Issue 43 / 14 November 2011

INVESTMENT in earlier and non-pharmacological interventions for children with disruptive behavioural disorders is urgently needed, according to child mental health experts.

Researchers from the Queensland Centre for Mental Health Research reviewed the evidence for risperidone in treating disruptive behavioural disorders (DBDs) such as conduct disorder and oppositional defiance disorder. They found that although risperidone was effective, side effects such as weight gain and somnolence were common. (1)

Risperidone has been approved for use in children over 5 years of age with disruptive behavioural disorders and sub-average intellectual functioning since 2006.

The researchers identified seven randomised controlled trials, but these included a total of only 657 children and six of the trials lasted 10 weeks or less, despite the often persistent nature of DBDs.

“I was surprised by the weakness of the evidence”, Dr James Scott, a coauthor of the paper and a child and adolescent psychiatrist at the University of Queensland Centre for Clinical Research, told MJA InSight.

“It has made me more careful about how I inform parents and patients about what we know and what we don’t know about this medication.”

Dr Scott said that risperidone prescriptions for children aged 14 years and under in Australia had increased by 25% from 2002 to 2007 according to unpublished research he recently conducted. However, this increase started from a very low base (0.12 defined daily doses per 1000 children).

In a coauthored Comment article in this week’s MJA InSight, Dr Scott called for urgent investment in non-pharmacological treatments, such as parent-training interventions. (2)

He said although non-pharmacological treatments, such as the positive parenting or home nurse visits programs used in the US, may involve higher up-front costs, economic modelling had shown that they were good value in the long-term.

“We know that disruptive behaviours are common in Australia and cause a lot of difficulties, and we know that at least a proportion of those are preventable. But it takes some desire on the part of the government to do something about it”, he said.

Mr John Gardiner, child and adolescent specialist clinical psychologist and senior lecturer in psychology at Murdoch University, said that services providing behavioural treatments were overwhelmed.

He said more than 35 children with behavioural problems, often with comorbid development disorders, had been waiting all year for treatment at the psychology clinic at Murdoch.

“If you extrapolate that across Australia, there is a large unmet demand from families who are struggling to cope with these very severe behavioural problems”, Mr Gardiner said.

He also called for increased investment in training allied health professionals to manage children with developmental disorders and behavioural problems, adding that allied health lagged behind paediatricians in this area.

Many of his medical colleagues were reluctant to prescribe risperidone, but were sometimes under pressure from families desperate for a solution and with few other options, he said.

However, the antipsychotic drug was useful in some situations, such as for short-term use during crisis periods.

“It often gives families a little window of opportunity to put some other initiatives in place.”

Professor Bruce Tonge, head of the Centre for Developmental Psychiatry and Psychology at Monash Medical Centre, said risperidone could be useful in managing very severe disruptive behaviours, including self-injury such as self-biting or self-hitting.

“Wherever possible, we try to find a non-pharmacological intervention for these behaviours. Medication is not the first choice, or even the second choice, but we may have to use it, and there is evidence that it can help”, he said.

– Sophie McNamara

1. Journal of Paediatrics and Child Health 2011; 3 November (online)
2. MJA InSight; 14 November 2011

Posted 14 November 2011

5 thoughts on “Children need antipsychotic alternatives

  1. Dr Ramesh Manocha says:

    Experts have proposed an array of strategies to tackle the the rising incidence of mental illness in young people ranging from increasing the number of psychiatrists and psychologists, to screening and early detection programmes and internet based treatment strategies. Our research suggests that meditation is a particularly suitable resilience building strategy because it is easy to learn, can be taught in a standardised format that is suitable to a broad cross section of candidates and provides immediate impacts across a range of challenges that young people might encounter that challenge their resilience. We have focused on a form of meditation that focuses on the experience of mental silence which can be taught at no or minimal cost using a variety of different but pre-existing infrastructures to both small or large groups. A 1-year observational study of a class of third grade children who received 10 minutes per day of mental silence training demonstrated an 84% reduction in their Strength and Difficulties Total Score and a 25% improvement in the Prof Social Score. Qualitative feedback fron teaching staff has been equally impressive. It is time to evaluate the potential of meditation as a population-wide primary prevention strategy for mental health.

  2. Dietitian says:

    I wonder why no one suggests dietary intervention for many of these children with behavioural problems. It doesn’t ‘cure’ the underlying problem, but it certainly significantly reduces the severity of the symptoms for many. It must be the best-kept secret of dietitians and the Royal Prince Alfred Hospital Allergy Unit. Additives and natural food chemicals (salicylates, amines and glutamates) as well as some whole foods can be major culprits. For any doctors wishing to refer patients to appropriate dietitians, a search can be made of the DAA website at ‘Find an Accredited Practising Dietitian’, search under Area of Practice ‘Allergy and food sensitivity’.

  3. Paediatrician says:

    Dr Scott’s “motherhood” statement is great. Of course we all agree, but just try accessing services for these children. I write this five minutes after a phone call from carers of a 15 yar old autistic girl with significant intellectual disability, as well as pseudohypopathyroidism and congental adrenal hyperplasia. She is on respiridone because of her violent behaviour and has been a recent inpatient at a tertiary adolescent psychiatric unit after a suicidal gesture. In the last 48 hours, she has been totally out of control at the residential unit, stabbed herself, put bricks through windows, assaulted carers and had three visits to the emergency department of the same tertiary hospital escorted by the police. The adolescent psychiatry team there says she does not need folowup with them and refuse to see her. So the carers contact me. I’m sure every general paediatrician in Australia can replicate versions of the same scenario. I’ll stop using drugs when those who object to them succeed in making the supposed better alternatives available, rather than criticising those at the coalface. We are such easy targets. Most of my colleagues refuse to see children with behavioural problems because of this. The general press has already commented in a negative way on this paper and will contiue to do so. I doubt very much that positive parenting would help at this stage but maybe an engagement with a mental health worker? One can write the same letter about ADHD and stimulants.

  4. Dr Elizabeth Green says:

    There has been a tangible social shift in WA at least in the last three years. We are now seeing children, parents, educators and doctors overwhelmed by behavioural, social, educational and mental health issues. We no longer have adequate access to paediatricians and child psychiatrists to assist and won’t because of the time intensity and emotion involved in training medical people in the area of developmental and behavioural paediatrics. The only solution I can see as a paediatrician at the coalface is to push for mammoth political and community support for children and their carers and mentors in the 0-3 year old age group. We need also to practice patience, encourage political vision and adopt a bipartisan approach as it will take a decade to see real change post intensive early childhood intervention.

  5. Bruni Brewin says:

    I totally agree with Dr Scott. My daughter works in adult autism. She notices that each time there is a non-attendance period – public holidays for example – a lot of effort needs to be taken to get her charges back to the behaviour they have been taught. Often the parents are so embroiled in their own problems, they don’t have the coping skills to help their children. Early intervention would make such a difference. But as has been pointed out, that needs to come with funding.

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