• More children being treated with behavioral drugs

    November 2012

    Antipsychotic drugs are prescribed in almost one out of three visits children make to psychiatrists in the United States, according to a new study. That’s a jump from about one in 11 visits during the 1990s. Researchers attribute the increase to doctors prescribing the drugs for disruptive behaviors such as attention deficit/ hyperactivity disorder (ADHD).


    “Antipsychotic drugs are prescribed in almost one out of three visits children make to psychiatrists in the United States.” 


    However, the U.S. Food and Drug Administration has not approved antipsychotic drugs for treatment of ADHD in children. The study, published recently in the Archives of General Psychiatry, found that roughly 90 percent of the antipsychotic prescriptions for children written between 2005 and 2009 were “off label” – prescribed for something other than for what they’re approved.

    UK study of antipsychotic prescription trends

    A separate study by University of Kentucky researchers found that antipsychotic drugs prescribed to Kentucky children on Medicaid rose 270 percent from 2000 to 2010. The largest growth was among minority children, who took medications to treat schizophrenia, bipolar disorder and depression. They took the medications at three times the rate of white children in 2010. The UK findings are reflected in similar cases in other states, according to a New York Times article. The article examined the practice of prescribing stimulants to students, not necessarily to treat ADHD but to boost their academic performance.

    The UK study, conducted by the UK Center for Business and Economic Research, also found geographical variations in drug prescriptions. For example, poor children in Western Kentucky received much larger quantities of ADHD drugs than children in Eastern Kentucky. However, portions of the study relied on grams per dosage. Some antipsychotic medications as well as ADHD drugs have more grams per dosage than others.


    “The American Academy of Pediatrics recommends elementary school children and adolescents with ADHD receive FDA-approved medications along with behavioral interventions.” 


    Diagnosis & treatment of ADHD

    ADHD is characterized by severe inattention and impulsivity. According to the Centers for Disease Control and Prevention, 9.5 percent of youth in the United States ages 4 to 17 were diagnosed with the disorder in 2007. The American Academy of Pediatrics (AAP) recently expanded its guidelines for the diagnosis and treatment of ADHD. In the November 2011 issue of Pediatrics, the AAP recommended that elementary school children and adolescents with ADHD receive FDA-approved medications such as Ritalin® along with behavioral interventions. Medications for children ages 4 to 6 have not been approved by the FDA, largely because the effects of these medications on brain development in young children are not completely understood.

    The AAP created a process to guide doctors in the diagnosis and treatment of ADHD and the consumer guide ADHD: What Every Patient Needs to Know. As they note in the guide, the causes and origins of ADHD are not clear. Here are a few points they make about what is known:

    • ADHD is a biological disorder in which the brain’s ability to properly use important chemical messengers is impaired.
    • The parts of the brain that control attention and activity level may show lower activity in children with ADHD.
    • There is a family connection with ADHD. Sometimes parents are diagnosed at the same time as their children.
    • Environmental toxins can play a role in the development of ADHD, but that is extremely rare.
    • Severe head injuries can cause ADHD in some cases. There is no evidence that ADHD is caused by eating too much sugar or by food additives, allergies or immunizations.

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Page last updated: 5/23/2014 2:05:17 PM
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    What the news means for you

    Guidelines in place for prescribing ADHD drugs

    Thomas L. Young, MD, FAAP
    Pediatrics

    Wright, Heather, MDThe increasing use of antipsychotic drugs for children, along with the number of all medications a child may be taking at one time, has been a concern among pediatricians for a long time. The report by the University of Kentucky raises the question of whether antipsychotic drugs are being overprescribed to children, but I don’t think it provides any answers. The study is also based on grams of medication, and some antipsychotic drugs have a higher dosage. For example, 54 mg is a typical dosage for Concerta®. For Intuniv®, a 2-3 gram dosage is typical, so that difference could skew the results.

    Most of the antipsychotic medications were being prescribed to treat schizophrenia, bipolar disorder, autism, disruptive behavior disorders and depression. The study also pointed out a geographic variability in prescription rates for medication specifically to treat ADHD. This could reflect a difference in access to care, or some health care providers may be prescribing more than others.

    Health care access

    The UK study looked at poor and disabled children on Medicaid. Part of the challenge with Medicaid is that only community mental health agencies and primary care centers are authorized to bill for mental health counseling services. There are community mental health clinics in every Kentucky county that are supposed to have psychiatrists on staff to diagnose and treat children with mental health problems. But sometimes waiting lists may be long or people don’t feel comfortable going to see a therapist.

    As for private practice psychiatrists, they aren’t allowed to bill Medicaid or received a lower reimbursement. It’s difficult for a private pediatric practice to find therapists for their office because the therapist must be approved by different private health insurances and cannot bill for mental health counseling. When the option for mental health therapy is not available, there is increased pressure for physicians to prescribe antipsychotics to help children with significant behavioral problems that might be addressed with quality counseling services.

    However, some solutions for access to mental health care have been initiated. Many health departments and schools in Kentucky are now able to bill for Medicaid services and are making therapists available. In some states, such as Massachusetts and North Carolina, psychiatrists are available for telephone consultations with private practice pediatricians about patients with ADHD and other mental health disorders.

    At UK Pediatrics we have an integrated model with mental health consultants in the clinic for consultation and treatment, and child psychiatry available as needed. Expanding this consultative model to other pediatric care settings could improve mental health services.

    Diagnosis and treatment for ADHD

    A pediatrician should be consulted first if parents and teachers suspect a child has ADHD. ADHD can co-exist with other conditions such as oppositional-defiant or conduct disorder, a learning disability, anxiety disorder or a mood disorder such as depression. The pediatrician can make an evaluation, which includes a physical examination, a history and the use of screening tools – the Vanderbilt Rating Scales – to determine the diagnosis. There is a scale for parents and one for teachers. The AAP guidelines specify that you need reports from both.

    Here at UK, we don’t schedule an appointment in our ADHD clinic until we review reports from both the parents and the teachers. Rating scales are also valuable in assessing how medications or therapy are working.

    UK’s treatment of ADHD

    In our clinic, we have two licensed clinical social workers on duty, and one day a week a child psychiatrist comes in. We also do follow-up with patients to see if ADHD is being effectively treated, and we monitor the child’s progress every three months. That’s where you get good-quality outcome.

    In most cases, children with ADHD need therapy as well as medication. However, studies have shown that those who exhibit no behavior problems do just as well on medications alone. The Multimodal Treatment of ADHD study, the most comprehensive study ever conducted on the disorder, showed that a combination of therapy and medication in one group and medication management alone in another were both significantly superior to intensive behavioral treatment alone. These benefits were found to last for as long as 14 months.

    There is no evidence that ADHD medications cause serious side effects on the brain in children older than 6. Ritalin and Adderall make up 90 percent of the drugs prescribed for ADHD, and they’ve been around since the 1950s. They do have addictive potential; however, if a child has ADHD, in my experience, they do not become addicted. One-third of the kids who take these medications will need to continue treatment as adults.

    Medication doesn’t cure ADHD; it helps manage the condition, much as insulin manages diabetes. The hope is that parts of the brain will mature and develop so that the medication is no longer needed.

    Dr. Young is a professor of pediatrics in the UK College of Medicine and a board-certified pediatrician at UK HealthCare.

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