If feasible, medications can be withheld when ADHD symptoms are unlikely to interfere with the child’s activity (eg, on weekends, vacations from school). Parents can plan to give the child a large breakfast before the stimulant medication, and can supplement intake with milkshakes and meal replacement shakes. Another option is to switch to a shorter acting medication, a different stimulant medication, or to non-stimulant treatment—for example with atomoxetine (Strattera) or clonidine (Kapvay)—or to add an appetite stimulant like cyproheptadine (Periactin). Finally, the emergence of true psychosis is uncommon but is reason for immediate cessation of the medication.
There are two categories of side effects to consider with these medications: neuromuscular and metabolic. First generation antipsychotics are thought to have worse neuromuscular adverse effects, while second generation antipsychotics (SGA) are notorious for causing metabolic derangements. However, either class can cause both groups of side effects. Pringsheim T et al (Paediatr Child Health 2011;l6(9):590-598) offer a summary of neurological side effects such as akathisia, withdrawal akathisia, tardive dystonia, and tardive dyskinesia and their management for antipsychotic use in children. Here, we will focus on SGAs and their characteristic metabolic side effects, given the increasingly common use of this class in pediatric mood, behavior, and psychotic disorders.
Metabolic effects of SGAs include weight gain, dyslipidemia, and increased blood sugar. One observational study showed weight gain of up to 20 pounds within two and a half months of children starting olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), or aripiprazole (Abilify) (Correll CU et al, JAMA 2009;302(16):1765-1773). The risk appears greatest with Zyprexa, clozapine (Clozaril), and Seroquel, and less, but still present, with Risperdal and Abilify (PringsheimT et al, Drug Saf 2011;34(8):651-668).
Addressing issues of weight with children and adolescents should be done with a nonjudgmental, collaborative approach. Cognitive behavioral therapy and nutrition counseling are evidence-based interventions in adults treated with SGAs to minimize weight gain or, in some cases, result in modest weight loss. Although there are not studies evaluating these interventions in kids, they should nonetheless be considered (Maayan L & Correll CU, Expert Rev Neurother 2010;10(7):1175-1200).
There are some expert, largely common sense guidelines that outline non-medication approaches, such as encouraging physical activity that kids find enjoyable, limiting screen time, and enlisting family involvement with planning healthy meals (Maayan & Correll op cit). If the metabolic abnormalities persist, the dose of the SGA should be lowered if clinically feasible. Switching to an alternate agent that is associated with less weight gain is a reasonable approach. For elevated glucose, you should consider consultation with an endocrinologist, as the addition of some medications such as metformin may help ameliorate the effects (Ho J et al, Paediatr Child Health 2011;16(9):575-580).
Lithium and divalproex sodium (Depakote) are the two most commonly used mood stabilizers for pediatric bipolar disorder. The most common side effects of lithium, FDA-approved for use in children 12 years of age and older, include gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain) and nervous system problems (headache, dizziness, tremor, and somnolence). GI symptoms may improve if you switch to prescribing coated capsules of lithium, called Lithobid, or if doses are split into two or three times daily.
Tremor is reversible only with a decrease in dose or cessation of the medication. One in five patients will report increased thirst and changes in appetite (Findling RL et al, J Child Adolesc Psychopharm 2011;21(3):195- 205), and acne is commonly reported as well. Acne is particularly pertinent to young patients’ adherence, and referral for dermatologic treatment may help. Due to a narrow therapeutic window, regular levels need to be checked and kidney and thyroid gland function must be monitored (Thomas T, Kuich KW, & Findling RL. Bipolar disorders. In: McVoy M & Findling RL, eds. Clinical Manual of Child and Adolescent Psychopharmacology, 2nd Ed. Arlington, VA: American Psychiatric Publishing; 2013:227-267).
Divalproex sodium is an anti-seizure medication used in the treatment of bipolar disorder (Thomas T et al, Pediatr Clin N Am 2011;58:173-187). GI side effects include nausea, vomiting, and diarrhea, and can be lessened by taking the medication with food or switching to Depakote, the coated version of this medicine. You can relieve effects on the central nervous system, such as headache, sedation, and cognitive slowing, by splitting doses, giving the medication at bedtime, or reducing the dose (Thomas, Kuich, & Findling op
Since divalproex sodium can cause life threatening liver and pancreas problems, any serious abdominal pain or ongoing vomiting or diarrhea should be evaluated urgently by checking a blood level and checking liver function tests, and may warrant stopping the medication. Female adolescent patients should also be educated on fetal risks if they become pregnant, as well as symptoms of polycystic ovarian syndrome (PCOS), such as hirsutism and irregular periods.
CCPR’s VERDICT: Prescribing psychiatric medications to your pediatric patients can have enormous benefits, but necessarily comes with the risk of side effects. For clinicians treating this vulnerable population, adverse effects must be treated with particular vigilance and awareness. By enhancing your understanding of psychotropic side effects, you will be better equipped to provide anticipatory guidance, manage concerns and symptoms as they arise in the course of treatment, and ensure the best possible outcome.