Sienna* was “hyperactive from birth” – rolling, crawling, walking ahead of time. But her active nature brought with it increasing difficulty managing her emotions as she grew up.
By the age of four, her mother Rachel* could no longer drive the car without Sienna throwing her shoes at her.
At preschool, Sienna bit and scratched other children, ripped up their artwork and threw sand.
Rachel took her daughter to a developmental paediatrician, “looking for a bit of peace for us [as her parents], but ultimately we just wanted her to be happier and to be calmer”.
However, when the doctor offered her a script for the antipsychotic drug risperidone, Rachel wasn’t sure. It is usually used to treat serious mental illness such as schizophrenia or bipolar disorder.
The doctor said Sienna could not be prescribed with alternative medications such as stimulants used to treat ADHD and autism, because she was too young to be diagnosed with those developmental conditions.
“It was really hard, I was very conscious that we’ve got a little growing developing brain here,” Rachel said.
“On the one hand, they’re telling me we can’t diagnose her with anything because she’s too young – but on the other hand, they’re saying: ‘Here, take an antipsychotic that would probably knock a 20-year-old man out.’”
A study led by the University of Adelaide has found Australian doctors are increasingly prescribing antipsychotic drugs to children and adolescents.
Published recently in the journal JCPP Advances, the study’s authors analysed the de-identified electronic health records of children and adolescents under 19 years of age, taken from a large general practice database.
Researchers then extracted the data from those given a mental health diagnosis, examining records from 2011 and 2017.
Of the 8,418 children and adolescents diagnosed with a mental illness in 2011, 191 (2%) were prescribed antipsychotics, the researchers found.
By 2017, this rose to 2.9%, with 893 of the 27,412 children and adolescents with mental illness prescribed antipsychotics. It is a rise the study authors described as significant. Of these prescriptions, 70% were ‘off-label’ in 2011, which rose to 80% in 2017. The most common diagnosis among children prescribed antipsychotics was depression or anxiety.
Off-label refers to a drug being prescribed outside its intended purpose, with paediatric antipsychotics only approved by Australia’s drugs regulator for bipolar disorder, psychoses, and severe self-destructive, disruptive or aggressive behaviours.
Study lead author Julie Klau said off-label prescribing is common in children and adolescents because there are so few studies performed in the age group, so evidence on effectiveness and safety is limited.
The greatest increases in off-label prescribing over the period were seen in girls aged 15‐to-18, children and adolescents living in disadvantaged areas, and children and adolescents in remote regions.
Prof Dave Coghill, the chair of developmental mental health at the University of Melbourne, who was not involved in the study, said: “I think probably these medications are overused as ways of controlling difficult or aggressive behaviours.”
“I think there are lots of non-drug ways that we can manage those behaviours, and one of the problems is, of course, people have great difficulty accessing those kinds of supports.”
Prof Valsamma Eapen, the chair of the faculty of child and adolescent psychiatry at the Royal Australian and New Zealand College of Psychiatrists, said that given the scarcity of the child psychiatry workforce, GPs and paediatricians have been increasingly prescribing psychotropics including antipsychotics.
“We need to see more training for GPs and paediatricians around prescribing practices and attitudes to antipsychotic use in children and adolescents,” Eapen said.
“Another concerning finding is the higher rate of antipsychotic use in patients from regional and remote communities and disadvantaged areas. This indicates a pressing need to address the lack of alternative management strategies, such as psychological interventions from child psychiatrists and mental health professionals in these areas.”
Associate Prof Daryl Efron said a limitation of the study is the mental health diagnoses could not confidently be linked to the reason for prescribing the medications because data recorded in general practice databases is not always rigorous, and information may be missing. But he described the findings as important.
Coghill and Effron said antipsychotics should be prescribed by a specialist, especially for those younger than 14. It is unclear from the study data whether the medication was first prescribed by a specialist or a GP.
More rigorous monitoring of antipsychotic prescribing is needed, the study authors concluded, and the impact of the pandemic on youth mental health and prescribing also needs further study, they said.
Rachel decided not to give her daughter the antipsychotic she was prescribed, after the experience of trialling the sedative clonidine – which the paediatrician had also prescribed – left Sienna unable to stand up.
Rachel emphasises: “I’m not an anti-medication person at all.”
A year later, when Sienna was diagnosed with hyperactive ADHD and prescribed Ritalin, “it was like someone has switched on a light within 15 minutes. It was like she had woken up out of a coma.”
* Names have been changed
SANE helpline on 1800 187 263 offers support for complex mental health issues.
