The proportion of children who became new users of antipsychotic
medications doubled from 1996 to 2001 among those enrolled in TennCare,
Tennessee's public health insurance program for Medicaid enrollees and the
Increases in new antipsychotic use were particularly steep for conduct
disorders and affective disorders, according to a report in the August
Archives of Pediatrics and Adolescent Medicine.
According to the study, the vast majority of the new users are receiving
atypical antipsychotics. In 1996, 6.8 percent of new users received an
atypical antipsychotic; by 2001 this had increased to 95.9 percent.
(New users were defined as those who were alive and continuously enrolled
in TennCare for 365 days before and 90 days after the date of the first
antipsychotic prescription. Children and adolescents had to be 2 to 18 years
old and could not have used antipsychotics in the preceding 365 days.)
"Although this trend coincided with the introduction of the atypical
antipsychotics, it is also possible that it was influenced by changing
attitudes and practices regarding the use of pharmacotherapy for mental
disorders in children," wrote lead author William O. Cooper, M.D.,
M.P.H., an associate professor of pediatrics at Vanderbilt University."
Data from studies of hospitalized children suggest that atypical
antipsychotics can successfully control disruptive behavioral symptoms. On the
other hand, before the introduction of the atypical antipsychotics, the severe
and frequent adverse effects of antipsychotics led to the recommendation that
these agents be used only in exceptional
"A recent systematic review of the evidence supporting use of
atypical antipsychotics in children and adolescents for [disruptive behaviors]
concluded that there was insufficient evidence to support their
efficacy," Cooper added.
But child and adolescent psychiatrist David Fassler, M.D., said that while
it is popular to disparage the use of antipsychotic medications in children,
their increasing use does not necessarily mean that they are being prescribed
"We should not jump to the conclusion that an increase in the use of
these medications automatically indicates a problem," he told
Psychiatric News. "We really need to understand more fully how
the medications are being used and monitored."
Fassler noted that specific recommendations about the use of antipsychotic
medications for aggressive youth—based on clinical experience and
published data—appeared in the February 2003 Journal of the Academy
of Child and Adolescent Psychiatry (see box on
page 42). That article
is not referenced in the report by Cooper and colleagues.
Fassler said the authors were right in pointing out that controlled studies
of the use of antipsychotic medications in children are lacking. And he agreed
with their cautions regarding the potential for inappropriate use and risk of
significant side effects.
"But the issue is more complex," he said. "The question
is how the medications are being used, whether the kids are being evaluated
and monitored, and what dosages are prescribed.
"If we limited our pharmacotherapy practice for children to
treatments that had achieved the level of evidence-based practice, you would
probably be limited to two or three interventions," he said.
Cooper's retrospective cohort study examined medication records for
children enrolled in Tennessee's TennCare program during the period from
January 1, 1996, through December 31, 2001.
TennCare is the state's program for Medicaid enrollees and uninsured
individuals. It operates under a 1994 federal waiver that permitted broadened
eligibility to include persons of low to moderate income who were uninsured
but would not qualify for Medicaid under federal guidelines.
The study analysis was restricted to the uninsured and those whose
enrollment was through the largest Medicaid component of the program, Aid to
Families With Dependent Children. This excluded children who might have been
enrolled as a result of severe mental illness and who, therefore, were likely
to have had antipsychotic use prior to enrollment.
Results adjusted for demographic characteristics showed that the proportion
of TennCare children who were new users of antipsychotics nearly doubled
during the study years, from 22.9 per 10,000 in 1996 to 45.4 per 10,000 in
Among the new users, 43.1 percent were diagnosed as having ADHD or conduct
disorder; 14.2 percent, bipolar disorder; 8.7 percent, schizophrenia or other
psychosis; 7.2 percent, another affective disorder; 6.2 percent, mental
retardation; 4.5 percent, other psychiatric disorders (primarily adjustment
reactions); and 2.2 percent, an acute psychotic reaction.
Only a small proportion of new users had diagnoses of Tourette syndrome
(2.1 percent) or autism (0.2 percent).
The new users had substantial previous use of other psychotropic drugs,
primarily stimulants (20.4 percent), selective serotonin reuptake inhibitors
or other antidepressants (29.6 percent), and lithium or other mood stabilizers
In an editorial in the same issue, Peter Conrad, Ph.D., a professor of
social sciences at Brandeis University, called on medicine to examine the
larger social implications—both costs and benefits—of increasing
use of psychotropics in children.
"From a social perspective, defining more and more children's
behaviors as medical problems diverts our attention from the possible social
and psychological origins of these difficulties," he wrote. "In
our medicalized culture, once an issue is defined as a medical problem, it
becomes difficult to refocus on social or population-based solutions. More
subtly, the treatment of behavioral and learning problems with psychotropics
may reduce our appreciation and tolerance of difference."
He added, "Physician researchers have often called for specific
studies of the safety, adverse effects, and efficacy of these medications for
pediatric populations. This is an important and urgent task, but it is also
time to ask why there has been such an upsurge in the use of psychotropic
medications in children and adolescents and to systematically investigate the
medical and social origins and consequences of this phenomenon."
An abstract of the study, "New Users of Antipsychotic
Medications Among Children Enrolled in TennCare," is posted online at<http://archpedi.ama-assn.org/cgi/content/abstract/158/8/753>.▪
Arch Pediatr Adolesc Med2004158753