress, and improve emotional regulation (Aung et al. 2013). For
TMM, traditional practices such as "Silat" (a form of martial arts) and breathing exercises are
also integrated into mental health care (Muhammad 2020). Engaging in these activities can
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enhance concentration, reduce hyperactivity, and foster a sense of calm for children. Research
has shown that regular tai chi and qigong practice can significantly improve children’s
psychological well-being and behavioural issues (Liu et al. 2021).
Dr Fairuz highlighted her views on a few considerations to be taken into account
before integrating T&CM into the current mental health practices among children and
adolescents. These include ensuring that the treatment is licensed or acknowledged by MOH.
Practitioners should have the necessary credentials and be registered with relevant regulatory
bodies (WHO 2023). In Malaysia, the Traditional and Complementary Medicine (T&CM) Act
2016 governs the licensing and regulation of T&CM practices, ensuring that these services meet
established safety and efficacy standards. Practitioners must obtain proper licensing from the
MOH to offer their services in medical institutions​legally. Besides that, Dr Fairuz also
emphasised that T&CM treatments should be evidence-based, at least at the level of blinded
randomised controlled trials. This is in line with statements by WHO (2023) that treatments
should be scientifically validated for their efficacy and safety and that clinical evidence databases
and T&CM knowledge platforms should be utilised to verify the effectiveness of specific
therapies.
Additionally, Dr Fairuz stressed having a thorough discussion with the family instead of
merely recommending the treatments to their children. Informed consent should be obtained only
after discussing potential benefits, risks and evidence supporting the effectiveness with the
caregivers or parents, and collaborative decision-making should be done to ensure their
preferences and concerns are addressed. Dr Fairuz pointed out that doctors should obtain assent
from children as an ethical practice. The reason is that children or adolescents with psychiatric
disorders often have limited knowledge about mental health and may struggle to access mental
health services (Kalaman et al. 2023). Therefore, the doctor should explain the children’s
condition and potential therapeutic options to the extent they can reasonably comprehend,
although they cannot legally consent to treatment (McVoy et al. 2023).
While Dr Fairuz did not specifically note which line of treatment T & CM is in for
treating mental illness among children and adolescents, she highlighted that prioritisation should
be placed on Western medications in the first place, and physicians play an essential role in
communicating the effectiveness and necessity of psychopharmacological interventions.
Secondly, the role of psychotherapy alongside medication can be highlighted to the parents to
show them how the sessions will be tailored to the child’s specific needs. Only then may
physicians review previous interventions’ assessments, including any previously attempted
T&CM treatments, psychotherapies or medications. She also emphasised encouraging family
participation and evaluating available family resources before discussing alternative treatment
options for the children.

FUTURE DIRECTION
Future research in paediatric psychopharmacotherapy should prioritise exploring how
drugs are metabolised and act at various developmental stages. This includes the impacts of
hormonal changes and puberty on drug efficacy and safety. Longitudinal studies are also
essential to investigate the long-term effects of psychotropic medications on the developing brain
and overall health. Addressing these areas could advance this field towards safer treatment
methods and improve mental health outcomes among this young population.
Besides, to address the notably high rate of missed appointments in Malaysia’s
psychiatric system, as Leong and colleagues (2006) reported, future efforts should focus on
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implementing and enhancing reminder systems tailored to patient preferences. This could include
automated phone calls, text messages, or emails to remind patients of their upcoming
appointments. Additionally, integrating flexible scheduling options and offering telehealth
services could help accommodate patients’ work or family commitments. Providing clear
communication and education about the importance of attending appointments and addressing
administrative errors through improved record-keeping and appointment management systems
would also be beneficial. By adopting these strategies, Malaysia’s psychiatric system can
improve attendance rates and ensure better continuity of care for patients.
The future direction of T&CM for treating mental illnesses among children and
adolescents in Malaysia appears promising and integrative. The MOH is expected to enhance
regulatory frameworks to ensure T&CM therapies' safe practice and efficacy, including
acupuncture and herbal medicine. Increasing collaboration between T&CM practitioners and
conventional healthcare providers will promote a holistic approach to mental health, integrating
evidence-based T&CM practices into mainstream treatment plans. Advances in research and
clinical trials will further validate the efficacy of T&CM, supported by databases and knowledge
platforms that consolidate clinical evidence. This aligns with what Dr Fairuz emphasised: more
research should be done, and the research should be upgraded to the meta-analysis level to
ensure the efficacy and safety of T&CM treatments before integration.
Lastly, as Dr Fairuz highlighted, actions must be taken to improve the affordability of
psychopharmacological treatments. Due to budget constraints, new medications are expensive,
and parents often cannot afford them. While families can seek financial assistance from NGOs or
through ‘zakat,’ it is crucial to revise policies so that insurance plans in Malaysia become more
inclusive, covering neurodevelopmental disorders and other mental health issues. Dr Fairuz
emphasised the importance of implementing national insurance and encouraging people to invest
in their mental health.

CONCLUSION
In conclusion, the use of psychopharmacotherapy in treating children and adolescents
with mental health and neurodevelopmental disorders is a complex yet crucial area of paediatric
care. Given the significant prevalence of these conditions globally and in Malaysia,
understanding the nuances of pharmacokinetics and pharmacodynamics in young patients is
essential for effective treatment. Psychotropic medications, while beneficial for managing severe
symptoms and improving quality of life, must be carefully prescribed and monitored due to their
varied efficacy and potential side effects. Addressing misconceptions, ensuring medication
adherence, and integrating psychotherapy are vital components of a comprehensive treatment
plan. Considering these medications’ economic burden and social stigma, a collaborative
approach involving healthcare providers, patients, and families is necessary to optimise
outcomes. Integrating TCM offers promising holistic options, enhancing the overall therapeutic
strategy. Through informed and empathetic care, we can better support the mental health needs
of children and adolescents, fostering their well-being and development.

“Don’t be afraid—just come and discuss how we can help your child – Dr Fairuz.”
 12

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