Antipsychotics prescribed at ‘high’ rate to youth with ADHD, study shows

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One in 20 children and young adults in Ontario are diagnosed with attention deficit hyperactivity disorder (ADHD), and a high percentage of them are prescribed antipsychotic drugs, even though their rate of psychosis is low, according to researchers of a new study released on Wednesday.

The study, published in The Canadian Journal of Psychiatry, found 11.9 per cent of young ADHD patients between the ages of 1 and 24 were prescribed antipsychotic medication. Yet it found few were diagnosed with other illnesses such as schizophrenia or bipolar disorder that are typically treated with antipsychotics, and less than 1 per cent had psychosis.

The study shows "the majority of kids with ADHD are getting stimulants, which are definitely first-line treatment, but it also shows that more than one in 10 are also being prescribed antipsychotics," said senior author Dr. Paul Kurdyak, lead of the mental health and addictions research program at the Toronto-based non-profit Institute for Clinical Evaluative Sciences. "While there's some evidence for the use of antipsychotics in ADHD, the one in 10 rate seems quite high."

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Although the study did not investigate why the patients were given antipsychotic prescriptions, one of the most common reasons for prescribing these drugs "off-label," or for uses other than for what they are developed, to ADHD patients is to treat general disruptive behaviour, said Kurdyak, who is also a scientist at the Institute for Mental Health Policy Research at Toronto's Centre for Addiction and Mental Health. However, he said, antipsychotics can have side effects, including rapid weight gain and metabolic illnesses that make children susceptible to developing diabetes.

"[For] a child who's being prescribed antipsychotics, you would also hope that every other treatment alternative would have been tried so that the risks that are inherent with antipsychotic use in kids is balanced by the benefits, given the severity of the situation," Kurdyak said.

The study, funded by the Institute for Clinical Evaluative Sciences and the Ontario Ministry of Health and Long-term Care, examined the randomly selected records of 10,000 patients between the ages of 1 and 24 from an electronic database, collected from family physicians in Ontario. The researchers found 5.4 per cent of patients were diagnosed with ADHD, in line with the prevalence of the disorder elsewhere, Kurdyak said.

Of those patients with ADHD, 70 per cent were prescribed ADHD medications, including stimulants and atomoxetine. Among those prescribed antipsychotics, the most common was the drug risperidone.

Dr. Chris Wilkes, past president of the Canadian Academy of Child and Adolescent Psychiatry and who was not involved in the study, said the prevalence of antipsychotic prescriptions for ADHD patients is not surprising, as earlier studies have shown similar findings.

Since ADHD often comes with other disruptive behavioural disorders, "a lot of pediatricians and psychiatrists will [use] a pharmacological adjunct, such as an antipsychotic, as a tranquilizer. So that happens quite commonly," said Wilkes, an associate professor and division head of child and adolescent mental health and addictions at the University of Calgary. "Now, is this the right thing to do? I think that's a great question."

Wilkes said repetitive physical activity, such as swimming, dancing and drama, can help children and adolescents regulate their disruptive behaviour, which would minimize the use of antipsychotic medications. But they often get little opportunity to regulate themselves through physical activity during school time or at home. At school, in particular, students are typically expected to do one cognitive activity after another, he said.

As a result, "we tend to do what's easiest as opposed to what's optimal for the child," he said, likening the use of antipsychotics to "the McDonald's fix" to get patients to relax quickly.

There are instances when a quick fix may be necessary, Wilkes said. But beyond the risk of side effects of antipsychotics, "we also give the wrong message in terms of how to regulate yourself by taking a pill," he said. Instead, "maybe the best thing to regulate yourself is to do something physical, which can help considerably."