Child and adolescent psychiatrist Dr. Candida Fink discusses the issues surrounding the use of antipsychotics in children and what you should know.
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.
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.
JB: So considering that these are very significant, life-altering, life-changing issues, one would think choosing to use an antipsychotic would not be something taken lightly? And you think they’ve been prescribed too easily in practice?
Dr. Candida Fink: Too easily, meaning too little concern for the severity of side effects, I think… when they first came out [we] didn’t have much knowledge of the longer-term side effects. Some people were like, “Oh, yeah, good, no Parkinson’s, no TD,” and then sort of pulling back from that because they work to reduce agitation. I mean, there is certainly a group of kids, and particularly closer to 18, who have serious mental illness that will benefit from them and need these medications. The equation should always be, when does the risk of not medicating, not choosing this medicine, begin to outweigh the risk of the medicine? We’ve seen children with very disruptive and serious mental illness or neurodevelopmental disabilities that require this level of medication, But I think there has been far too little consideration for the long-term effects in a lot of circumstances.
JB: What about non-medical interventions for conditions that antipsychotics might be used for?
Dr. Candida Fink: When we’re treating children, we think neuro-developmentally, so we have to look at the child in the context of their own body, brain and their development, which is a complex mix of what they came with genetically, risks and vulnerabilities. Also, the environment they grew up in and the supports we can provide them. Trauma is a huge, often unidentified, piece of the history in children who are struggling with serious emotional behavior, dysregulation, aggression, those kinds of things.
The most important thing is both a comprehensive and thorough diagnostic assessment of the child that includes information not just from a child, that includes multiple collateral sources. You are looking for a good developmental story, trying to determine if there’s trauma, and then developing a set of interventions that is comprehensive based on all those things. You need to be looking at their school intervention, you need to look at parents and support, health. There’s a broad range of intervention that needs to be put into place, the parenting education, school education and remediating their learning and language issues before we just say, “Hey, that kid is having a temper tantrum, give him some risperidone.”
JB: So, there’s a combination of pharmaceutical interventions and behavioral therapy as part of the treatment plan. Is the issue that you’ve been seeing is that clinicians are relying a little bit too much on the drugs and not enough on this other piece, which seems that you would need to do in order to really get the best outcomes from treating the child.
Dr. Candida Fink: I do think that there are patterns of inadequate time and energy given to more thorough diagnostics and into the clinic, and that’s for a variety of reasons. One of the patterns that we’ve grown into [is] a separate therapist and separate psychiatrist, which can be beautiful if you’re working together as a team. If no one is talking to each other, then you’re not putting that piece together. Reimbursement is a huge problem. They are paying you $25 for visiting the kid, you know, and you’re talking about an hour with this family. Now I have to spend time on the phone with the school, I have to talk to the therapist, I have to talk to this worker, it’s resource intensive.
I would say that if anyone suggests an antipsychotic and has not met with you or your child for more than 15 minutes, run.
So, there are certainly reimbursement issues, shortage of resources, shortage of enough treaters. There are just enough child psychiatrists to go around. We are trying to make sure that we’re building a profession…of understanding the children medically does not mean, okay, the only answer I have is a pill.
JB: As a parent, if your child’s psychiatrist or doctor suggests an antipsychotic, what are the kind of questions that you want to ask the medical provider, and would you advise them to go for a second opinion if the doctor says your child be should be on an antipsychotic?
Dr. Candida Fink: I would say that if anyone suggests an antipsychotic and has not met with you or your child for more than 15 minutes, run. You need another first opinion. If you have an evaluation and the doctor is recommending [an antipsychotic], the questions you want to understand are, what is your working diagnosis – they may not have a full one, it may be complicated, but okay, talk to me, tell me about your thinking. How does the diagnosis [inform] this medication choice or are there other medications you considered and why you have come to this one?
I want to know potential side effects or how often it would be monitored, can I reach you if I have a problem in between, how long do you think they may need to be on it? Those should be questions that are fair and appropriate to have with the prescriber about those who are going to use it. Even if you have a good evaluation, if you’re not sure, if you don’t feel okay, and you’re still not sure, get a second opinion.