What is a safe tapering plan for a 9-year-old boy with autism and Attention Deficit Hyperactivity Disorder (ADHD) who is currently taking Abilify (aripiprazole) 15mg, citalopram 40mg, and clonidine (clonidine) 0.1mg to discontinue all medications?

Safe Medication Discontinuation Plan for a 9-Year-Old with Autism and ADHD

Given that none of the current medications are providing adequate benefit and the family wishes to discontinue all medications, taper aripiprazole first (as the antipsychotic with the highest long-term side effect burden), followed by citalopram, and maintain clonidine until last to prevent rebound hypertension and provide behavioral stability during the transition. 1

Rationale for Medication Discontinuation Sequence

The American Academy of Child and Adolescent Psychiatry recommends removing medications based on several principles when multiple agents are being used: prioritize discontinuing medications with the greatest long-term side effect potential, remove augmenting agents before primary treatments, and consider which disorder is most severe or impairing. 1

In this case:

• Aripiprazole should be tapered first because antipsychotics carry significant long-term metabolic and neurological risks in children, and this medication is not providing adequate symptom control. 1
• Citalopram should be tapered second as SSRIs have limited evidence for treating irritability in autism and may be contributing to behavioral activation. 2
• Clonidine should be discontinued last to maintain some behavioral stability and prevent dangerous rebound hypertension during the transition period. 1, 3

Specific Tapering Schedule

Phase 1: Aripiprazole Taper (Weeks 1-8)

Week 1-2: Reduce aripiprazole from 15 mg to 10 mg nightly 3

• Monitor closely for increased irritability, aggression, or sleep disturbance
• Watch for withdrawal dyskinesias (involuntary movements that may emerge during taper) 1

Week 3-4: Reduce aripiprazole from 10 mg to 5 mg nightly 3

• Continue behavioral monitoring with structured rating scales (e.g., Aberrant Behavior Checklist) 4, 5

Week 5-6: Reduce aripiprazole from 5 mg to 2.5 mg nightly 3

Week 7-8: Discontinue aripiprazole completely 3

• Allow 2-4 weeks of observation after complete discontinuation before starting the next taper 1

Phase 2: Citalopram Taper (Weeks 9-16)

Important: Citalopram at 40 mg is the maximum FDA-approved dose for adults and exceeds typical pediatric dosing. Gradual tapering is essential to avoid SSRI discontinuation syndrome. 2

Week 9-10: Reduce citalopram from 40 mg to 30 mg nightly 3, 2

• Monitor for withdrawal symptoms: anxiety, irritability, dizziness, nausea, insomnia 3, 2

Week 11-12: Reduce citalopram from 30 mg to 20 mg nightly 3, 2

Week 13-14: Reduce citalopram from 20 mg to 10 mg nightly 3, 2

Week 15-16: Discontinue citalopram completely 3, 2

• Allow 2-4 weeks of observation before starting clonidine taper 1

Phase 3: Clonidine Taper (Weeks 17-20)

Critical Warning: Abrupt clonidine discontinuation can cause severe rebound hypertension, tachycardia, and behavioral deterioration. 6

Week 17-18: Reduce clonidine 0.1 mg XR to 0.05 mg (half tablet) nightly 6

• Monitor blood pressure and heart rate at least twice weekly 6
• Watch for rebound hyperactivity, insomnia, and irritability 6

Week 19-20: Discontinue clonidine completely 6

• Continue blood pressure monitoring for 1-2 weeks after complete discontinuation 6

Essential Monitoring During Tapering

Weekly monitoring should include: 1, 6

• Structured behavioral rating scales (Aberrant Behavior Checklist or similar)
• Sleep patterns and quality
• Aggression/violence episodes (frequency and severity)
• Vital signs (blood pressure and heart rate, especially during clonidine taper)

Red flags requiring immediate intervention: 1, 2

• Severe increase in aggression or self-injury
• Suicidal ideation or statements (SSRIs carry black box warning for suicidality in children) 2
• Blood pressure >95th percentile for age during clonidine taper
• Emergence of involuntary movements (tardive dyskinesia from aripiprazole withdrawal) 1

Critical Pitfalls to Avoid

Do not taper multiple medications simultaneously. Complete one medication taper and allow stabilization before starting the next. 1

Do not rush the timeline if withdrawal symptoms emerge. If severe symptoms develop, return to the previous dose and slow the taper rate by extending each reduction phase by 1-2 weeks. 3

Do not discontinue clonidine abruptly under any circumstances. Rebound hypertension can be dangerous and potentially life-threatening. 6

Do not assume behavioral worsening is solely withdrawal. This child has severe baseline irritability and aggression that may re-emerge as medications are removed, requiring consideration of alternative behavioral interventions or medication strategies. 4, 5

Alternative Considerations

If severe behavioral deterioration occurs during tapering that poses safety risks, consider:

• Pausing the taper and implementing intensive behavioral interventions 7
• Re-evaluating whether complete medication discontinuation is appropriate given the severity of symptoms since age 2 4, 8
• Consulting with a developmental neuropsychiatrist for alternative medication strategies if behavioral interventions prove insufficient 6

The entire discontinuation process will take approximately 20 weeks (5 months) minimum. Attempting faster tapers significantly increases the risk of severe withdrawal symptoms and behavioral crisis. 1, 3