Electroconvulsive therapy (ECT) is a well-tolerated, well-established, and efficacious treatment in adults, particularly in the setting of severe mood and psychotic disorders. In children and adolescents, however, ECT is infrequently administered and likely underutilized. Results from older studies evaluating the utility of ECT in children and adolescents were mixed, but recent studies have supported ECT treatment success in these patients, with particularly high response rates for treating depression. In this Perspectives, we discuss the current clinical indications for ECT in managing mood and psychotic disorders in children and adolescents. We then review the pretreatment evaluation and management of patients receiving ECT and examine the efficacy of ECT for those indications. We also address issues unique to children and adolescents, versus adults, that need to be considered when determining whether treatment with ECT is appropriate for a patient in this age group. Included in this context are the distinct side-effect profile in children and adolescents, ethical issues regarding informed consent, incorporating the child into the decision-making process when developmentally appropriate, and the need to take into account differing state jurisdictional processes.