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Beyond the Label: Antipsychotic Prescribing Practices at a Paediatric Neurodisability Service in Australia
Ella May Huber1,2, Monica Sophie Cooper1,2,3
1Department of Neurodevelopment & Disability, Royal Children's Hospital, Melbourne, Victoria, Australia.
Insights
Antipsychotic medications are increasingly prescribed for children with neurodevelopmental disabilities, often for challenging behaviors. Off-label use and polypharmacy are common, highlighting gaps in current evidence for these complex cases.
Area of Science:
- Pediatric Neurodevelopmental Psychiatry
- Pharmacovigilance in Children
- Child and Adolescent Psychiatry
Background:
- Increasing use of antipsychotic medications in children globally.
- Limited research on antipsychotic prescribing for children with complex neurodevelopmental disabilities.
- Need for understanding prescribing patterns and indications in this population.
Purpose of the Study:
- To characterize antipsychotic prescription patterns in children with neurodisability.
- To identify common antipsychotic drugs, indications, and co-prescribing practices.
- To assess the extent of off-label use and psychotropic polypharmacy.
Main Methods:
- Retrospective review of medical records at a children's hospital in Australia.
- Inclusion criteria: children under 19 newly prescribed antipsychotics by neurodevelopment specialists (2018-2022).
- Data collected: drug frequency, age, sex, indications, off-label use, and psychotropic polypharmacy.
Main Results:
- 167 encounters for 147 patients (4% of seen patients) were analyzed.
- Risperidone (64%) and olanzapine (18%) were most common; 62% risperidone and 97% olanzapine were off-label.
- Challenging behaviors (74%) were the primary indication; psychotropic polypharmacy was present in 78% of cases.
Conclusions:
- Antipsychotics are prescribed to a small subset of children with neurodisability, mainly for behavioral issues.
- High rates of off-label prescribing and polypharmacy were observed.
- Prescriptions often occur in clinical situations lacking robust evidence.
Background:
The use of antipsychotic medications in children has been increasing in Australia and abroad. Children with complex physical and neurodevelopmental disability remain understudied in the prescribing literature, and we do not have a nuanced understanding of why and to whom antipsychotic medications are prescribed.
Methods:
We conducted a retrospective review of records to characterise antipsychotic prescription patterns for children with neurodisability at the Royal Children's Hospital, Melbourne, Australia. We used the Electronic Medical Record to identify children under 19 years, newly prescribed an antipsychotic medication by Department of Neurodevelopment and Disability clinicians between 24/09/2018 and 26/09/2022. We identified 167 encounters for 147 patients, representing 4% (147/3673) of the patients seen in that period. Main outcome measures were the frequency of antipsychotic medication prescription by drug, age category and sex; indication frequency; proportion of off-label use; and frequency and level of psychotropic polypharmacy.
Results:
In our cohort, 71% of children had intellectual disability (104/147), 42% autism spectrum disorder (61/147) and 42% cerebral palsy (61/147). Risperidone was the most prescribed antipsychotic medication, in 64% (107/167), followed by olanzapine in 18% (32/167). Off-label prescription was 62% (66/107) for risperidone, 97% (31/32) for olanzapine. The indication for antipsychotic medication was challenging behaviour in 74% (123/167), including aggression in 31% (52/167), agitation in 20% (33/167) and self-injury in 17% (28/167). Nonbehavioural indications included anxiety symptoms in 19% (32/167) and sleep disorders in 14% (24/167). Psychotropic polypharmacy (two or more concurrent psychotropic medications) was present in 78% (130/167), with sedatives (69%, 115/167) and antidepressants (31%, 52/167) most common.
Conclusions:
A small proportion of children with neurodisability were prescribed antipsychotic medications, most frequently risperidone for challenging behaviours. Off-label prescription and psychotropic polypharmacy were common. Prescription occurred in a variety of clinical scenarios that sit outside the current field of evidence.
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