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with Steven Parker, MD

This blog is now retired. Dr. P passed away on Monday, April 13, 2009. The WebMD Community will dearly miss his kind, caring, and often humorous manner.

Monday, June 12, 2006

Children and antipsychotic medications

Are antipsychotic medications overprescribed for children?

Dr. P’s Pediatric Journal Club

The study

The researchers extracted data from a national survey of doctors’ office visits during 1993-2002, looking for the use of “antipsychotic medications” in children and adolescents (under the age of 21 years).
What the study found
  • 18% of visits to a psychiatrist resulted in a prescription for an antipsychotic medication.
  • In 1993, 201,000 prescriptions for antipsychotic medications were written for children under 21 years of age. In 2002, 1,224,000 prescriptions were written.
  • This adds up to about 14 per 1,000 children and adolescents receiving these medications ( compared to about 2.75 per 1,000 in 1993), about a five-fold increase.
  • These meds were mainly prescribed for Disruptive Disorders (38%), Mood Disorders (such as childhood bipolar in 32%), Pervasive Developmental Disorders or Autism Spectrum or Mental Retardation (17%), and Psychotic Disorders (14%)

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Dr. P comments

The plot thickens in this highly debated area of the psychiatric care of our children.

I’ve blogged before about the increase in ADHD (Attention Deficit Hyperactivity Disorder) and antidepressant medications over the past 15 years (neither of which I’m going to discuss again here). So it comes as no surprise that the newer generation of ‘atypical’ antipsychotic medications (such as Risperdal, Clozaril, Zyprexa, Seroquel, Abilify **) are being used with increasing frequency in the younger age groups.

So (you appropriately ask), is this a worrisome trend or is this good news?

The potentially worrisome part:

  • While safer in most cases than the older antipsychotic medications (such as Haldol, Mellaril, Thorazine), these meds are not without side effects. Significant weight gain and elevation of fat in the blood, at the very least, are quite common.
  • Since these medications are relatively new on the scene, their long-term use has not been well-studied, especially when started in childhood. Could there be unexpected side effects (negative or positive) that will show up in a decade or two?
  • If all you have is a hammer, everything looks like a nail.” There is no question these medications can be very beneficial for some children. But might their effectiveness and relative safety short-circuit attempts to first try to solve behavior/psychiatric problems with slower and more labor-intensive environmental interventions? Are we too quick to default to medications as the first line of treatment? Could this trend reflect an easy way out for a society facing a critical shortage of mental health professionals for children?

The positive side:

  • There are an increasing number of studies and lots of clinical experience showing these medications often really help some children (especially childhood bipolar disorder and disruptive disorders in children with developmental disabilities).
  • So far, aside for the weight gain and elevation of fat levels, the medications are usually well tolerated and appear to be reasonably safe.
  • While imperfect, these medications do represent an important advance in treatment for many children. Over time, even safer and more effective medications are going to emerge.

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A case from Dr. P’s clinic

Try to put aside your opinions for a second and let me present to you a case from my own practice. I’ll tell you what I have done, then you can decide if you agree with it or not.

When I first met him 3 years ago, Billy (not his real name) was an exceptionally hyperactive two and a half year old. Even more remarkable, he would occasionally go for 72 hours without any sleep! He was bright, cute, but could be very aggressive and unmanageable. His intense tantrums could last for hours. Babysitters refused to care for him more than once. He was expelled from his day care. As you might guess, life with Billy was incredibly difficult.

Despite being unsure of his diagnosis, I decided – at the tender age of 3 years – to start ADHD stimulant medications + a medication for sleep. These did help for about a year or so, but began to lose effectiveness when he was four.

Because of his extreme symptoms and a positive family history, I had always been suspicious that Billy was manifesting, at an unusually young age, symptoms of Childhood Bipolar Disorder. So, reluctantly, I started Risperdal (one of the newer antipsychotic medications).

His mom described the difference as ‘miraculous’. Billy’s hyperactivity, aggressiveness, and disruptive behaviors became quite manageable. Now he loves to go to preschool where, instead of being constantly punished and berated for his misdeeds, he proudly reports his many successes. His learning is at age-level. Baby sitters are now happy to give mom a break. He’s gained a lot of weight but otherwise seems a healthy and much happier little boy.

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So, was I right to start an antipsychotic medication in a boy who is only four years old? What were/are the risks of using – or of not using – the medication?

Frankly, I struggle with these questions every time the issue of using psychiatric medications comes up (which is more and more often!). I
don’t see any easy, pat answer to the good news/bad news question. For better or for worse, I take it case by case and weigh the pros and cons as best I can.

Anyway, I hope I’ve at least highlighted for you the complexity and importance of what is at stake. This is an issue and a debate only likely to grow in intensity and importance over the next years. Your thoughts?

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Article cited:

Archives of General Psychiatry, June 2006

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** I’m using the trade names for these medications, instead of the actual drug names, since these are names most people know them by and since you can’t get generic brands for them as yet anyway.

Related Topics: Bipolar Disorder: Recognize the Symptoms, Bipolar Youths May Misread Faces

Update: Welcome Pediatric Grand Rounds readers!

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Posted by: Steven Parker MD at 8:47 am

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