Science & Pseudoscience Review in Mental Health

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Overuse of Prescription Stimulants for Children reported in new Duke Study

While the American Academy of Peditricians and the American Academy of Child and Adolescent Psychiatrists have asserted that stimulant medication (such as Ritalin®) is not over-prescribed in the United States, a recent study by a psychiatrist (Adrian Angold) and an epidemiologist (Jane Costello) at Duke University appeared in the August issue of the Journal of the American Academy of Child and Adolescent Psychiatry that refutes these assertions and casts serious doubt on the widespread prescribing of stimulants like Ritalin® for children and adolescents.

The purpose of the Angold et al. study was to examine the use of prescribed stimulants in relation to research diagnoses of attention-deficit hyperactivity disorder (ADHD) in a largely rural community sample of children. The study found that over a four year period, almost three quarters of children with an unequivocal diagnosis of ADHD received stimulant medications. Most children with impairing ADHD symptoms not meeting full criteria for DSM-III-R ADHD did not receive stimulant treatment. The use of stimulants as a treatment for these children not meeting the full ADHD diagnostic criteria was significantly related to the level of symptoms reported by parents and teachers and was much more common in individuals who met criteria for Oppositional Defiant Disorder (a diagnosis which has at its core behavior which, as the name suggests, is disruptive and defiant but not necessarily impulsive or over-active). The majority of individuals who received stimulants were never reported by their parents to have any impairing ADHD symptoms. These children's parents did report higher levels of nonimpairing ADHD symptoms, had higher levels of teacher-reported ADHD symptoms, and interviewer-observed ADHD behaviors, but these behaviors typically fell far below the threshold for a DSM-III-R diagnosis of ADHD. An additional finding was that the average duration of treatment by stimulants was over 50 months (or just over four years) for children ranging in age from 9 to 13. Finally, girls and older children with ADHD were less likely to receive stimulant treatment.

These findings do point out that approximately one-quarter of children qualifying by rigorous standards as having ADHD (and therefore displaying a very significant range of impulsive and over-active behaviors) are not receiving stimulants as a form of treatment. The study did not detail the reasons why these children, who clearly met DSM-III(R) criteria for ADHD, did not receive stimulant medication (a range of reasons are seen every day ranging from religious objections to medicating young children to inadequate financial/insurance resources to pay for the prescription each month). However, the main point of the Angold et al. study is that while only 3.4% of the 4500 children assessed met the full criteria for ADHD - over 7.3%, which is more than double that number, received prescriptions from physicians for stimulants.

These findings contradict earlier, smaller, and less robust studies (e.g., Jensen, 1999) which found that community samples were not receiving stimulant treatment often enough (the source for claims that stimulants are actually under-prescribed). In the Jensen study this "under-treatment" of ADHD via stimulant medication was reported as a predominant problem. The prevalence of stimulant use in the Jensen study was only 1.2% - or less than half of the estimated national utilization rates for 1995 (Safer et al., 1996). This is not unexpected given that the data for the study were collected during the first half of 1992 and the Angold, et al. study demonstrates an increasing propensity to prescribe between 1992 and 1996 (figures indicate that in 1992 there were approximately 150 million daily doses of Ritalin and in 1996 that figure had jumped by over 100% to approximately 325 million daily doses). So it may be that if Jensen et al. were to repeat their study, they would find a different picture. There is considerable variation in prescribing practices among physicians, and that could also be responsible for the differences between Jensen et al. findings and the Angold, et al. findings. Both studies document a very unsatisfactory state of affairs in the relationship between ADHD and its treatment with stimulants in the community.

There is good evidence in the medical literature that stimulants can help impulsive and hyperactive children and adolescents with their behavior (Goldman et al., 1998). However, there is little evidence that stimulants should be prescribed to children and adolescents for other disorders. Goldman and colleagues point out that "most individuals [in their study] received stimulants for a long time (a mean duration of more than three years) is also cause for concern. Together, these results present a troubling picture of a serious mismatch between need for stimulant treatment and the provision of such treatment." Their findings are consistent with the research "showing that increasing numbers of children are now receiving stimulant medications" and the authors go beyond that "to suggest that current treatment practice in the community is far from optimal."

The Angold et al. study leaves one big mystery: Why did the children in the Duke study with no symptoms of ADHD receive prescriptions from physicians for stimulant medication? The study does not say directly but others have suggested (Vitiello, 2000) that parents and teachers may be lobbying physicians to write prescriptions for stimulant medication. There is some support within the Angold et al. study for this contention. Angold et al. reports that "[t]eacher reports also predicted stimulant use in children without a diagnosis of ADHD".

Finally, none of the studies reported on here considered, in any way, the use of non-medication treatments of ADHD which have proven effective. There are a variety of behavior therapy approaches that have undergone rigorous federally-funded investigation and been found to be as effective as medication alone in the treatment of the inattention and hyperactivity seen in ADHD children and adolescents (Carlson, et al., 1992; Pelham, Wheeler, & Chronis, 1998) .


References

Angold, A., Erkanli, A., Egger, H. L., & Costello, E. J. (2000). Stimulant Treatment for Children: A Community Perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 975-984.

Carolson, C.L., Pelham, W.E., Milloh, R., & Dixon, J. (1992). Singe and combined effects of methylphenidate and behavior therapy on the classroom performance of children with ADHD. Journal of Abnormal Child Psychology, 20, 213-232.

Goldman L.S., Genel, M., Bezman, R.J., & Slanetz, P.J. (1998). Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Journal of the American Medical Association, 279, 1100-1107.

Jensen P.S., Kettle L., & Roper M.S., et al. (1999), Are stimulants overprescribed? Treatment of ADHD in four US communities. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 797-804.

Pelham, W.E., Wheeler, T., & Chronis, A. (1998). Empirically supported psycho-social treatments for attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 27, 189-204.

Safer, D.J., Zito, J.M., & Fine, E.M. (1996), Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics, 98, 1084-1088.

Vitiello, B. (2000). Stimulant Treatment for Children: A Community Perspective: Commentary. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 992-994.