Are we Prescribing too Many Antipsychotic Medications for Children with ADHD?

A recent study by the Institute for Clinical Evaluative Sciences found almost 12 per cent of children and youth with attention deficit hyperactivity disorder, or ADHD, were prescribed antipsychotics like Risperdal, Zyprexa and Seroquel. Since the study found that 5% of Ontario children have ADHD, this means that .06% of children may be receiving antipsychotic medications. The study went on to report that 20% of children with ADHD were also receiving antidepressants for depression or anxiety which the lead researcher Dr. Paul Kurdyak, head of the mental health and addictions program at ICES, did not find surprising since these disorders frequently coexist with ADHD. However, the researchers did find it surprising, that children with ADHD would be receiving antipsychotic medications when these medications have not been shown to treat ADHD.

Unfortunately the article implies that these medications are being used to treat simple ADHD, while at the same time conceding that these medications have a sedating effect and assist with disruptive behaviour. Unfortunately what the researchers did not mention is that some children with a more severe presentation of ADHD can also have extreme forms of emotional dysregulation, in some cases so severe that they are unable to attend school or be involved in normal family life without experiencing episodes of emotional “meltdown” and sometimes aggression.  This would be the common profile of the majority of children who are receiving these medications. Normal levels of ADHD disruptive behaviour would not commonly warrant a prescription of antipsychotic medication.

In addition, it makes perfect sense that more people who see a psychiatrist have these medications prescribed. It is child and adolescent psychiatrists who generally see these more severe cases. General practitioners and paediatricians refer these more difficult cases to child and adolescent psychiatrists, when they have been unable to successfully treat the child themselves. Of course, better education for front line physicians on how to assess, diagnosis and treat ADHD appropriately may be helpful as well.  We know that the sooner we diagnose and treat ADHD the better chance we have of reducing co-existing disorders and the long term consequences of ADHD.

No one would argue that if there is a choice antipsychotic medication should never be given to children and that psychotherapy should always be the first choice of treatment. Unfortunately it is also true that affordable family, child and youth mental health therapy is very difficult to access across this country resulting in a two tier mental health system. However, after speaking with many of these families and the physicians who treat these children it is clear that even when parents do everything right and therapy is implemented, for some children and youth it is still not enough.

Also, no one would disagree that many of these medications have significant side effects and should not be a first line treatment. However, at this time there are no medications that have been approved to specifically treat these symptoms in children and youth so physicians are forced to use these medications off label. Obviously more research is required.

One new medication, Intuniv, has been approved by Health Canada for treating children and youth with ADHD and has been found to be very helpful for many children with emotional dysregulation and aggression issues. This medication is not an antipsychotic medication and can be prescribed along with ADHD stimulant medication or on its own for those who have difficulty tolerating stimulant medication, or have not found stimulant medication to be effective. While Intuniv does have some mild side effects, as do all medications, they seem to be far fewer than those of antipsychotic medications.

For this reason CADDAC is currently asking the Ontario Public Drug Program to include this medication on their list of approved medications making it accessible to families receiving their medication through this program. Advocacy on this issue in other provinces is also on the agenda. As this study indicates not many children will require this medication, and while it will not work for all children with these symptoms, I have spoken to many families who have indicated that it has changed their child’s life and their family’s quality of life.

Of course, better access to newer more easily tolerated once-a-day ADHD medications being covered on provincial drug programs would be helpful and may actually help to decrease prescribing of antipsychotic medication. Coverage across Canada is sporadic leaving vulnerable families unable to access a wide variety of ADHD medications.  The more choices we have in ADHD medication the better chance we have of being able to achieve the best treatment options for each child and adolescents with mental health disorders. Unfortunately mental health medications are definitely not a one-size fits all scenario.

My major concern about articles on this particular study such as this CBC article, and often articles on other ADHD topics, is that writing about these very complex issues superficially and with an aim to sensationalize only increases misunderstanding about childhood mental health and the way we treat it. They also result in increased stigma, confusion and fear for parents and care givers trying their best to make informed decisions on treatment for their children.