Antipsychotic Treatment for Children with Hyperactivity or Disruptive Disorders

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New evidence1 can help clinicians, caretakers, and others weigh the benefits and harms of antipsychotic treatment for children and adolescents.

The Findings

For children with diagnosed attention deficit hyperactivity disorder (ADHD) and/or disruptive, impulse-control, and conduct disorders (DICDs), the benefits of antipsychotic treatment may be modest and the harms may be significant. The harms can affect children throughout their lifetimes. Children taking antipsychotics should be monitored carefully by a clinician.

Possible Benefits of Antipsychotics

  • Second-generation antipsychotics, especially risperdone, probably moderately reduce conduct problems and aggression in children with DICDs, ADHD with severe aggression, or both.
  • Antipsychotic treatment likely reduces hyperactivity and overall illness severity to some degree in children with DICD, with or without ADHD. However, there may be no benefit in children who have only ADHD with severe aggression and who are resistant to stimulants.
  • There are very limited data on the effects of antipsychotics on symptoms in children with ADHD who have neither a comorbid DICD nor severe aggression. Most findings are from short-term studies.

Possible Harms of Antipsychotics

  • Studies have found that children taking antipsychotics may gain significant weight. The amount gained varies by drug, but olanzapine seems to cause the most weight gain.
  • Second-generation antipsychotics likely increase the occurrence of several side effects. These include drowsiness, tiredness, involuntary movements, elevated triglycerides, and increases in weight and body mass index.
  • The metabolic changes that accompany treatment with antipsychotics can increase the risk of heart disease, stroke, and diabetes.
  • Published studies report side effects that occur over relatively short treatment periods (6 to 12 weeks). Data on the adverse effects of longer-term treatment are more limited; it is likely that the adverse events associated with antipsychotic use in children are underestimated.

Providers often use second-generation antipsychotic medications such as risperidone (Risperdal) or olanzapine (Zyprexa) to treat hyperactivity, aggression, and disruptive conduct in children and young adults with ADHD or DICDs. The Food and Drug Administration has not approved the use of antipsychotics for treating ADHD or DICDs, but clinicians may prescribe the drugs off label.

Antipsychotic Treatment and Monitoring for Foster Children on Medicaid

Children on Medicaid who are also in foster care are prescribed these drugs at much higher rates than privately insured children. They are also more likely to have prescriptions for multiple antipsychotics. Although the percentage of foster children receiving antipsychotics has declined in recent years, the disparity persists.

Monitoring of children on Medicaid who are treated with antipsychotics is inconsistent. Clinicians monitor foster children on Medicaid for adverse metabolic effects only 28% of the time.2

About the Evidence

This Evidence Update is based on a recently updated review of research, which includes 135 research studies completed between January 1989 and April 2016. The federal Agency for Healthcare Research and Quality performed the review. The full report updates an earlier version published in February 2012. It can be found at: https://effectivehealthcare. ahrq.gov/topics/antipsychoticschildren-update/research-2017.

NOTE: This Evidence Update looks specifically at evidence related to antipsychotic use for children diagnosed with ADHD and disruptive disorders; it does not report on other approved and off-label antipsychotic use.

Download this Evidence Update


Sources

1. Pillay J, Boylan K, Carrey N, et al. Firstand Second-Generation Antipsychotics in Children and Young Adults: Systematic Review Update. Prepared by the University of Alberta Evidence Based Practice Center. Agency for Healthcare Research and Quality; March 2017. Errata January 2018.
2. Crystal S, Mackie T, Fenton MC, et al. Rapid Growth of Antipsychotic Prescriptions for Children Who Are Publicly Insured Has Ceased, But Concerns Remain. Health Affairs. 2016;35(6):974-82.

The information in this publication is not intended to be a substitute for professional medical advice.

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