Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Thursday, October 9, 2014

Antipsychotics for ADHD: A Big Unknown

Polypharmacy, or use of multiple psychiatric drugs, for treatment of Attention Deficit Hyperactivity Disorder(ADHD) is on the rise. A recent study compared treatment with "basic therapy"-stimulants plus parent training- with "augmented therapy" those two plus risperidone, an atypical antipsychotic. The study concluded that treatment with risperidone was "superior." 

When children show dramatic improvements in behavior on risperidone, now being prescribed with increasing frequency for ADHD and a range of other disorders that represent difficulty with emotional regulation, we need to ask ourselves one question. Does this change in behavior represent increased capacity for organization and self-regulation, or does it reflect a kind of compliance?

We have over 40 years of longitudinal research in developmental psychology showing that safe, secure relationships support development of the capacity for emotional regulation, cognitive resourcefulness and social adaptation. We have evidence from the field of epigenetics that these relationships, through changes to gene expression, change the structure and function of the brain.
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When children struggle with emotional and behavioral regulation, many evidence-based interventions can support development of these capacities. These include child-parent psychotherapy, DIR floortime, the Neurosequential Model of Therapeutics, and mentalization based treatment.  These relationship-based interventions foster our innate need for connection.

The mechanism of action of risperidone is to block dopamine receptors in the cortex. We do not know what changes in the lower regulatory centers of the brain, if any, are occurring. It is possible that these centers remain dysregulated, and that this dysregulated signal is blocked by the medication. The antipsychotic might promote compliance, with improvement in behavior, but the underlying disorganization might remain. If that is the case, then the medication is not changing the brain in the way that we know relationships can change the brain.

This is an important question to answer. It goes well beyond the known significant side effects of antipsychotics. For when medication is so effective at controlling behavior, the motivation for investing time and effort in relationship-based interventions may be lost. Prescribing medication takes much less time. With atypical antipsychotics the results are often immediate, and can be dramatic.

If risperidone is found to significantly alter the brain’s capacity for emotional regulation, then it might have a role to play. But if it does not, and we have well-established methods of intervention that do, then the possibility exists that by prescribing this medication to children, particularly in the absence of relationship-based interventions, we are actively interfering in their development. 

I am hopeful that all professionals who strive to promote healthy development in children can work to answer this question in a timely manner.

4 comments:

  1. Antipsychotics "work" in this population because they are basically doping the child up. The same with anticonvulsants for the pseudo-diagnosis of "pediatric bipolar disorder" (Biederman, according to the NY Times, promised the makers of risperdal that it would work before he even did the study). And if you follow the child for more than a few weeks, you'll usually find that they are no longer doing even that.

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  2. Neither of the first two links (to JAACAP) seem to be about treating ADHD.

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  3. I disagree with Dr. Allen (though I acknowledge that some doctors and parents and use medications in the manner he suggests). I often tell my Abnormal Psychology class that I can stop any disruptive childhood behavior -- with general anesthesia. The real question is whether the medications we us (if used properly) can control dysfunctional behaviors without impairing other adaptive thoughts, emotions, and behaviors. I believe that at least some psychiatric medications can achieve this, but it takes a lot of care to avoid simply "doping people up."

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  4. The point of the post is that we do know that supporting relationships changes the brain, particularly in work with young children and their caregivers. So if we are going to use antipsychotics, particularly if they are uses in place of these other interventions, it is imperative that know they are promoting healthy brain development and not simply increasing compliant behavior

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