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.
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.
Claudia M. Gold is a pediatrician who blogs at Child in Mind and is the author of Keeping Your Child in Mind.
