Survey of Atypical Antipsychotic Prescribing by Canadian Child Psychiatrists and Developmental Pediatricians for Patients Aged Under 18 Years

Objective: To describe self-reported patterns of prescribing atypical antipsychotics (ATAs) and monitoring practices of child psychiatrists and developmental pediatricians in Canada. Method: We surveyed members of the Canadian Academy of Child and Adolescent Psychiatry and members of the Developmental Paediatrics section of the Canadian Paediatric Society regarding the types and frequencies of ATAs they prescribed, the ages and diagnoses of patients for whom they prescribed these medications, and the types and frequencies of monitoring used. Results: Ninety-four percent of the child psychiatrists (95%CI, 90% to 97%) and 89% of the developmental pediatricians (95%CI, 75% to 96%) prescribed ATAs, most commonly risperidone (69%). Diagnoses included psychotic, mood, anxiety, externalizing, and pervasive developmental disorders. Prescribing for symptoms such as aggression, low frustration tolerance, and affect dysregulation was also common. Twelve percent of all prescriptions were for children under age 9 years. Most clinicians monitored patients, but there were wide variations in the type and frequency of tests performed. Conclusions: Despite the lack of formal indications, ATAs were prescribed by this group of clinicians for many off-label indications in youth under age 18 years, including very young children. Neither evidence-based guidelines nor a consensus on monitoring exist for this age group. (Can J Psychiatry 2007;52:363-368) Information on funding and support and author affiliations appears at the end of the article. Clinical Implications * Prescribing of ATAs is common by child psychiatrists and developmental pediatricians in Canada. * The medications are prescribed for various diagnoses and symptoms, and patients include the very young. * Monitoring is reported to be common, but there is little consensus as to what tests should be done or how often. Limitations * The data did not reflect actual prescriptions. * The data were subject to recall bias. * The respondents may not represent other clinicians. Key Words: antipsychotics, children, youth, Canada Abbreviations used in this article AIMS Abnormal Involuntary Movement Scale ATA atypical antipsychotic CACAP Canadian Academy of Child and Adolescent Psychiatry CI confidence interval CP child and adolescent psychiatrists DP developmental pediatricians EKG electrocardiogram In the last 2 decades, the treatment of psychosis has been revolutionized by the widespread adoption of ATAs.1-3 These agents, which in Canada presently include risperidone, olanzapine, quetiapine, and clozapine, have fewer propensities to cause extrapyramidal side effects and carry a significantly lower risk of tardive dyskinesia than do typical agents.4 For adults, monitoring guidelines and established indications for the use of these medications exist, but not for children, with some exceptions. Some data exist to support the use of clozapine to treat refractory schizophrenia in patients aged under 18 years5 and to reduce aggression in this population6; the review by Kranzler and colleagues7 cites it as the drug of choice for this indication. Olanzapine has been reported to provide good response in early-onset schizophrenia. The adoption of ATAs as first-line drugs is primarily based on a similar practice for treating adults. The more acceptable side effect profile and the safety of ATAs have broadened the indications for their use. ATAs are being used increasingly to treat various nonpsychotic disorders, not only in adults but also in children and adolescents.8-14 As is often the case, controlled trials are rare and are characterized by small sample sizes, diagnostically heterogeneous samples, retrospective designs, short follow-up, and the lack of control groups. 15-18 Some data support short-term, sustained efficacy in reducing aggression,19-24 tics,25 and mania. …