Sultan Lab for Mental Health Informatics

Pediatric Psychotropic Prescribing in the United States: A National Picture

Stimulants, antidepressants, and antipsychotics are the three most commonly prescribed psychotropic medication classes for American children and adolescents. Each class has its own clinical rationale, its own developmental epidemiology, and its own controversies. Public discussions of pediatric psychiatric medication often conflate these classes — treating "American kids are overmedicated" as a single phenomenon. The actual data reveal three distinct prescribing stories with different age peaks, different sex distributions, different prescriber specialties, and different relationships to underlying disorder prevalence.

The Sultan Lab for Mental Health Informatics at Columbia University Irving Medical Center published one of the most comprehensive national analyses of these three drug classes simultaneously. Dr. Sultan's 2018 study, co-authored with international experts including Dr. Christoph Correll (Zucker Hillside Hospital), Dr. Michael Schoenbaum (National Institute of Mental Health), Dr. John Walkup (Northwestern University), and Dr. Mark Olfson (Columbia University), analyzed 6,351,482 pediatric psychotropic prescriptions from the IMS LifeLink LRx Longitudinal Prescription database for the year 2008, adjusting denominators to the U.S. population using Medical Expenditure Panel Survey data.

The Headline: Three Classes, Three Stories

By Age Band: Total Psychotropic Prescribing

The total annual percentage of American children and adolescents filling at least one prescription for any of the three psychotropic classes (stimulants, antidepressants, or antipsychotics) varies dramatically by age:

Nearly 8% of American adolescents — about 1 in 13 — filled a prescription for a stimulant, antidepressant, or antipsychotic in a single year. Among school-age children, the figure was about 1 in 19. These are not exotic numbers. They describe a generation in which psychiatric medication is a routine feature of childhood for millions of American kids.

By Drug Class: Distinct Developmental Peaks

The three drug classes show distinct age trajectories that reflect the underlying conditions for which they are prescribed:

These three drug classes are not one phenomenon. Stimulants peak in elementary school. Antidepressants rise through adolescence and continue rising into young adulthood. Antipsychotics peak in late adolescence. Each class follows its own developmental and clinical logic, and conflating them obscures the very different questions each raises about American pediatric mental health care.

Stimulants: Concentrated in Middle Childhood, Predominantly Male

Stimulant medications — methylphenidate and amphetamine derivatives — are FDA-approved for the treatment of attention-deficit/hyperactivity disorder. The Sultan 2018 analysis confirmed that stimulant prescribing concentrates in the age band where ADHD is most commonly diagnosed and treated: middle childhood, ages 6-12.

Prevalence by Age and Sex

The male predominance of stimulant prescribing in middle childhood (2.7x) is consistent with community epidemiological studies showing that ADHD is approximately 2.5 times more common in boys than girls during childhood. The convergence of male and female stimulant prescribing rates by age 21 is consistent with epidemiological data showing that ADHD prevalence is more similar between men and women in adulthood. This pattern suggests that the population-level male/female ratio of stimulant prescribing broadly tracks the underlying epidemiology of ADHD — while also raising concerns about historic underdiagnosis of ADHD in girls and women.

Stimulant Treatment vs. ADHD Prevalence

Despite concerns about stimulant overprescribing in popular media, the Sultan 2018 data reveal a different picture when compared to community ADHD prevalence:

• Community ADHD prevalence (school age): 8.6% (Merikangas 2010 NHANES)
• Stimulant treatment rate (school age, 6-12): 4.6% (Sultan 2018)
• Implied undertreatment gap: ~46% of school-age children with ADHD are not receiving stimulant treatment

This gap remains substantial even when assuming that only children with moderate-to-severe ADHD should receive pharmacological treatment (approximately 75% of ADHD cases per NCS-A data). The Sultan 2018 stimulant prescribing rate is well below the community ADHD prevalence rate, suggesting that the overall American pattern is one of under-treatment relative to disorder prevalence — not overtreatment. The clinical questions raised by stimulant prescribing are therefore more about which children are reached and which are missed than about whether too many children are being treated overall.

Antidepressants: Rising Through Adolescence, Increasingly Female

Antidepressants — primarily selective serotonin reuptake inhibitors (SSRIs) but also atypical antidepressants — are FDA-approved for the treatment of depression in adolescents (fluoxetine, age 8+; escitalopram, age 12+) and for several anxiety disorders. The Sultan 2018 analysis found that antidepressant prescribing rises throughout adolescence and continues climbing into young adulthood, with a marked female predominance by the late teens.

Prevalence by Age and Sex

The reversal of sex predominance during adolescence is one of the most striking findings. In middle childhood, boys are more likely than girls to receive antidepressants — consistent with male predominance of pediatric ADHD-associated anxiety and depression. By late adolescence, the pattern flips dramatically: young adult women are more than twice as likely as young adult men to be on antidepressants, reflecting the well-documented female predominance of mood and anxiety disorders that emerges around puberty.

Antidepressant Treatment vs. Disorder Prevalence

As with stimulants, antidepressant prescribing rates are below community disorder prevalence:

• Adolescent depression community prevalence: 4-5% (Costello et al.)
• Child/adolescent anxiety disorder prevalence: 15-20% (Beesdo et al.)
• Adolescent antidepressant treatment rate: 2.8% (Sultan 2018)

The gap is particularly stark for anxiety disorders, which are far more prevalent than the antidepressant treatment rate would suggest. The post-2004 FDA black-box warning for pediatric SSRI suicidality may have contributed to sustained undertreatment of adolescent depression and anxiety. Multiple analyses (Libby et al. 2009, Mojtabai & Olfson 2016) document that pediatric antidepressant prescribing declined after the black-box warning and did not fully recover for over a decade, even as adolescent depression diagnoses continued to rise.

Antipsychotics: Lower Overall Prevalence, Heterogeneous Indications

Antipsychotic medications are FDA-approved in pediatric populations for schizophrenia (age 13+), bipolar mania (age 10+), irritability associated with autism spectrum disorder (age 5+ for risperidone, age 6+ for aripiprazole), and Tourette disorder. They are also used off-label in children for aggression, mood dysregulation, and ADHD-associated disruptive behavior — uses for which the FDA has not granted approval and for which clinical trial evidence is variable.

Prevalence by Age and Sex

Antipsychotic prescribing is the lowest of the three drug classes overall but peaks in adolescence. The 3-to-1 male predominance in middle childhood (6-12) reflects the dominant clinical use case at that age: off-label prescribing for aggressive and disruptive behavior, often in children with ADHD. The narrowing of the sex ratio in adolescence reflects the increasing contribution of mood disorders (which are female-predominant) as the clinical driver in older children.

The implications of this antipsychotic prescribing pattern are addressed in detail on the pediatric antipsychotic overuse page, including Dr. Sultan's 2019 JAMA Network Open finding that 1 in 40 children newly diagnosed with ADHD receive an antipsychotic within a year — without any FDA-approved indication.

Who Prescribes These Medications: The Specialty Mix

One of the most striking findings of Sultan 2018 was the dramatic difference in prescriber specialty across the three drug classes. This finding has important implications for understanding both clinical practice and policy interventions.

Stimulants: Pediatricians Dominate

Pediatricians wrote 43.7% of stimulant prescriptions to school-age children — nearly half. This is appropriate: pediatricians manage ADHD as part of their primary care practice, and the American Academy of Pediatrics provides clinical practice guidelines for pediatric ADHD assessment and treatment.

Antidepressants: Specialty Care

Pediatricians wrote only 11.8% of adolescent antidepressant prescriptions — despite being the main mental health contact for most American teenagers. Antidepressant prescribing for adolescents is dominated by general and child psychiatrists. The structural problem this creates: pediatricians are comfortable diagnosing and treating ADHD with stimulants but much less comfortable diagnosing and treating depression or anxiety with antidepressants (Fremont et al. 2009). When depressed or anxious adolescents present to their pediatrician, they are typically referred to specialists who often don't exist in adequate supply.

Antipsychotics: Predominantly Psychiatry, But Pediatricians Still Involved in Preschoolers

The striking number: pediatricians write 21.3% of antipsychotic prescriptions to preschoolers (3-5 years). A primary care physician is prescribing one of the most metabolically risky drug classes in psychiatry to a child whose brain is still developing, typically in a 15-minute visit, often without specialty consultation. This pattern reflects the inadequate supply of child psychiatrists and the limited access to behavioral therapy — not the recklessness of pediatricians, who are working within significant constraints.

What This Pattern Means for American Children

The Sultan 2018 findings paint a complex picture of American pediatric psychotropic prescribing — one that resists simple "overmedicated" or "undermedicated" framings.

The Treatment Coverage Gap

For all three drug classes, prescribing rates are below community disorder prevalence:

• Stimulants (4.6% school age) vs. ADHD prevalence (8.6%) — ~46% undertreated
• Antidepressants (2.8% adolescents) vs. anxiety prevalence (15-20%) — massively undertreated
• Antidepressants (2.8% adolescents) vs. depression prevalence (4-5%) — ~30-44% undertreated

This means the dominant clinical reality is that millions of American children and adolescents with diagnosable mental health conditions are not receiving evidence-based treatment. The "overmedication" narrative obscures this reality.

The Distributional Problem

At the same time, the distribution of who receives medication is uneven and often clinically questionable. School-age boys with ADHD-related aggression may be receiving antipsychotics they don't need (Sultan 2019), while adolescent girls with depression don't receive SSRIs they would benefit from. The right framing is not "more or less medication" but "right medication to the right child."

The Workforce Bottleneck

Approximately 7,000 child and adolescent psychiatrists practice in the United States, serving roughly 70 million children. This workforce shortage means that primary care physicians manage the majority of pediatric mental health concerns — comfortably for ADHD (where stimulant management is straightforward), uncomfortably for depression and anxiety (where they refer to specialists who don't exist in adequate supply), and inappropriately when they prescribe antipsychotics to preschoolers in the absence of behavioral alternatives.

Key Publications from the Sultan Lab

The Sultan Lab's research program on pediatric psychotropic prescribing patterns includes:

• Sultan RS, Correll CU, Schoenbaum M, King M, Walkup JT, Olfson M. "National Patterns of Commonly Prescribed Psychotropic Medications to Young People." J Child Adolesc Psychopharmacol. 2018;28(3):158-165. doi:10.1089/cap.2017.0077 — The foundational paper described on this page.
• Sultan RS, Wang S, Crystal S, Olfson M. "Antipsychotic Treatment Among Youths With Attention-Deficit/Hyperactivity Disorder." JAMA Network Open. 2019;2(7):e197850 — The antipsychotic-for-ADHD study.
• Sultan RS et al. "ADHD Medication and Substance-Related Outcomes." JAMA Psychiatry. 2025 — The protective-effects analysis.

Frequently Asked Questions

What percentage of American children are on psychiatric medications?

According to Sultan 2018, approximately 7.7% of American adolescents (1 in 13) and 5.4% of school-age children (1 in 19) filled at least one prescription for a stimulant, antidepressant, or antipsychotic in a single year. Among preschoolers (3-5 years), the rate is much lower at 0.8%. These rates have been broadly stable since the late 2000s, with antipsychotic prescribing in young children declining since 2008 due to state oversight policies while stimulant prescribing has continued to expand among adolescents and young adults.

Are American children overmedicated or undermedicated?

Both, depending on the drug and population. For all three major drug classes, prescribing rates are below community disorder prevalence — meaning the majority of children with diagnosable conditions are not receiving evidence-based pharmacological treatment. At the same time, the distribution of who receives medication is uneven and sometimes clinically questionable. The honest scientific framing is "wrong medications going to wrong children" rather than "too many drugs."

Why does prescribing vary so much by drug class?

Each drug class is prescribed for different underlying conditions with different developmental epidemiology. Stimulants treat ADHD, which peaks in middle childhood. Antidepressants treat depression and anxiety, which rise through adolescence and into young adulthood. Antipsychotics treat a heterogeneous mix of conditions including schizophrenia, bipolar disorder, autism-associated irritability, and off-label uses for aggression. The drug classes are not interchangeable and should not be conflated in policy discussions.

Why do pediatricians prescribe so many stimulants but so few antidepressants?

Survey research (Fremont et al. 2009) suggests that pediatricians are comfortable diagnosing ADHD and prescribing stimulants — partly because ADHD presents in distinctive ways during well-child visits and partly because stimulant management is relatively straightforward. They are much less comfortable diagnosing depression and anxiety in children and adolescents and prescribing antidepressants. This comfort gap creates a structural problem: pediatricians are the main mental health contact for most American children, but they often refer out for depression and anxiety treatment to specialists who exist in inadequate supply.

How does the Sultan 2018 study relate to other pediatric prescribing research?

The Sultan 2018 study integrated prescription data on all three major pediatric psychotropic drug classes simultaneously in one analysis — an approach that distinguished it from earlier studies focused on individual drug classes. It built on foundational work by Mark Olfson at Columbia (Olfson 2002, 2012, 2015, 2016) and provided a more comprehensive picture of how the three classes interact and differ. It also served as the foundation for Dr. Sultan's subsequent 2019 study (antipsychotic prescribing in ADHD youth) and 2025 study (ADHD medication protective effects).

Related Resources

• Pediatric Antipsychotic Overuse - Sultan 2019 study findings on antipsychotic prescribing in ADHD youth
• ADHD Stimulant Prescribing Patterns - IQVIA national analysis 2016-2024
• ADHD Antipsychotic Research - Sultan Lab antipsychotic research overview
• Off-Label Antipsychotic Prescribing - Clinical complexity of off-label use
• Sultan Lab for Mental Health Informatics - Full lab overview
• ADHD Medications Guide - Clinical medication information
• Complete Publication List - All Sultan Lab peer-reviewed research
• Media Coverage - Press coverage of Sultan Lab research