The antipsychotics. A pediatric perspective

Using pharmacotherapy to address sleep disturbances in autism spectrum disorders

INTRODUCTION

Sleep disorders are the second most common medical comorbidity in autism spectrum disorder (ASD), with effects on daytime behavior and functioning, mood and anxiety, and autism core features. In children with ASD, insomnia also has a negative impact on the whole family's quality of life. Therefore, treatment of sleep disturbances should be considered as a primary goal in the management of ASD patients, and it is important to clarify the scientific evidence to inappropriate treatments.

AREAS COVERED

The authors review the current literature concerning the pharmacological treatment options for the management of sleep-related disorders in patients with ASD (aged 0-18 years) using the PubMed and Cochrane Library databases with the search terms: autism, autistic, autism spectrum disorder, ASD, drug, drug therapy, drug intervention, drug treatment, pharmacotherapy, pharmacological treatment, pharmacological therapy, pharmacological intervention, sleep, sleep disturbance, and sleep disorder.

EXPERT OPINION

Currently, clinicians tend to select medications for the treatment of sleep disorders in ASD based on the first-hand experience of psychiatrists and pediatricians as well as expert opinion. Nevertheless, at the present time, the only compound for which there is sufficient evidence is melatonin, although antihistamines, trazodone, clonidine, ramelteon, gabapentin, or suvorexant can also be considered for selection.

Antipsychotics in the Management of Disruptive Behavior Disorders in Children and Adolescents: An Update and Critical Review

Disruptive behaviour disorders (DBDs) in childhood include conduct disorder (CD) and oppositional defiant disorder (ODD). Though psychological therapies are considered to be the first-line treatment for DBDs, many patients require adjunctive pharmacotherapy for the control of specific symptoms, such as aggression. Three prior systematic reviews have examined the evidence for the use of antipsychotics in DBDs and have concluded that their efficacy is marginal and limited by adverse effects. This paper has two objectives: (i) to summarize the findings of existing systematic reviews of antipsychotics for the management of DBDs in children and adolescents (2012-2017), and (ii) to provide an update to these reviews by examining recent clinical trials of antipsychotics in this population, published in the period from 2 January 2017 to 10 October 2022. The PubMed, Scopus and ScienceDirect databases were searched for relevant citations using the search terms "disruptive behaviour disorder", "oppositional defiant disorder", "conduct disorder" and their variants, along with "antipsychotic", "atypical antipsychotic" and the generic names of all currently approved atypical antipsychotics. Six relevant trials were identified during this period, including five randomized controlled trials and one naturalistic open-label trial. These trials were critically evaluated in terms of outcome measures, efficacy and safety. Overall, the data from these trials suggests that of all available antipsychotics, risperidone appears to be effective in the short-term management of DBDs. All available antipsychotics are associated with significant metabolic adverse effects in this population. These results are discussed in the light of global trends towards increasing off-label prescription of antipsychotic medication in children and adolescents and of recent literature on the neuropharmacology of aggression in this patient population. The need for rational, short-term use of these drugs is highlighted, as well as the importance of post-marketing surveillance for long-term or severe adverse events.

Risperidone induced alterations in feeding and locomotion behavior of Caenorhabditis elegans

Antipsychotic drugs (APDs) are prescribed for the treatment of psychiatric illness. However, these drugs can also contribute to several developmental and behavioral disorders. Contemporary studies to evaluate the toxic effects of numerous atypical antipsychotics are reported to cause behavioral alteration at variable doses in mammals and nematodes. Risperidone, the second most prescribed drug in India, requires more exploration of its adverse effects on humans. Here, we explore effects on feeding behavior and locomotion patterns due to risperidone exposure in C. elegans model. The study targets to work out the toxic effects of risperidone exposure on feeding and locomotion behavior in addition to the expected pharmacological effects. N2 wild type strain was exposed in liquid culture assay for 2, 4, 6, 8, 10, and 12 hours with fixed 50 µM concentration. Feeding behavior was depleted due to inhibition in pharyngeal pumping varying from 11.05% - 45.67% in a time-dependent manner. Results of locomotion assay also show time-varying increase in reversals (4.9%-34.03%) and omega bends (26.23%-62.17%) with reduction in turn counts (29.07%- 42.2%) and peristaltic speed (31.38%-42.22%) amongst exposed groups as to control. The present work shows behavioral alterations due to risperidone exposure (50 µM) in C. elegans is in a time-dependent manner. The study concludes that risperidone exposure in C. elegans produces toxic effects with time, possibly caused by antagonizing other receptors apart from serotonin (5-H2T) and dopamine (D2) adding to its expected pharmacological effects.

Risperidone in children and adolescents with conduct disorder: a single-center, open-label study

BACKGROUND

Risperidone is one of the most commonly used atypical antipsychotic drugs in the treatment of children and adolescents. However, the data about its use in children and adolescents with conduct disorder (CD) are limited.

OBJECTIVE

The aim of this study was to investigate the effectiveness and tolerability of risperidone in controlling major symptoms of CD in children and adolescents diagnosed with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and severe CD.

METHODS

Children and adolescents were eligible for this single-center, open-label study if they met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for ADHD and ODD and also were diagnosed with severe CD. The patients were treated with risperidone in an open-label fashion for 8 weeks, starting at a daily dosage of 0.25 mg or 0.5 mg (depending on their body weight) in 2 divided doses.

RESULTS

The study population comprised 21 children and adolescents (17 boys, 4 girls) with a mean (SD) age of 10.8 (3.6) years. The mean (SD) dosage of risperidone at the end of 8 weeks of treatment was 1.27 (0.42) mg/d (range, 0.75-2.0 mg/d). On the basis of the global improvement subscale of the Clinical Global Impression scale, 16 of 20 patients (80%) were classified as responders. Significant improvements were observed after risperidone treatment in the inattention, hyperactivity/impulsivity, ODD, and CD subscales of the Turgay DSM-IV-Based Child and Adolescent Behavior Disorders Screening and Rating Scale (parent and teacher forms). No severe adverse events were reported.

CONCLUSIONS

The results of this study are consistent with previous findings and suggest that risperidone may be an effective and well-tolerated atypical antipsychotic drug for the treatment of children and adolescents with CD. However, further studies, particularly placebo-controlled and double-blinded, are needed to better define the clinical use of risperidone in children and adolescents with CD.

Treatment of early onset schizophrenia: recent trends, challenges and future considerations

Early onset schizophrenia (onset before adulthood) is a rare, severe, and chronic form of schizophrenia. The clinical presentation of schizophrenia at this unusually early age of onset has been associated with premorbid developmental abnormalities, poor response to neuroleptic treatment, greater admission rates, and poor prognosis. This is a brief, condensed review of current treatment strategies for the early onset population highlighting the need for novel treatment strategies for these generally treatment-refractory cases. Based on the current literature, second-generation antipsychotics remain the mainstay of treatment, although current medications provide suboptimal response at best. Based on the adult literature, combining antipsychotic treatment with psychotherapeutic intervention may be a more comprehensive treatment strategy. Indeed, early detection, identification of relevant biomarkers, coupled with advancing knowledge of the neurochemical and neuroanatomic pathways may help design informed and novel treatment strategies.

Treatment of early-onset schizophrenia

PURPOSE OF REVIEW

Treatment of children who develop schizophrenia in childhood and early adolescence presents unique considerations. There has been increasing attention to the importance of early intervention and whether treatment effects may be affected by brain development.

RECENT FINDINGS

Several recent trials support the use of antipsychotics for treatment of schizophrenia in children and adolescents. Clozapine shows greater efficacy in children and adolescents than it has in adults. A large-scale trial comparing a first-generation antipsychotic (molindone) with newer agents did not find significant differences in treatment response, although the newer antipsychotics were associated with more severe weight gain. Data regarding effects of antipsychotics on brain development in children and young adolescents with schizophrenia are sparse, although one report found no difference between effects of clozapine and olanzapine on cortical thickness.

SUMMARY

Although psychosocial interventions are an important adjunctive treatment, antipsychotic medications continue to be the mainstay of treatment. Careful monitoring of metabolic side effects and age-appropriate intervention is particularly important, as children and adolescents appear to be more likely to develop metabolic abnormalities such as pronounced weight gain, which may significantly impact adherence as well as lead to other health issues.

Antipsychotic drugs alter neuronal development including ALM neuroblast migration and PLM axonal outgrowth in Caenorhabditis elegans

Antipsychotic drugs are increasingly being prescribed for children and adolescents, and are used in pregnant women without a clear demonstration of safety in these populations. Global effects of these drugs on neurodevelopment (e.g., decreased brain size) have been reported in rats, but detailed knowledge about neuronal effects and mechanisms of action are lacking. Here we report on the evaluation of a comprehensive panel of antipsychotic drugs in a model organism (Caenorhabditis elegans) that is widely used to study neuronal development. Specifically, we examined the effects of the drugs on neuronal migration and axonal outgrowth in mechanosensory neurons visualized with green fluorescent protein expressed from the mec-3 promoter. Clozapine, fluphenazine, and haloperidol produced deficits in the development and migration of ALM neurons and axonal outgrowth in PLM neurons. The defects included failure of neuroblasts to migrate to the proper location, and excessive growth of axons past their normal termination point, together with abnormal morphological features of the processes. Although the antipsychotic drugs are potent antagonists of dopamine and serotonin receptors, the neurodevelopmental deficits were not rescued by co-incubation with serotonin or the dopaminergic agonist, quinpirole. Other antipsychotic drugs, risperidone, aripiprazole, quetiapine, trifluoperazine and olanzapine, also produced modest, but detectable, effects on neuronal development. This is the first report that antipsychotic drugs interfere with neuronal migration and axonal outgrowth in a developing nervous system.

Control of psychomotor agitation and aggressive behavior in patients with autistic disorder: a retrospective chart review

OBJECTIVE: To evaluate the efficacy of pharmacotherapy on the symptoms of psychomotor agitation and aggressive behavior in a sample of patients with autistic spectrum disorder. METHOD: The charts of all patients with a diagnosis of autistic spectrum disorder, receiving care for psychomotor agitation and/or aggressive behavior in two psychiatric outpatient departments between 2001 and 2006, were reviewed. The Clinical Global Impression-Severity and -Improvement scales (CGI-S and CGI-I) were applied to the data retrieved from the charts. RESULTS: The majority of the 26 patients included were treated with second-generation antipsychotics. A positive, statistically significant correlation was found between the implementation of pharmacotherapy and a reduction in CGI-S scores (p<0.05). Treatment response in patients with no mental retardation was better than in those mentally retarded (p<0.05). The majority of patients in whom clinical improvement was found following implementation of treatment had participated in at least one form of intervention therapy in addition to the principal treatment (p<0.05). CONCLUSION: Second-generation antipsychotics seem to reduce psychomotor agitation and aggressive behavior in patients with autistic spectrum disorder; however, further studies are required to evaluate the side effects of these drugs in relation to their beneficial effects.

Antipsychotic drugs disrupt normal development in Caenorhabditis elegans via additional mechanisms besides dopamine and serotonin receptors

Antipsychotic drugs may produce adverse effects during development in humans and rodents. However, the extent of these effects has not been systematically characterized nor have molecular mechanisms been identified. Consequently, we sought to evaluate the effects of an extensive panel of antipsychotic drugs in a model organism, Caenorhabditis elegans, whose development is well characterized and which offers the possibility of identifying novel molecular targets. For these studies, animals were grown from hatching in the presence of vehicle (control) or antipsychotic drugs over a range of concentrations (20-160microM) and growth was analyzed by measuring head-to-tail length at various intervals. First-generation antipsychotics (e.g., fluphenazine) generally slowed growth and maturation more than second-generation drugs such as quetiapine and olanzapine. This is consistent with in vitro effects on human neuronal cell lines. Clozapine, a second-generation drug, produced similar growth deficits as haloperidol. Converging lines of evidence, including the failure to rescue growth with high concentrations of agonists, suggested that the drug-induced delay in development was not mediated by the major neurotransmitter receptors recognized by the antipsychotic drugs. Moreover, in serotonin-deficient tph-1 mutants, the drugs dramatically slowed development and led to larval arrest (including dauer formation) and neuronal abnormalities. Evaluation of alternative targets of the antipsychotics revealed a potential role for calmodulin and underscored the significance of Ca(2+)-calmodulin signaling in development. These findings suggest that antipsychotic drugs may interfere with normal developmental processes and provide a tool for investigating the key signaling pathways involved.

Effectiveness, safety, and pharmacokinetics of quetiapine in aggressive children with conduct disorder

OBJECTIVE

To provide an initial description of the effectiveness and pharmacokinetics (PK) of quetiapine in aggressive children with conduct disorder (CD).

METHOD

This 8-week, open-label outpatient trial, enrolled patients ages 6 to 12 years with CD. Outcome measures included the Rating of Aggression Against People and/or Property Scale (RAAPPS), Nisonger Child Behavior Rating Form (NCBRF), and the Conners Parent Rating Scale (CPRS-48). Blood sampling for PK analyses occurred at the end of weeks 2 and 8.

RESULTS

Seventeen children (16 boys, mean age 8.9 years) were treated. The mean dose at week 8 was 4.4 mg/kg (SD = 1.1 mg/kg). Significant decreases in the baseline scores of the RAAPPS, and several subscales of the NCBRF and the CPRS were found by the end of the study (p <.05). No patients discontinued because of an adverse event. No patients experienced extrapyramidal side effects. Quetiapine disposition was linear over the dose range studied. The elimination half-life of the drug averaged 3.9 and 2.9 hours and total body clearance averaged 3.5 and 3.0 L/hr/kg after study weeks 2 and 8, respectively.

CONCLUSIONS

These preliminary data suggest that aggressive children with CD may benefit from quetiapine. The PK of quetiapine supports twice-daily dosing in children with CD.

Overdoses and ingestions of second-generation antipsychotics in children and adolescents

OBJECTIVE

We reviewed the available published data on intentional or unintentional secondgeneration antipsychotic overdoses in children and adolescents. The prescribing of secondgeneration antipsychotics has continued to increase over the past decade for children, adolescents, and adults. The authors reviewed the existing literature to determine the circumstances, presenting problems, treatment, and outcomes of youths who were exposed to nontherapeutic doses of these medications.

METHODS

A systematic English-language Medline search of all reports (1989-2005) and a review of the bibliographies of all articles obtained was done to identify papers reporting an overdose or ingestion of a second-generation antipsychotic. Data were reviewed on clozapine, risperidone, olanzapine, ziprasidone, quetiapine, and aripiprazole. The annual reports of the American Association of Poison Control Centers National Data Collection System were reviewed from 1990 to 2003, the most recent report currently available. All fatalities in children and youths under 18 years of age were included.

RESULTS

The literature review identified 40 reports that included 63 patients, ranging in age from 1 day to 17 years of age. The clinical presentations included drowsiness, lethargy, agitation, irritability, combativeness, and tachycardia. There were 11 fatalities in the cases reviewed, 1 from clozapine overdose, 3 from risperidone overdose, 2 from olanzapine overdose, and 5 from quetiapine overdose. All other cases reported no significant sequelae and resolved without any reported clinical consequences. Duration of overdose symptoms ranged from 24 hours to 7 days. One case of clozapine intoxication showed resolution of symptoms in 6 hours and, in another case of olanzapine overdose, symptoms resolved in 13 days. The most frequently employed treatments included intubation, gastric lavage, activated charcoal, intravenous fluids, artificial respiration, and restraints or sedatives.

CONCLUSIONS

There is a need for future case reports to include serum medication level, weight of patient, coingestants, the health of the patient at baseline, relevant laboratory and toxicology studies and a standardized scale to rate the level of consciousness, such as the Glasgow Coma Scale. The existing pharmacovigilance data reports indicate these medications are relatively safe when taken in overdose, particularly when coingestants are not involved.

Unanswered questions regarding atypical antipsychotic use in aggressive children and adolescents

The aim of this paper was to discuss the arguments for and against the use of atypical antipsychotics in children and adolescents with aggression, and provide recommendations for future research. A MEDLINE search (1985-2004) was performed to identify key literature. Search terms included, but were not limited to, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, children, and adolescents. The search was limited to English-language literature and randomized controlled trials. The use of atypical antipsychotics in children and adolescents has increased significantly over the past few years. Atypical antipsychotics are associated with a more favorable side-effect profile, and growing evidence supports their efficacy for aggression in this population. However, the long-term effects of these agents are unknown. No head-to-head evidence exists to suggest whether pharmacological or nonpharmacological treatments are superior for managing aggression associated with childhood and adolescent psychiatric and behavioral conditions. Future research of atypical antipsychotics in children and adolescents needs to evaluate not only the efficacy but also the effectiveness. Examination of treatment mediators and moderators may help to optimize treatment regimens and improve patient outcomes. Finally, effective interventions require the development and implementation of evidence-based treatment strategies using a multidisciplinary approach.

Regional variation and clinical indicators of antipsychotic use in residential treatment: a four-state comparison

The last decade saw an increase in psychotropic use with pediatric populations. Antipsychotic prescriptions are used frequently in residential treatment settings, with many youth receiving antipsychotics for off-label indications. Residential treatment data from 4 states were examined to determine if regional variation exists in off-label prescription and what clinicalfactors predict use. The study used clinical and pharmacological data collected via retrospective chart reviews (N = 732). The Child and Adolescent Needs and Strengths Assessment-Mental Health Version was used to measure symptom and risk severity. Of youth receiving antipsychotics, 42.9% had no history of or current psychosis. Statistical analyses resulted in significant regional variation in use across states and yielded attention deficit/impulsivity, physical aggression, elopement, sexually abusive behavior, and criminal behavior as factors associated with antipsychotic prescription in nonpsychotic youth. Antipsychotic prescription is inconsistent across states. Off-label prescription is frequent and likelihood of use increases with behavior problems.

The Subjective Experience of Youth Psychotropic Treatment

The psychotropic treatment of youth is increasing dramatically. This article examines child and adolescent psychopharmacological research and argues that social work practice and research must examine the complex relationships, social and psychological, in youth pharmacologic treatment. Regarding identity formation, this article explores the developmental consequences when youth adopt an illness narrative to make sense of everyday medication treatment. A conceptual framework for mapping the socio-cultural context of youth medication management is outlined. In the conclusion, youth psychotropic treatment is connected to a perplexing 'interpretive gap,' which highlights the subjective quality of medication treatment.

Understanding predisposition to schizophrenia: toward intervention and prevention

OBJECTIVE

Early intervention to prevent schizophrenia is one of the most important goals of schizophrenia research. However, the field is not yet ready to initiate trials to prevent prodromal or psychotic symptoms in people who are at risk for developing the disorder. In this paper, we consider some of the major obstacles that must be studied before prevention strategies become feasible.

METHOD AND RESULTS

One of the most important hurdles is the identification of a syndrome or set of traits that reflects a predisposition to schizophrenia and that might provide potential targets for intervention. In a recent reformulation of Paul Meehl's concept of schizotaxia, we integrate research findings obtained over the last 4 decades to propose a syndrome with meaningful clinical manifestations. We review the conceptualization of this syndrome and consider its multidimensional clinical expression. We then describe preliminary research diagnostic criteria for use in adult, nonpsychotic, first-degree relatives of patients diagnosed with schizophrenia, based on negative symptoms and neuropsychological deficits. We follow this with evidence supporting the validity of the proposed syndrome, which mainly includes social dysfunction and response to a low dosage of one of the newer antipsychotic medications.

CONCLUSIONS

Continued progress toward the eventual initiation of prevention strategies for schizophrenia will include sustained efforts to validate the traits reflecting a predisposition to develop the disorder (for example, schizotaxia), follow-up studies to confirm initial findings, and the identification of potentially useful preventive interventions.

A systematic review of the use of atypical antipsychotics in autism

Conventional antipsychotic medication is commonly prescribed to patients with autistic spectrum disorder. However, a high incidence of severe adverse reactions highlights the need to find more favourable treatments. Atypical antipsychotics may combine efficacy in ameliorating some autistic symptoms with a lower incidence of some adverse reactions. This article reviews the use of atypical antipsychotics in autistic disorder, with particular focus on behaviour, cognition and physical well-being. Thirteen studies using risperidone, three using olanzapine, one using clozapine, one using amisulpride and one using quetiapine were identified. Few firm conclusions can be drawn due to the limitations of the studies; however, there is an indication that risperidone may be effective in reducing hyperactivity, aggression and repetitive behaviours, often without inducing severe adverse reactions. Olanzapine and clozapine may also be effective; however, there is little evidence for using amisulpride or quetiapine in this population. Randomized trials are required to clarify the effectiveness of these agents.

Paediatric uses of atypical antipsychotics

Antipsychotics are commonly prescribed to children and adolescents. With the relatively recent availability of the atypical antipsychotics, physicians have begun prescribing these agents to young people in the hope of finding safe, effective alternatives to the typical antipsychotics. This report reviews what is currently known about the use of the atypical antipsychotics in young people. Most of the currently available data are based on case reports and case series. The results of only a handful of prospective trials pertaining to the use of the atypical antipsychotics in youths have been reported. Based on the available information, it appears that clozapine has a role in juvenile treatment resistant schizophrenia. When considered as a group, the 'first-line' atypical antipsychotics risperidone, olanzapine and quetiapine appear to have promise as treatments for several neuropsychiatric disorders in young people. These conditions include psychotic, mood, disruptive, movement and pervasive developmental disorders. Unfortunately, as has historically been the case, the demand to address the clinical needs of young patients with neuropsychiatric disorders has outpaced empirically based information. This is particularly important because significant side effects can occur when children or adolescents are treated with atypical antipsychotics. Since there is a paucity of short-term and almost no long-term safety data pertaining to these agents in young people, careful consideration must be made prior to initiating atypical antipsychotic treatment for a child or teenager. Based upon what is known about these agents, a rational approach to the use of these drugs in juveniles is offered.

The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part II: Tactics. Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

Expert consensus methodology was used to develop a medication treatment algorithm for attention-deficit/hyperactivity disorder (ADHD). The algorithm broadly outlined the choice of medication for ADHD and some of its most common comorbid conditions. Specific tactical recommendations were developed with regard to medication dosage, assessment of drug response, management of side effects, and long-term medication management.

METHOD

The consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families developed evidence-based tactics for the pharmacotherapy of childhood ADHD and its common comorbid disorders. The panel discussed specifics of treatment of ADHD and its comorbid conditions with stimulants, antidepressants, mood stabilizers, alpha-agonists, and (when appropriate) antipsychotics.

RESULTS

Specific tactics for the use of each of the above agents are outlined. The tactics are designed to be practical for implementation in the public mental health sector, but they may have utility in many practice settings, including the private practice environment.

CONCLUSIONS

Tactics for psychopharmacological management of ADHD can be developed with consensus.

A double-blind pilot study of risperidone in the treatment of conduct disorder

OBJECTIVE

To examine whether risperidone is superior to placebo in the treatment of youths with conduct disorder.

METHOD

This was a 10-week, randomized, double-blind, placebo-controlled study with 2 parallel arms. Ten youths were randomly assigned to receive placebo and 10 youths were randomly assigned to receive risperidone. Patients were seen weekly throughout the trial. Medications could be increased at weekly intervals during the first 6 weeks of the study from an initial dose of 0.25 mg or 0.50 mg each morning, depending on patient weight. Patients weighing less than 50 kg had a maximum total daily dose of risperidone of 1.5 mg. Patients weighing 50 kg or greater had a maximum total daily dose of risperidone of 3.0 mg. The primary outcome measure was the Rating of Aggression Against People and/or Property Scale.

RESULTS

Risperidone was superior to placebo in ameliorating aggression on most measures. Risperidone was reasonably well tolerated, with none of the risperidone-treated patients developing extrapyramidal side effects.

CONCLUSIONS

These data provide preliminary evidence that risperidone may have efficacy in the treatment of youths with conduct disorder. Because of the small sample size and the brief length of this study, further research is necessary to confirm these findings.