Why it’s important to optimize stimulant treatment for ADHD before adding other medications
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.