Antipsychotic medications, especially second-generation antipsychotics, have increasingly been prescribed to children under age 18 in the United States. They are approved to treat pediatric bipolar and psychotic disorders and aggressive behaviors among patients with autism, but they are often used off label to control disruptive behaviors of children without autism and treat mood problems of children without bipolar disorder. The most vulnerable children, such as those in foster care, are the most likely recipients. Common known risks are potentially serious, and suspected long-term developmental risks to the brain and body are largely unstudied. Safer and equally efficacious therapies, both psychosocial and pharmacological, are available. Critical implications for mental health services include implementing prevention activities, training and monitoring prescribers and other clinicians, increasing efforts to protect children as the most vulnerable patients receiving these medications, increasing access to safer medications and evidence-based psychosocial interventions, educating all stakeholders, and enhancing shared decision making.