Letter to the Editor

Possible Acute Confusional State After Risperidone in a Pediatric Patient

339

JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGYVolume 14, Number 3, 2004Mary Ann Liebert, Inc.Pp. 339–341

RISPERIDONE IS AN ATYPICAL antipsychotic thathas been used widely in the recent years in

children and adolescents for a variety of diag-noses, including autism and mental retarda-tion (McCracken et al., 2002; Malone et al.,2002). Previous studies reported a relativelymild side effect profile for risperidone in chil-dren, with the most frequent side effects beingdrowsiness, weight gain, constipation and fa-tigue (McCracken et al., 2002; Malone et al.,2002). While delirium and acute confusionalstate have been reported as side effects in olderpatients on risperidone (Ravona-Springer etal., 1998; Doig et al., 2000), these side effectshave not been reported in children. In this re-port, we describe the case of a male child whodeveloped an acute confusional state after tak-ing a single dose of oral risperidone.

CASE REPORT

A 6 year old boy was referred to our childpsychiatry department because of repetitivetongue licking, and playing with his hands,masturbation, inattentiveness, and academicfailure in the first grade. Tongue licking beganwhen the child was three month’s old, andmasturbation and playing with his handsbegan after one year of age. Frequency and in-tensity of tongue licking and playing with hishands decreased with age, and the quality ofthese behaviors changed. While he licked histongue all day when he was younger, he hadbegun to do this only when he was bored in re-cent years, like playing with his hands. He waslicking his lips both at school and at home.

This behavior interfered with his learning, andalso impaired his relations with peers sincethey teased him. He stopped the behaviorwhen he was busy with something. Parentstried to distract the child with cartoons or justby calling him when he begun licking his lips.This sometimes worked. Masturbation wasdaily and very frequent at the beginning, andoccured at bedtime. He rubed his genitals tothe floor with his clothes on. At the beginning,the child masturbated when his parents werethere, but with time he began to masturbateonly when he was alone. He did not mastur-bate at school, or in front of other children.While disturbing, the stereotypic behaviorsdecreased spontaneously with time. The pe-diatricians and adult psychiatrist that hisparents applied used behavioral techniquesmainly based on distracting the child, butthese were not totally successful. Although ac-ademic failure was evident since he attendedschool, he was placed in a regular school set-ting, because he was not mentally retarded.The child attempted to complete his home-work. Parents did not report attention prob-lems (distractibility, loosing things, etc.).Specific learning disabilities were not as-sessed. The boy reported that he was alsoupset by his behaviors and that he tried to stopthem but could not. He was also disturbedabout his academic failure. He reported tohave normal perinatal, natal, developmentaland medical history except the above-men-tioned symptoms and a single episode of un-complicated febrile convulsion. The DSM–IVStereotypic Behavior Disorder diagnosis wasmade, and IQ evaluation was planned. Ris-

13805C02.PGS 10/15/04 2:37 PM Page 339

peridone 0.25mg/day p.o. was initiated. Ris-peridone was chosen as the initial medicationbecause of relatively milder side effects andbecause it was reported to be effective in re-ducing stereotypic behavior (McCracken et al.,2002). However, the patient was given 1 mg/d(0.05 mg/kg/d) because the parents misun-derstood the instructions. Thirty minutes aftertaking the first dose of the medication, the pa-tient became agitated. He did not recognize hismother, and he began to talk in an incompre-hensible way and was anxious. He continuedto be agitated at the hospital emergency roomand was aggressive to the medical personnel.He could not answer easy questions, such ashis name. In his first medical examination atthe emergency ward, the patient was agitatedand uncooperative. The laboratory work-uprevealed normal throat culture, normal CRP,8750/ml white blood cells, 12.7 g/dl Hgb, nor-mal ECG, normal urine analysis, normal bloodbiochemistry except slightly lower Cl (89mmol/dl; normal range: 90–140) and Na (128mmol/dl; normal range: 135–150) that werenormalized the next day. At the time of admis-sion and during the follow-up the patient didnot have fever, and blood pressure remainedwithin normal limits. Physical and neuro-logical examination were normal except foragitation and miosis. Risperidone was dis-continued, and supportive treatment was ini-tiated. There was no definitive dischargediagnosis. The acute confusional state lastedfor 16 hours. Full IQ score of the patient, whichwas evaluated after the patient discharged,was 82 (Stanford-Binet test). The symptomsdid not change after the single dose of risperi-done, however during 6 months of follow-up,playing with his hands and masturbation fur-ther decreased considerably without specifictreatment, but licking his lips did not. The par-ents refused to use another psychoactive drug,so we could not evaluate the response of thechild to other medications.

Sudden onset of disturbance of conscious-ness and psychomotor activity accompaniedby irritability, anxiety and fear is consistentwith the diagnosis of delirium. Acute confu-sional state was clearly temporarily relatedwith the risperidone intake, and the symp-

toms were reversed after 16 hours with non-specific supportive treatment. Blood Na levelwas slightly low during admission, but thislevel of hyponatremia does not seem to beonly cause of the clinical picture. Miosis is nota usual side effect of risperidone, and thecause of this finding was not clear, but it re-solved with time after supportive treatment.The medical and neurological examination ofthe patient, laboratory results, and the abruptonset and course of the symptoms did notsupport other diagnostic possibilities likecentral nervous system infection, malignantneuroleptic syndrome, or other metabolicproblems and toxic conditions. This suggeststhat risperidone might be the cause of thesymptoms. Delirium is a known side effect ofmany drugs that affect the central nervoussystem including antidopaminergic drugs.Previous case reports indicated that, particu-larly in older patients, confusional states anddelirium are possible after risperidone treat-ment and that symptoms usually dissipatedafter discontinuation of the drug. Like olderpatients, children may be particularly vulner-able to some side effects of the psychophar-macological drugs, and it is known thatdelirium is more frequent in children (APA,1994). We thought that it was appropriate toacknowledge the risk of confusional statewith risperidone in children.

REFERENCES

American Psychiatric Association: Diagnostic andStatistical Manual of Mental Disorders. 4th ed(DSM–IV). Washington DC, APA, 1994.

Doig A, Sembhi S, Livingston G: Acute confusionalstates during treatment with risperidone. Int JGeriatr Psychiatry 15:534–535, 2000.

Malone RP, Maislin G, Choudhury MS, Gifford C,Delaney MA: Risperidone treatment in childrenand adolescents with autism: Short- and long-term safety and effectiveness. J Am Acad ChildAdolesc Psychiatry 41:140–147, 2002.

McCracken JT, McGough J, Shah B, Cronin P, HongD, Aman MG, Arnold LE, Lindsay R, Nash P,Hollway J, McDougle CJ, Posey D, Swiezy N,Kohn A, Scahill L, Martin A, Koenig K, VolkmarF, Carroll D, Lancor A, Tierney E, Ghuman J,Gonzalez NM, Grados M, Vitiello B, Ritz L,

340 LETTERS TO THE EDITOR

13805C02.PGS 10/15/04 2:37 PM Page 340

Davies M, Robinson J, McMahon D: Risperidonein children with autism and serious behavioralproblems. N Engl J Med 347:314–321, 2002.

Ravona-Springer R, Dolberg OT, Hirschmann S,Grunhaus L: Delirium in elderly patients treatedwith risperidone: A report of three cases. J ClinPsychopharmacol 18:171–172, 1998.

1Ozgur Oner, M.D.1Ayla Aysev, M.D. Prof.Dr.

2Ipek Kaplan, M.D.1Ankara UniversityFaculty of Medicine

Child Psychiatry DepartmentCebeci, Ankara, Turkey

2Cumhuriyet UniversityFaculty of Medicine

Department of PediatricsSivas, Turkey

LETTERS TO THE EDITOR 341

13805C02.PGS 10/15/04 2:37 PM Page 341