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ADHD & Antipsychotic Research
Landmark JAMA Study by Dr. Sultan

By Dr. Ryan Sultan, Columbia University Psychiatrist & ADHD Specialist
Last Updated: February 16, 2026

Quick Answer: Dr. Sultan's JAMA research found many youth with ADHD receive antipsychotics without FDA-approved indications. Antipsychotics are appropriate only for severe aggression or comorbid conditions (psychosis, bipolar), not for core ADHD symptoms.

🔬 The Research: A Critical Finding

As a Columbia University psychiatrist who researches and treats ADHD, I led a study that revealed a troubling pattern in pediatric psychiatry: many youth with ADHD were being prescribed antipsychotic medications without clear medical justification.

Publication: "Assessment of Prescribing of Antipsychotic Medications for Youths With Attention-Deficit/Hyperactivity Disorder"

Journal: JAMA Network Open, 2019

Lead Author: Ryan S. Sultan, MD

Citations: 411+ (as of 2026)

Impact: Influenced prescribing guidelines and clinical practice nationally

What we found: A significant proportion of youth with ADHD were prescribed second-generation antipsychotics (like risperidone, aripiprazole, quetiapine) without having FDA-approved indications for these medications.

This research sparked national conversations about appropriate prescribing practices, medication safety in youth, and the need for evidence-based treatment algorithms.

💊 What Are Antipsychotics?

Overview:

Antipsychotic medications (also called "neuroleptics") were originally developed to treat psychosis (hallucinations, delusions) in conditions like schizophrenia. They work primarily by blocking dopamine D2 receptors.

Second-Generation Antipsychotics (SGAs):

The medications most commonly prescribed to youth include:

FDA-Approved Uses in Youth:

Antipsychotics have narrow, specific FDA approvals in children and adolescents:

Notably absent: ADHD is NOT an FDA-approved indication for any antipsychotic.

⚠️ The Problem: Off-Label Prescribing Without Clear Indication

What Our Research Found:

Key Finding: Many youth with ADHD were prescribed antipsychotics without documented diagnoses that would justify antipsychotic use (no schizophrenia, bipolar disorder, or autism).

Possible explanations for this pattern:

1. "Chemical Restraint" for Behavioral Control:

2. Treatment-Resistant Aggression:

3. Comorbid Conditions (Undiagnosed or Undocumented):

4. Off-Label Use for Sleep or Anxiety:

🚨 Why This Matters: Risks of Antipsychotics in Youth

Antipsychotics are powerful medications with significant side effects, especially in children and adolescents:

1. Metabolic Side Effects:

Youth are particularly vulnerable because:

2. Neurological Side Effects:

3. Hormonal Side Effects:

4. Cardiac Risks:

5. Psychological Effects:

Bottom Line: These risks are acceptable when treating serious conditions like schizophrenia or bipolar disorder—conditions that cause severe impairment. But they're NOT acceptable for routine behavioral management or as substitutes for proper ADHD treatment.

✅ When ARE Antipsychotics Appropriate for Youth with ADHD?

Despite the concerns, there are situations where antipsychotics are appropriate:

1. Comorbid Psychotic Disorder:

2. Comorbid Bipolar Disorder:

3. Autism Spectrum Disorder with Severe Irritability/Aggression:

4. Severe, Treatment-Resistant Aggression:

5. Acute Crisis Stabilization:

🎯 The Right Approach: Treatment Algorithm for ADHD with Aggression

If a youth with ADHD exhibits significant aggression or behavioral dyscontrol, here's the evidence-based approach:

Step Intervention Rationale
1. Optimize ADHD Treatment Stimulant medication (methylphenidate or amphetamine) at adequate dose Untreated ADHD → impulsivity → aggression. Treating ADHD often reduces aggression.
2. Add Behavioral Therapy Parent training (e.g., Parent-Child Interaction Therapy), anger management, social skills training Teaches coping skills, emotional regulation, and conflict resolution.
3. Consider Alpha Agonists Guanfacine (Intuniv) or clonidine (Kapvay) FDA-approved for ADHD, reduce impulsivity and aggression, improve frustration tolerance.
4. Evaluate for Comorbidities Screen for mood disorders (bipolar, depression), anxiety, trauma, learning disabilities Aggression may be symptom of untreated condition. Treat the root cause.
5. Consider Mood Stabilizers Lithium, valproate, lamotrigine (if bipolar or severe mood lability) Target mood dysregulation without antipsychotic side effects.
6. Assess Environment Family dysfunction, trauma, abuse, bullying, academic failure Address environmental stressors contributing to aggression.
7. Antipsychotic (Last Resort) Risperidone or aripiprazole at lowest effective dose Only after Steps 1-6 exhausted. Use time-limited trials. Monitor side effects closely.

Key principle: Antipsychotics should be the last step, not the first. Too often, they're prescribed prematurely without exhausting safer, evidence-based alternatives.

📊 Clinical Implications of Our Research

Our research at Columbia has influenced clinical practice in several ways:

1. Increased Scrutiny of Prescribing Practices:

2. Guideline Updates:

3. Insurance Prior Authorization:

4. Informed Consent:

💡 What Parents Should Know

If your child with ADHD is prescribed an antipsychotic, ask these questions:

  1. "What specific condition is this medication treating?"
    • There should be a clear diagnosis (bipolar disorder, psychosis, severe aggression) beyond ADHD alone
  2. "Have we optimized ADHD treatment first?"
    • Has your child tried stimulants at adequate doses? Non-stimulants? Alpha agonists?
  3. "Have we tried behavioral interventions?"
    • Parent training, therapy, school accommodations?
  4. "What are the side effects, and how will we monitor for them?"
    • Weight, metabolic labs, movement disorders, hormonal effects
  5. "Is this a time-limited trial, or long-term treatment?"
    • Antipsychotics should be re-evaluated regularly (every 3-6 months minimum)
  6. "What happens if we don't use this medication?"
    • Understand the risks of untreated symptoms vs. medication side effects

Remember: You have the right to ask questions, seek second opinions, and advocate for your child. A good psychiatrist will welcome these conversations and provide clear, evidence-based reasoning.

🎓 My Approach as a Clinician

In my practice at Columbia University, I follow these principles:

1. ADHD First:

2. Behavioral Interventions:

3. Diagnostic Clarity:

4. Conservative Prescribing:

5. Informed Consent:

6. Close Monitoring:

You can hear me discuss these principles on the ADHD reWired podcast episode: "Why Treat ADHD?"

✅ Bottom Line

Key takeaways from our research:

  1. Antipsychotics are NOT first-line treatment for ADHD. Stimulants and non-stimulants are.
  2. Antipsychotics have significant side effects (metabolic, neurological, hormonal) that must be weighed against benefits.
  3. Off-label prescribing requires clear justification—not just "behavioral control."
  4. Appropriate uses exist: comorbid psychosis/bipolar, severe treatment-resistant aggression, autism with irritability.
  5. Comprehensive treatment approach: Optimize ADHD treatment, behavioral therapy, address comorbidities BEFORE considering antipsychotics.
  6. Families should advocate: Ask questions, understand rationale, ensure evidence-based care.

Our research has helped bring attention to this issue and improve prescribing practices. The goal isn't to demonize antipsychotics—they're valuable tools when used appropriately—but to ensure they're prescribed thoughtfully, with clear medical justification, and only after safer alternatives have been tried.

📖 Related Content

About the Author:
Dr. Ryan Sultan is a board-certified psychiatrist at Columbia University and ADHD specialist. His research on psychopharmacology and prescribing practices has been published in JAMA Network Open and cited 411+ times.

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