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Reply: Atypical Antipsychotic Use in Treating Adolescents and Young Adults with Developmental Disabilities

In our clinical practice, we have also observed that some persons with DD at times experience a “dramatic and longlasting response to low-dose atypical neuroleptics” but that “this population, however, seems particularly sensitive to neuroleptic-induced movement disorders (NIMDs), hence caution and close monitoring are required” (1). What we feel deserves greater emphasis for practitioners less familiar with this etiologically and symptomatically diverse population with different types and degrees of DD is that the diagnostic complexities involved are substantial. Even establishing a diagnosis of schizophrenia or autism–pervasive developmental disorder (PDD) can be challenging; differentiating symptoms of psychosis from symptoms of anxiety in persons with autism–PDD can be still more problematic. Friedlander and others did not comment on these challenges in their paper, nor did they attempt to tease apart whether outcome was due to the atypical antipsychotic medication per se or whether and to what extent associated interventions with other medications or nonpharmacologic therapies may have contributed (a difficult thing to establish in a small sample). To identify those for whom atypical antipsychotics are effective, and in what context, further research on larger series is warranted. Friedlander and others note that, even with their clinic’s conservative prescription practices, one-half the individuals in the sample were taking atypical antipsychotics—even when psychotic symptoms were not documented. We agree with the authors that, in the absence of clearly identified psychiatric disorders for which these medications are indicated, the practice of using either typical or atypical antipsychotics to treat behaviour disturbances is no longer tenable. We urge psychiatrists to identify and carefully monitor, in both their research and clinical practice, the target symptoms that the antipsychotic is intended to address, particularly when the symptoms are not psychotic (as may have been the case for many of the individuals with autism–PDD in the present sample). Proceeding in this way helps to ensure that the old practice of overprescribing neuroleptics, noted by Friedlander and others, does not transfer into overprescribing newer antipsychotic medications, particularly in situations where the prescribing physician does not have access to a comprehensive multidisciplinary evaluation process.