How many children are taking antipsychotic medications? In a recent study published in JAMA Psychiatry, Mark Olfson, Marissa King, and Michael Schoenbaum reported that over 1% of boys between the ages of 7 and 12 and nearly 0.5% of girls in this age group are prescribed antipsychotic drugs. In adolescents 13 to 18 years of age, the percentages increase to 1.4% and 0.95% in males and females, respectively. These investigators also report that about 85% of youngsters between the ages of 7 and 18 who are prescribed antipsychotics are also prescribed one or more other psychiatric medications, such as stimulants, antidepressants, and/or mood stabilizers. 

Antipsychotics, including drugs such as haloperidol (Haldol), risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel), are powerful medications that are effective in treating psychotic symptoms such as hallucinations and delusions. Some of these drugs can lead to serious side effects, including substantial weight gain as well as other metabolic disturbances. They also have the potential to cause movement disorders of various kinds. Some of these movement disorders can be long lasting even if the drug is stopped.

Should we be especially cautious about prescribing antipsychotics to children? There is rapid growth of the human brain from birth through the early 20s. During these formative years, nerve cells are extraordinarily active - forming and trimming connections with other nerve cells. The nature of these connections is vital in determining how we think, feel, and behave. The degree of growth and the formation of connections are strongly influenced by genetics and environment. The tailoring of these brain connections becomes much less dramatic during the third decade of life.

Nerve cells that utilize dopamine and serotonin are involved in the remarkable changes in the brain that occur during development. Antipsychotics have powerful effects on these and other neurotransmitter systems. Little is known about the long-term effects of influencing dopamine and serotonin during the critical periods of rapid brain development in children. It is appropriate to ask if there is strong evidence supporting the benefit of these medications for specific psychiatric conditions in our youngsters and whether the potential benefits outweigh the potential risks. 

In adults, antipsychotic medications are helpful in treating schizophrenia or bipolar disorder. Although these disorders may exist in children, they are uncommon until adolescence. Whether antipsychotic drugs help kids with schizophrenia or bipolar disorder is not known, but most children currently taking these drugs do not appear to have either of these disorders.

Depressive disorders, anxiety disorders, and attention deficit/hyperactivity disorder (ADHD) do occur in youngsters. However, we are unaware of strong data supporting the use of antipsychotics for these disorders, particularly in this age group. Nevertheless, it is likely that antipsychotics are being prescribed to youngsters with these disorders.

Some evidence suggests that antipsychotic medications may have short-term benefit in helping children with severe agitation or irritability in the context of autism. The decision to use these medications for such symptoms requires careful consideration of possible risks versus benefit and should involve discussion between the family and the physician. If treatment is elected, it would be prudent to re-evaluate the decision on a routine basis. 

It seems unlikely that most of the children taking antipsychotics are ill with severe autism, however. Some children demonstrate agitation and irritability that may be related to conduct disorder or other conditions. It is not clear that antipsychotics help agitation and irritability associated with these conditions. 

We are unaware of well-designed studies demonstrating long-term benefit of using antipsychotics for conduct disorder. When out-of-control behaviors occur, families are desperate. It is possible that short-term use of antipsychotics may help, but the decision to use these drugs should be made very carefully and re-evaluation of the benefits and risks should occur frequently. Unknown benefit versus the potential for significant risks should be considered and discussed with families. Behavioral interventions may be more effective and will likely have fewer side effects than antipsychotic medications.

In summary, antipsychotic medications are being prescribed to over 1% of boys 7 to 12 years old and to about 1.4% of boys 13 to 18.  In girls, the percentages are about 0.44% and 0.95% in these two age groups, respectively. It remains to be determined whether these drugs are being overprescribed in children, but since about 85% of the time antipsychotics are being used in combination with other psychoactive drugs, concerns should also be raised about the risks of poly-psychopharmacology

Doctors and families should discuss the use of these medications in kids and should consider simplifying medication regimens whenever possible. Family, behavioral, and cognitive therapies may be more effective than pharmacologic treatments for some of the conditions currently being treated with antipsychotic medications.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.

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