More than 25 years ago, we identified a troubling pattern in Hampton Roads, Virginia, a region including Norfolk, Virginia Beach, and Portsmouth, where children with ADHD were frequently prescribed multiple psychiatric medications. This prescribing cascade often occurs when one drug’s side effects are treated with another, exposing children to unnecessary risks.
In 1993, Children’s Hospital of The King’s Daughters opened a neurodevelopmental center with two pediatric ADHD specialists. I was brought on as a psychologist to assist with assessments. Despite my concerns, 75% of the first 188 cases were diagnosed with ADHD, and local doctors began replicating this approach.
To study the prevalence accurately, we examined school health records in two districts covering about 30,000 elementary students. Only children with physician-signed forms for mid-day medication doses were counted. Even by this conservative measure, 8–10% were diagnosed with ADHD, but because long-acting medications had become common, the real figure was likely around 18%. Later surveys including parental reports confirmed rates of 17–19% for children in grades 1–5, far above the national average of under 3% at the time.
Among diagnosed children, medication use was high. 84% were medicated, 28% were on two or more psychiatric
Research, including the federally funded MTA study, shows that behavioral therapy alone can be highly effective with long-term outcomes often better than medication. Yet, despite warnings from psychologists and researchers, aggressive ADHD treatment expanded nationally. Today, ADHD diagnosis rates vary from 6% in California to 16% in Louisiana, with some communities reaching levels seen in Hampton Roads decades ago.
Polypharmacy, or the use of multiple psychiatric drugs, is increasingly common. Antipsychotics, prescribed to 40% of ADHD-diagnosed youth, can cause metabolic problems, weight gain, and irreversible neurological damage. Antidepressants bring their own risks, including sexual dysfunction that may persist long after discontinuation. Gradual supervised tapering, known as deprescribing, is the safest approach, but few clinicians are trained to guide families.
Parents often feel powerless to challenge excessive prescriptions, lacking information and support. Organizations like the Inner Compass Initiative aim to provide resources for safely reducing medications, but such guidance is limited for children.
Instead of testing unproven drug combinations in research studies, resources should focus on preventing ADHD prescribing cascades and developing safe deprescribing protocols. Children deserve care that prioritizes safety, evidence-based interventions, and long-term wellbeing.
Related topic：
