"The emergency use of medication to control behavior should not be considered a standard treatment for inpatient children and adolescents who manifest aggressive and disruptive behaviors" (Pappadopulos et al., 2003).
A medication trial should be of adequate duration and dose before changing medications. If the initial atypical antipsychotic is ineffective, the panel recommended an alternative atypical antipsychotic before another drug category is tried (Pappadopulos et al., 2003). In the TRAAY schema, failure to respond to two adequate trials of atypical antipsychotics will warrant changing to a mood stabilizer, a typical antipsychotic or a drug combination. A partial response to an atypical antipsychotic could be heightened by a mood stabilizer, the panel noted, but the combination should only be employed after reassessing diagnosis and the adequacy of behavioral interventions and of the pharmacotherapy of the primary disorder, including dose and duration.
The panel recommended routine and systematic monitoring of medication side effects, and tapering to discontinue one or more combined medications if response is not forthcoming. In reducing polypharmacy, the panel suggests deleting first those agents with the most dangerous side effects or adverse interaction potential, or side effects, which could be misinterpreted as treatable symptoms, or those having little empirical data on efficacy. An antipsychotic dose that has been effective for aggression associated with psychotic illness might also be reduced, according to the panel, after approximately six months without aggressive symptoms.
In concluding, the panel cautioned, "To avoid the risk of 'chasing symptoms' rather than treating the primary disorder, these recommendations should not be used in isolation å all decisions must be guided by a biobehavioral hypothesis that is revised as new information about the patient's response to different agents is revealed" (Pappadopulos et al., 2003).