When second-generation antipsychotics such as Risperdal and Seroquel burst onto the scene in the 1990s, they changed the face of schizophrenia treatment.
The drugs were remarkably effective at curbing psychosis. Their makers created high-profile marketing campaigns suggesting that the powerful drugs could help with depression, too.
More recently, the spotlight on antipsychotics has driven doctors to prescribe them for many other conditions, especially in children with serious behavioral problems such as hyperactivity and aggression. A shocking number of these kids — about 58,000 — are between the ages of 1 and 6, according to a study of 2010 prescription data published in JAMA Psychiatry this month.
Of all boys aged 10 to 18 in the U.S., about 1.5% receive antipsychotic medications. But here's what's really interesting: After age 18, that number drops by half. This suggests, some say, that the drugs are often used not to treat a psychiatric diagnosis, but to make kids more subdued in school.
"It looks like many kids are being managed for disruptive behaviors with these medications," Michael Schoenbaum, a researcher at the National Institute of Mental Health and one of the authors of the new study, told BuzzFeed News. "And when either they mature or their environment changes — when they're less under the control of their parents and the school system — use falls by half."
Schoenbaum's study is part of a growing awareness among doctors that antipsychotics are often prescribed to children as a quick fix for challenging behaviors. This is particularly troubling, researchers say, because these children might be better served with a much safer option: psychotherapy.
Antipsychotics are not supposed to be widely used in kids. The FDA has only approved them to treat children with bipolar disorder or autism. But doctors can still prescribe the drugs to children without those diagnoses, in what's known as "off-label" use.
Antipsychotic Prescriptions By Age
Researchers can’t tell exactly what behaviors or conditions most children are being prescribed the drugs for, because the majority of them aren’t diagnosed with a mental illness.
"A lot of these kids don't receive any clinical psychiatric diagnosis, so we don't know what's going on, but we'd hope these would be used cautiously," Mark Olfson, a research psychiatrist at Columbia University and another author on the JAMA Psychiatry study, told BuzzFeed News. "These medications have substantial side effects, and there's a lot we don't know about their safety."
It's hard to know why so many of these kids lack psychiatric diagnoses, Olfson added. It might be because kids are getting the pills from pediatricians without a specialty in psychiatry, or because parents are concerned that a diagnosis would be stigmatizing. Or it could be that they don't have a real mental illness, and are getting these powerful drugs to make them more compliant at school and home.
The antipsychotic most often prescribed to children is risperidone. In adults, common side effects include rapid weight gain and metabolic changes that can put people at greater risk of diabetes and cardiovascular problems.
These side effects may be even worse in children. A 2000 study found that children on risperidone gained almost five pounds a month in the six months the study lasted, with no signs of slowing down. This might be because risperidone and other atypical antipsychotics affect metabolic hormones and the neurotransmitter dopamine, all of which are important for healthy growth and maturation.
There is some evidence that the drugs affect brain development in rats, though it's unclear what effects they have in humans.
The FDA has approved a few antipsychotics for use in childhood bipolar disorder, and to treat aggression in children with autism. However, the majority of kids taking antipsychotics who have a psychiatric diagnosis have something much more common: ADHD.
This is troubling to many researchers, who say that antipsychotics are way too strong to treat ADHD.
"There's a lot of data that with kids with disruptive behavioral problems and ADHD, the best practice is careful use of stimulants and psychotherapy," Schoenbaum said. "It does not include giving these kids antipsychotic medication."
Many of the children being prescribed these drugs are very young.
Some 58,000 kids under the age of 7, and 360,000 kids between 7 and 12, were prescribed antipsychotics in 2010, according to the JAMA Psychiatry study.
"What does it mean for a 5-year-old kid to have ADHD?" Schoenbaum said. "I think what's really going on here is these are kids with substantial self-control issues, they have lots of disruptive behaviors.
"Antipsychotics kind of dampen people's energy," Schoenbaum added. "They're acting out and difficult to handle, and if you prescribe them these medications they're easier to handle."
A big part of the problem is that there is a major shortage of child psychiatrists, Claudia Gold, a child mental health specialist at the Brazelton Institute at Boston Children's Hospital, told BuzzFeed News. This makes it more likely that children will receive prescriptions from a general practitioner or an adult psychiatrist who doesn't necessarily understand the way these conditions present in kids.
All the experts BuzzFeed News spoke to agreed that psychotherapy should be the first line of defense for kids who are acting out at home or in school.
Some kids might be getting bullied in school or abused at home, and responding in the only way they know how. As Christoph Correll, a professor of psychiatry at Hofstra North Shore LIJ School of Medicine, put it: "Aggression is the language of the inarticulate."
But psychotherapy takes time — and money. Parents who can't afford time off work to take their children to therapy (or to sit in parent-teacher conferences when their kids misbehave) might be desperate for a quick fix.
"It falls on the pediatrician and the parent to say, we're not just going to medicate this problem away," Gold told BuzzFeed News. "We have the knowledge to help kids in meaningful ways without drugs, and we need to focus on those interventions."