While antipsychotic drugs are most associated with treating conditions such as bipolar disorder and schizophrenia, they are often prescribed to adolescents and young children as well. Oftentimes, antipsychotic prescriptions are written for children for conditions that the drugs are not even approved for, such as irritability associated with ADHD (attention-deficit/hyperactivity disorder). A study published last year found that 60% of children between the ages of 7 and 12 were given an antipsychotic for the treatment of ADHD.
Dr. Candida Fink
Antipsychotics can also have severe side effects, such as weight gain, elevated cholesterol, higher diabetes risk and tremor. MedShadow Content Editor Jonathan Block recently sat down with Candida Fink, MD, a board certified child and adolescent psychiatrist –- and a member of MedShadow’s board of directors –- about the use of antipsychotics in children.
Fink is the co-author of The Ups and Downs of Raising a Bipolar Child (with Judith Lederman, Simon and Schuster, 2003) and Bipolar Disorder for Dummies (with Joe Kraynak, John Wiley & Sons, 2015). Based in New Rochelle, NY, Dr. Fink specializes in child and adolescent psychiatry, with expertise in developmental disabilities, ADHD, pediatric anxiety and mental health issues in school settings. You can find out more about her at www.finkshrink.com.
Jonathan Block: What conditions would an antipsychotic be prescribed to a child for?
Dr. Candida Fink: The most appropriate and FDA indicated uses of antipsychotics in adolescents and younger are for schizophrenia and bipolar disorder. And, in younger kids, there are 2 that are approved for autism. It would not be to treat autism, but to treat the irritability associated with autism. Those are the biggest, most common antipsychotic indications.
They are clearly used for a wide variety of other things. Antipsychotics are sedating, and so they have found this usage in kids who are aggressive or having outbursts – even when you don’t necessarily have a clear diagnosis of bipolar disorder or any clear diagnosis of a psychotic situation or it’s not autism. So I think that’s the place where it’s most overused. Just the other thing to mention is that it is used to augment antidepressant treatment and treatment-resistant depression [even though] there are no childhood FDA indications for that and the research is limited using it as an add-on.
JB: There are first- and second-generation antipsychotics. Which ones tend to be safer and/or more effective?
Dr. Candida Fink: There was a big meta-analysis done in 2009 that basically showed that the first generation and second generation had mostly equivalent benefits, except for clozapine, which is sort of in its own world. The difference is more about what type of side effects that you got. The older ones don’t have the weight gain and metabolic disorders as much. The newer ones don’t have the movement disorders and the Parkinsonism, so those are trade-offs. In this day and age, almost no one is going to use a first generation in a child except maybe in the most extreme state hospital scenarios. Interestingly, if you go back and look, Haldol has FDA indications down to 3-year-olds for non-psychotic behavior disorder, which is a term for psychosis.
So, with that being said, for schizophrenia treatment, it probably looks like both are similar. In adult schizophrenia, they are very equivalent and effective for the most part, but different in types of side effects, Because the side effects of the first generation are not considered very severe or not more severe, but more life altering. As the second generation came out, the first thought was [these drugs do not have] Parkinson-like side effects, and they’re not going to give them tardive dyskinesia, they’re not going to make them have distorted movements permanently for the rest of their life.
JB: When kids are generally given an antipsychotic, is the hope that it is a short-term thing or is it generally considered a lifetime?
Dr. Candida Fink: When it’s used appropriately, you want to think about it in terms of the shortest possible time, such as to get through a crisis, to wait while other medications [take effect] or wait while we’re putting on non-medical interventions, maturation and growing up. Unless you have a lifelong disorder like schizophrenia, and sometimes autism, you really want to be thinking about this, when possible, always want to be as short term as possible. That, of course, being one way to minimize the weight gain…but the longer-term metabolic side effects really can be serious.
JB: Do you know if there are any studies or is anyone looking into the threshold level of, say, if they’re on the antipsychotic for 3 months, the weight gain is this, on the fourth month that?
Dr. Candida Fink: I don’t think anyone is doing that research. I don’t think it’s been broken down in that detail. I think, in general, [you want to be on an antipsychotic] the shortest amount of time. But I am not aware of any research to sort of break it down with any medicines.
JB: At MedShadow, we’re all about side effects.I wanted to discuss some of the side effects that are associated with the first- and second-generation antipsychotics in children?
Dr. Candida Fink: With the first generation, they all can be somewhat sedating. They have a range of sedative qualities. Some are much more sedating than others. Also, with the first generation, the biggest package of side effects that we are concerned about are, primarily, movement disorders, and there are 2 types, reversible and irreversible. The reversible are Parkinson’s-like symptoms. When we block dopamine in the brain, we’re causing disturbance in the sort of movement regulatory system, and so [children on antipsychotics can] have rigidity and stiffness and look like they have Parkinson’s. That is completely reversible and it’s not a permanent effect.
The side effects that we worry about most in second-generation really are related to metabolic disorders, primarily. Weight gain is by far and away one of the biggest side effects of the second generation, and then longer-term disruptions in the entire metabolic system.
The longer-term effect is called tardive dyskinesia, which is a movement disorder, but that tends to be regarded as longer [duration]. Those are involuntary deriving movements that tend to involve shoulders, And no one has a really good idea how to reverse it. So that’s the big bet with first generation.
Another thing … that is not common, is neuroleptic malignant syndrome, and I’m not sure how much less the second generation might be at risk, but any antipsychotic medicine can cause a very bad side effect on neuroleptic malignant syndrome, which can kill. So that’s when your body temperature goes up, changes.It’s a very bad potential side effect, rare, but it does happen.
The side effects that we worry about most in second-generation really are related to metabolic disorders, primarily. Weight gain is by far and away one of the biggest side effects of the second generation, and then longer-term disruptions in the entire metabolic system, decreased sensitivity in insulin, changes in glucose metabolism, type 2 diabetes, lipid changes. This places people at higher risk of cardiovascular disease and that kind of thing. So, there are absolutely the long-term risks.