Management

Since their introduction in the 1950s, there has been an interest in treating some children and adolescents with severe psychiatric disorder with neuroleptics. However, at the same time, clinicians have been hesitant to treat children and apprehensive of causing irreversible damage to the developing nervous system. Reports of extrapyramidal side-effects, and especially the many published child and adolescent cases with neuroleptic malignant syndrome, (26> have contributed to make neuroleptics drugs of second or third choice for nearly all psychiatric disorders during childhood and adolescence, except for psychosis with teenage onset.

The following guidelines are based on clinical experience from Northern Europe and do not necessarily reflect practice in the United States or other parts of the world.

Autism

Despite the demonstrated efficacy of neuroleptics in autistic disorder, they are not widely used in the treatment of this disabling disorder. Autism is usually lifelong and, once started, treatments are sometimes difficult to withdraw. The potentially severe side-effects limit the use of the typical neuroleptics in autism. However, haloperidol can be helpful for the short-term reduction of severe stereotypy, introversion, hyperactivity, and aggressiveness in doses ranging from 0.02 to 0.20 mg/kg per day (in one or two doses), but should be used with great caution and rarely, if treatment is expected to exceed about 3 months.

Atypical neuroleptics, including risperidone, are sometimes tried for target symptoms such as severe aggression and destructive and self-destructive behaviours, but, given the lack of controlled studies for this age group, they should not be prescribed for longer periods.

Schizophrenia and other forms of psychoses in adolescence

Most young people with major psychosis, and perhaps especially those with schizophrenia, are treated with neuroleptics as a major adjunct to the management of severe behavioural disturbance. Low-dose preparations of typical neuroleptics should be preferred over high-dose medications. In general, guidelines appropriate for adults may be followed for older adolescents. Children and younger adolescents should be treated very cautiously, if at all. Dosage in this age group has not been well studied, but should probably be kept under 0.12 mg/kg per day. Medication should always be combined with other interventions, including daily-life activity training, remedial education, family support, and various forms of psychotherapy.

Tourette's syndrome and other tic disorders

Neuroleptics are effective in reducing tic symptoms, but should not be seen as a standard part of management in Tourette's syndrome or related disorders. The most handicapping symptoms in these conditions are usually the comorbid problems associated with obsessive-compulsive disorder and/or attention-deficit hyperactivity symptoms. Such symptoms either respond poorly to neuroleptics or considerably better to other drugs. In very severe tics, that are themselves severely disabling, a trial of pimozide 1 to 8 mg in one (or two) daily dose(s) may be indicated in individuals aged 12 years and above.

Autism

Autism

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