ANTIPSYCHOTICS IN CHILDREN
In children and adolescents, "antipsychotic" medications are often used for conditions where the individual is not psychotic. A child or teen who is psychotic is out of touch with reality. He may "hear voices" or have strange and untrue ideas (for example, thinking that others can hear his thoughts, or are trying to harm him, or that he is the President of the United States or some other famous person). Such conditions, most typically schizophrenia, rarely occur in children, and in general, only begin to occur in later adolescence. Antipsychotic medications, as their name suggests, act against these psychotic symptoms. But in children and adolescents, "antipsychotic" medications are much more often used for non-psychotic symptoms and conditions, such as severe aggression or irritability that sometimes accompanies disorders such as autism, ADHD, depression, or bipolar disorder. These medications do not "cure" any of these difficulties, but they can reduce symptoms of aggression, mood swings, extreme irritability, and psychotic thinking. In some cases, they can shorten acute episodes of an illness as well, such as a bipolar manic state or acute psychosis.
TYPES OF ANTIPSYCHOTIC MEDICATIONS
There are a number of antipsychotic (neuroleptic) medications available. These include risperidone, aripiprazole, olanzapine, quetiapine, ziprasidone, and paliperidone, and others soon to be released. As best we know, they all work, and most of them have been approved by the FDA for schizophrenia and bipolar disorder in youth. Two of them, risperidone and aripiprazole, are approved for treating irritability in autism. The main differences between these agents are in their potency (the required dose amount prescribed to produce therapeutic effects) and in their side effects. Some people might think that the higher the dose of medication, the more serious the illness, but this is not always true.
A doctor will consider several factors when prescribing an antipsychotic medication, besides how "ill" someone is. These include the child's age, body weight, and type of medication. Past history is important, too. If a person took a particular medication before and it worked, the doctor is likely to prescribe the same one again. The main difference among the "antipsychotic" medications in their side effects (actions of the medication other than the one intended for the illness). All these medications vary in their side effects, and some people have more trouble with certain side effects than others. A side effect may sometimes be desirable. For instance, the sedative effect of some antipsychotic medications is useful for patients who have trouble sleeping or who become agitated during the day.
Unlike some prescription drugs, which must be taken several times during the day, antipsychotic medications can usually be taken just once a day. Thus, patients can reduce daytime side effects by taking the medications once, before bed. Some antipsychotic medications are available in forms that can be injected once or twice a month, thus assuring that the medicine is being taken reliably.
ANTIPSYCHOTIC MEDICATION SIDE EFFECTS IN CHILDREN
The most common side effects of antipsychotic medications are usually mild, such as sedation, and can be controlled by reducing the dose. Many common side effects, such as drowsiness or dizziness when suddenly standing up, disappear after the first few weeks of treatment.
In children and youth, more worrisome side effects include weight gain, which must be considered and prevented by carefully monitoring the child's diet at the outset when beginning the medication. Other side effects that may be caused by some antipsychotic medications include decrease in sexual ability or interest, problems with menstrual periods, sunburn, or skin rashes. If a side effect is especially troublesome, it should be discussed with the doctor who may prescribe a different medication, change the dosage level or schedule, or prescribe an additional medication to control the side effects.
Movement difficulties can also occur with the use of antipsychotic medications, although most of them can be controlled by low doses, "going slow" when changing doses up or down, or by using an anticholinergic medication. These movement problems include muscle spasms of the neck, eye, back, or other muscles; restlessness and pacing; a general slowing-down of movement and speech; and a shuffling walk. Some of these side effects may look like psychotic or neurologic (Parkinson's disease) symptoms, but aren't. If they are severe, or persist with continued treatment with an antipsychotic, it is important to notify the doctor, who might either change the medication or prescribe an additional one to control the side effects.
ARE THERE BENEFITS OF USING ANTIPSYCHOTICS IN CHILDREN?
Just as people vary in their responses to antipsychotic medications, they also vary in their speed of improvement. Some symptoms, such as aggression and irritability, may diminish in days, while others take weeks or months. For many patients, substantial improvement is seen by the sixth week of treatment, although this is not true in every case. If someone does not seem to be improving, a different type of medication may be tried.
Even if a child or adolescent is feeling better or completely well, she or he should not just stop taking the medication. Continuing to see the doctor while tapering off medication is important. Some children may need to take medication for an extended period of time, or even indefinitely. These individuals usually have chronic (long-term, continuous) schizophrenic disorders, or have a history of repeated schizophrenic episodes, and are likely to become ill again. Also, in some cases a person who has experienced one or two severe episodes may need medication indefinitely. In these cases, medication may be continued in as low a dosage as possible to maintain control of symptoms. This approach, called maintenance treatment, prevents relapse in many people and removes or reduces symptoms for others.
While maintenance treatment is helpful for many children and youth, a drawback for some is the possibility of developing long-term side effects, particularly a condition called tardive dyskinesia. This condition is characterized by involuntary movements, and while more common in adults, has nonetheless been reported in children and teens. These abnormal movements most often occur around the mouth, but are sometimes seen in other muscle areas such as the trunk, pelvis, or diaphragm. The disorder may range from mild to severe. For some people, it cannot be reversed, while others recover partially or completely. Tardive dyskinesia is seen most often after long-term treatment with antipsychotic medications. There is a higher incidence in women, with the risk rising with age. There is no way to determine whether a child will develop this condition, and if it develops, whether the child will recover. At present, there is no effective treatment for tardive dyskinesia. The possible risks of long-term treatment with antipsychotic medications must be weighed against the benefits in each individual case by patient, family, and doctor.
Antipsychotic medications can produce unwanted effects when taken in combination with other medications. Therefore, the doctor should be told about all medicine being taken, including over-the-counter preparations, and the extent of the use of alcohol. Some antipsychotic medications interfere with the action of antihypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy), and medications used for Parkinson's disease. Some antipsychotic medications add to the effects of alcohol and other central nervous system depressants, such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics.
THERAPEUTIC USES OF ANTIPSYCHOTICS IN CHILDREN
The most common use of antipsychotic medications in children and teens is for managing aggression. One of the useful methods that can help busy doctors evaluate aggression and its severity is through the use of rating scales. Some rating scales many of the key symptoms of aggression, for completion by either a youth or someone who knows the child well, i.e. a parent or teacher. Such rating scales do not say "why" a child has aggression problems, but they can be useful in tracking the severity of aggression symptoms. These scales are about 75=85% accurate, are are often used to monitor response to antipsychotic treatment.
Because these tools can improve the quality of care when using atypicals, REACH Institute's President Peter S. Jensen, M.D., led a US Steering Committee consisting of pediatricians, child psychiatrists, psychologists, researchers, and policy makers to put together a comprehensive set of recommendations to guide primary care clinicians through the key steps in evaluating and managing youth aggression, including the use of atypicals. This program is called "T-MAY" - Treatment of Maladaptive Aggression in Youth. The TMAY project resulted in a very user-friendly toolkit that includes public domain aggression rating scales free for download, side effects rating scales, and many other useful tools. If you want to learn more about TMAY and download the T-MAY toolkit and accompanying rating scales, follow the T-MAY link. In addition, more tools than just T-MAY are available, and you can reach them through the REACH Institute's aggression toolkit link.
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