We Must Stop the ADHD Prescribing Cascade, Not Perpetuate It

More than two decades ago, as clinical psychologists engaged in health research, we identified a region-specific tendency to use psychiatric drug combinations to treat childhood ADHD. The trend stemmed from care delivered through the pediatric hospital located in the southeastern corner of Virginia known as Hampton Roads, which includes Norfolk, Portsmouth, Virginia Beach and several other cities.

In 1993, Children’s Hospital of The King’s Daughters recruited two pediatric specialists with ADHD expertise to the region to run its new four-story neurodevelopmental center. I was hired to provide psychological input to multidisciplinary team assessments led by the pediatric specialists. Over my repeated objections, the specialists diagnosed ADHD in 75% of the first 188 consecutive cases we evaluated. Community doctors and mental health professionals emulated the pediatric specialists.

The specialists and I held different views about our center’s high rate of diagnosis. They thought it reflected a pent-up demand for services. They presumed the high rate reflected a referral bias and was no cause for concern. That did not make sense to me because ADHD was often discussed among adults in my social circle, which included parents of my daughter’s elementary school friends.

I decided to study the prevalence of ADHD in the region in a way that would not be confounded by a referral bias. This involved an assessment of the school health records for every single child in two entire school districts, which combined reflected the demographic characteristics of the entire Hampton Roads region of Virginia. To this end, my colleagues at Eastern Virginia Medical School (EVMS) counted children as ADHD-diagnosed only if their school nurse records contained a physician-signed form stating that the child had ADHD for which he or she was to receive a mid-day dose of medication for the condition.

Accordingly, about 8-10% percent of the 30,000 elementary schoolchildren had been diagnosed with ADHD. Shocking as that rate seemed at the time, we knew it underestimated the extent of ADHD treatment because we had used an extremely conservative method for identifying cases. By the time of our study, long-acting medications that obviated the need for mid-day dosing by a school nurse had become popular. About half of ADHD-medicated schoolchildren were on long-acting medications, meaning ADHD diagnoses in the region were twice as high as school nurse records indicated, about 18%.

To move beyond the limits of research that tied prevalence rates to school nurse record counts, we conducted epidemiological studies that incorporated parental reports of ADHD diagnoses and treatment. Indeed, the rate of ADHD diagnosis was much higher than school nurse reports indicated. Our initial study focused on students in grades 2-5 to align with previously published epidemiological investigations of ADHD treatment. Among students in grades 2-5, 17% had been diagnosed with ADHD; among students in grades 1-5, 19% carried that diagnosis. Most (84%) of the ADHD-diagnosed children were medicated for the disorder. Many of the ADHD-medicated students were heavily medicated: 28% were on two or more psychotropics (usually a stimulant and an antidepressant); 8% were on three or more; and 1% were on four or more. Bear in mind, these data were from a quarter of a century ago, when national estimates were that fewer than 3% of American children had been diagnosed with ADHD and even fewer medicated for the condition. These findings indicated that ADHD-drug treatment among children in Hampton Roads was as aggressive, if not more aggressive, than the treatment of adult schizophrenia.

When I presented these findings at the 2001 annual meeting of the American Psychological Association (APA) in San Francisco, I suggested we needed to establish “a public health agenda that includes improved systems for tracking ADHD diagnoses, treatments, and outcomes,” as quoted in an APA Monitor report of the symposium. Russell Barkley, an ADHD opinion leader who received millions of dollars of support from the pharmaceutical industry had a different view. He told the audience to “stop hand-wringing about the extent to which we are using medication in this country.” After the meeting, the coauthor of this article (Antonuccio), offered his insights and support. As one of the first to identify that depression can be treated as effectively if not more effectively with behavioral interventions than medications, his expertise enabled us to critique studies that seemed to oversell the benefits and under-report the risks of ADHD drug treatments. Together, we published numerous academic papers and opinion pieces in which we warned about the harms of ADHD overtreatment.

We sounded the alarm to no avail. Others did too. Dr. William Pelham was one of the investigators of the federally-funded randomized controlled trial that compared outcomes among ADHD-diagnosed patients under different treatment conditions. This major study, the MTA study, followed a cohort of children who were randomly assigned to receive medication, medication plus behavioral therapy, behavioral therapy alone, or routine community care. Initial 14-month results looked promising for the use of medication. Medication reduced hyperactivity slightly, although it did not improve any educational outcomes. However, Pelham noted that 75% of the children who received behavioral prior to the initiation of medication fully resolved all their ADHD symptoms. Moreover, the modest medication effects that were observed initially had disappeared completely by the three-year follow-up. After three years, children on medication had worse educational outcomes and substantial decreases in physical growth. Pelham noted, “In the short run [medication] will help the child behave better, in the long run it won’t. And that information should be made very clear to parents.”

The massive ADHD overtreatment that began in southeastern Virginia 25 years ago should have been curtailed. Instead, it morphed into a national disaster. Today, statewide ADHD prevalence rates vary from a low of 6% in California to a high of 16% in Louisiana. But within states, prevalence rates vary even more such that many U.S. communities now treat children for ADHD at rates that rival what we documented in Hampton Roads 25 years ago.

Tens of thousands of American children are currently on ADHD polypharmacy treatment regimens, according to a recent analysis of a national database. Commenting on the report, Dr. Mark Olfson, a professor of psychiatry and epidemiology at Columbia University Irving Medical Center, said, “We need long-term studies following young people to fully understand the effects of psychiatric medications on the developing brain.” From our perspective, the use of psychotropic drug cocktails in children—especially young children—does not need to be studied; it needs to be stopped. Instead, some communities with exceptionally high rates of pediatric psychotropic prescribing, like the nation’s first ADHD “hot spot,” have opened child-specific psychiatric inpatient facilities to manage the fallout. This includes an uptick in psychiatric crises and violence among children treated for mental health conditions.

While acknowledging that ADHD-diagnosed children may receive drug combinations for a variety of reasons, such care is often a function of the “prescribing cascade” wherein one drug is used to treat the adverse effects of another drug. This is precisely what we observed long ago, when the rate of ADHD diagnosis and polypharmacy treatment in Hampton Roads was unconscionably high. What’s critical to underscore is this: there is no scientific evidence base for routine use of multiple psychiatric drugs. Research has clearly demonstrated that psychiatric polypharmacy is unhealthy when used to treat adults. It increases the risk of drug interactions, weight gain, severe side effects, relapse, and a shortened lifespan. We know little about the impact of psychiatric polypharmacy in children but we know plenty about the harms of drugs that are commonly added to ADHD stimulant prescriptions.

Antipsychotics are increasingly added to ADHD treatment regimens. According to a study published in Pediatrics, 40 percent of ADHD-diagnosed 2-24-year-olds are now on an antipsychotic. Antipsychotic-induced health problems in children are similar to those experienced by adults. These problems are metabolic dysfunction, which includes weight gain and diabetes. For many, they cause permanent neurological injuries such as intense restlessness (akathisia) and uncontrollable body movements (tardive dyskinesia).

Antidepressants are also added to an ADHD drug treatment regimen. Between 2016 and 2022, more than 221 million antidepressant prescriptions were written for US teens and young adults. A recent New York Times Magazine story recounted a loss of sexual desire among teenagers who had been medicated with antidepressants known as SSRIs. Sexual dysfunction caused by antidepressants is common among adults, affecting as many as 60% of patients who take this medication. Symptoms include deadened desire, genital numbness, erectile dysfunction for men, elusive arousal for women, delayed and dulled orgasms or the inability to reach orgasm at all. The medical community presumes these sexual side effects eventually fade. But the symptoms can persist for many patients even after the medication is stopped, resulting in a new label known as PSSD (post-SSRI sexual dysfunction). The nonprofit PSSD Institute has documented that a significant percentage of people experience sexual dysfunction for years or even decades after discontinuing their medication.

To avoid the possibility of severe withdrawal symptoms, gradual tapering of psychiatric drugs is usually recommended. Psychiatric deprescribing refers to an intentional and systematic approach to tapering under supervision. The art and science of safe deprescribing is a nascent field. Few clinicians have sought training to oversee the process. Consequently, patients have resorted to online peer support for help through organizations such as the Benzodiazepine Information Coalition.

While unprecedented numbers of American children have been placed on psychiatric polypharmacy regimens, few parents are informed about the potential dangers associated with starting, stopping, or reducing these medications. Laura Delano, a descendant of Eleanor and Franklin Delano Roosevelt, received the best mental health care money could buy. Yet, she was subjected to harmful polypharmacy throughout adolescence and young adulthood. Having suffered both from being put on too many medications and misguided efforts to discontinue them, she formed the Inner Compass Initiative. It is a relatively new online resource for people who want to safely discontinue their psychiatric medications. Earlier this year she published her related memoir, Unshrunk.

For children, little help is available. It is our experience that most parents and children would prefer fewer ADHD medications, yet they feel disempowered in these decisions. Without knowledge, they are reluctant to challenge the standard of care—care that has evolved to include routine use of untested and unsafe drug combinations. Increasing numbers of American parents could face a quandary. They may want to reduce their children’s medication but receive little support or guidance to do so.

Drug companies might be willing to fund research focused on the effects of polypharmacy in children, but such studies would likely unjustifiably risk the health and wellbeing of study subjects. We already know combining medications increases risk without adding benefit. Our limited resources would be better spent on developing safe deprescribing protocols and preventing ADHD prescribing cascades.