Journal of Child and Adolescent Psychopharmacology

d-Amphetamine transdermal system (d-ATS) is FDA-approved for treating attention-deficit/hyperactivity disorder (ADHD) in adults and pediatric patients ≥6 years. In a pivotal study, d-ATS met its primary (SKAMP total score) and secondary endpoints. This analysis further evaluated d-ATS efficacy using SKAMP subscale scores and total score by subgroup.

The pivotal study comprised a 5-week, open-label dose-optimization period (DOP) followed by a 2-week, randomized, cross-over double-blind treatment period (DBP). All eligible patients received d-ATS 5 mg/9 h, with weekly evaluation for dose increase and the optimal dose maintained during the DBP. Preplanned subgroup analyses of mean SKAMP total score in the DBP by optimized dose, sex, age group, ADHD type, and baseline ADHD severity were conducted. Efficacy was assessed by difference (d-ATS vs. placebo) in least-squares (LS) mean SKAMP total and subscale scores (Attention, Deportment, and Quality of Work) from a mixed-model repeated-measures (MMRM) analysis and is reported throughout as LS mean (95% confidence interval [CI]). Model-based effect sizes were calculated post hoc.

In total, 110 patients were enrolled in the DOP; 106 were randomized in the DBP. The LS mean difference in SKAMP total score of d-ATS versus placebo was −5.9 (−6.8, −5.0), with differences in subscale scores (Attention, Deportment, and Quality of Work) of −1.4 (−1.7, −1.1), −1.9 (−2.2, −1.5), and −1.3 (−1.5, −1.0), respectively. Model-based effect sizes were 0.57, 0.42, 0.43, and 0.47, respectively. Patients receiving d-ATS demonstrated improvements versus placebo in LS mean SKAMP total score at each optimized dose in both male and female patients and children and adolescents and regardless of ADHD subtype or baseline ADHD severity.

Consistent efficacy of d-ATS across subgroups and all SKAMP subscale scores suggests broad utility of d-ATS in all patients, regardless of age, sex, ADHD type, or baseline ADHD severity, and broad applicability of these results to patients with varying clinical presentations of functional impairment by ADHD.

Oxidative stress (OS) has been implicated in the pathophysiology of attention-deficit/hyperactivity disorder (ADHD), yet findings—particularly regarding treatment-related changes—remain inconsistent. This study evaluated short-term differences in circulating oxidant/antioxidant markers after methylphenidate (MPH) treatment and explored whether baseline biomarkers predict clinically significant symptom improvement.

In this single-center, prospective observational cohort study, medication-naïve children aged 6–11 years diagnosed with DSM-5-TR ADHD were assessed at enrollment and after 3 months of conventional MPH treatment. Clinical severity was measured using the Conners’ Parent Rating Scale–Revised: Short Form (CPRS-R:S) and Conners’ Teacher Rating Scale–Revised: Short Form (CTRS-R:S). Serum biomarkers included total oxidant status (TOS), total antioxidant status (TAS), superoxide dismutase (SOD), malondialdehyde (MDA), oxidized LDL (Ox-LDL), and the OS index (OSI = TOS/TAS). Changes were tested with paired analyses; correlations were examined between percent changes in scale scores and biomarkers; and ROC analyses evaluated baseline biomarkers’ ability to identify a >50% reduction in CPRS-R:S and CTRS-R:S total scores.

Thirty-nine participants completed both assessments (SOD analyses: n = 37). Significant reductions were observed in CPRS-R:S and CTRS-R:S total and subscale scores (all p < .001). TOS, TAS, SOD, MDA, and Ox-LDL decreased significantly over 3 months, while OSI showed a nonsignificant downward trend (p = 0.066). No significant correlations emerged between percent symptom change and percent biomarker change. In ROC analyses, baseline MDA, Ox-LDL, and TOS significantly discriminated >50% CPRS-R:S improvement (AUC ≈ 0.71–0.74), whereas for >50% CTRS-R:S improvement, several biomarkers demonstrated good discrimination (AUC ≈ 0.82–0.85).

Three months of MPH treatment was associated with robust clinical improvement and parallel reductions in multiple oxidant and antioxidant biomarkers. Baseline OS markers may help identify children most likely to show marked symptom reduction, though findings should be interpreted cautiously, given the sample size.

Increasing dispensing of sedative antipsychotics in children and adolescents has been reported in several countries, including the Netherlands, raising concerns about appropriate prescribing and safety. While previous studies have described antipsychotic use in Dutch youth, detailed information on dispensing patterns, dosages, treatment duration, and prescribers of sedative antipsychotics remains limited. This study therefore examined the dispensing patterns of quetiapine, olanzapine, and pipamperone and compared them with aripiprazole and risperidone, using data from the IADB.nl database.

Data from the IADB.nl pharmacy dispensing database (120 Dutch community pharmacies) were analyzed to assess sedative antipsychotic dispensing patterns in children and adolescents, aged between 0 and 19 from 2017 to 2022. Dispensing rates, dosages, durations, sex differences, and prescriber types were analyzed using descriptive statistics, Kaplan–Meier survival analysis, Wilcoxon signed-rank tests, and Kolmogorov–Smirnov tests.

Dispensing rates increased for quetiapine (0.33 to 0.63/1000) and olanzapine (0.16 to 0.23/1000) from 2017 to 2022, while pipamperone decreased (0.54 to 0.33/1000). Most quetiapine prescriptions (91.5%) were low-dose (<100 mg). Girls received significantly lower doses (43.37 mg) compared with boys (53.25 mg). Median use duration was shortest for quetiapine (3 months) and longest for pipamperone (10 months). General practitioners (GPs) initiated 26% of sedative antipsychotic prescriptions, with quetiapine being the most frequently prescribed, especially by GPs. Specialist-initiated prescriptions generally had longer durations than those initiated by GPs.

Rising quetiapine and olanzapine prescriptions, especially low-dose quetiapine despite known adverse effects, raise safety and efficacy concerns. Increased olanzapine use may reflect broader indications; decreased pipamperone suggests shifting preferences. Sex differences in dosage and treatment duration underscore potential clinical or pharmacological differences. These findings call for safer use through individualized prescribing based on clinical indication, patient characteristics, and clear treatment goals, supported by specialist oversight and structured monitoring, alongside stricter guideline adherence and further research on the long-term impacts of sedative antipsychotics in youth.

Delirium in the setting of critical illness occurs in 15%–60% of pediatric patients and is associated with increased duration of hospital admission. Strategies for symptom management include minimizing exposure to deliriogenic medications, optimizing day–night cycles, and in some cases prescribing antipsychotic medications. Symptom management occurs while simultaneously identifying and treating the underlying etiology. Over a 5-year period, our pediatric intensive care units implemented several unit-based initiatives to prevent and minimize the severity of delirium in critically ill children. The objective of this study is to retrospectively characterize antipsychotic prescribing practices over the study period.

Over a 5-year timeframe in our children’s hospital, we extracted dispensing data for risperidone, olanzapine, quetiapine, and haloperidol. We used descriptive statistics to characterize patients initiated on an antipsychotic in an ICU area, dosing information, and quantitative change in annual orders over the study period.

During the study period, 533 antipsychotic orders were placed for 165 patients. Most of the identified patients were male (60.6%) and Black (44.2%). Ninety (16.9%) of the medication orders remained active after patient transfer to a general care floor. Risperidone was the most prescribed antipsychotic (54%), with a 413% increase observed between 2016 and 2018, followed by a decline of 89% between 2018 and 2021. Use of other antipsychotics was less than risperidone but consistent during the study period. Risperidone was more commonly prescribed for younger children, and prescribing patterns suggest a preference for nighttime administration.

Implementation of unit-based initiatives to promote delirium screening and awareness led to an initial increase in antipsychotic medication prescribing for critically ill children with delirium. This was followed by a significant decline in antipsychotic prescribing with the inclusion of the child and adolescent psychiatry team in our delirium management and prevention algorithm. This study highlights the importance of collaboration with the child and adolescent psychiatry team in the management of pediatric delirium across the hospital system. Additional research on antipsychotic prescribing practices and the associated impact of nonpharmacologic interventions and multidisciplinary collaboration for delirium treatment is warranted.

Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by abrupt-onset neuropsychiatric symptoms, often infection-triggered. Intravenous immunoglobulin (IVIG) is recommended by expert guidelines in select cases, yet insurance denials and high out-of-pocket costs have been barriers to access.

We surveyed 60 caregivers and adult PANS patients who pursued IVIG therapy, collecting data on insurance coverage, treatment protocols, financial strategies, and quality of life (QoL) before and after treatment.

Most patients (88%) eventually received IVIG, 10% were still in pursuit, and 2% discontinued trying. Insurance approval without appeal occurred for 24%, often for patients with comorbidities for which IVIG is typically covered. Only 5% of those receiving IVIG for PANS alone were treated within a month of the doctor’s order compared with 38% of those receiving IVIG for comorbidities plus PANS; 14% waited ≥9 months. Financial strain was routine: at least one-third of families without “substantial” insurance coverage (≥70% of expenses) reported extreme stress (10 on scale of 1 to 10), 58% borrowed money, and 21% sold major assets. Even families with substantial insurance coverage commonly depleted savings or took on additional work. Before IVIG, patient QoL ratings were poor (means 2.1–2.9 across domains), with over one-third selecting the lowest possible overall QoL rating. During the 6 months following IVIG initiation, mean ratings rose to 6.2–6.8, with over 60% reporting “good” to “exceedingly good” overall outcomes. Caregivers reported parallel gains, with family QoL ratings rising from 2.4–4.0 pretreatment to 5.7–6.6 posttreatment.

Families pursuing IVIG for PANS reported prolonged delays, repeated denials, and financial strain, often resorting to loans, asset sales, and additional work. Despite these burdens, IVIG was correlated with marked improvements in perceived QoL for patients and caregivers.

The prevalence of opioid use disorder (OUD) among adolescents has increased, yet few adolescents receive medication for OUD (MOUD), particularly buprenorphine. However, initiation can be challenging, as the medication, a high-affinity partial agonist at the mu opioid receptor, can precipitate withdrawal if administered inappropriately. Many adolescents lack access to appropriate levels of supervised care, making it increasingly important for physicians to feel equipped to initiate buprenorphine at home. This is a preliminary feasibility case series for a protocol used in a pediatric addiction clinic for home initiation of buprenorphine in patients 18 and younger. The primary objective is to outline the protocol used, and the secondary objective is to examine the rate of successful initiation.

Patients aged 18 years old and younger, who entered treatment for OUD in a child and adolescent outpatient psychiatry clinic between 2022 and 2024 and who chose home buprenorphine initiation were consecutively included. Data from the intake appointment and planned follow-ups at the 1 and 3 month mark were collected. The data collected included characteristics of adolescents who entered treatment and the proportion who successfully initiated buprenorphine. Successful initiation was defined as those who self-reported initiation of buprenorphine at the first follow-up appointment.

Out of 19 patients (mean age = 15.7), we found that 10 (53%) adolescents initiated buprenorphine at the first follow-up appointment, 3 (16%) were successful at subsequent follow-up appointments, and 6 (32%) adolescents dropped out of treatment. We also identified several individual and systemic barriers to successful initiation including insurance status, transportation and housing status, and relapse on fentanyl.

This early descriptive study finds that a standard protocol for buprenorphine initiation in adolescents implemented by a trained health care professional in an outpatient setting is preliminarily feasible.

Selective serotonin reuptake inhibitors (SSRIs) are generally regarded as safe and widely used in children and adolescents. Although rare, SSRIs can cause neuroendocrine side effects such as hyperprolactinemia and galactorrhea. Galactorrhea is inappropriate milk secretion outside of pregnancy or breastfeeding and may occur with normal prolactin levels. Although numerous cases have been reported in adults, only a few have been reported in adolescents.

A PubMed and Embase search was conducted to identify English-language case reports and case series involving patients ≤18 years with SSRI-associated galactorrhea. Seven adolescent female cases were identified, including five case reports and two cases from pharmacovigilance data.

SSRIs involved included citalopram, escitalopram, fluoxetine, sertraline, and paroxetine, as well as sequential exposure to other serotonergic antidepressants. Time to onset ranged from days to several weeks after initiation or dose escalation, with longer latency reported in a pharmacovigilance case. Prolactin levels ranged from normal to markedly elevated. In all cases, galactorrhea improved or resolved after dose reduction, discontinuation of the offending agent, or treatment modification, with recurrence observed in some patients following exposure to another serotonergic antidepressant.

Reports show that SSRI-induced galactorrhea and hyperprolactinemia, though uncommon, can occur in adolescents. Clinicians should be aware that SSRI-related galactorrhea may occur even when prolactin levels are normal or mildly elevated and should actively inquire about this adverse effect. Further research is needed to clarify prevalence, risk factors, and mechanisms involved.