Monthly Archives: February 2015

NYC Child, Adolescent and Adult Psychiatrist Diary: ADHD, the Parent, and the School

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In a previous article, we discussed the fact that kids with ADHD are increasingly prescribed not only Ritalin and Adderall (which are FDA approved for ADHD), but also antipsychotic medications (which are not).

Why?  Here’s the typical story:

A parent comes to see me saying, “The school is really concerned about Johnnie’s behavior. The teachers and school psychologist are calling me every day about how aggressive and disruptive he is. They want me to speak to you about his medications. They feel that being on Ritalin is not enough and that he may need something like Risperdal. The school staff told me that this is a safe and effective treatment for ADHD and that other kids in his class are taking it.”

They said WHAT? No,  no, no!  Risperdal is NOT a treatment for ADHD. It is an antipsychotic medication FDA approved to treat Bipolar disorder, Schizophrenia, and irritability in children with Autism.

Risperdal is by no means a benign medication. It is in the category of major tranquilizers and carries with it the risk of weight gain, as well as elevated blood sugar and cholesterol.

I don’t   want to sound like I am placing blame on our parents, teachers and schools. Many of our schools are  inundated with too many students and have too few resources. I have the utmost respect and admiration for them, and I’m truly inspired by the work they do.

But we need to educate our parents, teachers and schools about psychotropic medications,  their indications for use, and their side effects.  Many parents and  educators have unrealistic expectations about these medications and misunderstand their role in treatment.   Too many  in the mental health field are either quick to start or to  advocate for the use of these powerful medications before more beneficial alternatives are utilized.

I often have to explain to parents that psychotropic medications are only a piece of the overall treatment. Behavioral interventions, programs, and other school activities are in my opinion a much larger and effective piece of the puzzle.

Applied Behavioral Analysis (also known as ABA) is  a scientifically validated approach to modify problem behaviors. ABA is nationally recognized as safe and effective and is endorsed by many state and federal agencies including the U.S Surgeon General and the New York State Department of Health.

ABA therapy has demonstrated improvements in learning, reasoning, communication and adaptability in children with Autism. Many of these same principles are also being applied to help treat kids with other behavioral disorders including ADHD.

I would love to receive phone calls from teachers and parents asking me about ABA therapy rather than pushing for the use of powerful medications like Risperdal.

As I  discussed in a previous article commenting on Dr. Richard Friedman’s New York Times article, often all that  is needed is a reassessment of the child’s individual education plan, classroom setting and size.

Let’s not forget the power of talk therapy. Kids need to have someone to talk and share their feelings with.  They may be depressed or anxious over conflicts in the house, parents separating and divorcing,  or perhaps even domestic violence.

Sometimes aggression in school is due to a child’s feelings of inadequacy about having learning difficulties and not being able to comprehend the material like the other children.

So please let’s not be so trigger-happy with psychotropic medication. Save the Big Guns for when there are no other alternatives.

And let’s not forget  the various scientifically validated behavioral therapies that we have at our disposal.  As far as I know, ABA therapy has yet to be associated with weight gain or diabetes.

©Roey Pasternak, MD
New York City

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Adderall vs Risperdal.

Why it’s important to optimize stimulant treatment for ADHD before adding other medicationspic-boy-sitting-laptop

As a child, adolescent, and adult psychiatrist seeing people with ADHD, I’m stunned by how many of them arrive in my office already taking medications that no one (including the FDA) ever intended to  be used for this condition.

Stimulants such as Ritalin (methylphenidate) have been used in children to treat symptoms of ADHD since the 1960’s. We have decades of experience as well as substantial research evidence  supporting their effectiveness.  Although stimulants are by no means free of side effects, today we have more sophisticated formulations of these medications that are quite well tolerated by most people.

But it’s surprising how many people bring their ADHD kids to see me, and I find out that someone has prescribed Risperdal or Abilify.  These are not stimulants.  They’re atypical antipsychotics.  They’re not approved for ADHD.  So why are practitioners in the community prescribing them for ADHD kids?

Risperdal and Abilify have been available since the 1990’s, and have been marketed as an alternative to older generation antipsychotics for treating schizophrenia and bipolar illness.  We think that they are less likely to cause  EPS (Parkinson-like symptoms). However they do have some potential serious side effects such increased risk for high blood sugar levels, excess body fat around the waist and increased cholesterol levels.

In 2006 the FDA approved the use of the Risperdal to treat irritability in children and adolescents age  5-17 with Autism.  In 2009 Abilify followed suit and also obtained FDA approval for the same indication in children with Autism.

Since the FDA approved Risperdal and Abilify for use in children with Autism, there has been a substantial increase in the use of these medication to treat aggression and disruptive behaviors in non-Autism kids. Sometimes these medications are prescribed rather quickly before exhausting non-drug treatments or other medications with fewer side effects.

The impulsiveness and hyperactivity of Kids with ADHD can look superficially like irritability. It can take a trained psychiatrist to tell the difference.

It really irks me when new patients come to see me on inadequate doses of  stimulants plus  an antipsychotic. When I ask why the antipsychotic was prescribed, parents often say the following: “I thought that the Risperdal was also for the ADHD.”

Sometimes all that’s needed is for the stimulant to be adequately dosed.

In children with Autism, Risperdal and Abilify can be wonder drugs for  aggression, irritability, and tantrums.  But in kids with ADHD, there are usually better solutions that are safer for the child.

Let’s pay attention to diagnosis. And let’s make sure we use the right medicines at the right doses.

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