Antipsychotics Too Often Prescribed For Aggression In Children

Powerful antipsychotic medications are being used to treat children and teenagers with ADHD, aggression and behavior problems, a study finds, even though safer treatments are available and should be used first.

"There's been concern that these medications have been overused, particularly in young children," says Mark Olfson, a professor of psychiatry at Columbia University who led the study. It was published Wednesday in JAMA Psychiatry. "Guidelines and clinical wisdom suggest that you really should be using a high degree of caution and only using them when other treatments have failed, as a last resort."

Olfson and his colleagues looked at prescription data from about 60 percent of the retail pharmacies in the United States in 2006, 2008 and 2010. That included almost 852,000 children, teenagers and young adults. Teens were most likely to be prescribed antipsychotics, with 1.19 percent getting the drugs in 2010, compared to 0.11 percent in younger children. Boys were more likely to be given the medications.

Antipsychotic medications like clozapine and olanzapine are used to treat schizophrenia, bipolar disorder and some symptoms of autism. They have not been approved by the Food and Drug Administration to treat aggression and ADHD, but are prescribed off label to reduce disruptive behavior.

Use of antipsychotics in children has been questioned because the drugs can have serious side effects, including tremors, weight gain, increased diabetes risk and elevated cholesterol.

This study, which may be the broadest look yet at use of antipsychotics in children, found that most children had not been diagnosed with a mental disorder before being given antipsychotics.

ADHD was the most common diagnosis, applied to 52.5 percent of young children, 60 percent of older children, and 34.9 percent of teenagers diagnosed with ADHD. Depression was the most common diagnosis in young adults, with 34.5 percent. The researchers determined that by looking at inpatient and outpatient claims for a smaller subset of patients in 2009.

"About half of the kids with ADHD have aggression and have disruptive behaviors," Olfson says. "They can be difficult to control." The medications do reduce aggression, Olfson says, but that can also be achieved with behavioral programs such as teaching problem solving skills.

"Behavior modification and family treatment is something that should always some first, but less than one quarter of children and teens are getting that," says Christof Correll, a professor of psychiatry at Hofstra North Shore-Long Island Jewish School of Medicine. He wrote an editorial accompanying the study.

"Physicians use these medications too fast," Correll says. There are a lot of reasons for that, he says, including a shortage of psychotherapists, the amount of time required for family therapy and lack of insurance coverage. As a result, many parents don't seek help until a child is in serious trouble, perhaps about to be expelled or land in juvenile detention.

Only a minority of children had seen a child or adolescent psychiatrist before being treated, the study found.

Earlier studies have found that giving families training on how to deal with aggression can reduce disruptive behavior. Appropriate dosing with stimulant medications like Ritalin also can help.

"It is complicated, and that's why it's hard to fault families or clinicians," Correll adds. Behavior problems can have interfere with a child's education, social interactions and development, he notes, so parents shouldn't delay seeking help. "They should try to get guidance counselor involvement at school, and not dismiss it until it's too late."

Seeking out a psychiatrist or other specialist can not only help find appropriate treatments, but can speed up referrals to therapists, Correll says.

The study, which was funded by the National Institute of Mental Health, involved researchers at Columbia University, Yale and NIMH.