Antipsychotic medications for children and adolescents

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.

Trends in antipsychotic drug use by very young, privately insured children

OBJECTIVE

This study describes recent trends and patterns in antipsychotic treatment of privately insured children aged 2 through 5 years.

METHOD

A trend analysis is presented of antipsychotic medication use (1999-2001 versus 2007) stratified by patient characteristics. Data are analyzed from a large administrative database of privately insured individuals. Participants were privately insured children, aged 2 through 5 years, with 12 months of continuous service enrollment in 1999-2001 (N = 400,196) or 2007 (N = 755,793). The main outcomes are annualized rates of antipsychotic use and adjusted rate ratios (ARR) of year effect on rate of antipsychotic use adjusted for age, sex, and treated mental disorder.

RESULTS

The annualized rate of any antipsychotic use per 1,000 children increased from 0.78 (95% confidence interval [CI] 0.69-0.88) (1999-2001) to 1.59 (95% CI 1.50-1.68) (2007) (ARR 1.76, 95% CI 1.56-2.00). Significant increases in antipsychotic drug use were evident for boys (ARR 1.66, 95% CI 1.44-1.90) and girls (ARR 2.26, 95% CI 1.70-3.01) and for children diagnosed with several different psychiatric disorders. Among antipsychotic-treated children in the 2007 sample, pervasive developmental disorder or mental retardation (28.2%), attention deficit/hyperactivity disorder (ADHD) (23.7%), and disruptive behavior disorder (12.9%) were the most common clinical diagnoses. Fewer than one-half of antipsychotic-treated young children received a mental health assessment (40.8%), a psychotherapy visit (41.4%), or a visit with a psychiatrist (42.6%) during the year of antipsychotic use.

CONCLUSIONS

Despite increasing rates of antipsychotic use by very young children, provision of formal mental health services remains sparse. These service patterns highlight a critical need to improve the availability of specialized and well integrated mental health care for very young children with serious mental health problems.

Paediatric atypical antipsychotic monitoring safety (PAMS) study: pilot study in children and adolescents in secondary- and tertiary-care settings

BACKGROUND

In the UK, treatment with antipsychotic medications for children is usually initiated by specialists in secondary care. Recent studies have shown an increase in the prescribing of atypical antipsychotics in children. The severity of possible adverse effects to antipsychotics in adults has lead to awareness of the importance of investigating the potential adverse effects of these agents in children. Additionally, there have been many reports proposing that the newer atypical antipsychotics are associated with many of the same adverse effects seen with the older generation drugs in children. The aim of the Paediatric Atypical Antipsychotic Monitoring Safety (PAMS) study was to determine the feasibility of conducting a prospective targeted pharmacovigilance study to monitor adverse drug reactions (ADRs) associated with atypical antipsychotic therapy in children seen in secondary- and tertiary-care settings.

METHODS

Participants were identified from the clinical members of the UK Paediatric Psychopharmacology Groups in London and the West Midlands. Participating clinicians reported the number of patients (aged<or=18 years) taking atypical antipsychotic treatment who were under their care and any reportable ADRs experienced by these patients during the period September 2006-September 2007. Participants contributed data via password protected online data collection forms.

RESULTS

A total of 35 clinicians consented to participate in the study. However, data from 22 of the participating clinicians were excluded because of incomplete reporting. Data from the remaining 13 (37%) clinicians were eligible for the final analysis. There were 281 patients who received atypical antipsychotic treatment under the care of the 13 participating clinicians. From these 281 patients, 40 ADR reports (0.14 ADR reports per patient; 95% CI 0.10, 0.19) from 37 patients were entered into the database. Of the 37 patients, 13 experienced more than one ADR, bringing the total number of ADRs to 56 (0.20 ADR per patient; 95% CI 0.15, 0.25). The most commonly reported ADRs were weight gain, extrapyramidal symptoms and hyperprolactinaemia. Rare ADRs, including neuroleptic malignant syndrome, were also reported. The durations of atypical antipsychotic drug exposure were recorded for 54 of the 56 ADRs reported. The median duration of exposure was 42 days (interquartile range 23.25-90 days).

CONCLUSIONS

Our study demonstrates that a clinician-based targeted pharmacovigilance study on atypical antipsychotics in children provides useful qualitative data. However, this pilot study raised many methodological issues, which should be addressed for the study to be extended nationally. Specifically, significant funding is needed to improve the reporting rate and the overall data obtained. Furthermore, the study yielded a very high incidence of serious ADRs, thus supporting the need for a larger and improved pharmacovigilance study to evaluate the safety of atypical antipsychotics in children.

A non-randomized, open study with aripiprazole and ziprasidone for the treatment of aggressive behavior in youth in a community clinic

Forty-six patients (36 male, mean age 11.9 +/- 2.6) with a variety of diagnoses and with significant aggressive behavior were treated in an open, non-randomized fashion with Aripiprazole or Ziprasidone. Patients were diagnosed with the Mini International Neuropsychiatric Interview and the Child/Adolescent Symptom Inventory. The primary outcome measure was the Overt Aggression Scale (OAS). After 2 months, 34 patients were still in treatment. The average improvement of the OAS in these 34 patients was 63%. Clinical Global Impression-Improvement Scale was 2.1 +/- 1.2. Neither at baseline, nor at 2 months, were there any statistically significant differences between the Aripiprazole and Ziprasidone groups. Sedation was the most common side effect.

Side effects of second-generation antipsychotics: the experiences, views and monitoring practices of Australian child psychiatrists

OBJECTIVE

The aim of this study was to ascertain the experiences, views and monitoring practices of Australian child psychiatrists regarding the metabolic and other side effects of second-generation antipsychotics (SGAs).

METHOD

A 19-item questionnaire was posted to all members of the RANZCP Faculty of Child and Adolescent Psychiatry living in Australia.

RESULTS

Of the 290 eligible members of the Faculty of Child and Adolescent Psychiatry, 126 (43%) returned a useable survey. SGAs are commonly prescribed for a range of disorders. The majority of respondents expressed a high level of concern regarding weight gain and other metabolic side effects. Weight gain was the most frequently observed and monitored side effect in clinical practice. Other side effects were observed and monitored to a variable extent. Notably, monitoring practices did not parallel psychiatrists' reported level of concern or knowledge regarding weight gain and metabolic side effects,nor coincide with published recommendations.

CONCLUSIONS

Further research is required into the use, efficacy, side effects and monitoring of SGAs in children and adolescents, and there is a need to ensure that monitoring guidelines are implemented in clinical practice. This need is heightened by the likelihood that our data on clinicians' practice, which is based on their perceptions, may overestimate what actually occurs.

The use of antipsychotic medication in child and adolescent psychiatric treatment in Denmark. A cross-sectional survey

The number of children and adolescents with psychiatric disorders being treated with antipsychotic medication is increasing significantly; however, only a limited evidence-base is available on this topic, especially when children are concerned. This study reports and discusses the use of antipsychotic medication in children and adolescents below 19 years of age in Denmark. A national cross-sectional survey registered the use of antipsychotic drugs on a given date. A questionnaire was sent to all child and adolescent psychiatric departments and all consultants in child and adolescent psychiatry throughout the country. All children and adolescents, aged 0-18 years, registered in treatment with antipsychotic medication, were included. Sixty-seven per cent of clinics and 63% of consultants participated. The total number of subjects registered in examination or treatment in the participating units was 3854. Antipsychotic medication was used in n=244 (6.4%) of these cases. Eighty-eight patients received additional medication, of which 24% received antidepressants, 8% sedative medication and 4% psychostimulants. The age of the patients was 4-18 years, and 63% was male. The most frequent diagnoses for patients in antipsychotic treatment were: schizophrenia, schizotypal disorder, autism spectrum disorders and personality disorders. Monotherapy was used in 87% of cases. Sixty-four per cent of patients treated with antipsychotics, received a second-generation antipsychotic as the main treatment. All 244 patients received one or more additional treatment modalities other than medication. Antipsychotic medication has a definite role in the treatment of children and adolescents with psychiatric disorders. Second-generation antipsychotics used as monotherapy prevail.

Clinical effectiveness of quetiapine in children and adolescents with Tourette's syndrome : a retrospective case-note survey

BACKGROUND AND OBJECTIVE

Tourette's syndrome is a relatively common biological genetic disorder with a broad spectrum of neurobehavioural manifestations. Unfortunately, treatment of the condition is often unsatisfactory and all available drugs are associated with potential adverse effects. We therefore aimed to investigate the efficacy of quetiapine, a newer atypical antipsychotic, in the treatment of children and adolescents with Tourette's syndrome.

METHODS

This was a retrospective study carried out in outpatient clinics. Twelve patients aged 8-18 years with Tourette's syndrome (diagnosed according to Diagnostic and Statistical Manual IV criteria) who were receiving quetiapine therapy and had no diagnosis of epilepsy, major depression or psychotic disorder, were included in the study. The main outcome measure was the Yale Global Tic Severity Scale (YGTSS) score.

RESULTS

The initial dose of quetiapine was 25 mg/day, but the mean dose was increased to 114.6 +/- 51.6 mg/day and 175.0 +/- 116.8 mg/day at the fourth and eighth weeks of treatment, respectively. The YGTSS score, which was 21.6 +/- 4.0 at baseline, showed significant decreases at 4 and 8 weeks (reducing to 7.5 +/- 7.4 and 5.6 +/- 8.1, respectively; p < 0.003). Routine laboratory parameters and serum prolactin level were all normal and did not change throughout treatment. Mild but significant increases in both bodyweight and body mass index at 4 and 8 weeks compared with baseline were observed.

CONCLUSION

Other than causing mild weight gain, quetiapine appears to be an effective, safe and well tolerated drug in children and adolescents with Tourette's syndrome.

Trends in the use of typical and atypical antipsychotics in children and adolescents

OBJECTIVE

To estimate prevalence rates of antipsychotic use in children and adolescents from 1996 to 2001 in three state Medicaid programs (midwestern [MM], southern [SM], and western [WM]) and one private managed care organization (MCO).

METHOD

Prescription claims were used to evaluate antipsychotic prevalence, defined as the number of children and adolescents up to the age of 19 years with at least one prescription claim for an antipsychotic per 1,000 enrolled youths.

RESULTS

From 1996 to 2001, the prevalence of total antipsychotic use increased in each program (MM: 4.7 to 14.3 per 1,000; SM: 6.3 to 15.5; WM: 4.5 to 6.9; and MCO: 1.5 to 3.4). Typical antipsychotic use decreased (MM: 3.7 to 2.0 per 1,000; SM: 4.6 to 1.5; WM: 4.4 to 1.3; and MCO: 1.2 to 0.9), while atypical antipsychotic use dramatically increased (MM: 1.4 to 13.1 per 1,000; SM: 2.5 to 14.9; WM: 0.3 to 6.2; and MCO: 0.4 to 2.7).

CONCLUSIONS

The increased prevalence of antipsychotic use in children and adolescents from 1996 to 2001 was attributed to increased use of atypical antipsychotics. Given the limited data with atypical antipsychotics in youths, this emphasizes the need for additional studies of these agents and other treatment modalities in this population.

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.

Pediatric quetiapine overdose: a case report and literature review

Quetiapine is a medication approved for the treatment of psychotic disorders in adults. At this time it is not approved for the treatment of children or adolescents. It is an atypical antipsychotic agent that is efficacious in treating both the positive and negative symptoms of schizophrenia. There is currently little information available concerning the safety of quetiapine in overdose, and there are no previous case reports of quetiapine overdose in the pediatric population. We present the case of a 15-year-old girl who ingested 1250 mg of quetiapine (21.6 mg/kg) in a suicide attempt. She developed multiple symptoms including tachycardia, agitation, hypotension, and unconsciousness. We compare her symptoms to previous adult cases of quetiapine overdose and review overdose treatment recommendations. We also examine clinical situations that may lead to a more severe clinical course.

A case series of eight aggressive young children treated with risperidone

The aim of this study was to examine the use of risperidone in routine clinical care for very aggressive young children. This is a retrospective medical chart review of patients age less than 6 years 11 months who were treated with risperidone for 1 to 10 months during the 1-year study period. Treatment response, side effects, and Clinical Global Impression (CGI) scores were identified. One hundred and five such young children were identified; 8 had been treated with risperidone (6 boys, 2 girls: mean age 4.9 +/- 0.8 years). Risperidone was used in combination with other psychotropic medications in 7 of the 8 children. The mean daily dose of risperidone was 1.25 +/- 0.27 mg. Seventy-five percent of the children were on concomitant lithium, valproate, or carbamazepine; 63% were on stimulants or alpha adrenergics. This was a highly comorbid group, with 7 children presenting with attention deficit hyperactivity disorder and 5 children with bipolar disorder not otherwise specified. The average baseline CGI severity was 5.5 (SD = 0.5), and at last visit it was 3.5 (SD = 0.5), p < 0.0001. Mean CGI improvement score was 1.9 (SD = 0.6). Adverse effects included significant weight gain (mean 5.5 +/- 4.9 kg, p < 0.05) in 6 patients. One child had hyperprolactinemia. Given the potential development of atherosclerosis in obesity and endocrine response in hyperprolactinemia, risperidone should be reserved for those children with severe aggressive behavior who failed multiple trials with other agents. Further controlled trials are needed.

Trends in antipsychotic use in a Texas medicaid population of children and adolescents: 1996 to 2000

The purpose of this study was to examine the current trends in prescribing antipsychotics to children and adolescents within the Texas Medicaid Program. Total enrollments of children and adolescents, ranging from infants to 19-year-olds, in the Texas Medicaid Program were determined for each calendar year from 1996 to 2000. Prevalence was defined as the number of children and/or adolescents with at least one Medicaid prescription claim for an antipsychotic per 1,000 enrollees. Trends in prevalence were assessed over a 5-year period using annual descriptive analyses. In addition, total expenditures for antipsychotics were evaluated within this population. Over the 5-year period, an additional 12.25 children and adolescents per 1,000 enrollees (+160%) were prescribed antipsychotics. The prevalence of atypical antipsychotics increased by 13.29 per 1,000 enrollees (+494%) over the same period. In children and adolescents above 2 years of age, the prevalence of antipsychotic use increased in all groups. Antipsychotic usage was more common in children and adolescents between the ages of 10 and 14 years compared to other age groups. Male and female antipsychotic prevalence rates increased during the 5-year period. The increase in total expenditures was related to the increased utilization of atypical antipsychotics.

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Aims and method

All child and adolescent psychiatrists and community paediatricians in the former Trent Region were surveyed about their antipsychotic prescribing practice during 1 year, including monitoring, and whether they would like consensus guidelines on prescribing and monitoring of antipsychotics in children and adolescents.

Results

The majority (88%) of child psychiatrists and 33% of paediatricians had prescribed atypical antipsychotics, most commonly risperidone. Only two psychiatrists had prescribed a typical antipsychotic and no paediatrician had done so. Challenging behaviour in developmental disorders was the most common indication for atypicals. Both child psychiatrists and paediatricians prescribed atypicals for non-psychotic developmental disorders, whereas prescribing for psychosis occurred almost exclusively among psychiatrists. Height, weight and blood pressure were routinely monitored, but waist circumference was rarely measured and there was wide variation in the monitoring of other parameters such as blood glucose, prolactin and extrapyramidal side-effects. Three-quarters of the participants felt there was a need for guidance on prescribing and monitoring atypical antipsychotic therapy.

Clinical implications

The greater prescription of antipsychotics by child and adolescent psychiatrists may reflect differences in case-load and training. Routine monitoring of adverse effects is inconsistent among prescribers. The survey highlights the need for training and guidance on prescribing and monitoring of atypical antipsychotic use in children and adolescents.