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Is Stimulant Medication Overprescribed?
An article published in the recent issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) is sure to add to the ongoing controversy about the possible overprescription of stimulant medication. Upon initially reviewing this paper, a clear case for dramatic overuse of medication to treat ADHD seems evident. A closer inspection of the results, however, suggests that the issue is not so straight-forward. This is an important study that will probably get plenty of press, so I wanted to include a careful review of it in ADHD RESEARCH UPDATE.
In this paper (Angold, A. et. al., (2000). Stimulant treatment for children: A community perspective. JAACAP, 39, 975- 984.) the authors examine the use of stimulant medication in relation to a research-derived diagnosis of ADHD in a community sample of children. Participants in this impressive study were a representative sample of 4500 children ages 9 to 16 from 11 different counties in western North Carolina. Each year for 4 years, these children and their parents were administered structured psychiatric interviews to enable careful diagnoses - not just of ADHD, but of a variety of psychiatric conditions - to be made. Parents were also asked to provide information on any treatment the child had received during the prior year for a mental health condition, including treatment with stimulant medication for ADHD. In addition, the teachers of these children were asked to complete a standardized behavior rating scale each year. Ratings from multiple teachers were collected whenever possible.
A study of this magnitude is an enormous undertaking, and the overarching objective was to obtain reliable estimates of the frequency of a wide variety of psychiatric problems within a community sample of children, the kinds of services for psychiatric problems that children receive, and the match between the rate of problems and available services. In this particular paper, however, the authors were interested in a much more circumscribed question. Specifically, they were interested in how the rate of stimulant medication treatment in this community compared to the community rate of ADHD. Their data would enable them to answer to the these important questions:
- 1). What percentage of children with a verified diagnosis of ADHD are actually being treated with stimulant medication?
- 2). How often are children without a verified diagnosis of ADHD being treated with stimulant medication?
Because current evidence suggests that carefully conducted treatment with stimulant medication is an effective treatment approach - although many children require additional interventions as well - the answer to this question provides a crude indication of how often children with ADHD are receiving an empirically supported treatment.
To my knowledge, even the most ardent supporters of medication treatment for ADHD do not endorse its use for children without a carefully established ADHD diagnosis. Thus, the answer to this question provides some indication of how often stimulants are being prescribed inappropriately.
Note: An important issue that was not really possible to address in this study concerns the manner in which medication treatment is carried out. One can not assume that a child with a clear diagnosis of ADHD who is prescribed medication is receiving appropriate treatment. This is because medication treatment in the community is often carried out in a far from optimal manner, and is often not combined with behavioral interventions that may be necessary.
Results
What Is The Rate Of ADHD In This Community Sample?
The initial data presented by the authors concerns the rate of ADHD diagnoses in this large and representative community sample. Of the children interviewed, 3.4% were regarded as having a definite diagnosis of ADHD. Boys (5.3%) were more likely to have a definite diagnosis than girls (1.5%). An additional 2.7% had sufficient impairment from ADHD to warrant the diagnosis of ADHD-Not otherwise specified. Boys were over represented in this group as well (i.e. 4.4% vs. 1.0%). (Note: ADHD-NOS is the term applied when a child does not meet complete diagnostic criteria for ADHD but still has a number of symptoms that are causing impairment. For a review of current official diagnostic criteria click here.) Overall, therefore, 6.2% of the population were diagnosed with either definite ADHD or ADHD-NOS. This prevalence rate is consistent with what has been found in other studies, and represents the % of the population who were found to meet diagnostic criteria for ADHD at any time during the 4-year study.
Note: One problem with the diagnostic procedure used in this study that will have important implications to be discussed below is that diagnoses were based solely on the parent interview data. Thus, even though behavior rating scale data was collected from teachers, ADHD diagnoses were assigned strictly based on what parents reported. The authors explain this choice by noting that they did not have full diagnostic information from teachers, and that parent reports are used for diagnosis in most "real world" clinic settings.
Although these points are well taken, the absence of teacher- reported information being used in the diagnostic process would almost certainly result in a lower prevalence rate than if it were included. This is because teachers often observe ADHD symptoms that parents do not. I thus think it is quite likely that the prevalence rates reported above underestimates the true rate in the community.
What Is The Rate Of Stimulant Medication Treatment In This Community Sample?
At one or more points during the 4 years of this study, 7.3% of the children had been treated with stimulant medication. This is over twice the number of children who received a definite diagnosis of ADHD (although the caveat noted above about the probable underidentification of ADHD is an important one). It is also slightly higher than the combined rate of ADHD and ADHD-NOS.
This overall rate, however, does not tell us whether the children receiving medication were the ones who actually had ADHD. Instead, it just indicates the percentage of children in the community who had received stimulant medication. When the authors examined this important question, they found that approximate percentage of children treated with stimulants was 72%, 23%, and 5% for children with ADHD, ADHD-NOS, and without ADHD or ADHD-NOS respectively.
Because this last group is so much larger than the others in terms of absolute numbers (remember, the vast majority of children had no ADHD diagnosis), it means that at any given time, the number of children without ADHD in this community who were being treated with stimulants was greater than the number of children with ADHD who were being treated. The authors estimated, in fact, that 57% of the children who were treated with stimulants did not have ADHD or even ADHD-NOS. It is also interesting to note that boys with ADHD were far more likely to be treated with medication than girls with ADHD (80% of ADHD boys vs. only 41% of ADHD girls).
What Do These Numbers Say About The Overtreatment Vs. Undertreatment Problem?
One unfortunate problem with data such as this is that it is relatively easy to focus on numbers that support the point one wants to make and ignore the bigger picture. It is thus important to carefully consider the implication of these findings.
First, in regards to possible undertreatment, these data show that almost 30% of children with a definite diagnosis of ADHD did not receive stimulant medication treatment at any point over the 4-year study period. One possible explanation for this is that although these children were diagnosed with ADHD in the study, they were never diagnosed appropriately by their physician in the community. In this study, diagnostic information was not routinely shared with parents nor were treatment recommendations made by the research staff. So, it is quite possible that many children who clearly met diagnostic criteria for ADHD were simply never diagnosed by their own health care provider, and thus never received medication treatment.
It is also possible that many of these children were diagnosed in the community and parents were informed of this treatment option but elected not to consider it for their child. Alternatively, some parents of diagnosed children may never have been appropriately informed of the possible benefits of medication. This information would be very interesting to have but was not presented in the paper.
One conclusion that can be made with greater certainty, however, concerns the undertreatment of girls with ADHD. Recall that girls with confirmed ADHD were half as likely as boys with ADHD to be treated with medication. Because medication has been shown to be an effective treatment, the fact that girls with ADHD are less likely than boys to receive it is problematic. My hunch is that the reason for this finding is the previously shown fact that physicians are prone to miss the diagnosis of ADHD in girls. In other words, fewer girls with ADHD were treated with meds because fewer girls who were diagnosed with ADHD by the researchers ever received this diagnosis by their own physician. This, of course, is just speculation, but is seems plausible. It would be interesting to know if this were true, and even more interesting to know whether girls were less likely than boys to receive meds even when their physician had diagnosed them with ADHD.
Despite these uncertainties, the bottom line is that many children with ADHD - and the majority of girls with ADHD - were not receiving medication treatment in this community. Of course, whether or not this is a problem depends on the value one places on this treatment modality. It is also important to recognize that because the reliance on parent data only to make diagnoses probably resulted in a number of children with ADHD going undiagnosed, the actual number of ADHD children who were not treated is probably higher - and may have been substantially higher.
What about the overtreatment problem? As noted above, about 5% of children without ADHD were reported to have received medication treatment. In fact, at any given time, more children without ADHD were on medication than children with ADHD.
Certainly, this is an important problem. The magnitude of this problem, however, may not be quite as great as it initially appears. One very interesting comparison the authors made looked at the children without ADHD or ADHD-NOS who were receiving stimulants and those who were not. They found was that although the parents of children in both groups reported few if any ADHD symptoms, the interviewers observed ADHD symptoms in 50% of the children who were treated with meds compared to only 10% in those not treated. In addition, the ADHD symptom ratings from teachers was actually higher in the non-ADHD children who were being treated than in the children with definite ADHD.
So, in many cases, children who did not have ADHD according to their parents were clearly displaying high levels of ADHD symptoms according to their teachers. These were the children in the study "without ADHD" who were likely to be receiving medication treatment. One would imagine that at least some of these children would have turned out to have a confirmed diagnosis of ADHD if parent and teacher information was combined - a procedure not implemented in this study for the reasons noted above. Thus, the number of children treated with meds who did not have ADHD is probably fewer than what is reported in this study.
(Note: It is important to emphasize that the data presented above, although representative of the community in which they were collected, still applies to this one community. To what extent similar patterns would be found in other communities across the county is unclear, as it is well-know that prescribing patterns can vary greatly across physicians.)
Summary
It would not be surprising if the results of this study are presented in the media as prima fascia evidence that children are often treated with stimulants for "no good reason". Unfortunately, this practice certainly goes on, and it seems inevitable that far more children receive stimulant medication than truly need it. One only has to consider studies reviewed in prior issues of ADHD RESEARCH UPDATE in which it was reported that as many as 20% of white male 5th graders in some communities are receiving medication to know that this must be the case.
What can get lost in the understandable concern over such findings is the equally concerning fact that large numbers of children with ADHD are never identified or treated in any way other than being punished repeatedly for their behavior. In the current study, almost a third of all children with ADHD never received medication. For females with ADHD, the odds of being treated with meds were less than 50/50. Once again, this is a problem only to the degree that one believes stimulant medication to be a safe and effective treatment for ADHD. However, because research conducted to date indicates that well conducted medication treatment is probably the most effective treatment for ADHD currently available, it is not unreasonable to be concerned about this finding.
The "safest" conclusion one can make from data such as this is that at any given time, there are probably thousands of children in the US who are treated with stimulants they probably don't need and thousands of children with ADHD who could benefit from stimulants but not receiving them. The solution to this problem is to increase the ability of community physicians to evaluate children for ADHD in a careful and systematic manner, and to help them prescribe medication when appropriate in a systematic manner that is likely to provide the maximum possible benefit.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.