We've noticed that you're using an ad blocker

Our content is brought to you free of charge because of the support of our advertisers. To continue enjoying our content, please turn off your ad blocker.

It's off now Dismiss How do I disable my ad blocker?
❌

How to disable your ad blocker for our site:

Adblock / Adblock Plus
  • Click on the AdBlock / AdBlock Plus icon on the top right of your browser.
  • Click “Don’t run on pages on this domain.” OR “Enabled on this site.”
  • Close this help box and click "It's off now".
Firefox Tracking Prevention
  • If you are Private Browsing in Firefox, "Tracking Protection" may casue the adblock notice to show. It can be temporarily disabled by clicking the "shield" icon in the address bar.
  • Close this help box and click "It's off now".
Ghostery
  • Click the Ghostery icon on your browser.
  • In Ghostery versions < 6.0 click “Whitelist site.” in version 6.0 click “Trust site.”
  • Close this help box and click "It's off now".
uBlock / uBlock Origin
  • Click the uBlock / uBlock Origin icon on your browser.
  • Click the “power” button in the menu that appears to whitelist the current website
  • Close this help box and click "It's off now".
  • Topics
  • CME
  • Special Reports
  • Slideshows
  • Quizzes
  • Blogs
  • Conferences
  • Classifieds
  • Archives

Modern Medicine Network
  • Login
  • Register
Skip to main content
Modern Medicine Network
  • Login
  • Register
Menu
User
Home
  • Topics
  • CME
  • Special Reports
  • Slideshows
  • Quizzes
  • Blogs
  • Conferences
  • Classifieds
  • Archives

SUBSCRIBE: eNewsletter

Problems of Overdiagnosis and Overprescribing in ADHD

  • Daniel F. Connor, MD
Aug 11, 2011
Volume: 
28
Issue: 
8
  • ADHD, Attention Deficit Disorders, Child Adolescent Psychiatry

Trends in ADHD diagnosisADHD is the most extensively studied pediatric mental health disorder, yet controversy and public debate over the diagnosis and medication treatment of the disorder continue to exist.1 Questions and concerns are raised by professionals, media commentators, and the public about the possibility of overdiagnosis of ADHD in youths and the possibility of overprescribing stimulant medications. Fueled by sensational media coverage that emphasizes controversy over rationality, the debate can at times become quite heated, leading to a general public assumption that ADHD is overdiagnosed and that stimulant drugs are overused and overprescribed in children and adolescents with and without ADHD.2

Trends in ADHD diagnosis and stimulant treatment

ADHD is a psychiatric disorder with a long history. It was first described by the English pediatrician Sir George Frederick Still in 1902, and initial diagnostic classifications emphasized the symptoms of hyperactivity and impulsivity. The diagnostic terms used to describe children with this disorder changed frequently in the 20th century. With the introduction of DSM-III in 1980, the symptom of inattention gained ascendancy and the condition was officially listed as attention-deficit disorder. DSM-IV contains the diagnosis of ADHD with 3 subtypes: combined, inattentive, and hyperactive-impulsive. Further modifications of the criteria for the disorder are expected when DSM-5 is introduced.

Before 1970, the diagnosis of ADHD was relatively rare for schoolchildren and almost nonexistent for adolescents and adults. Between 1980 and 2007, there was an almost 8-fold increase of ADHD prevalence in the United States compared with rates of 40 years ago. Considering the prevalence of school-administered stimulants as synonymous with the prevalence of ADHD, Safer and colleagues3,4 estimated the prevalence of ADHD in American schoolchildren as 1% in the 1970s, 3% to 5% in the 1980s, and 4% to 5% in the mid to late 1990s. In 2007, using data from the National Survey of Children’s Health, Visser and colleagues5 reported that 7.8% of youths aged 4 to 17 years had a diagnosis of ADHD and 4.3% reported current use of a medication for the disorder.

The rise in prevalence stemmed from a complex confluence of forces and events that came together in the first half of the 1990s and permitted a dramatic expansion of ADHD diagnosis and treatment.6 The growing political strength of children’s welfare advocates and the mental health consumer’s movement associated with decreasing stigma resulted in changes to federally funded special education programs. The Individuals with Disabilities Education Act recognized ADHD as a disability, and children with ADHD became eligible for school accommodations.

Beginning in the 1990s, Congress expanded eligibility criteria for Medicaid, especially for children. This fueled a rapid increase in coverage for psychotropic medications, including stimulants.6 At the same time, scientific knowledge about the longitudinal course of ADHD and its lifetime morbidity, heritability, and neurobiology was rapidly increasing, This provided empiric evidence as well as a scientific and neurobiological rationale for medication intervention.7,8 Also, the managed care psychiatric carve-out health insurance industry sought to rein in the costs associated with psychiatric illness and supported pharmacological interventions for complex psychiatric disorders, including pediatric disorders.

In 1997, Congress passed the FDA Modernization Act, which encouraged the pharmaceutical industry to develop and test drugs for children by extending patent exclusivity. This resulted in a dramatic increase in randomized controlled trials in children that involved stimulant compounds for ADHD and further supported an evidence-based rationale for medication intervention in ADHD. As a result, the prescribing of stimulants for children with ADHD increased 4-fold between 1987 and 1996, with a further increase of 9.5% between 2000 and 2005. Currently, slightly more than 4% of children and adolescents in the United States use ADHD medications.5,9

Doubt and confusion as to where this disorder fits into the general spectrum of illness further feeds the general perception that ADHD is a socially constructed disorder rather than a valid neurobiological disorder.

The rise in stimulant prescribing for youths must be taken in context. Between 1990 and 2005 there was a rapid rise in pediatric prescriptions for many psychiatric medications—not only stimulants. There was a 5-fold increase for antipsychotics between 1993 and 2002, and a 3-fold increase for antidepressants between 1997 and 2002.10,11 Thus, the rise in stimulant prescribing for pediatric ADHD was only part of a larger shift to an emphasis on medication interventions for the treatment of children with early-onset and complex behavioral and mental health disorders.

Stimulant overprescribing

Public perception of stimulant overprescribing is driven by concerns over the rapid rise in the amount of available stimulants produced in the United States over the past 3 decades. For sale stimulant production quotas are published yearly by the Drug Enforcement Administration.12 The rapid rise in the production quota of for-sale methylphenidate (excluding amphetamine) is seen in the Figure. With the production of more stimulants every year, worries about the increased availability of stimulants for abuse and diversion rise as well. Rising production rates are cited as proof of stimulant overprescribing by physicians and indirect evidence of the overdiagnosis of ADHD among children.2

The extant scientific research suggests a much more complicated and nuanced picture of stimulant prescribing. Comparisons of the prevalence of ADHD among youths aged 4 to 17 years (7.8%) with stimulant prescription rates of between 4.3% and 4.4% do not support the idea of a culture of permissive stimulant overprescribing.5,9 Moreover, recent data from the National Health and Nutrition Examination Survey, a nationally representative probability sample of children aged 8 to 15 years living in the community, indicated an ADHD prevalence rate of 7.8%. However, only 48% of the ADHD sample had received any mental health care over the past 12 months.13

Pages

  • 1
  • 2
  • 3
  • 4
  • next ›
  • last »
References: 

References

1. Goldman L, Genel M, Bezman R, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA. 1998;279:1100-1107.
2. LeFever GB, Arcona AP, Antonuccio DO. ADHD among American schoolchildren: evidence of overdiagnosis and overuse of medication. Sci Rev Ment Health Pract. 2003;2:49-60.
3. Safer DJ, Malever M. Stimulant treatment in Maryland public schools. Pediatrics. 2000;106:533-539.
4. Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics. 1996;98(6, pt 1):1084-1088.
5. Visser SN, Lesesne CA, Perou R. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics. 2007;119(suppl 1):S99-S106.
6. Mayes R, Bagwell C, Erkulwater J. ADHD and the rise in stimulant use among children. Harvard Rev Psychiatry. 2008;16:151-166.
7. Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd ed. New York: Guilford Press; 2006.
8. Solanto MV. Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. Behav Brain Res. 1998;94:127-152.
9. Castle L, Aubert RE, Verbrugge RR, et al. Trends in medication treatment for ADHD. J Atten Disord. 2007;10:335-342.
10. Olfson M, Marcus SC, Weissman MM, Jensen PS. National trends in the use of psychotropic medications by children. J Am Acad Child Adolesc Psychiatry. 2002;41:514-521.
11. Vitiello B, Zuvekas SH, Norquist GS. National estimates of antidepressant medication use among U.S. children, 1997-2002. J Am Acad Child Adolesc Psychiatry. 2006;45:271-279.
12. Drug Enforcement Administration, US Department of Justice. Controlled Substances: Proposed Aggregate Production Quotas for 2008. http://www.deadiversion.usdoj.gov/fed_regs/quotas/2008/fr1107.htm. Accessed July 7, 2011.
13. Merikangas KR, He JP, Brody D, et al. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics. 2010;125:75-81.
14. Centers for Disease Control and Prevention. Mental health in the United States. Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder—2003. MMWR. 2005;54:842-847.
15. Angold A, Erkanli A, Egger HL, Costello EJ. Stimulant treatment for children: a community perspective. J Am Acad Child Adolesc Psychiatry. 2000;39:975-984.
16. Kollins SH. Abuse liability of medications used to treat attention-deficit/hyperactivity disorder (ADHD). Am J Addict. 2007;16(suppl 1):35-42; quiz 43-44.
17. Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47:21-31.
18. Kollins SH. A qualitative review of issues arising in the use of psycho-stimulant medications in patients with ADHD and co-morbid substance use disorders. Curr Med Res Opin. 2008;24:1345-1357.
19. Biederman J, Monuteaux MC, Mick E, et al. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med. 2006;36:167-179.
20. Pappadopulos E, Jensen PS, Chait AR, et al. Medication adherence in the MTA: saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioral treatment. J Am Acad Child Adolesc Psychiatry. 2009;48:501-510.
21. Volkow ND, Ding YS, Fowler JS, et al. Is methylphenidate like cocaine? Studies on their pharmacokinetics and distribution in the human brain. Arch Gen Psychiatry. 1995;52:456-463.
22. Kollins SH. ADHD, substance use disorders, and psychostimulant treatment: current literature and treatment guidelines. J Atten Disord. 2008;12:115-125.
23. Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with of attention-deficit/hyperactivity disorder. American Academy of Child Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(10 suppl):85S-121S.
24. King RA. Practice parameters for the psychiatric assessment of children and adolescents. American Academy of Child Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(10 suppl):4S-20S.
25. Bridges J, Fitzgerald L, Meyer J. New workforce roles in health care: exploring the longer-term journey of organisational innovations. J Health Organ Manag. 2007;21:381-392.
26. Sciutto MJ, Eisenberg M. Evaluating the evidence for and against the overdiagnosis of ADHD. J Atten Disord. 2007;11:106-113.
27. Conners CK, March JS, Francis A, et al. Treatment of attention-deficit/hyperactivity disorder: expert consensus guidelines. J Atten Disord. 2001;4(suppl 1):S1-S128.

Related Articles

  • Severe Mental Illness on the Decline in Youngsters--An 'Unexpected' Finding
  • Autism: The Answer May Be Reflected in the Mirror Neuron
  • DECADE OF DISCOVERY IN PEDIATRIC BD
  • Treatment Resistance in Youths With ADHD and Comorbid Conditions
  • Celebrity Triggers Tumult Over Psychiatric Care: Did the News Media Make Things Worse?

Resource Topics rightRail

  • Resource Topics
  • Partner Content
ADHD
Schizophrenia
Bipolar Disorder
Geriatric Psychiatry
Major Depressive Disorder
Smart IOP – A New Kind of Intensive Outpatient Program
Three Things Mental Health Professionals Need to Know About Telemedicine – TODAY!
How Telemedicine Can Transform Patient Engagement

Current Issue

Psychiatric Times Vol 35 No 3
Mar 12, 2018 Vol 32 No 3
Digital Edition
Subscribe
Connect with Us
  • Twitter
  • Facebook
  • Google+
  • LinkedIn
  • RSS
Modern Medicine Network
  • Home
  • About Us
  • Advertise
  • Advertiser Terms
  • Privacy statement
  • Terms & Conditions
  • Editorial & Advertising Policy
  • Editorial Board
  • Contact Us
Modern Medicine Network
© UBM 2018, All rights reserved.
Reproduction in whole or in part is prohibited.