Psychotropic Medications for Children
Psychotropic medications, which can alter mood, perception, cognition, and behavior, have become a commonplace treatment for psychiatric disorders, eclipsing even the use of psychotherapy as a preferred treatment.[1] Children ages 0-18 also receive psychotropic meds to treat a variety of disorders including ADHD/ADD, anxiety, depression, psychosis and other disorders. Applying psychopharmacology to children is controversial due to the potential for interference with developmental processes. All psychoactive drugs can cause side effects and, in children, a relevant concern is that childhood prescriptions can lead to lifetime dependency on psychopharmacology.
How prevalent is psychopharmacology in children? Are children who need psychoactive meds receiving them? What other treatments are available and to what degree are other treatments provided with or in lieu of psychoactive meds?
Drug manufacturers continue to develop new, more powerful psychoactive drugs with fewer side effects.[2] The development of SSRIs (selective serotonin reuptake inhibitors) like Prozac was hailed as revolutionary in the psychiatric community because of the reduced side effects of these drugs compared to earlier treatments.[3] Other drugs, like second-generation anti-psychotics, were also seen as an important step toward bringing functionality and normalcy to patients struggling with psychosis.[4]
In fact, prescribing patterns of psychoactive drugs to adolescents showed a sharp uptick between 1994 and 2001 reflecting the development of newer, better meds.[5] Was there a concomitant increase in psychoactive drug prescriptions for children?
Declines in Psychoactive Drug Prescriptions
In a 2014 publication about psychoactive drug prescriptions for preschool children, the authors noted that “the use of psychotropic medications in young children approximately doubled between 1995 and 2001” which raised alarm, but “the vast majority of preschool children identified as having emotional or behavioral problems did not receive psychotropic medications” (p. 208).[6]
A later comprehensive study, which reviewed a prescription database, suggested that for children ages 3 and older, psychoactive meds are most likely under-prescribed based on the number of children with psychiatric diagnoses. For example, the prevalence estimates for anxiety, depression, and ADHD in pediatric populations is higher than the number of medications prescribed to treat these disorders. Their data showed that the youngest children received the fewest prescriptions (0.8% of population) and adolescents were the most likely to receive a prescription (7.7%). When looking at prescriptions for specific classes of drugs, older children were more likely to be prescribed stimulants (such as for ADHD), and antidepressant use increased with age.
However, the authors were less certain about the application of antipsychotic meds in pediatric populations due to off-label use of these medications (such as for irritability in children with Autism Spectrum Disorder). Overall, the authors concluded that “at a population level, prescriptions of stimulants and antidepressant medications for children and adolescents do not appear to be prescribed at rates higher than the known rates for psychiatric conditions they are designed to treat” (p. 162).[7]
Prescriptions for Psychosis
A 2021 publication by Bushnell and colleagues focused on prescriptions for anti-psychotic drugs given to young children (2-7 years old). They reviewed a national database of privately-insured patients, including data from 2007-2017. Their interest, not isolated to the prevalence of these prescriptions, sought to identify diagnoses that lead to prescriptions for anti-psychotics.
Anti-psychotic prescriptions were given to 0.27% of young children in 2007, rising to 0.29% in 2009, and then declining to 0.17% in 2017. The authors found an increasing number of prescriptions were written in response to a diagnosis in 2017, compared to 2009. Even in 2017, 11% of patients were prescribed anti-psychotics in the absence of a mental disorder diagnosis. What types of psychiatric diagnoses warranted an anti-psychotic prescription? The most common included pervasive developmental disorder, conduct disorder, and ADHD. Less common disorders for which anti-psychotics were prescribed included psychosis and Autism. However, anti-psychotics for conduct disorders and ADHD are “off-label” as they have not received FDA approval for treating these conditions.[8]
As a powerful class of drugs with potentially significant side effects, anti-psychotic prescriptions should be given only after a full psychiatric evaluation by a qualified professional. However, one study found that “fewer than half of young children receiving antipsychotic treatment had a visit with a psychiatrist” (p. 14).[9]
Effects of Psychoactive Drugs on Development
Children with psychiatric disorders are particularly amenable to therapeutic interventions, due to rapid changes in brain development.[10] In pediatric populations, the potential for drugs to negatively influence developmental trajectories is high. As explained in a 2019 publication, “the long-term effects of most medications on children’s metabolism, neurologic function and other systems are largely unknown, because the few existing trials have been short-term studies of one medicine for one specific disorder, not long-term studies of the polypharmacy for mixed conditions that occurs regularly in routine care” (p. 358).[11] Therefore, non-pharmacological treatments must be incorporated to improve long-term outcomes. Proponents of pharmacological interventions prefer this faster route to relief, particularly for depressed and anxious adolescents who may attempt suicide, but short-term prescription treatments do not preclude the inclusion of psychotherapy. In addition to psychotherapy, parent management training and social skills training can be particularly effective at behavioral control of young children’s symptoms.
The Problem of Polypharmacy
Although definitions of polypharmacy vary, when applied to psychiatric polypharmacy, it involves taking two or more psychoactive drugs.[12] The American Academy of Family Physicians compiled a list of negative consequences of polypharmacy, and these negative consequences can befall the young as well as the old. Patients with mental health conditions “are often prescribed psychotropic medications with adverse effects, and more medications may be added to mitigate side effect profiles” (p. 33).[13] Each additional prescription in a child’s regimen increases the risk of adverse reactions.
In a 2021 publication that reviewed 35 studies of pediatric psychoactive polypharmacy published between 2000 and 2020, the authors discovered that “as many as 300,000 youth now receive 3 or more [drug] classes concomitantly” (p. 1). Treatments for ADHD, one of the most-commonly-treated mental health conditions in children, often include a mixture of different classes of drugs including stimulants and anti-psychotics. Long-term effectiveness of polypharmacy and the use of off-label drugs in combination raises risks to children. In a particularly illuminating quip, the authors stated: “when society asks medicine to relieve social ills, we get prescriptions” (p. 10).[14]
A recent study of pediatric polypharmacy shared good news about trends in prescribing multiple psychoactive drugs to this population. Among world regions studied, North America had the lowest rate of pediatric polypharmacy in children. They also documented a decline in polypharmacy across the last three decades from 45.6% to 34%.[15]
Advocating for Your Child’s Mental Health
Parents are the best advocates for the physical and mental health care of their children. Parents’ daily interactions with their children provide valuable insights to practitioners about the best interventions to help their children achieve successful mental health outcomes. The resiliency of children bodes well for potential treatment outcomes and should give hope to parents.
What can parents do to ensure their children receive timely and effective interventions? [16] [17]
- Many drugs are prescribed in the absence of a diagnosis. An accurate diagnosis is an essential precursor to treatment.
- See a mental health specialist, such as a psychiatrist or psychologist, to get a diagnosis. Pediatricians and general practitioners are not qualified to give a mental health diagnosis.
- Don’t see medication as the only or the best treatment. Children who need drugs for psychiatric illness may not need them forever, especially if they receive psychotherapy or behavioral interventions.
- Keep your child’s mental health specialist in the loop about side effects. Ask for adjustments in medications and/or dosages when needed.
- Work with relevant school personnel to ensure your child is receiving all applicable services.
- Arm yourself with knowledge. Learn everything you can about your child’s diagnosis and the recommended treatments.
- Find a support group. The National Alliance on Mental Illness (NAMI) provides peer-led family support groups. Click here to access the NAMI support group page.[18]
The National Institutes of Mental Health publish online a four-page factsheet on children and mental health. It covers relevant topics including when to seek help, choosing a mental health professional, treatment options, and working with schools.[19] Click here to access the fact sheet.
©Jennie Dilworth, Ph.D
[1] In 2020, 16.5% of adults took psychotropic drugs compared to 10.1% who received psychotherapy. Terlizzi E. P., & Norris T. (2021). Mental health treatment among adults: United States, 2020. NCHS Data Brief, no 419. Hyattsville, MD: National Center for Health Statistics.
[2] https://scitechdaily.com/scientists-have-developed-a-new-better-antidepressant/
[3] Hillhouse, T. M., & Porter, J. H. (2015). A brief history of the development of antidepressant drugs: from monoamines to glutamate. Experimental and Clinical Psychopharmacology, 23(1), 1–21. https://doi.org/10.1037/a0038550
[4] Fabrazzo, M., Cipolla, S., Camerlengo, A., Perris, F., & Catapano, F. (2022). Second-Generation Antipsychotics’ Effectiveness and Tolerability: A Review of Real-World Studies in Patients with Schizophrenia and Related Disorders. Journal of Clinical Medicine, 11(15), 4530. https://doi.org/10.3390/jcm11154530
[5] Thomas, C. P., Conrad, P., Casler, R., & Goodman, E. (2006). Trends in the use of psychotropic medications among adolescents, 1994 to 2001. Psychiatric Services, 57(1), 63-69.
[6] Madden, C., Black, B., & Willsie, D. (2014). Treating our youngest patients: psychotropic medications in early childhood. Missouri Medicine, 111(3), 207.
[7] Sultan, R. S., Correll, C. U., Schoenbaum, M., King, M., Walkup, J. T., & Olfson, M. (2018). National patterns of commonly prescribed psychotropic medications to young people. Journal of Child and Adolescent Psychopharmacology, 28(3), 158-165.
[8] Bushnell, G. A., Crystal, S., & Olfson, M. (2021). Trends in antipsychotic medication use in young privately insured children. Journal of the American Academy of Child & Adolescent Psychiatry, 60(7), 877-886.
[9] Olfson, M., Crystal, S., Huang, C., & Gerhard, T. (2010). Trends in antipsychotic drug use by very young, privately insured children. Journal of the American Academy of Child & Adolescent Psychiatry, 49(1), 13-23.
[10] Rapoport, J. L., & Gogtay, N. (2008). Brain neuroplasticity in healthy, hyperactive and psychotic children: Insights from neuroimaging. Neuropsychopharmacology, 33(1), 181-197.
[11] Drake, R. E. (2019). Overmedicating vulnerable children in the US. Epidemiology and Psychiatric Sciences, 28(4), 358-359.
[12] Govaerts, J., Boeyckens, J., Lammens, A., Gilis, A., Bouckaert, F., De Hert, M., … & Desplenter, F. (2021). Defining polypharmacy: in search of a more comprehensive determination method applied in a tertiary psychiatric hospital. Therapeutic Advances in Psychopharmacology, 11, 20451253211000610.
[13] Halli-Tierney, A. D., Scarbrough, C., & Carroll, D. (2019). Polypharmacy: evaluating risks and deprescribing. American Family Physician, 100(1), 32-38.
[14] Zito, J. M., Zhu, Y., & Safer, D. J. (2021). Psychotropic polypharmacy in the US pediatric population: a methodologic critique and commentary. Frontiers in Psychiatry, 12, 644741.
[15] Baker, C., Feinstein, J. A., Ma, X., Bolen, S., Dawson, N. V., Golchin, N., … & Bakaki, P. M. (2019). Variation of the prevalence of pediatric polypharmacy: a scoping review. Pharmacoepidemiology and Drug Safety, 28(3), 275-287.
[16] https://www.nami.org/Your-Journey/Family-Members-and-Caregivers/Learning-to-Help-Your-Child-and-Your-Family
[17] https://www.psychologytoday.com/us/blog/when-your-adult-child-breaks-your-heart/201805/are-children-overprescribed-psychiatric
[18] https://www.nami.org/Support-Education/Support-Groups/NAMI-Family-Support-Group
[19] https://www.nimh.nih.gov/sites/default/files/documents/health/publications/children-and-mental-health/children-and-mental-health-is-this-just-a-stage.pdf