ADHD
among American Schoolchildren
Evidence of
Overdiagnosis and Overuse of Medication
Authors:
Gretchen B. LeFever and Andrea P.
Arcona - Center for Pediatric Research, Eastern Virginia
Medical School and Children's Hospital of the King's
Daughters
David O. Antonuccio - University of Nevada School
of Medicine, Veterans Affairs Sierra Nevada Health Care
System.
Author Note:
Correspondence concerning this
article should be addressed to Gretchen B. LeFever, Center for
Pediatric Research, 855 West Brambleton Avenue, Norfolk, VA
23510-1001. E-mail: glefever@chkd.com.
Abstract:
The 700% increase in
psychostimulant use that occurred in the 1990s justifies
concern about potential overdiagnosis and inappropriate
treatment of child behavior problems. A critical review of
epidemiologic research suggests that
attention-deficit/hyperactivity disorder (ADHD) is not
universally overdiagnosed; however, for some U.S. communities
there is evidence of substantial ADHD overdiagnosis, adverse
educational outcomes among children treated for the disorder,
and suboptimal management of childhood behavior problems.
Evidence of ADHD overdiagnosis is obscured when findings are
reported without respect to geographic location, race, gender,
and age. More sophisticated epidemiologic tracking of ADHD
treatment trends and examination of associated outcomes is
needed to appreciate the scope of the problem on a national
level. Meanwhile, a public health approach to ADHD that
includes the development and implementation of data-driven,
community-based interventions is warranted and is underway in
some communities. Guidelines for promoting judicious use of
psychotropic drugs are suggested.
Introduction
Until the latter half of the 20th century, treating
childhood behavior problems with medication was an almost
nonexistent practice. The current American proclivity toward
psychiatric drug therapy for behavior-disordered children
began in the 1960s, when the American medical profession
deemed it acceptable to use psychostimulants (especially
methylphenidate, commonly and hereafter referred to as
Ritalin) to ameliorate symptoms associated with minimal brain
dysfunction (MBD; Wender et al., 1971), or what is now
described as attention-deficit/hyperactivity disorder (ADHD;
American Psychiatric Association, 1994; Barkley, 1990). Over
the last three decades the rate of drug treatment for behavior
problems has increased exponentially, culminating in the
prescription of ADHD drug treatment for at least 5 to 6
million American children annually (Diller, 1998; Sinha,
2001). The high rate of prescription for Ritalin and expensive
brand-name drugs such as Adderall, Concerta, and Metadate
reflect a more general reliance on psychotropic drugs in
American healthcare practices. In 1998, doctors mentioned
psychotropic drug treatment an estimated 85.8 million times
during 36.7 million office visits (Health Care Financing
Administration, 2001) averaging 2.3 documented references to
psychotropic drug treatment per physician visit. The
unprecedented levels of drug treatment for child behavior
problems justify closer public and professional scrutiny.
Available research has not supported the idea of a widespread
overdiagnosis of ADHD across the country (Goldman, Genel,
Bezman, & Slanetz, 1998); however, there are clear
indications of overdiagnosis and overtreatment in a growing
number of communities. The fact that these problems are not
universal should not serve to dismiss concerns for communities
in which children are being diagnosed with and treated for
ADHD at remarkably high rates. Careful investigation into the
extent of overdiagnosis of ADHD and overuse of drug therapy is
necessary to develop appropriate methods for improving ADHD
care. This paper provides background information regarding
ADHD treatment and a summary of historical trends in ADHD
treatment, which set the stage for a critical review of
epidemiological research on ADHD and its treatment.
Defining ADHD
Overtreatment
Defining mental health disorders based on the concept
of statistical rarity is arguably problematic for many mental
health conditions (e.g., Wakefield, 1992), but not for all. In
fact, definitions of some disorders-including ADHD-are reliant
on the concept of statistical rarity, or what is
sometimes referred to as developmental deviance.
Consider the case of mental retardation vis-à-vis
intelligence. Mental retardation (the condition) is defined by
intelligence (the construct) that is measured to be at least
two standard deviations below the population mean. While some
individuals may have low intelligence, only those whose
intelligence is significantly developmentally deviant (i.e.,
statistically rare) are considered disordered. The diagnosis
of ADHD is conceptually akin to that of mental retardation in
that the definition of both disorders relies on the concept of
developmental deviance. As with intelligence, the hallmark
symptoms of ADHD (impulsivity, hyperactivity, and inattention)
exist in all children to some degree, but ADHD is said to
exist only when the behaviors are expressed to an extreme or
statistically rare degree.
Given that the definition of ADHD is based on
statistical rarity, only a limited number of children can
qualify as having the disorder. As in the case of mental
retardation, the ADHD prevalence estimate was set at 3% to 5%,
which restricts the disorder to those children whose
ADHD-related behavioral characteristics are approximately two
standard deviations away from the mean. The 3% to 5% estimate
may constitute a liberal estimate because, as with mental
retardation, statistical rarity is only one of several
criteria for the diagnosis. The problematic behavior must also
be persistent, pervasive, impairing, and not attributable to
other conditions or factors. Consistent with this logic, some
pediatric and behavioral experts argue that ADHD may affect as
few as 1% to 3% of children (Carey, 1999, 2000). This notion
received considerable attention by scientific experts on the
NIH-sponsored ADHD Consensus Development panel (Diagnosis and
Treatment of ADHD, 1998), although the consensus was to
maintain the decades-long prevalence estimate of 3% to 5%.
Some may argue that the current definition of ADHD is
flawed and that the concept of developmental deviance or
statistical rarity should be discarded. Because ADHD is
presumed to be a biological disorder, there may be no natural
limit to the number of children who could be affected by the
disorder and the 3% to 5% prevalence would be not only
arbitrary but also inappropriate. There is no pathognomonic
biological marker for ADHD (Barkley, 1999; Todd, 2000) and no
clearly defined and widely accepted ADHD assessment method
(Kessler, 1980), making it impossible to know precisely how
many children are actually affected by the disorder (Godow,
1997). Unless a biological marker is identified, an
agreed-upon gold standard diagnostic procedure is established,
or ADHD is redefined, a population-based ADHD rate exceeding
3% to 5% by definition represents a problem of ADHD
overdiagnosis. Thus, the 3% to 5% prevalence estimate is
presently the only benchmark that can be used to evaluate
possible ADHD overdiagnosis and overtreatment. Throughout this
paper, ADHD- related drug treatment trends and community-based
assessments of ADHD diagnostic rates are evaluated against the
3% to 5% benchmark.
Review
of National ADHD Drug Treatment Trends
Ritalin
For years, discussions about the overdiagnosis of ADHD
and overprescription of Ritalin have been one in the same.
Until the late 1990s the vast majority of children medicated
for ADHD received a psychostimulant and in 90% of these cases
Ritalin was prescribed (Hamilton, 2000; Wilens &
Biederman, 1992). Most Ritalin prescriptions are associated
with ADHD treatment among U.S. patients. Therefore, at least
until the late 1990s, Ritalin consumption has been used to
track general patterns of ADHD treatment in the United States
(LeFever, Dawson, & Morrow, 1999). Prescribing trends
prompted the United Nations International Narcotics Control
Board to issue its second warning in recent years that
American physicians may be overprescribing psychostimulants
(United Nations Information Service, 1997). This may become an
issue in other countries such as Australia (Carmichael, 1996)
and Canada (Miller, Lalonde, McGrail, & Armstrong, 2001),
where ADHD drug treatment is becoming increasingly popular.
The Early Years of Ritalin
Use As of 1960 negligible numbers of children were
medicated for MBD/ADHD (Safer & Zito, 1999). A decade
later, more than 150,000 school-age children were receiving
psychostimulant treatment annually in the United States
(Safer, 1971). Beginning with the conservative estimate that
50,000 American children were treated annually for ADHD in
1960, there was a six-fold increase in psychostimulant
treatment between 1960 and 1975. The rising rate of stimulant
treatment prompted one of the nation's foremost developmental
psychologists to address the topic in the New England
Journal of Medicine (Sroufe & Stewart, 1975).
Psychologist Alan Sroufe and psychiatrist Mark Stewart
cautioned against the dangers of continued escalation in
psychostimulant treatment, including possible reduction in
parent and teacher motivation to take other steps to help
children, inadequate monitoring of drug treatment, and
possible development of low self-esteem and drug abuse among
individuals treated with stimulants. Although these issues
have never been adequately resolved, stimulant treatment has
continued to increase unabated. The trends Sroufe and Stewart
observed during the 1970s pale in comparison with those of the
last two decades.
The Post-1990 Era of Ritalin Use
During the 1990s there was a 700% increase in the use
of psychostimulants, with the United States consuming nearly
90% of the world's supply of the drugs (Mackey & Kipras,
2001; Marshall, 2000). As of 1999, school nurses across the
country delivered more medications for mental health
conditions than for any other chronic health problem, and more
than half of these were specifically for ADHD (McCarthy,
Kelly, & Reed, 2000). As of today, up to an estimated 5 to
6 million American children receive ADHD-related drug
treatment annually (Sinha, 2001). These figures indicate that
from 1960 to the turn of the century there was a more than
100-fold increase in the annual rate of ADHD drug treatment
among U.S. children. Moreover, the use of psychostimulants and
other psychotropic drugs continues to rise.
Accumulating evidence indicates that Ritalin use is
highly variable across the country, with widening variation in
state-level and community-level ADHD drug treatment over time.
Drug Enforcement Agency (DEA) data for the years 1990 to 1995
indicated that the rate of Ritalin use was 6 times higher in
some states compared with others (Morrow, Morrow, &
Haislip, 1998) and was 20 times higher in some communities
compared with others (Eaton & Marchak, 2001; LeFever,
Arcona, & Stewart, 2001). In the years 1997 to 1999, some
states used 30 times more Ritalin than other states, and some
communities used 100 times more than others. Although the
validity of DEA data for capturing treatment patterns in not
entirely clear, the data represent one of the few sources of
information currently available for tracking treatment
patterns nationwide. Monitoring such data is also important
because if treatment varies substantially across geographic
regions, then the "average" practice may not be a very helpful
index of the legitimacy of concern (Angold, Erkanli, Egger,
& Costell, 2000).
Other
Psychotropic Drugs
National statistics on the use of psychotropic drugs
suggest that the current ADHD debate is no longer just about
such psychostimulants as Ritalin (Zito & Safer, 2001).
Between 1995 and 1998, antidepressant use increased 74% among
children under 18, 151% among children between 7 and 12, and
580% among children younger than 6 years of age. Mood
stabilizers increased 400% among children under 18, while the
use of new antipsychotic medications increased 300% among the
same age group (Diller, 2000). Recent analyses of the Kansas
Medicaid database indicate that antidepressants were
prescribed to children twice as often as any other type of
psychotropic drug from 1995 to 1996 (Fox, Foster, & Zito,
2000).
These changes are also relevant to ADHD treatment
practices because general practitioners and psychiatrists
increasingly prescribe a variety of psychotropic drugs and
drug combinations to ADHD children (Boles, Lynch, & DeBar,
2001; Popper, 2000; Zarin, Suarez, Pincus, Kupersanin, &
Zito, 1998). Perhaps the most common of these regimens is the
combined use of psychostimulants and antidepressants (Findling
& Dogin, 1998; Zito et al., 2002). This pattern was
observed in over one quarter of the children treated for ADHD
in southeastern Virginia (LeFever, 2000). These increases have
occurred despite the lack of convincing efficacy data for
antidepressants in children (Antonuccio, Danton, DeNelsky,
Greenberg, & Gordon, 1999). Still fewer data are available
regarding the use of other psychotropics and psychotropic drug
combinations in children. In one study, almost one fifth of
children receiving prescriptions for ADHD from psychiatrists
received drugs other than psychostimulants (Zarin et al.,
1998). Although ADHD drug treatment estimates are often based
on psychostimulant data, failure to consider a broader set of
drugs substantially underestimates the magnitude of ADHD drug
treatment in the United States.
The
Case against ADHD Overdiagnosis
Evidence
Potentially Supportive of Current Practices
Pooling findings from years of data from Baltimore
County schools and from state Medicaid claims databases, Safer
and his colleagues sought to address recent concerns about
Ritalin use. Their data sources indicated that the prevalence
of ADHD drug treatment doubled about every four to seven years
between 1971 and 1987 and more than doubled between 1990 and
1995; however, the rates of increase have been variable across
age categories (Safer, Zito, & Fine, 1996). Despite these
trends, Safer et al. considered ADHD treatment rates through
the mid-1990s to be unremarkable. However, they cautioned that
their data were insufficient to settle the matter of ADHD
overtreatment and that if treatment rates continued to
escalate, concerns about overtreatment would be justified.
In most of his work, Safer considered the rate of
school-based administration of Ritalin as synonymous with the
prevalence of ADHD. As such, Safer and colleagues established
the following estimates of ADHD prevalence among American
school children: 1% for the 1970s, 3% to 5% during the 1980s,
approximately 5% among students during the early to mid-1990s,
and 4% in the late 1990s (Safer, 2000; Safer & Krager,
1988, 1989, 1994; Safer & Malever, 2000; Safer et al.,
1996). They suggested that the discrepancy between escalating
national estimates of Ritalin use and relatively stable rates
of ADHD could be reconciled by considering several changes in
clinical practice. Specifically, they mentioned a growing use
of the medication among girls and adolescents, a growing
tendency to keep diagnosed patients on the medication for
longer periods of time, and more lenient ADHD diagnostic
criteria. Safer also attributed the rise in Ritalin use to a
broader acceptance of psychotropic treatment by the American
public (Safer et al., 1996).
Jensen and his colleagues conducted a study that has
been widely accepted as evidence against ADHD overdiagnosis
and overtreatment (Jensen et al., 1999). Using post hoc
analyses of data from a larger household survey, Jensen et al.
examined the rate of ADHD identification and treatment in
three U.S. cities and San Juan, Puerto Rico, in the first half
of 1992. They identified potential ADHD cases among children
and adolescents (9 to 17 years of age) by having lay providers
conduct structured interviews of parent-child dyads. If either
the child or the parent reported significant ADHD symptoms,
the child was classified as having probable ADHD. The rate of
Ritalin use was then examined among children who were
classified as either ADHD or non-ADHD. Accordingly, 5% of
children were identified with probable ADHD and only 12% of
these children were taking Ritalin at the time of the survey.
Because the rate of Ritalin use was substantially lower than
the rate of ADHD, they reported and commented publicly that
ADHD underdiagnosis and undertreatment was a major issue for
American children.
Inadequacy of the
Evidence
Addressing concerns about ADHD overdiagnosis requires
consideration of at least the following six factors: (1)
source of data, (2) sample size, (3) reporting of data by
known risk factors, (4) timeliness of data, (5) accuracy of
data, and (6) interpretation of data. When these factors are
considered, the studies previously described cannot be used to
dismiss concerns about ADHD overdiagnosis and overtreatment
among American children.
Data Source
Much of Safer's work has relied exclusively on school
records or Medicaid samples. It is increasingly difficult to
capture the extent of ADHD drug treatment by relying on school
records. Safer estimated that school records missed at least
20% of children who were medicated for ADHD, because they did
not necessarily receive a dose of their medication in school
(Safer & Krager, 1994). With the growing popularity of
long-acting drug treatments, the number of children medicated
exclusively at home has increased. It now appears that school
records alone may underestimate ADHD drug treatment by as much
as 50% by the late 1990s (LeFever, Villers, Morrow, &
Vaughn, 2002) and by 75% by 2002 (LeFever 2002). When
reviewing post-1995 studies of ADHD, accurate estimates of
drug treatment may require a doubling of figures obtained from
school records. Medicaid databases also underestimate
ADHD-related drug treatment because African American children,
who are overrepresented in these databases, are half as likely
as nonminority populations to receive ADHD drug treatment (Fox
et al., 2000; LeFever et al., 1999).
Sample Size
The Jensen et al. (1999) epidemiologic study was more
representative in that it involved community-based samples
drawn from three U.S. cities and San Juan, Puerto Rico.
However, it included only 1,285 children and 66 ADHD cases-far
too few children and cases to generate a representative
national picture of ADHD diagnosis and treatment. It is also
puzzling that only 5% of children were identified as probable
ADHD cases, because similar community-based studies estimate
probable ADHD cases to be as high as 16% to 26% (Bird et al.,
1988; Costello, 1989; Esser, Schmidt, & Woerner, 1990;
Offord et al., 1987; Wolraich, Hannah, Pinnock, Baumgaertel,
& Brown, 1996). This unexplained discrepancy complicates
the interpretation of the Jensen et al. findings.
Reporting Data by Known Risk Factors
Neither Safer nor Jensen reported ADHD rates by race
and gender. Such reporting is important (in addition to
reporting by age groups) because prevalence and treatment have
been documented to vary by all three factors, with the highest
rate of ADHD among 6- to 9-year-old white boys (LeFever et
al., 1999; Safer & Zito, 1999; Safer et al., 1996). Safer
(1999) has presented, although not published, data indicating
that from the early to mid-1990s the rate of ADHD treatment
(i.e., school-administered Ritalin) among white boys in
Baltimore County elementary schools was over 15%. Failure to
report more specific findings when they are available can
distort patterns in ADHD care. The Jensen et al. (1999) sample
involved individuals between 9 and 17 years of age. By
excluding a large proportion of children in the age group
(i.e., ages 6 to 9) most affected by and/or treated for the
disorder (Cohen et al., 1993; Safer & Zito, 1999; Safer et
al., 1996; Scahill & Schwab-Stone, 2000), the study may
have yielded an artificially low rate of ADHD and its
treatment.
Timeliness of Data
Data from Jensen et al. (1999) were collected during
the early part of 1992. Given the continuous increase in ADHD
drug treatment throughout the 1990s, those data may be
outdated. As the authors noted, very different results might
have been obtained if the study were repeated today. [c head]
Accuracy of Data The decrement that Safer noted in Ritalin use
from the mid- to late 1990s in his most recent study (Safer
& Malever, 2000) is curious. Although broad in terms of
the geographic study region, the most recent study was not as
thorough or methodologically rigorous as his previous studies.
The data were collected at the school level, rather than the
student level, and pertained only to Ritalin rather than a
broader array of stimulants and nonstimulant ADHD-related drug
treatments. School nurses reported the summary data under a
legislated mandate and no quality control checks were
reported. This means that study results were based on a
limited number of data points, captured only a subset of ADHD
drug treatment, and may be of questionable accuracy. Thus, the
estimated 4% ADHD prevalence rate (i.e., school-based
stimulant treatment rate) may poorly represent the actual data
and is most likely a significant underestimate of ADHD
diagnosed and treated prevalence.
Interpretation of Data
The magnitude of geographic variation in Ritalin use
and ADHD diagnosis is so substantial that no study has been
conducted that by itself is sufficiently methodologically
rigorous to dismiss concerns about ADHD overdiagnosis. The
data from Jensen et al. (1999) and the series of studies by
Safer and colleagues remain limited in their refutation of
ADHD overdiagnosis trends. As outlined later, a better
understanding of the issue is obtained by consideration of
ADHD prevalence findings from regions of the country with low,
moderate, and high rates of ADHD drug use.
Evidence of ADHD
Overdiagnosis
In response to high rates of clinic referrals for ADHD,
LeFever and colleagues (1999) examined the rate of medication
administered (daily) during the 1995-96 school year to
students in two school districts in southeastern Virginia
(LeFever et al., 1999). ADHD was defined by medication
administered in school during regular hours and physician
diagnosis. To guard against inflation of estimated drug
treatment rates, children enrolled in self-contained special
education classes, a group known to have a very high rate of
treatment, were excluded. Using this conservative method of
assessing ADHD treatment among nearly 30,000 students in
grades two through five, 8% to 10% of the students were
treated with stimulants for ADHD. Such population-based
studies of actual rates of diagnosis and treatment are
essential for addressing the current controversy, yet this
study has been excluded from major reviews on the topic (Brown
et al., 2001; Phelps, Brown, & Power, 2001) because
diagnostic criteria were not reported. National research has
documented that primary-care physicians rarely adhere to
standardized ADHD diagnostic criteria (Kellerher & Larson,
1998) and regardless of the diagnostic criteria, used by
practicing physicians in southeastern Virginia, the study
documented excessive rates of ADHD drug treatment across the
large and highly populated geographic region.
Findings from this study were consistent between two
racially, economically, and socially diverse school districts.
In both school districts, the rate of ADHD medication use was
highest among white males and lowest among black females; 17%
of white males and 3% of black females received ADHD
medication in school. As noted above, these findings are
consistent with research in public schools in Maryland (Safer,
1999). They indicate that in southeastern Virginia and
Baltimore County, Maryland, the rate of school- administered
ADHD drug treatment among elementary students was at least 2
to 3 times higher than the national estimate of the disorder.
To address the underestimation of ADHD diagnosis and
treatment that is inherent in exclusive reliance on
school-based records, LeFever and colleagues examined the rate
of ADHD diagnosis and treatment among children by means of
parental report (LeFever et al., 2002). In the same Virginia
region previously studied, parents of children enrolled in
three elementary schools that comprise a representative sample
of the entire school district's elementary population were
asked to complete a school health survey that focused on ADHD
and asthma. Parental report of school-based administration of
ADHD medication (9%) was consistent with objective assessment
of the same (8% to 10%). However, nearly twice as many
students had been diagnosed with ADHD compared with the number
medicated in school. Among elementary students, 17% of all
students and 33% of white boys had been diagnosed with ADHD
and the vast majority had been medicated for this condition at
some time during the 1997-98 school year. At the time of the
survey, which spanned the summer months (when drug therapy is
sometimes temporarily discontinued), 12% of all elementary
students were medicated for ADHD (LeFever et al., 2002).
Ninety percent of all identified cases had been medicated for
the disorder at some point and the majority had been treated
for over two years. These findings suggest that as of 1998,
school-based studies of ADHD prevalence captured approximately
half of the cases treated in the community. Preliminary data
from a follow-up study suggest that as of 2002, school records
capture as few as 25% of ADHD cases (LeFever, 2002).
Angold and colleagues (2000) conducted an epidemiologic
study of mental health status among children in 11 western
North Carolina counties from 1992 to 1996 (Angold et al.,
2000). The study included children and youth between 9 and 16
years of age and examined participants periodically for four
years. Based on parent report, almost three quarters of
children with an unequivocal ADHD diagnosis received
medication for the disorder. The majority of individuals who
received stimulants were never reported by their parents to
have any impairing ADHD symptoms, although they had
some degree of symptomatology per parent and teacher report.
In other words, even when symptoms were reported, they fell
well below the threshold for an ADHD diagnosis.
At some point during the Angold et al. (2000) study,
3.4% of children met unequivocal diagnostic criteria for ADHD
and 7.3% of children were treated with psychostimulants. This
rate of treatment is almost twice as high as would be expected
based on the estimated base rate of 3% to 5% and the
assumption that some lesser percentage requires drug
treatment. The figure is even more striking considering that
the sample excluded the majority of the age group most
commonly diagnosed and medicated for ADHD (i.e., children
between 5 and 10 years of age). Treatment for ADHD has been
observed to decline by as much as 20% a year between the ages
of 10 and 20 (Cohen et al., 1993). Furthermore, study
participants were drawn from rural and presumably underserved
populations. A more recently conducted study of a single rural
North Carolina county revealed that 10% of elementary students
had been diagnosed with ADHD (Rowland et al., 2002).
Goldstein and Turner (2000) attempted to replicate the
LeFever et al. (1999) school-based study in an entire Utah
school district. Examining rates of school-based
administration of ADHD medications for the 1997-98 school
year, Goldstein and Turner found that less than 2% of students
in Grades 1 through 5 received medication for ADHD. They
concluded that ADHD went unrecognized and untreated among a
sizable portion of children. This figure is not surprising
given that among the 50 states, Utah ranked 44th in Ritalin
consumption for the years 1997 to 1999 (Eaton & Marchak,
2001; LeFever et al., 2001). Because research suggests that
rates of ADHD drug treatment may be at least twice as high as
school nurse records indicate (LeFever et al., 2002), a 3% to
4% prevalence figure for Utah is a realistic estimate of the
number of children who were medicated for ADHD.
Strength of the
Evidence
These studies by LeFever et al. (1999, 2001), Angold et
al. (2000), and Goldstein and Turner (2000) suggest that ADHD
treatment practices are highly variable, which is supported by
per capita assessments of DEA Ritalin distribution data. Rates
of Ritalin distribution can be divided into quartile ranges
such that 1st quartile reflects relatively high-use regions,
the 2nd and 3rd quartiles reflect moderate-use regions, and
the 4th quartile reflects low-use regions. As such, Virginia
is a high-use state, North Carolina a moderate-use state, and
Utah a low-use state. This corresponds to the fact that
epidemiologic studies suggest that regional ADHD drug
treatment rates among elementary students are as high as 17%
in Virginia (high-use state), 7% to 10% in North Carolina
(moderate-use state), and 3% in Utah (low-use state).
Although some have argued that the relatively low rate
of school-based ADHD drug treatment observed in Utah (i.e.,
Salt Lake City area) is indicative of ADHD underdiagnosis,
this relatively low rate of treatment may actually reflect
appropriate care. At most 70% of children have a positive
response to ADHD drug therapy and up to 30% require
alternative treatments. Given this fact, the range of
treatments available, the range in severity of the disorder,
and parental preferences, drug treatment may be appropriate
for well below 100% of affected children and perhaps no more
than 70% of affected children. Accordingly, the rate of ADHD
drug treatment would not exceed 2.1% to 3.5% (i.e., 70% of the
estimated 3% to 5% of affected children). The use of stimulant
medication alone among American children has already exceeded
this rate (American Academy of Pediatrics, 2001). If drug
treatment is at a reasonable level in a state with one of the
lowest rates of Ritalin use (Utah), ADHD overdiagnosis may be
significant in the 36 states with moderate to high rates of
Ritalin use, suggesting that ADHD overdiagnosis and
corresponding drug treatment may be more widespread than
previously acknowledged by the American Medical Association
(Goldman et al., 1998).
A
combination of drug, behavioral, and educational interventions
is generally recommended for the treatment of ADHD. Available
evidence suggests that the underuse of behavioral
interventions may be as problematic as the overuse of drug
therapy. A survey of parents in the Jensen et al. (1999) study
revealed that close to 90% of children received medication
when their parents felt they needed medication for their
behavior problems. However, only about half of those who felt
the need for school or behavioral services actually received
them and about one third who felt their children needed
counseling received such services.
The
Value of ADHD Treatment- Overselling the Drugs?
Clinicians sometimes justify the high rate of drug
treatment for ADHD because "it works." Clinical
efficacy studies are designed to determine whether drugs
reduce narrowly defined symptoms (e.g., hyperactivity) without
adverse side effects, as delivered in controlled research or
laboratory settings and over short periods of time. Hundreds
of clinical efficacy studies have documented that
psychostimulant treatment reduces core symptoms associated
with ADHD. Clinical effectiveness studies are designed
to ascertain the benefit of drugs on major outcome variables
(e.g., educational success) as delivered in routine community
settings and over long periods of time (Wolraich, 1999).
Little information is available regarding treatment
effectiveness. Moreover, the accumulating evidence suggests
that, as currently delivered in routine community settings,
ADHD drug treatment is not nearly as effective as generally
assumed (Pelham, 1999).
The wide-scale use of Ritalin makes it possible to
evaluate the impact of such treatment on the health and well
being of large cohorts of children. On a national level,
increased use of psychostimulants does not appear to have led
to reduced associated risks of more serious problems such as
substance abuse, depression, suicide, and school dropout.
Since the 1970s, when ADHD treatment began, teenage depression
has skyrocketed, the rate of adolescent suicide has doubled
(Centers for Disease Control and Prevention, 2000), and rates
of high school dropout have remained unchanged (U.S.
Department of Commerce, 2000). These population indicators beg
for an examination of long-term outcomes associated with ADHD
drug treatment.
In southeastern Virginia, the region with the highest
documented rate of ADHD drug treatment of any community,
students identified with ADHD were 3 to 7 times more likely
than their peers to experience adverse educational outcomes.
Regardless of whether children diagnosed with ADHD were
medicated, they were far more likely than their schoolmates to
be expelled or suspended from school, require special
education services, and repeat a grade (LeFever et al., 2002).
Such findings underscore the need for research to move beyond
a focus on clinical efficacy studies to clinical effectiveness
studies. Forthcoming effectiveness studies also need to
consider major outcome measures (e.g., grade retention) over
long periods of time (e.g., several years).
Improving Care of
Children with Behavior Problems
Establishing a
Public Health Agenda
Despite pronouncements to the contrary by leading ADHD
researchers (Tennant, 1996), some of the communities
experiencing elevated rates of ADHD identification have been
compelled to act. For example, Johnston County, North
Carolina, and southeastern Virginia have taken a public health
approach to dealing with this complex and controversial issue
(Pills for preschoolers, 2000; Simpson, 2000). These
communities responded to identification of high rates of ADHD
treatment by forming regional coalitions, each with a primary
focus on improving the health and education of children with
ADHD and related disorders. The southeastern Virginia
coalition [1] has
increased the community's awareness and understanding of ADHD
issues and has been instrumental in the development and
funding of several ADHD intervention and prevention grants
(LeFever et al., 1999). The coalition worked with state
legislators to pass legislation requiring study of the
prevalence and impact of ADHD treatment in schools throughout
Virginia. Through its ADHD position statement and related
activities, the coalition is encouraging other communities to
consider adopting a public health approach to ADHD issues
(LeFever, 2001).
The efforts of such communities as southeastern
Virginia are laudable; however, a more comprehensive and
national public health agenda is urgently needed with regard
to child mental health generally (U.S. Department of Health
and Human Services, 2000) as well as ADHD specifically. The
agenda should include ongoing surveillance of the rate of ADHD
identification and treatment as well as outcomes associated
with varying levels of treatment. Although reviews of DEA data
and Medicaid claims contribute to our understanding of ADHD
treatment, each has its limitations and more sophisticated
tracking systems are needed (Fox et al., 2000). In addition to
improving surveillance methods, strategies to prevent the
emergence of disruptive behavior disorders are urgently
needed. We know a great deal about the combined influence of
child and environmental characteristics on the expression of
developmental problems as well as how to reduce the risk of
such problems (Shonkoff & Phillips, 2000). It is important
to apply this knowledge to reduce the number of children who
warrant psychiatric diagnoses (e.g., ADHD) and chronic
psychotropic drug treatment to function adequately in school.
Promoting
Judicious Use of ADHD Diagnostic Label and Associated Drug
Treatment
We agree with others (Sameroff, 2001) that the overuse
of psychotropic medications is a stopgap measure that is
tantamount to placing the problem exclusively "in the child"
rather than addressing the more complex issue of working to
adapt the child and environment to each other. When it appears
to be cost effective and efficient to "fix" the child through
use of medication, society is unwilling to expend resources to
design more development-enhancing environments that are
responsive to the needs of behaviorally demanding children.
Much has been learned through the years of research devoted to
establishing biological treatments for ADHD. However, one must
hope that society's belief in the safe and palliative nature
of these drugs is warranted and that the 200 years of research
showing that the long-term side effects of psychotropic drug
treatment are almost always greater than initially anticipated
(Olivieri, Cantopher, & Edwards, 1986) does not apply to
ADHD treatments. In fact, a recent meta-analysis (Schacter,
King, Langford, & Moher, 2001) concluded that (1) the
outcome literature does not offer enough safety data, (2)
there are many more side effects than usually appreciated, (3)
few studies evaluate long-term results, and (4) there is a
significant publication bias against studies showing no
advantage of stimulants.
Given the lack of: (1) an identified biological marker
for ADHD, (2) a single valid test or assessment approach for
diagnosing ADHD, and (3) evidence of long-term effectiveness
of psychotropic treatment, together with evidence that
behavioral treatment is arguably as effective (Pelham, 1999)
as drug treatments, judicious use of medical interventions is
warranted. New practice guidelines for treating ADHD have
recently been published (American Academy of Pediatrics,
2001). The following guidelines are offered to complement
these new guidelines and to promote prudent use of drug
treatment among children with ADHD-related symptoms and
diagnoses.
- Before any kind of treatment is offered, a suspected
case of ADHD requires a thorough diagnostic evaluation
applying the full DSM-IV criteria (including the need
to establish that the symptoms in question cannot be better
accounted for by another condition and are inconsistent with
developmental level).
- If a child receives a diagnosis of ADHD during the
preschool years, drug treatment should be avoided, as many
cases resolve by the first or second grade. Moreover, the
safety and efficacy of drug treatments have not been
adequately established in this population (Ghuman et al.,
2001; Spencer, Biederman, & Wilens, 2000). Training in
normal development and behavioral management is preferred
prior to age 6.
- Although some contend that behavioral treatments do
not add efficacy to medication alone (MTA Cooperative Group,
1999), behavioral interventions ought to be tried first
because of their arguably comparable efficacy and lower
medical risks than drug treatment (Pelham, 1999). This
approach is consistent with the Hippocratic dictum "first do
no harm" and reflects the costs and benefits of empirically
supported treatments.
- If the child has not responded adequately after 6
months of behavioral intervention, other treatments ought to
be considered, including empirically supported drug
interventions.
- Psychotropic medications should not be combined
unless data from controlled studies support the safety and
efficacy of the combination in children (Guevara, Lozano,
Wickizer, Mell, & Gephart, 2002).
Summary
ADHD is diagnosed and treated differently in
communities across the United States, as evidenced by the
30-fold variation in per capita rates of Ritalin use. The
probability that ADHD is diagnosed appropriately in some
communities should not serve to dismiss concerns about
overdiagnosis in all communities. Rates of treatment are
consistently highest among younger (i.e., under age 10),
nonminority, and male school-age children. The evidence of
ADHD overdiagnosis is obscured when findings are reported
without respect to geographic location, race, gender, and age.
The fact that ADHD is clearly overdiagnosed in some
communities and among some groups of children (e.g., one in
every three white elementary-aged boys in southeastern
Virginia) is lost in nationwide estimates of ADHD drug
treatment. It is essential that mechanisms be established to
track rates of child mental health diagnoses and psychotropic
drug treatment and its outcomes among American children. Until
we have a better understanding of these issues, it is
appropriate to be judicious in our use of psychotropic
medications and cautious about dismissal of concern about ADHD
overdiagnosis.
- The School Health Initiative for Education (SHINE) is
funded through a grant from Children's Hospital of The
King's Daughter's Health System, Norfolk, Virginia.
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