Tapering Antipsychotic Medications in Children and Adolescents: Part 1 3/21/24

Although pediatricians do not often initiate prescriptions for antipsychotic agents, this and a subsequent e-newsletter edition discuss important issues in their use that can be of relevance to pediatric practice, both in managing acute clinical situations and in managing care for youth with longer term needs for these medicines.

About 1% of children ages 7-12 and about 1.5% of adolescents ages 13-18 are prescribed antipsychotic medications¹ some of which are FDA approved for minors with psychiatric diagnoses including schizophrenia, bipolar disorder (BD), and irritability in autism².  This said, about 65% of antipsychotic medication prescribing is used off-label for issues such as severe aggression, agitation, disruptive behavior, irritability, and therapeutic augmentation when treating complex ADHD.  In these cases, antipsychotic medications may be of benefit but, in general, they should not be intended for high-dose or open-ended long-term use. This said, clinicians rarely consider or discuss discontinuation of antipsychotics or any psychotropic medications with their patients⁴. In this article and a subsequent article, we will discuss guidelines on when, how and how long to use antipsychotic medications and how to reduce or discontinue them in a safe and clinically appropriate manner.

The short answer is yes, which is why they are used, both for FDA approved conditions and also for non-psychotic disorders that present with very challenging behaviors and/or crisis situations.   In high-risk scenarios, antipsychotics can be crucial for short-term to medium-term stabilization, such as keeping a child out of the psychiatric hospital, allowing a student to stay in a less restrictive school environment, and in reducing the risk of aggression or injury.  This said, research does not clearly show that antipsychotic medication is always meaningfully helpful in some of the situations where it is commonly prescribed, such as for severe ADHD or Oppositional Defiant Disorder⁵.

Antipsychotic medication use has primarily been studied and FDA approved for short-term use (up to 6 months) in children^5or6 and, as yet, there are very few studies that assess benefits and side effects of longer-term antipsychotic use in children who are not suffering from a confirmed psychotic or bipolar disorder^6or7.

Regardless of diagnosis, common safety issues and concerns related to antipsychotic medications include: metabolic effects like weight gain, diabetes and hyperlipidemia; somnolence; prolonged QTc interval; prolactin elevation; extrapyramidal symptoms; and neuroleptic malignant syndrome. For these reasons and others, one should always have a careful conversation with patients and their families when initiating a trial of an antipsychotic medication about the planned duration of treatment of the medication, which should include factors like severity of symptoms, the natural course of the condition being treated, the age of the child, and response to other psychosocial interventions.

Particularly when used for non-psychotic illnesses, careful determination on an individual case by case basis is important, keeping in mind that the duration of treatment and dosage considerations should be carefully reviewed and reconsidered over time. Even for clinical situations when there is FDA approval, as is the case for irritability in autism, one should carefully consider if the patient truly meets criteria for prescribing (e.g., in autism, such criteria would be serious aggression, self-injury, and/or severe mood lability) and if there could be another approach such as addressing sensory or communication difficulties or using of an alternative medication with a safer side effect profile.

SmartCare’s On-Demand telephone consultation service is a readily accessible resource for primary care pediatricians needing support in managing patients with behavioral health challenges.  Call us at (858 880-6405).

Part 2 of today’s newsletter article will discuss clinical considerations in managing patients being treated with antipsychotic medications with a focus on pragmatic strategies in tapering and discontinuing these medications when indicated.

References:

¹ Olfson M et al., JAMA Psychiatry; 2015; 72(9):867-874.

² Harrison J et al., Journal of Pediatric Health Care; 2012; 26(2): 139-145

³ Sohn M et al., Medicine 2016; 95(23): e3784

⁴ Dinnessen M et al., European Child and Adolescent Psychiatry; 2020; 29 (12): 1717-1727

⁵ Lentini G et al., Biomedicines 2022;10(11): 2818

⁶ Aman M et al., Journal of Child and Adolescent Psychopharmacology; 2015; 25(6):482-493

⁷  Singappuli P et al., CNS Spectrums 2022; 27(5):570-587