Epidemiologic and clinical perspectives on antipsychotic treatment of children and adolescents.

AbbreviationsADHD attention-deficit hyperactivity disorderCD conduct disorderDBD disruptive behaviour disorderODD oppositional defiant disorderSGA second-generation antipsychoticDuring the past several years, an increasing number of children and adolescents have been treated with antipsychotics. A substantial proportion of these young people are diagnosed with ADHD, CD, or ODD.' Safety concerns, especially weight gain, have focused attention on the risk-benefit trade-offs of evolving antipsychotic prescribing standards and practices2 and have increased interest in evaluating the efficacy of antipsychotics for DBDs.In this issue of The Canadian Journal of Psychiatry, Dr Scott ? Patten and colleagues3 provide a timely review of trends in antipsychotic use among young people and Dr Tamara Pringsheim and Dr Daniel Gorman4 assess clinical trials of SGAs for DBDs. Taken together, these 2 articles inform critical ongoing clinical, policy, and academic discussions over the appropriate role of SGAs in child and adolescent mental health care.We learn from Dr Patten and colleagues3 that antipsychotic use in young people has increased in Canada, the United States, the United Kingdom, Italy, and the Netherlands, with considerably lower absolute use rates in Europe than in North America. Adults in Europe and North America are also increasingly receiving antipsychotics.5 In youth, uniformly higher rates of antipsychotic treatment among males than females, with peak use in late childhood and early adolescence, are consistent with the clinical epidemiology of the disruptive behavioural disorders.6 Although more detailed practice-based research is necessary to determine the most common target symptoms of child and adolescent antipsychotic treatment, the diagnostic patterns suggest that controlling problematic aggressive behaviours is a common clinical objective.Large cross-national differences in antipsychotics are unlikely to be explained in full by variations in the underlying prevalence of child and adolescent disorders in clinical care. Instead, Canadian and US physicians appear to be more receptive than their European colleagues to prescribing antipsychotics to young people. Greater SGAuse in the United States than in Germany or the Netherlands has also been described in the treatment of child-onset bipolar disorder.7 To help ensure that North American physicians strike an appropriate balance, now may be a good time to reassess the efficacy of nonpharmacological interventions for aggressive behaviours in youth, such as parent management training, cognitive problem solving skills training, multisystemic therapy,8 and other interventions that incorporate cognitive-behavioural therapy strategies.9Antipsychotics have traditionally been the province of psychiatric practice. Dr Patten and colleagues3 make the point that primary care physicians play a significant role in antipsychotic treatment of children and adolescents. While psychiatrists account for most (62%) antipsychotic prescriptions for Canadian youth, family physicians (17%) and general practitioners (17%) also make nontrivial contributions.10 Early adopters of medical interventions are often specialists rather than primary care physicians." For stimulants - the most well-established psychotropic treatment of youth, Canadian psychiatrists account for only 17% of prescriptions.10 Over time, it will be important to track the diffusion of antipsychotic treatment of children and adolescents from psychiatrists to primary care physicians. If pediatricians and family practitioners assume a more prominent role in prescribing antipsychotics to children and adolescents, increased consultations with psychiatrists will need to ensure appropriate patient selection and medication dosing.The review by Dr Pringsheim and Dr Gorman4 establishes that substantial progress has been made in defining the efficacy of risperidone in children with aggressive behaviour, especially in the context of CD or ODD. …