The Use of Antipsychotic Medications in Children

Jill Littrell, PhD
30
1937

Increasing Use of Antipsychotic Medications

Mark Olfson and colleagues have been monitoring the use of antipsychotic medications for the treatment of children over many years.  Since the mid-1990s antipsychotic medications have been increasingly prescribed for children, adolescents, and adults (Correll & Blader, 2015; Littrell, 2015).  In the most recent report, Olfson, King, and Schoenbaum (2015) find a small reduction in the use of antipsychotics for younger children from 2006 to 2010, but an increase in use for older children from 2006 to 2008.  According to the report, “The percentages of young people using antipsychotics in 2006 and 2010, respectively, were 0.14% and 0.11% for younger children, 0.85% and 0.80% for older children, 1.10% and 1.19% for adolescents, and 0.69% and 0.84% for young adults.” (p.867.)

Antipsychotics Are Primarily Used for Behavioral Control in Young Children

In an editorial discussing the Olfson et al. publication, Correll and Blader (2015) indicated that antipsychotic drugs have received FDA approval for only schizophrenia, bipolar mania, irritability associated with autism, and Tourette syndrome in children.  Correll and Blader noted that most of the prescriptions of antipsychotics for children reported by Olfson et al. were for conditions which had not been approved by the FDA (called off-label use).  Olfson et al. reported that for younger children those receiving antipsychotic medications most often carried a diagnosis of ADHD with aggression and/or disruptive behavior disorders.  For adolescents, most carried a diagnosis of depression.  Less than 25% of the children being treated with antipsychotics were receiving any type of talk therapy or family instructions on behavioral control.

Horrendous Side Effects of Antipsychotic Medications

Antipsychotic drugs all share the property of blocking dopamine receptors.  They have very significant side effects.  Their use has been questioned for even the conditions for which they were initially designed to treat (see below).

  • Antipsychotic drugs, particularly the second generation antipsychotics such as risperidone, olanzapine, Seroquel cause weight gain that does not plateau.  They induce diabetes and increase fats in the blood such that risk of heart disease is greatly increased.  Children are much more sensitive to these effects (Correll & Blader, 2015)
  • Antipsychotics induce breast development in boys (references in Chapter 6 of Littrell)
  • Antipsychotics induce hormonal changes associated with osteoporosis (decreased bone strength) (references in Chapter 6 of Littrell)
  • Some second generation antipsychotics induce cardiac arrhythmias that are associated with risk of sudden death (references in Chapter 6 of Littrell)
  • Antipsychotics induce the expression of more dopamine receptors to which dopamine will bind more avidly such that after removal rebound psychosis might ensue (Grace, 2012; Seeman et al., 2005)
  • Antipsychotics induce dystonia or involuntary movement disorders which can make walking and locomotion almost impossible; dystonia occurs immediately upon antipsychotic initiation in about 15.7% of persons (Ballerini, Bellin, Niccolai, Pieroni, Ferrara, 2002); antipsychotics also can induce a second type of motor problem which is similar to the motor problems seen in those with Parkinson’s disease, although second generation antipsychotics are less likely to induce these effects (See Chapter 6 in Littrell, 2015)
  • Antipsychotics have been shown in primates to reduce the volume of the brain by significant amounts (Dorph-Petersen et al., 2005; Konopaske et al., 2007).  Brain volume reduction has also been shown in people as well (Fusar-Poli et al., 2013; Ho, Andreasen, Ziebell, Pierson, & Magnotta, 2011).  In terms of mechanism through which antipsychotics might reduce brain volume, recent research suggests that these drugs induce activation of white blood cells in the cortex (Cotel et al., 2015).


Concurrent Use of Antipsychotics with Other Medications

According to the Olfson et al. (2015) report, many children prescribed antipsychotic medications were concurrently prescribed other classes of medication in addition to their antipsychotics.  For small children, 58.7% were also receiving stimulants; for older children 68.7% were receiving concurrent stimulants; for older adolescents, 59.1% were receiving concurrent antidepressants.  Poly-pharmacy is alarming because drugs are evaluated for safety individually.  Little information is available regarding the safety of various drug combinations.

Not only is poly-pharmacy an adventure into the land of the unknown with regard to safety, but knowledge regarding the mechanism of action of various drugs introduces wonderment over the rationale for the combinations being used in the treatment of children.   The current combinations of drugs being used to treat children are totally irrational.   Stimulants increase the release of dopamine, while antipsychotics block dopamine receptors that will receive the dopamine or serotonin message.  The purported mechanism of action of antidepressants is increasing the availability of serotonin, which will be countered by the action of the atypical antipsychotic, which block serotonin receptor (Loy et al., 2012).  Again, it makes no sense to increase a neurotransmitter and then block its action.

Rather than having a theoretical basis for the use of antipsychotics, the current use of antipsychotics is based on the limited findings from 8 studies that they decrease aggressive behavior.  The Cochrane Review (Loy et al., 2012) concluded that

“There was some evidence of limited efficacy of risperidone in reducing aggression and conduct problems in children and youths (aged 5 to 18 years) with disruptive behavior disorders in the short term (four to 10 weeks) from a small number of studies in which there was some risk of bias of overestimating the true intervention effect” (p. 19.)


Irony that Antipsychotics Are Being Questioned for Use in Those Who Have Psychosis

Antipsychotics are able to significantly reduce auditory hallucinations in those with psychosis.  However, even for those with psychosis, antipsychotic use is being questioned.  Long term studies find that those who are not medicated have better long term functional recovery (employment and social relationships) than those who are medicated (Harrow, Jobe, & Faull, 2012; Wunderink et al., 2013, see discussion in Chapter 6 of Littrell, 2015).  It’s ironic that while antipsychotics are being questioned for the population for which they were initially named, they are being extended for use in new populations.

Alternatives to Antipsychotics for the Treatment of Aggression/Disruptive Behavior in Children

Physicians may feel compelled to prescribe because they are motivated to decrease the distress in families who are raising difficult children. However, alternatives to antipsychotics, without the horrendous side-effects, are available.  Omega-3s have been shown to improve aggressive behavior in children (Raine, Portnoy, Liu, Mahoomed, & Hibbein, 2015).  With regard to the older children treated for depression with antipsychotics, omega-3s, exercise, and meditation all ameliorate depression (see Chapter 4 in Littrell, 2015).

Perhaps, today’s physicians need to remember the admonition: “First, do no harm”?

* * * * *

References:

Ballerini, M., Bellin, S., Niccolai, C., Pieroni, V., & Ferrara, M.  (2002).  Neuroleptic-induced dystonia: incidence and risk factors.  European Psychiatry, 17 (6), 366-368.

Correll, C. U., & Blader, J. C.  (2015).  Antipsychotic use in youth without psychosis:  a double-edged sword.  JAMA Psychiatry, 72(9), 859-860.

Cotel, M-C., Lenartowicz, E. M., Natesan, S., Modo, M. M., Cooper, J. D., Williams, S. C. R., Kapur, S., & Vernon, A. C.  (2015).  Microglial activation in the rat brain following chronic antipsychotic treatment at clinically relevant doses.  European Neuropsychopharmacology, http://dx.doi.org/10.1016/j.euroneuro.2015.08.004.

Dorph-Petersen, K. A., Pierri, J. N., Perel, J. M., Sun, Z., Sampson, A. R., & Lewis, D. A.  (2005).  The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation:  A comparison of haloperidol and olanzapine in macaque monkeys.  Neuropsychophramacology, 30(9), 1649=1661.

Fusar-Poli, P., Smieskova, R., Kempton, M. J., Ho, B. C., Andeasen, N. C. & Borgwardt, S.  (2013).  Progressive brain changes in schizophrenia related to antipsychotic treatment:  A meta-analysis of longitudinal MRI studies.  Neuroscience and Biobehavioral Reviews, 37(8), 1680-1691.

Grace, A. A. (2012).  Dopamine dysregulation by the hippocampus: implications for the pathophysiology and treatment of schizophrenia.  American Journal of Psychiatry, 161(9), 1750-1780.

Harrow, M., Jobe, T. H., Faull, R. N.  (2012).  Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime?  A 20-year longitudinal study.  Psychological Medicine, 42(10), 2145-2155.

Ho, B. C., Andreasen, N. C., Ziebell, S., Pierson, R., & Magnotta, V.  (2011).  Long-term antipsychotic treatment and brain volume:  a longitudinal study of first-episode schizophrenia.  Archives of General Psychiatry, 68 (2), 128-137.

Konopaske, G. T., Dorph-Petersen, K. A., Pierri, J. N., Wu, Q., Sampson, A. R., & Lewis, D. A.  (2007).  Effect of chronic exposure to antipsychotic medication on cell numbers in the parietal cortex of macaque monkeys.  Neuropsychopharmacology, 32 (6), 1216-1223.

Loy, J. H., Merry, S. N., Hetrick, S. E., & Stasiak, K.  (2012).  Atypical antipsychotics for disruptive behavior disorders in children and youths.  Cochrane Database System Review, doi: 10.1002/14651858.CD008559.pub.2.

Olfson, M., King, M., & Schoenbaum, M.  (2015).  Treatment of young people with antipsychotic medications in the United States.  JAMA Psychiatry, 72 (9), 867-874.

Raine, A., Portnoy, J., Liu, J., Mahoomed, T., & Hibbeln, J. R.  (2015).  Reduction in behavior problems with omega-3 supplementation in children aged 8-16 years:  a randomized, double-blind, placebo-controlled, stratified, parallel-group trial.  Journal of Child Psychology and Psychiatry, 56 (5), 509-520.

Seeman, P., Weinshenker, D., Quirion, R., Srivastava, L. K., Bhardwaj, S. K., Grandy, D. K., . .. Tallercio, T.  (2005).  Dopamine supersensitivity correlates  with D2high states, implying many paths to psychosis.  Proceedings of the National Academy of Sciences, 102(9), 3513-3518.

Wunderink, L., N., Nieboer, R. M., Wiersma, D., Sytema, S.  & Nienhuis, F. J.  (2013).  Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy:  long-term follow-up of a 2-year randomized clinical trial.  JAMA Psychiatry, 70 (9), 913-920.

30 COMMENTS

  1. Hi Jill,

    Excellent review of the facts about anti-psychotics. It is clear that these drugs are being used for off-label prescriptions in children. Using these drugs for behaviour problems ends up with the child being blamed for the complex family and social issues that can lead to behaviour problems. The psychological ramifications of a child being labelled and being forced to take medication cannot be neglected. As well, one has to be concerned with any prescriptions to children about the effects on the developing brain. Anti-psychotics can also have serious effects on cognition in many people.
    One problem with allowing the use of these medications for on-label prescriptions is that it is very easy within the structure of the DSM to stick a label on almost any child. Thus “bipolar” has become a fad diagnosis, applied to anyone who has mood changes. As children in difficult circumstances will almost always have variable moods, it is very easy for a physician to justify the use of medication with these kinds of diagnoses.
    There needs to be a ban on these medications in children, except perhaps under extreme circumstances within psychiatric hospital settings. It is just too easy for a doctor to reach for a prescription pad when confronted with complex issues.

  2. Thanks you so much for this review and for emphasizing that antipsychotic use is questioned even for those with psychosis. I find that even many people who are so upset about the overuse of antipscychotic medication for children and adolescents, still fail to understand the potential horror if these medications do indeed give the severely ill less of a chance of recovery.

  3. Dr. Littrell:

    I agree with Sa. Often, people like you who point out the absurdity of the explosion of polypharmacy and off labeling prescribing of ‘anti-psychotics’ involving children on the basis that their brains are still developing fail to point out the absurdity of using ‘anti-psychotics’ to treat psychosis or mania, bi-polar etc. You are one of the first advocates to question the use of neuroleptics for all people, not just children. It makes me uncomfortable when people only advocate for less off label prescriptions.

    Everyone’s brain is still developing! Neuroplasticity is possible for all age groups. I’ve personally seen my 25 year old daughter decline cognitively and become horribly ‘locked in’ (i.e. addicted) to these neuroleptics while ridiculous new drugs were added to her cocktail to counter the horrific side effects. I think we should either use the term neuroleptic when referring to this class of drugs or use quotation marks around the term ‘anti-psychotics’ to remind readers that this term is a marketing term and has no basis in scientific fact. This class of drugs in no way, ‘cures’ psychosis; in fact they often make psychosis worse, as with my daughter. They cause dissociation and diminish a person’s executive functioning, the part of the brain which one so desperately needs to make judgements about what is real and what is not and what kind of behavior is warranted. Is is possible for people to pass legislation that would put this class of drugs in a new legal category so they are harder to prescribe, not just for children but for all people? The longer people are on high doses of neuroleptics, the greater the risk that they will enjoy a full recovery, or is that the hidden agenda of psychiatry, to keep an entire population of customers dependent on psychiatric care?

    • madmon and sa,
      I think that the abuse of medicating in children has other implications, besides the issue of influencing negatively brain plasticity or general development: a “few little drops” at 4 years of age, became a substantial dose at 12/14, and tolerance and cumulative effects are hence for life. Somebody should do a naturalistic study on this
      I also think that the issue of leverage with the enormous impact that it has on informed consent is much greater on children particularly if they are learning disabled: either he takes the medication or he will be excluded, not just said but acted in many ways to obtain a result which leads sooner or later to stigma, and reprisals like exclusion..
      And the issue of off-label prescribing is a red herring. In fact antipsychotics which are prescribed in autism, where the evidence that there are some brain abnormalities is strong, do not stop causing a lowering of epileptic thresholds, or dysphagias, o diabetes etc because they are prescribed on-label, on the contrary.
      On the question of ceasing to call anti-psychotics by that name, I strongly disagree: They called them that name and they should respond for their use when there is not psychosis and for the doubtful effectiveness when there is. Calling them neuroleptics is hiding the felony-

    • You are right madmom, we should be considering all people not just children and adolescents. I am so grateful for all the research and work that is being done in the area of neuroplasticity of the brain.

      Your daughter is one of the young people I I continue to keep in my thoughts and hopes for a successful recovery. For me I am starting to believe there is more strength and resilence inside my loved one then I can actually see in terms of outside behaviour….

  4. “There was some evidence of limited efficacy of risperidone in reducing aggression and conduct problems in children and youths (aged 5 to 18 years) with disruptive behavior disorders in the short term (four to 10 weeks) from a small number of studies in which there was some risk of bias of overestimating the true intervention effect”

    honestly, I don’t care if they reduce aggressive behaviour or not You know what also reduces aggressive behaviour? Beating someone to unconsciousness. It also reduces all the other behaviours and that’s also what the anti-psychotics do. They turn people into unmoving, unfeeling zombies. It’s sick to do that to anyone. These drugs should be banned for children.

  5. Jill,

    Great summary of the issues and attendant literature. I’m glad that you mentioned the absurdity of increasing dopamine (or serotonin) on the one hand and then blocking its activity when the increase causes problems. The one aspect I’d like to highlight is that stimulants and/or antidepressants often CAUSE the very symptoms that are then identified as “bipolar disorder” or “psychotic disorder NOS” and then “treated” with antipsychotics. Working with foster youth, I’ve seen many, many kids who were started on stimulants and then became aggressive as a result, and instead of stopping or decreasing the stimulants, they get a new diagnosis and a prescription for Abilify or Risperdal. It does not surprise me that a significant majority of the kids taking antipsychotics are on stimulants. It is very likely that absent the stimulants, the “aggression” being treated with the “antipsychotics” would not even be an issue.

    It is hard to overstate my frustration with this particular brand of criminal activity on the part of the psychiatric profession.

    — Steve

    • It could not be more obvious that it is the behavior of psychiatrists that needs to be controlled . Maybe if there was an organization like say the Society Dedicated To Force Feed Neuroleptics To Psychiatrists and Pharma Executives (so they could better understand firsthand what misery and damage they are creating) these merciless pseudo educated behavior control specialists posing as health angels of mercy would have more incentive to control their own unacceptable behavior. They may even become anti-psychiatry . Certainly we hope they would learn to stop forcing their “treatments ” on adults and children .
      Also mandating insurance availability to cover Traditional Naturopathy, Homeopathy , And energy healing systems like YuenMethod could also make available real healing systems for suffering humanity to freely choose them if they need. Otherwise see the movie “Ethos” on Netflix for some accurate related analysis.
      Common sense says continuing to harm children will eventually come back on those that do it , and there is no place to hide.

  6. Peter Breggin, who is a lifelong libertarian, now believes that we should be working towards a ban on psychiatric drugs for children. Enough said.

    I believe that fish oil/omega-3 and other alternative ‘treatments’ will prove to be useless and a distraction from the real issues – the quality of children’s lives.

  7. Jill,

    I’d also like to point out that the neuroleptics can actually create both the negative and positive symptoms of “schizophrenia:”

    “Neuroleptic induced deficit syndrome is principally characterized by the same symptoms that constitute the negative symptoms of schizophrenia—emotional blunting, apathy, hypobulia, difficulty in thinking, difficulty or total inability in concentrating, attention deficits, and desocialization. This can easily lead to misdiagnosis and mistreatment. Instead of decreasing the antipsychotic, the doctor may increase their dose to try to “improve” what he perceives to be negative symptoms of schizophrenia, rather than antipsychotic side effects.” (https://en.wikipedia.org/wiki/Neuroleptic-Induced_Deficit_Syndrome)

    This also leads to polypharmacy, which can result in neuroleptic induced anticholinergic intoxication syndrome, aka anticholinergic toxidrome, which can emulate the positive symptoms of “schizophrenia:”

    “Agents with anticholinergic properties (e.g., sedating antihistamines; antispasmodics; neuroleptics; phenothiazines; skeletal muscle relaxants; tricyclic antidepressants; disopyramide) may have additive effects when used in combination. Excessive parasympatholytic effects may result in … the anticholinergic intoxication syndrome … Central symptoms may include memory loss, disorientation, incoherence, hallucinations, psychosis, delirium, hyperactivity, twitching or jerking movements, stereotypy, and seizures. Central nervous system-depressant effects may also be additively or synergistically increased when these agents are combined …” (http://www.drugs.com/interactions-check.php?drug_list=2330-1540,1744-1113&types%5B%5D=major&types%5B%5D=minor&types%5B%5D=moderate&types%5B%5D=food&types%5B%5D=therapeutic_duplication&professional=1)

    It is possible most “major mental illnesses,” are completely iatrogenic.

    • I should mention that, according to my medical records, the psychiatric “professionals” misdiagnose anticholinergic toxidrome as “the classic symptoms of schizophrenia,” and I’m certain “I’m not the only one.”

      I would imagine most of the polypharmacy results in varying degrees of anticholinergic toxidrome, not the hypothesized “bipolar” and “schizophrenia” disorders. Drugging children, and the forced or coerced drugging of adults, should be made illegal. The ADHD drugs and antidepressants create the “bipolar” symptoms, as Whitaker pointed out. And the “gold standard” treatment for “bipolar” and “schizophrenia,” the neuroleptics, create the “schizophrenia” symptoms.

        • I so agree. Even if we accept psychiatry’s model (which I most strongly do NOT), the emergence of NEW symptoms after “treatment” should cause any doctor with an IQ over 85 to consider that the drug is most likely the cause of the “symptoms.” But for some reason that never occurs to them, and adding another drug is always the solution. If one drug fails, let’s try two. I’d call it stupidity, but too much money is involved. I think the proper name is “corruption.”

          —- Steve

          • I agree, Steve, psychiatry is a completely corrupt industry – one whose goal is to defame and torture as many innocent little children and people as they can get their hands on. I will confess, I found the psychiatrists I dealt with to be stupid and delusional, as well as corrupt, however. When I confronted my psychiatrist with all his delusions written into his medical records, which were finally handed over by some decent and disgusted nurses in my PCP’s office, he declared my life to be a “credible fictional story.” Can “fictional” people blog?

            What trained medical professional, in their right mind, would ever believe neuroleptic drugs are “wonder drugs”? They’ve been known to be torture drugs for decades. The USA has been taken over by the exact same “evil banks and corporations” that financed WWII, and about whom Thomas Jefferson forewarned us – and they’re playing the exact same game they did prior to WWII in Germany, with the USA today.

            One has to wonder whether my child and I were attacked and gaslighted by my ex-religion (which has left me with a life mirroring that of the woman in Revelations 12), just after 9.11.2001, because I come from an intelligent and ethical American banking family. The Holy Bible also forewarns us that the “one monetary system” which is planned will be based upon evil, a little wisdom. I’m glad so many others online are now waking to reality, too.