Psychotropic medications for behavioural disorders in children: Are we getting it right?

Psychotropic medications are used to treat mental health conditions by regulating the levels of certain chemicals in the brain. In children, they are often used to treat behavioural issues including attention deficit-hyperactivity disorder (ADHD). As one of many treatment options, psychotropic medicines should not always be the first choice for children, especially since their effects on their developing brain are not fully understood. At the University of Louisville, Professors Deborah W Davis and W David Lohr investigated the use of psychotropic medication in children in Kentucky, USA. Their findings reveal that current guidelines are often not adhered to, and the researchers advocate for a reassessment of treatment plans for some children.

Attention deficit-hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder worldwide with approximately 7 million (11.4%) children aged between three and 17 years diagnosed in the US in 2022. The diagnosis is given when a child’s behaviour meets certain criteria with symptoms including persistent inattention with or without hyperactivity and impulsivity. The treatment options for children with ADHD that have disruptive behaviours or that experience challenges in paying attention at school include psychological therapies such as behavioural health therapy, psychotropic medicines, or a combination of the two.

Behavioural health therapy (BH) focuses on regulating the thoughts and emotions that can affect a child’s behaviour negatively. BH involves regular sessions with a therapist, which for younger children includes their parents or carers who are needed to support their child’s behaviour changes. The psychotropic medicines used to treat ADHD but not to cure it include stimulants of the nervous system such as methylphenidate (Ritalin) and alpha-adrenergic agonists (A2As). These medicines specifically target the areas in the brain responsible for attention, and aim to improve the ability to focus and reduce any hyperactivity and impulsivity symptoms.

Current guidelines

According to the American Academy of Pediatrics (AAP) guidelines, BH interventions should be offered to all preschool-age children with behavioural disorders including ADHD as a first line of therapy prior to prescribing medication. This is particularly important since a recent study demonstrated that children from five to 13 years diagnosed with ADHD were less likely to need any medication at all when initially offered BH, and when medication was prescribed, a significantly lower dose was required to control symptoms. Unfortunately, there is evidence that these guidelines are not always followed, with the prescribing of medicines often being the first choice in the US for supporting behavioural issues in children. Professors Deborah W Davis and W David Lohr at Louisville University, USA, have carefully examined these practices, specifically in the Kentucky area.

Davis and Lohr found that only a fraction of those aged between two and five years old with ADHD received BH in combination with medications or BH on its own. This finding raised the researchers’ concerns especially since the long-term effects of psychotropic medication on the rapidly developing brains of young children are not fully understood and could pose a threat to their normal growth, development, and mental health. The researchers investigated the matter further by examining the degree to which young children receive BH prior to medication as per the AAP guidelines.

The Kentucky numbers

Davis and Lohr collected data from the records of children aged between four and five years who had their first dose of stimulants and/or alpha-2 agonists in 2017 and were under the care of the Kentucky Cabinet for Health and Family Services, Department of Medicaid Services from 2015 to 2017.

The data included patient demographic information such as age, sex, date of birth and ethnicity, as well as their diagnosis, procedures and prescriptions. The data was reviewed retrospectively to determine if BH was received before any psychotropic medication was prescribed. From the 836 records that met the study criteria, the team identified 352 children who received BH prior to receiving any medication (42.1%) and 484 children who were only given medication as a treatment (57.9%).

Medicines over psychotherapy?

Analysis of the data revealed that children with an ADHD diagnosis were more likely to be offered BH compared to children without a diagnosis. Also, children that received two types of psychotropic medications, as well as children that were diagnosed with more than one mental disorder, were more likely to have received BH. This means that children with a more complex presentation were offered therapy as well as medications in an effort to give them a higher chance of treating their symptoms; however, it also means that there were a lot of missed opportunities to treat all children with first-line behavioural treatment, something that could have reduced or entirely eliminated the need for administering psychotropic medication.

Most importantly, the findings demonstrated that the AAP clinical guidelines regarding the use of BH as the first-line treatment for preschoolers with behavioural disorders were more often not followed, with only 42% of the affected young children having received BH prior to being started on psychotropic medicines. The remaining 58% received only medications in the form of a stimulant, an A2A or both, while it was also found that 27% of the total of children were treated with two or more psychotropic medications at the same time.

Overprescription of psychotropic medication?

There is growing evidence that the use of psychotropic medication as treatment for mental health conditions including behavioural problems in young children has been increasing dramatically in US in recent years. The number of children receiving two or more psychotropic medications simultaneously is also on the rise.

In another study published in 2020, Davis and Lohr found that 38% of children from low-income families who were under six years of age with a diagnosis of ADHD (2,500 children in the study) received a stimulant medication. Davis highlights, ‘It is important to note that the American Academy of Pediatrics recommends behavioural health interventions for children between the age of four and five years before being prescribed medication. There is no recommendation for medication use in children less than four years.’ The study also highlighted that primary care physicians are the most frequent prescribers of these types of medications. Additionally, children of certain ethnicities are more likely to receive a diagnosis of ADHD and treatment with A2As.

The long-term side effects of psychotropic drugs on youth and their developing young brains, especially those under six years of age, are not entirely known. It is, therefore, important to prioritise children’s safety by weighing the potential risks against the benefits of using such medications and by adhering to the relevant AAP clinical guidelines where available.

The findings from Davis and Lohr’s studies highlight the need to support BH practices and find ways to increase the number of children receiving this type of psychological treatment. Examples of ways to approach this challenge include supporting parents to get involved in their young person’s treatment, or to tackle misconceptions or prejudices from clinicians. In Kentucky, there is a shortage of child and adolescent psychiatrists. Employing mental health professionals with expertise in assessing and treating young children with behavioural disorders would not only support their primary care givers to meet the ever-increasing demand for mental health services, but would also help to offer those services earlier and prevent an over reliance on medication.

Future research

The use of several different drugs to treat a health condition, also known as polypharmacy, is an ongoing issue in mental health care services despite the fact that psychological therapies such as BH are proven to be effective. This is why Davis and Lohr believe that there is an important need for further research to identify the factors that impact on the offering, engagement, and completion of BH treatment such as access to qualified clinicians, delays in referrals, clinician and family bias, and other barriers to access.

The findings of such research could help to tailor these mental health therapy programmes to the varying needs of the families of children, for example by improving neighbourhood access, or adjusting them to certain racial and ethnic idiosyncrasies. Research that will help improve parental engagement of both mothers and fathers will also be very important since BH cannot be offered to children of pre-school age without their participation.