Monitoring the Safety of Second Generation Antipsychotics in Children and Adolescents with Autism Spectrum Disorder

Background: Approximately 17.5% of youth with autism spectrum disorder (ASD) are being treated with second-generation antipsychotics (SGAs; Park et al., 2016). While SGAs have been found to reduce irritability and associated behaviours (e.g., aggression and self-injury) in youth with ASD, a range of side effects (e.g., sedation, weight gain, extrapyramidal symptoms, and metabolic changes) has been reported. Therefore, careful monitoring of youth taking these medications is imperative. However, as the core and associated symptoms of ASD can make medical procedures challenging, monitoring the safety of SGAs may be particularly difficult in this population. The potential for undetected SGA side effects is a significant concern, given rates of SGA prescription to youth with ASD. To date, no investigations have been published describing how closely physicians monitor SGA side effects in youth with ASD or the barriers that they face in doing so.

Objectives: To begin to understand physicians’ current practices in SGA monitoring and the challenges of monitoring SGAs in youth with ASD.

Methods: We designed an online questionnaire that was completed by 31 specialist physicians (General Pediatricians, Developmental Pediatricians, Psychiatrists, and Neurologists) serving children and adolescents with ASD in one region of Canada. Our survey examined physicians’ reports of ordering vs. completion of monitoring tasks recommended by the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotic Medications in Children, as well as their perceptions of factors relevant to SGA safety monitoring in youth with ASD.

Results: Of the monitoring tasks queried, physicians were most likely to measure height, weight, and blood pressure at baseline and as part of ongoing follow-up (>75% attempted these tasks 76-100% of the time). Waist circumference measurements and electrocardiograms (ECGs) were the monitoring tasks least often carried out at both time points (>50% attempted/ordered these tasks 0-25% of the time). Fasting and non-fasting bloodwork were frequently not ordered at baseline (>45% ordered these tasks 0-25% of the time), but were somewhat more likely to be ordered at follow-up. Neurological exams were attempted 76-100% of the time by 68% of physicians at baseline and 48% of physicians at follow-up. As expected, physicians indicated that ECG and fasting and non-fasting bloodwork were the procedures that youth with ASD have the most difficulty completing successfully. When asked their perspectives on child, family, physician, and other/system factors that impede completion of these procedures, physicians identified youth distress, activity level, and refusal, as well as family anticipatory anxiety, previous failed attempts, and competing commitments, as the most significant barriers.

Conclusions: Given rates of prescription of SGAs to youth with ASD and the side effects associated with these medications, careful monitoring is necessary. However, our results indicate inconsistent physician practices in ordering/completing various monitoring tasks at baseline and follow-up. Further, our findings suggest that many youth with ASD struggle to complete successfully the medical procedures required for thorough SGA monitoring. Additional research is indicated aimed at supporting physicians in their monitoring of SGAs and youth with ASD and their families in successfully completing associated monitoring tasks.