Antipsychotics Frequently Part of Kids' ADHD Treatment

Megan Brooks

January 20, 2017

Many children with attention-deficit/hyperactivity disorder (ADHD) are prescribed an antipsychotic, yet up to 25% of these children apparently have no other mental health diagnosis for which these medications are indicated.

"We don't know why these children and youth with ADHD are on antipsychotics, but there is a risk associated with early antipsychotic exposure, so we need to know more about why they are being used so that the benefits can be weighed against the risks," senior investigator Paul Kurdyak, MD, PhD, of the Institute for Clinical Evaluative Sciences in Toronto, Canada, said in a news release.

The study was published online January 18 in the Canadian Journal of Psychiatry.

Primary Care Setting

"Some patients with ADHD require more complex care, including the use of antipsychotics," Dr Kurdyak and first author Tanya Hauck, MD, PhD, psychiatry resident at the University of Toronto, told Medscape Medical News in a joint email.

"While this is beyond the scope of our study, we are concerned that antipsychotics are being prescribed in part due to a lack of readily available psychological or behavioural treatments based on other evidence that access to mental health resources for children and youth in Ontario is challenging," they added.

"ADHD is common and commonly treated in primary care settings, but many studies have been done with survey or questionnaire data," the investigators note.

"The purpose of this study was to understand ADHD in a primary care population, where most ADHD is treated. Linking family physician electronic charts to other data, such as health insurance billings, allowed for a rich and detailed data set so that we could study how ADHD is treated in the community," they add.

Among 10,000 Ontario children aged 1 to 24 years, the prevalence of ADHD was 5.4% (7.9% males, 2.7% females).

Seventy percent of children with ADHD had been prescribed a stimulant or nonstimulant ADHD medication. Nearly 12% had received an antipsychotic prescription, but for 1 in 4 of these children, no psychiatric diagnosis was noted in the chart other than ADHD.

"We would expect some prescriptions for antipsychotics in youth with ADHD, particularly youth with complex presentations or comorbid conditions such as psychotic illnesses, but nearly 12% was higher than we expected," Dr Kurdyak and Dr Hauck said.

The most prescribed antipsychotic in children with ADHD was risperidone (Risperdal, Janssen).

"Given the significant risks of antipsychotics in children, we hope that all alternatives are considered before they are prescribed, although there are cases when they are needed," the investigators note.

They also point out that it is important to note that psychiatric consultation was the only predictor of antipsychotic prescription (odds ratio, 3.85; 95% confidence interval, 2.11 - 7.02), which suggests that children who received an antipsychotic had more complex presentations.

The Ontario study also showed that 1 in 5 youth (19.8%) with ADHD received an antidepressant prescription. Increasing age, psychiatric consultation, and diagnoses of both anxiety and depression predicted antidepressant prescriptions.

"The high number of youth with ADHD who do receive an antidepressant illustrates how ADHD is often not the only condition these youth experience," Dr Hauck said in the news release.

The investigators emphasize that the data reflect only the writing of prescriptions. It is not known whether the prescriptions were filled, nor do the data show the degree of medication adherence.

Moreover, the data came from a family physician/general practitioner database and so do not include patients who exclusively see pediatricians for their medical care.

Undiagnosed Comorbid Conditions?

"There is a subset of kids with ADHD who have a lot of severe psychiatric comorbidity, and that's why the only predictor of antipsychotic prescriptions in this study was psychiatric consultation," Stephen V. Faraone, PhD, of the Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, New York, told Medscape Medical News.

"These are serious cases and are appropriately referred to a psychiatrist. So I would say this study kind of confirms what you would expect," said Dr Faraone, who was not involved in the research.

Dr Faraone is also not surprised that for 1 in 4 children with ADHD who received an antipsychotic, there was no record of another psychiatric diagnosis.

"I wouldn't be surprised if sometimes a psychiatrist doesn't want to make another diagnosis, like pediatric bipolar disorder, because, one they're not comfortable; two, they don't want to stigmatize; or three, they're not sure, but they know that this kid is really disturbed and very aggressive and possibly having some psychosis," he told Medscape Medical News.

"In some ways, the term 'antipsychotic' is a misnomer. Obviously, the drugs are used to treat psychosis, but they are frequently used in pediatric bipolar disorder and also in autism spectrum disorder with aggression, both of which are comorbid with ADHD," Dr Faraone added.

Funding for the study was provided by the Institute for Clinical Evaluative Sciences and the Ontario Ministry of Health and Long-Term Care. The authors have disclosed no relevant financial relationships.

Can J Psychiatry. Published online January 18, 2017. Full text

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