CCPR: Dr. Elliott, in your view, when is it is most appropriate to use antipsychotics in children?

Dr. Elliott: In adolescents, sometimes a clear psychotic thought process appears, and in such cases the use of antipsychotics is unambiguously appropriate. The symptoms may involve hallucinations or delusions, and the diagnosis may be schizophrenia or some other disorder; regardless of the diagnosis, antipsychotics work well in such cases. As you move to younger children, frank psychosis becomes less common, but it can still occur. In my own clinical experience, the youngest, clearly psychotic individual I’ve worked with was 4½-years-old. When I first saw him I thought he had a brain tumor, because he was so dysfunctional. He had clang associations, he was rocking back and forth and drooling, and there appeared to have been a fairly abrupt onset. But a medical work up showed no neurologic explanation and his psychosis cleared with haloperidol (Haldol). 

CCPR: This makes sense, and I think most of us would agree that frank psychosis in a child is an indication for a trial of antipsychotics. But there are other situations where the picture is murkier. 

Dr. Elliott: Yes there are, and this is partly because the atypical antipsychotics (APs) have been relabeled and used as mood stabilizers in adults. With children, unfortunately, mood instability is often quite difficult to diagnose with precision. The whole idea of bipolar disorder in children has broadened over the years, especially in the US, to cover a wide range of behaviors. At its broadest, any child with recurrent meltdowns who can’t handle transitions may be at risk of receiving a diagnosis of bipolar disorder. If that happens, the likelihood is high that APs will be recommended. This is partly because we are really treating their behavior, and partly because APs are easier than mood stabilizers to use, as it may be difficult to get the frequent blood samples in these children that are required for medications such as lithium or valproic acid (Depakote) or other non-AP mood stabilizers. 

CCPR: Yes, the overdiagnosis of bipolar disorder in kids is a problem. How do you go about clarifying the diagnostic picture to prevent this?

Dr. Elliott: Part of what I’m looking for is where and when the problem began. Can we identify any precipitating factors? The differential diagnosis is fairly broad—the most common competing diagnoses are anxiety, attachment problems, behavioral rigidity, and ADHD. Often, these children have problems from very early on, starting in preschool with a pattern of getting kicked out of class, having meltdowns, and getting aggressive if confronted about not following rules. But, a cardinal feature is inability to handle unexpected situations and responding with a meltdown. For example, a child’s school schedule changes—he expects math at 11 a.m. and instead has to attend a school assembly. Telling him to go to the auditorium may send him into a rage, or he might start crying inconsolably. Or, the mother might say, “Instead of going home, we have to stop at the grocery store,” and he may jump out of his seat belt and threaten to jump out of the car. The real difficulty is it is unpredictable: one day he is fine, and another day the whole world collapses when the family runs out of cereal. These children have a sort of internal picture of how the world is supposed to be; and, when that changes, there is a behavioral deterioration. 

CCPR: How do we approach helping kids respond differently?

Dr. Elliott: Every case is different. There are a variety of established techniques, such as parent management training and evidence-based treatments for disruptive behaviors. One technique is to teach children to tolerate changes in routine or create a structure to minimize the impact of the changes. For example, imagine the child will have to go to a doctor’s appointment, which is not part of his usual routine. His parents may need to warn him three weeks in advance, put it on the calendar, talk about it every other day, and that may work great. But a different child may spend the three weeks obsessing about it, getting so anxious that he cannot go to school. In these cases, you’re better off waiting until the morning of the appointment and just say, “Hey, we are going to do something different today.” Usually, parents learn this about their particular child, and there is no single recipe. 

CCPR: At what point do you move to medications with these children? 

Dr. Elliott: The most common scenario is when the behavior therapists throw up their hands and say, “Nothing is working.” The parents have been trying hard—they’ve read some of the books such as The New Strong-Willed Child, they’ve tried various techniques at home, but the child is still irritable and having meltdowns and the parents want to try medications (Dobson JC. The New Strong-Willed Child. Carol Stream, Illinois: Tyndale House Publishers; 2014). An interesting example of this was in the research studies leading to the approval of risperidone for irritability in autism. The original research plan was that risperidone would be used sparingly, in a way that would calm down the child enough to maximize benefits from behavioral and parenting techniques parents learned as part of the study. The design was to start with risperidone, train parents with more effective parenting approaches, and then discontinue the risperidone, with parents using just behavioral techniques. But it turned out that a lot of parents found, when they stopped the risperidone, the difficult behaviors returned. Many of them dropped out of the study because they preferred to continue the risperidone, finding it to be more helpful in allowing the children to do normal activities. So generally, I broach the possibility of medications when other techniques have been tried and were not helpful enough. The threshold varies: some clinicians insist that failure go on for a long time. I have a lower threshold because we have evidence that a combination of medications and non-medication approaches work better than either one alone, and the success rate of behavior therapy is higher if the child is less volatile, which APs help to achieve. Ultimately though, this is a family decision; usually, they are coming to me and asking me to start meds. 

CCPR: What do you start with?

Dr. Elliott: I generally don’t start with APs—more often with an antidepressant or an alpha-adrenergic blockade agent. They often work and, from a side-effect perspective, tend to be less worrisome.

CCPR: Why do these medications work for behavioral issues?

Dr. Elliott: Because, at least for non-autistic children, often anxiety is the underlying cause of the meltdowns. Antidepressants can raise the threshold and allow the child to tolerate a little more frustration, avoiding an episode. A classic example is a child with a lot of obsessive behaviors whose meltdowns occur almost always when they are involved in a behavior that gets interrupted such as lining things up or counting. From the school’s point of view, it may simply be time to change from activity A to activity B, but the child becomes upset because they’re not able to finish their routine. In these cases, antidepressants for obsessive-compulsive disorder (OCD) can make a big difference. 

CCPR: How do you choose among the antidepressants?

Dr. Elliott: The best-studied antidepressants for children are the SSRIs, and in my opinion, there’s no truly compelling evidence of one being better than another—though there is some disagreement in the field about this. Generally, my approach is that if there’s a family member doing well on one, I’ll choose that one. If a family just believes in one, they have a positive transference and that may enhance the likelihood they’ll stick with a med. If the child is sluggish, I may use sertraline or fluoxetine, which are more activating. If they are already hyperactive or having insomnia I stay away from those, and I might go to citalopram or escitalopram. 

CCPR: When you do go to antipsychotics for kids, which do you choose?

Dr. Elliott: Among the antipsychotics, we have the most experience with risperidone and aripiprazole, both of which are approved for irritability in autism, and we have a fair amount of experience with quetiapine. I personally like risperidone, which was the first one we began using in children. Risperidone is sedating, so it is good for children with insomnia. But it has a higher likelihood of side effects such as weight gain.

CCPR: How do you dose risperidone? 

Dr. Elliott: I’ll start most children on 0.25 mg or 0.5 mg once a day, but sometimes you need to dose it two or three times a day. My personal maximum dose is 4 mg a day. In terms of increased eating, it is not always dose-related, and a patient’s appetite can skyrocket. It’s important to understand that while, statistically, risperidone has a higher probability than aripiprazole to cause weight gain, there are a lot of children taking risperidone who don’t have increased appetite. Fortunately, if you can stop the medication, that side effect goes away. Where a conflict can arise is if the medication produces substantial improvement but also significant weight gain. Metformin sometimes works to reduce appetite and thus prevent weight gain. The pharmaceutical companies say, “Eat less and exercise more,” but that’s very hard advice for children—or most adults, for that matter—to follow.

CCPR: When do you choose aripiprazole?

Dr. Elliott: When a child is too sleepy and too slowed down, I use aripiprazole. I start at 2.5 mg to 5 mg once a day, and 20 mg is my maximum dose. It is less sedating than risperidone, which is sometimes good and sometimes not. Though it probably produces less of the compulsive eating, my clinical experience is that the likelihood of some weight gain is fairly high—and it tends to be the worst possible kind of weight gain, abdominal fat, so they get pot bellies. One increasingly common recommendation is to include abdominal girth as a standard measure when seeing these patients, regardless of which AP one chooses. 

CCPR: Thank you, Dr. Elliott.