Introduction
Both the medical and lay press have directed a lot of attention lately to the treatment of children and adolescents with antipsychotic medications. The literature is clear that the number of children taking this class of medications has risen sharply since their release (Arch. Gen. Psychiatry 2006;63:679-85). What is much less clear is the degree to which this increase represents a reasonable intervention for patients in significant need versus an overuse when other strategies are more appropriate.
Case Summary
Cody is a 6-year-old boy who lives with his younger sister and single mother. The family struggles financially, and the father, who has never had much contact with his son, is currently incarcerated. Since he was a toddler, Cody has been prone to high levels of aggressive behavior and frequent, intense angry outbursts. He was asked to leave his preschool due to his behavior and now is commonly disruptive at school. His pediatrician diagnosed him with attention-deficit/hyperactivity disorder a year ago and began a trial of a psychostimulant, which made him even more irritable, and was discontinued. Cody and his mother now present with concerns that there is “something more” affecting his behavior. The pediatrician now considers whether or not treatment with an antipsychotic medication is reasonable at this point.
Dr. David C. Rettew
Discussion
The above clinical scenario represents a critical and often antagonizing moment in treatment for both the family and the treating physician, yet it is hardly uncommon. The situation often is made more complicated by the fact that what is often the first plan of action, namely referral or consultation with a child psychiatrist, can be very difficult to access.
The American Academy of Child and Adolescent Psychiatry has published online guidelines for the use of antipsychotic medication in youth (http://bit.ly/1eat7e9). Key recommendations and points from this 27-page document and 19 recommendations include the following:
• Patients being considered for treatment with an antipsychotic medication should receive a “meticulous diagnostic assessment” with any medication prescribed being part of a “multidisciplinary” treatment plan (Recommendation 1).
• Prescribers should “regularly check the current literature” regarding the scientific evidence for antipsychotic medication use (Recommendation 2).
• Antipsychotic medications are considered first-line medication treatment for bipolar disorder, schizophrenia, tics/Tourette’s, and autism. (Recommendation 2).
• Antipsychotic medications are not first-line treatment for several other diagnoses and behaviors, including disruptive behavior disorders such as ADHD, aggression, eating disorders, and post-traumatic stress disorder (PTSD). Their use should be considered only after other pharmacologic and nonpharmacologic interventions have failed (Recommendation 2).
• Antipsychotic medications are not advised for preschool-aged patients. (Recommendation 2).
• Dosing should be as low as possible and not exceed the maximum recommended dose for adults (Recommendation 4).
• Simultaneous treatment with multiple antipsychotic medications is not recommended (Recommendation 8).