Antipsychotics in the Management of Disruptive Behavior Disorders in Children and Adolescents: An Update and Critical Review

Abstract

Disruptive behaviour disorders (DBDs) in childhood include conduct disorder (CD) and oppositional defiant disorder (ODD). Though psychological therapies are considered to be the first-line treatment for DBDs, many patients require adjunctive pharmacotherapy for the control of specific symptoms, such as aggression. Three prior systematic reviews have examined the evidence for the use of antipsychotics in DBDs and have concluded that their efficacy is marginal and limited by adverse effects. This paper has two objectives: (i) to summarize the findings of existing systematic reviews of antipsychotics for the management of DBDs in children and adolescents (2012–2017), and (ii) to provide an update to these reviews by examining recent clinical trials of antipsychotics in this population, published in the period from 2 January 2017 to 10 October 2022. The PubMed, Scopus and ScienceDirect databases were searched for relevant citations using the search terms “disruptive behaviour disorder”, “oppositional defiant disorder”, “conduct disorder” and their variants, along with “antipsychotic”, “atypical antipsychotic” and the generic names of all currently approved atypical antipsychotics. Six relevant trials were identified during this period, including five randomized controlled trials and one naturalistic open-label trial. These trials were critically evaluated in terms of outcome measures, efficacy and safety. Overall, the data from these trials suggests that of all available antipsychotics, risperidone appears to be effective in the short-term management of DBDs. All available antipsychotics are associated with significant metabolic adverse effects in this population. These results are discussed in the light of global trends towards increasing off-label prescription of antipsychotic medication in children and adolescents and of recent literature on the neuropharmacology of aggression in this patient population. The need for rational, short-term use of these drugs is highlighted, as well as the importance of post-marketing surveillance for long-term or severe adverse events.

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“…Indeed, the Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines of 2018 indicate Clozapine as a third-line drug in mania and as the only potential adjuvant in maintenance treatment [110], while an Asian consortium has accepted its use in very limited clinical scenarios [111]. However, various systematic reviews have reported that Clozapine used in monotherapy or combined with other drugs in BD is frequently associated with a reduction of both manic and depressive symptoms, extending the interval between cycles, and lowering psychotic symptoms as well as hospitalization rates and suicidal and/or aggressive behaviours, ultimately improving psychosocial functioning [50,51,53,108,112].…”

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“…Evidence on the use of low doses of antipsychotics for disruptive behaviours in children is limited to short-term studies (Rajkumar, 2022). Notably, as in individuals with disabilities, pharmacological treatments are often unnecessarily long, without discontinuation even after a persisting clinical improvement, 'exit strategy' (i.e.…”

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