The Pre-Prescribing Funnel
There’s a moment I think about— that slow unfolding that happens before anyone ever says the word medication.
By the time a child reaches the point where antipsychotics are on the table, the story usually didn’t start there. Is this your story, too?
“They’ll grow out of it.”
It often begins here.
I was frustrated (and dumbfounded!) by my pediatrician’s failure to act years ago when one of my sons was not developing typically in his first 7 years. I wanted help and answers NOW, but my pediatrician kept saying, “Let’s wait another year.”
Another year of sleepless nights, I thought? Another year of irritability, meltdowns, screaming matches? Part of me wanted to say, here, you babysit him for a week or two, and then let’s see if you still feel the same way!
We parents notice things—sleep is off, regulation is fragile, development feels off, and behaviors don’t quite match the explanations we’re being given.
And the response from the doctors is often well-meaning, but incomplete:
- “Let’s watch it for a while.”
- “Some kids just develop differently.”
- “She’s just sensitive.”
- “They’re fine.”
So time passes, and the child adapts the only way a nervous system knows how—by escalating louder when it isn’t understood. (Remember, biology, not behavior!)
Then the waiting begins
When families do push for help, we often enter a kind of holding pattern.
Evaluations are scheduled months, or even years, out. Specialists are overbooked. Therapy waitlists stretch into seasons. School meetings may be helpful, but limited in what they can actually change.
We collect fragments of the story:
- one label from here
- one recommendation from there
- a partial answer, never a full picture
And in the middle of it, we’re still living with our same child—who is still struggling, still overwhelmed, still communicating in the only language their nervous system has available: difficult behaviors, hyperactivity, and meltdowns.
School becomes the pressure point
Not because anyone is doing anything wrong—but because schools are carrying more weight than they were ever designed to hold.
There are too many children. Too few supports. Too little time.
The message from the school might start out nicely—“We need this to stabilize.”
But if behavior becomes disruptive enough, it can become the moment families first hear the suggestion (and sometimes it’s phrased as a demand!), “Let’s talk about medication.” Not because the child is “bad,” but because the system is strained.
Everyone is doing their best… but separately
One provider is treating sleep.
Another is addressing behavior.
The school is managing the classroom.
The family is trying to hold everything together at home.
But no one is holding the full story.
And without that full story, treatment becomes reactive—focused on the most visible or urgent symptom, not the underlying conditions that created it.
Then comes the “crisis version” of your child
This part is important and often misunderstood. By the time many children reach specialty care, they are not being seen on their best days.
They are seen:
- after sleep deprivation
- after repeated dysregulation
- after school calls
- after caregiver exhaustion has set in
They are seen in their most activated, most overwhelmed state. And sometimes, so are we! In that moment, everyone is trying to do something—anything—that brings relief quickly.
And medication enters the story here
Not as a first idea or a simple choice. But as something that appears when everything else has already been tried—interventions that apparently didn’t fully address what was driving the behavior underneath.
It becomes the fastest available response in a system that has run out of time.
The part I can’t stop thinking about
Antipsychotics don’t usually appear at the beginning of the story.
They appear later
- after systems are overwhelmed
- after families have been pushed past exhaustion
- after behaviors have escalated into crisis
- and after earlier supports that might have changed the trajectory were delayed, limited, or never fully accessible.
I can’t help but think—what would have changed this story if appropriate support had arrived earlier? (And yes, sometimes an antipsychotic is the appropriate choice—there is a higher rate of psychiatric needs on the autism spectrum.) See my opinion piece, Would You Give a Horse an Antipsychotic? here for a great analogy of what I mean by appropriate support.
Next Time
This will all tie in to driving readiness—I promise— so join me next time for a more clinical discussion of antipsychotic use in autistic children, teens and adults.