Children and Antipsychotic Medications

Antipsychotics are medications that were developed to help adults with psychosis, a condition that causes a person to lose touch with reality. Antipsychotics reduce the delusions and hallucinations that are common symptoms of psychosis.

But antipsychotic medications have also been proven to be effective at reducing other troubling emotional and behavioral symptoms. And they are being widely prescribed for children as well as adults.

In children and teenagers, antipsychotics are most often used to reduce aggression, irritability, and other disruptive or problem behaviors. They are prescribed for kids on the autism spectrum, or with ADHD, other disruptive behavior disorders, or unspecified behavior issues. 

Antipsychotics are also used to treat kids with OCD and Tourette’s when therapy or other medications haven’t been effective.

Because they can have serious side effects, including weight gain and hormonal, metabolic and neurological changes, use of antipsychotics in children should be carefully considered and closely monitored by a doctor.

Most of the antipsychotic medications prescribed for children are “atypical” or “second-generation” (SGA) antipsychotics. Developed in the 1990s, they’re called “atypical” because, as compared to earlier antipsychotics, they have fewer of a type of side effects that impact motor control and coordination.

All antipsychotic medications work by reducing the level of dopamine — a neurotransmitter that helps regulate mood, behavior, concentration, and movement — in the brain. Neurotransmitters are chemicals that activate receptors on the surface of cells in the brain and elsewhere in the nervous system. They work like a key that unlocks the receptor. 

Antipsychotics are what are called “dopamine receptor antagonists,” meaning that they block dopamine’s ability to activate certain receptors. This reduction of dopamine activation in the brain has been found to not only reduce symptoms of psychosis, but also inhibit hyperactivity, aggression, impulsivity, and other problematic behaviors. Some atypical antipsychotics can also block or activate receptors for the neurotransmitter serotonin, further affecting mood and behavior.

SGAs work within two weeks of starting treatment and reach their full effect in 2-3 months.

Atypical antipsychotic medications include:

• Aripiprazole (Abilify, Aristada)
• Asenapine (Secuado, Saphris)
• Brexpiprazole (Rexulti)
• Cariprazine (Vraylar)
• Clozapine (Clozaril, Versacloz)
• Iloperidone (Fanapt)
• Lumateperone (Caplyta)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa, Lybalvi, Symbyax)
• Quetiapine (Seroquel)
• Paliperidone (Invega)
• Pimavanserin (Nuplazid)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

While these medications all affect neurotransmitters, including dopamine, they each have a unique impact on brain function. That means that if a child doesn’t respond to one antipsychotic, another might work for them. Or if a child experiences troubling side effects on one medication, another might have fewer side effects. 

The most common use of SGAs in kids is to calm down children whose severe behavior problems are making it difficult for them to them to function in school and within their families. This includes kids on the autism spectrum, especially when they reach early adolescence and their aggression may be a danger to other children, their parents and themselves.

Paul Mitrani, MD, a child and adolescent psychiatrist at the Child Mind Institute, lists three reasons why a child might be prescribed an SGA:

• When the child is experiencing psychotic symptoms, which are very rare in kids
• When there is a crisis — acute aggression or irritability or self-harm is causing a risk to the safety of the child or others
• When a child’s behavior is so intense or extreme that they may be unable to go to school or live at home

Risperidone and aripiprazole are the two SGAs that are most often prescribed for children to manage extreme behavior. Both are FDA approved for irritability in children on the autism spectrum; for other kids with behavior issues they are used off-label.

Experts agree that in a noncrisis situation, children should have access to behavioral therapy and parent training, which can reduce problem behavior, before putting them on antipsychotic medication. But the reality is that for many kids those therapeutic alternatives are not available. In that case medication may be seen as a quick, effective, affordable alternative.

For children with ADHD who are taking stimulant medication, antipsychotics are sometimes used to help with behavioral symptoms that are not adequately covered by stimulants. “While stimulants are very effective for treating ADHD, kids will sometimes ‘crash,’ with a return of symptoms after the stimulant wears off, or struggle in the morning before the stimulant starts working,” explains Dr. Mitrani. “If these problems are really interfering with a child’s ability to function, and other medications, like guanfacine, are not effective, we will consider antipsychotics as a way to help them regulate their behaviors better.”

One advantage is that there are antipsychotics that come in liquid form, Dr. Mitrani explains, which makes them easier for kids who have trouble swallowing pills, and makes it possible to deliver smaller doses. “With kids, we want to start at low doses and see how they respond, and liquid medications allow more flexibility to find the best dose for them.”

The first-line treatment for children with OCD is a form of cognitive behavioral therapy called exposure with response prevention (ERP), sometimes combined with an antidepressant medication (usually an SSRI). But antipsychotic medications are sometimes added to the mix to help mitigate obsessive thoughts. “An antipsychotic can help improve flexibility,” Dr. Mitrani explains, “when you’re stuck on these negative thoughts, whether they’re hallucinations, in schizophrenia, or obsessions, in OCD. It can reduce the stickiness of those intrusive thoughts.”

The first-line treatment for children with Tourette’s syndrome is therapy called comprehensive behavioral intervention for tics (CBIT). But if that doesn’t prove effective, and the tics are causing distress or interfering with the child’s functioning, the use of an SGA may be recommended. Dopamine, which is blocked by antipsychotic medications, has been strongly linked with Tourette’s.

Both risperidone and aripiprazole have been shown to be effective for reducing tics and are widely used. Aripiprazole has been approved by the FDA for Tourette’s. Risperidone is used off-label.

The rates and severity of side effects differs among these medications. And while they may occur at the beginning of treatment, they may also develop after sustained use. “The adult studies have shown,” Dr. Mitrani notes, “that the longer you’re on a antipsychotic and the higher the dose, the more likely that you may have those side effects. But they can also happen at initiation.”

Here is a summary of major side effects:

Weight gain:  SGAs often cause significant weight gain. The amount of weight gain varies with different medications. According to the American Association of Child and Adolescent Psychiatry (AACAP), the largest weight gain appears to be with clozapine and olanzapine, and significant weight gain occurs with risperidone and quetiapine. Aripiprazole and ziprasidone appear to have the lowest propensity for weight gain. Some studies suggest that SGA-associated weight gain may be greater in young people than in adults.

Metabolism effects: SGAs can cause what are called “metabolic abnormalities,” including high blood sugar (hyperglycemia) and high cholesterol (hyperlipidemia) and a rise in other lipids and triglycerides. These can increase the risk of developing diabetes and heart disease. 

Hormonal effects: Antipsychotics can affect the body’s levels of the hormone prolactin. In girls, high prolactin levels (hyperprolactinemia) can affect fertility and cause missed periods and leaky discharge from breasts. In boys, it can cause infertility and breast growth, called gynecomastia, which does not disappear if they stop taking the medication. Of the SGAs, risperidone shows the greatest increase in prolactin levels and aripiprazole the least.

Neurological effects: Another set of possible side effects includes something called “tardive dyskinesia,” which is characterized by repetitive, involuntary movements, including facial grimaces. The risk of tardive dyskinesia increases with the dose and duration of the treatment, and it can be permanent. The risk of neurological side effects is greatest with risperidone, ziprasidone, and aripiprazole.

Heart and circulatory problems: Antipsychotic drugs can alter the heart’s rhythm and cause orthostatic hypotension, which is a drop in blood pressure when a person stands or sits up quickly that can make them fall or pass out.

Because these side effects can be serious, AACAP recommends that children going on an antipsychotic should have baseline measures of vital signs, including body mass index, blood pressure, and glucose levels to rule out heart and other health problems that could be exacerbated by the medication. Dr. Mitrani also includes liver and thyroid function tests.

Weight and lab tests should be done at baseline (before starting medication) and labs should be repeated 3 months after starting, Dr. Mitrani advises. They should be repeated at intervals of at least once a year after that — more frequently if any labs come back abnormal and the family wants to continue with the medication, which they may do if they are trying to alleviate them by modifying diet and exercise. “With these side effects, the earlier you catch them the better,” Dr. Mitrani notes. “You can take the child off the medication, try something different, or even start a medication that hopefully mitigates side effects if the medication is helping.”

Dr. Mitrani reports that there are studies showing that some medications such as metformin (a diabetes medication), can help reduce the metabolic side effects of SGAs — weight gain, increased cholesterol, risk of diabetes. “We also emphasize the benefits of healthy diet choices and exercise,” he adds, “and will sometimes refer families to a nutritionist.”

When these medications are used to stabilize a child in crisis, they are typically used for a period of months, Dr. Mitrani explains, so that other interventions can be put into place to address the underlying problems. Otherwise, the risk is high that the problem behavior will recur when the medication is withdrawn. “Three months of stability gives the child, the parents, and the school time to make some changes,” he adds, “so that hopefully when they come off the medicine, the improvement is sustained.”

Some children take SGAs indefinitely, including kids on the autism spectrum who might otherwise need residential care. When they are used long-term, they should be monitored at least every 3 months if they’re stable, Dr. Mitrani advises, “but more frequently if symptoms continue or worsen, since we want to avoid hospitalization or needing to be placed outside of the home.”

Atypical antipsychotic medications should not be abruptly discontinued unless a severe and/or dangerous side effect has developed. Taking a child off antipsychotic medication should be gradual, with close monitoring by a doctor.

A child who abruptly stops taking the medication is at risk for something called, “withdrawal dyskinesia,” which causes involuntary movements of the face, arms, and legs, including jerking and grimacing. The movements are worse when the child is stressed or anxious. In most cases withdrawal dyskinesia will subside without treatment in 1–2 months. But if the movements are causing the child distress, a psychiatrist may  recommend that the antipsychotic be restarted and tapered gradually over 1–3 months.

Since the medication has been effectively reducing problematic symptoms, its abrupt discontinuation can destabilize the child and cause a return of the behavior.