by Barbara Geller, M.D. and Martha Hellander

Antipsychotic medications in the neuroleptic group (including Abilify, Clozaril, Geodon, Haldol, Risperdal, Seroquel, Thorazine, and Zyprexa) are often used to treat symptoms such as psychosis and severe aggression that may occur in patients with a variety of psychiatric conditions including bipolar disorder. Children taking these medications must be regularly monitored for development of side effects that appear in the face and body and how the child walks (gait). These include Parkinsonism, tardive dyskinesia, and akathesia. Parents may notice these side effects in their children. If so, the child's doctor should be notified immediately.

In Parkinsonism, the gait becomes "shuffling," which means the child appears to be pushing their feet along the ground rather than taking steps. Body posture while walking looks as if the child is bent over so that the head leads the walking movement. Arm swing that accompanies the usual gait decreases. In addition, the face becomes flattened into a mask-like quality without the normal mobility and expressiveness. Drooling during the day and night also occurs. A tremor of the fingers occurs at rest (e.g., while the child is absorbed in a TV show) and it looks as if the child is rolling a small object between the thumb and other fingers. Limbs may feel stiff, and "cogwheeling" may occur. Cogwheeling can be diagnosed by moving your child's arms at the elbows and at the wrists and seeing if the movement feels as if it is broken up by cogs. Parkinsonism is also called an extrapyramidal side effect because of the part of the brain that is affected. Parkinsonism usually disappears when the medication dose is lowered or the medicine is stopped.

A more serious side effect is tardive dyskinesia (late occurring abnormal movements). Although these were initially called tardive because they were noticed in adults after years on medication, they may occur earlier in the course of neuroleptic (antipsychotic) medication in children. Because these movements are usually irreversible, catching them before the irreversible stage is crucial. Later on these movements look as if someone is smacking their lips, rolling around their tongue in the mouth or repeatedly sticking out their tongue. Fortunately, the earliest evidence of a tardive is abnormal tongue movements that are "worm-like." If medication is stopped at the worm-like stage, the tardive is reversible. To observe your child for a worm-like tongue, first observe your child's tongue before medication is begun and make notes of your observation. Some people have large, wavy movements (undulations) of their tongue normally; others have motionless tongues. If on medication, your child develops movements of the tongue that appear as if the tongue is made of little worms inching their way from the throat to the lips (or from side to side), let your doctor know at once. To examine a child's tongue, ask them to first keep busy by holding up their hands and touching their thumbs repeatedly to each of the other fingers, while sticking out their tongue.

Akathesia is another neurological side effect. This effect causes people to look as if they are running in place in a state of agitation. Because it can make children look like they are more agitated and more active, it is sometimes mistaken for the bipolar disorder getting worse. If this mistake occurs, the child may may be given more medication that will only worsen the akathesia. This side effect improves if the medication is lowered or stopped.

If you notice any of these movement side effects in your child, report it to the doctor immediately.

Barbara Geller, M.D., is Chair of the The Balanced Mind Foundation Scientific Advisory Council. Martha Hellander is The Balanced Mind Foundation's former executive director.