Study: ADHD meds unlikely to cause psychotic experiences in kids
Key takeaways:
- Previous research showed that children who took stimulants for ADHD were at increased risk for psychotic symptoms.
- After adjusting for confounding factors, researchers did not identify a causal link.
Treatment with stimulants is unlikely to cause psychotic symptoms in children with ADHD, according to a new study published in Pediatrics.
The findings contradict previous studies that saw an association between stimulant medications for ADHD and an increased risk for psychosis in children.
“That is what we found in our initial results, too,” Ian Kelleher, MD, PhD, professor of child and adolescent psychiatry at the University of Edinburgh’s Centre for Clinical Brain Sciences, told Healio. “But those results were heavily confounded — that is, there were lots of factors beside the stimulants themselves that could have been responsible for the psychotic experiences.”
Kelleher and colleagues assessed data from 8,391 children aged 9 to 14 years who participated in the Adolescent Brain Cognitive Development Study between 2016 and 2020.
Kelleher said they used a framework that aimed to emulate the rigor of a randomized controlled trial. They compared the prevalence of psychotic experiences among two groups of children with ADHD: those who had used stimulants, and those who had not. Psychotic experiences included paranoia, hallucinations and other delusions that caused at least moderate distress to the participant. Notably, the researchers did not include psychosis related to substance misuse.
Then, Kelleher said his team weighted their analyses for differences between the groups that could lead to confounding results, including factors like ADHD severity, concurrent mental health symptoms and other factors.
None of the participants had used stimulant medication at baseline, and at 1 year follow-up, 5.5% participants received a prescription, as reported by their parents. According to the researchers, children who were prescribed stimulants were more likely to be boys, and they reported more mental health symptoms at baseline.
At baseline, 18.9% of participants had experienced at least one instance of psychotic symptoms, according to the researchers. At follow-up, 15.1% reported at least one psychotic experience that occurred between baseline and 1 year follow-up, they wrote.
Although stimulant prescriptions were associated with higher odds for psychotic symptoms in an unadjusted analysis (OR = 1.46; 95% CI, 1.15-1.84), Kelleher said he was surprised to learn that psychotic experiences were actually a predictor for later stimulant use (OR = 1.93; 95% CI, 1.57-2.37).
“That’s the first clue that stimulants may not actually be causing the psychotic experiences, which is what our subsequent findings supported,” he said.
Ultimately, the researchers found no causal effect between stimulants and psychotic symptoms in a more robust estimation that adjusted for confounding factors (OR = 1.09; 95% CI, 0.71-1.56).
“These results are reassuring for pediatricians and child psychiatrists that routine stimulant treatment is unlikely to cause psychotic experiences,” Kelleher said. “We do not know whether these results would also hold true for people treated in later adolescence and adulthood — but those are important questions given that stimulants are increasingly being prescribed for those age groups.”
For more information:
Ian Kelleher, MD, PhD, can be reached at pediatrics@healio.com.
Perspective
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There have been recurring reports of psychotic events, such as hallucinations and delusions, in relation to treatment with stimulant medications such as methylphenidate and amphetamines for decades, with an uncertain relationship continuing despite long investigation.
This study looked at a large sample of over 8,000 children aged 9 to 14 years old who were followed for 1 year in the Adolescent Brain Cognitive Development longitudinal study (2016-2020) across 21 research sites. Interestingly, hallucinations and delusions were reported in as many as nearly 19% of the children before starting the study or medication, and 15% experienced at least one during the study, making such reports commonplace in children during this age. (Paranoia, auditory hallucinations, and perceiving a supernatural presence were most common. Note that these episodes did not qualify as frank psychosis.)
The investigators looked to see if there was a relationship between occurrence of such symptoms and prescription of a stimulant medication, and there was no causal relationship between medication prescription and these episodes. There was a relationship between these episodes and stimulant use, although the medication did not appear causal but instead just associated with the episodes (and vice versa). ADHD severity as well as other mental health symptoms were contributory to the psychotic experiences, not the medication. Of course, those with more severe ADHD are more likely to be prescribed these medications than those with fewer symptoms.
So, in summary, hallucinations and delusion are generally common in this age group and more common in those with ADHD and other mental health conditions. The use of stimulant medication was not a factor, with absence of evidence of causality.
Conclusions for the professional: ADHD medications do not appear to be causing psychotic experiences, such as hallucinations and delusions, as previously speculated. They remain an important tool in the treatment of ADHD, and the prescribing professional should monitor and weigh the benefits and adverse effects rigorously as usual. If psychotic experiences emerge, it is likely not related to medication treatment and is likely episodic without evidence of frank psychosis in the child. Those children most vulnerable to such episodes are those with more severe ADHD and/or other mental health problems.
Conclusions for the lay person: Stimulant medications being prescribed for ADHD do not appear to cause hallucinations or delusions. A child with other mental health problems, including more severe ADHD, may be generally more vulnerable to experiencing these symptoms.
Member, Healio Pediatrics Peer Perspective Board
Center for development and learning, Kennedy Krieger Institute
Professor of pediatrics, Johns Hopkins University School of Medicine
Sources/Disclosures
Source:
O’Hare K, et al. Pediatrics. 2025;doi:10.1542/peds.2024-069142.
Disclosures: Kelleher reports no relevant financial disclosures.
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