problems of over diagnosis and over prescribing in adhd

Psychiatric Times. Vol. 28 No. 8CLINICAL

Problems of Overdiagnosis and Overprescribingin ADHDBy Daniel F. Connor, MD | August 11, 2011Dr Connor is Lockean Distinguished Professor of Psychiatry and Chief, Division of Child andAdolescent Psychiatry at the University of Connecticut School of Medicine in Farmington. Dr Connorreports that he receives grant support from Shire Pharmaceuticals, Inc, and is a consultant for Shire andSupernus Pharmaceuticals, Inc. He receives royalties from the Guilford Press and WW Norton and Co.He also receives support from the NIMH and contracts for the state of Connecticut.

ADHD is the most extensively studied pediatric mental health disorder, yetcontroversy and public debate over the diagnosis and medication treatment of thedisorder continue to exist. Questions and concerns are raised by professionals,1

media commentators, and the public about the possibility of overdiagnosis ofADHD in youths and the possibility of overprescribing stimulant medications.Fueled by sensational media coverage that emphasizes controversy overrationality, the debate can at times become quite heated, leading to a generalpublic assumption that ADHD is overdiagnosed and that stimulant drugs areoverused and overprescribed in children and adolescents with and withoutADHD.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 SirGeorge Frederick Still in 1902, and initial diagnostic classifications emphasized the symptoms ofhyperactivity and impulsivity. The diagnostic terms used to describe children with this disorder changedfrequently in the 20th century. With the introduction of DSM-III in 1980, the symptom of inattentiongained ascendancy and the condition was officially listed as attention-deficit disorder. DSM-IV containsthe diagnosis of ADHD with 3 subtypes: combined, inattentive, and hyperactive-impulsive. Furthermodifications 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 foradolescents and adults. Between 1980 and 2007, there was an almost 8-fold increase of ADHDprevalence in the United States compared with rates of 40 years ago. Considering the prevalence ofschool-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 the1980s, and 4% to 5% in the mid to late 1990s. In 2007, using data from the National Survey ofChildren’s Health, Visser and colleagues reported that 7.8% of youths aged 4 to 17 years had a5

diagnosis of ADHD and 4.3% reported current use of a medication for the disorder.

Psychiatric Times. Vol. 28 No. 8 August 11, 2011

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The rise in prevalence stemmed from a complex confluence of forces and events that came together inthe first half of the 1990s and permitted a dramatic expansion of ADHD diagnosis and treatment. The6

growing political strength of children’s welfare advocates and the mental health consumer’s movementassociated 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 withADHD 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. At the6

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 ascientific and neurobiological rationale for medication intervention. Also, the managed care7,8

psychiatric carve-out health insurance industry sought to rein in the costs associated with psychiatricillness and supported pharmacological interventions for complex psychiatric disorders, includingpediatric disorders.

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

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

The rise in stimulant prescribing for youths must be taken in context. Between 1990 and 2005 there wasa rapid rise in pediatric prescriptions for many psychiatric medications—not only stimulants. There wasa 5-fold increase for antipsychotics between 1993 and 2002, and a 3-fold increase for antidepressantsbetween 1997 and 2002. Thus, the rise in stimulant prescribing for pediatric ADHD was only part10,11

of a larger shift to an emphasis on medication interventions for the treatment of children withearly-onset and complex behavioral and mental health disorders.

Stimulant overprescribing

Public perception of stimulant overprescribing is driven by concerns overthe rapid rise in the amount of available stimulants produced in theUnited States over the past 3 decades. For sale stimulant productionquotas are published yearly by the Drug Enforcement Administration.12

The rapid rise in the production quota of for-sale methylphenidate(Drug (excluding amphetamine) is seen in the information on methylphenidate)

. With the production of more stimulants every year, worriesFigureabout the increased availability of stimulants for abuse and diversion rise as well. Rising productionrates are cited as proof of stimulant overprescribing by physicians and indirect evidence of theoverdiagnosis of ADHD among children.2



The extant scientific research suggests a much more complicated and nuanced picture of stimulantprescribing. Comparisons of the prevalence of ADHD among youths aged 4 to 17 years (7.8%) withstimulant prescription rates of between 4.3% and 4.4% do not support the idea of a culture of permissivestimulant overprescribing. Moreover, recent data from the National Health and Nutrition Examination5,9

Survey, a nationally representative probability sample of children aged 8 to 15 years living in thecommunity, indicated an ADHD prevalence rate of 7.8%. However, only 48% of the ADHD sample hadreceived any mental health care over the past 12 months.13

Clearly, not every person who meets criteria for ADHD is in need of a medication intervention. Adiscrepancy between ADHD prevalence and rates of stimulant prescriptions does not automaticallyprove that medications are underprescribed in the population. Nor do data support a conclusion that anepidemic of ADHD med-ication overprescribing is occurring.

Stimulant prescription rates are complex and vary by geographic location, age, and gender. Studies14

have found overprescribing in some regions of the United States and underprescribing in others. Asreported by the CDC in 2003, ADHD prevalence ranged from a low of 5.0% in Colorado to a high of11.1% in Alabama. Rates of medication treatment for ADHD ranged from 40.6% of patients inCalifornia to 68.5% in Nebraska. These data do not sug-gest a pattern of overprescribing of14

stimulants. However, in an 11-county epidemiological study of mental health status among children inwestern North Carolina, Angold and colleagues found that 7.3% of children were receiving stimulants15

but only 3.4% of children met an unequivocal diagnosis of ADHD, which suggests that pockets ofoverprescribing do exist.

In addition, stimulant prescription rates vary by sex and age. ADHDdiagnostic rates and stimulant treatment rates are higher in boys than ingirls younger than 20 years. Rates of stimulant treatment are highest9

among boys aged 12 years and girls aged 11 years, and they decline withage. The National Survey of Children’s Health showed that the factors14

associated with medication treatment for ADHD included younger age,the burden of impairment from symptoms, and a recent health care

contact. Some factors associated with possible ADHD misdiagnosis and stimulant misprescribing are5

listed in Table 1.

Simple pronouncements of the overmedication of youth with ADHD based on temporal trends in theabsolute rate of rise of stimulant quota production and stimulant prescriptions cannot be supported. Themajority of the literature published to date does not support the general idea that ADHD isoverdiagnosed nor does it support the idea that stimulants are overprescribed in children and adolescentsin the United States. However, the data also suggest that there continue to be geographic areas ofstimulant overprescribing or inappropriate prescribing.

What is already known about overdiagnosis and overprescribing in ADHD? ADHD is the most extensively studied pediatric mental health disorder, yet controversy and public

debate over the diagnosis and medication treatment of the disorder continue. Questions and concernscontinue to be raised by professionals, media commentators, and the public about the possibility that

ADHD is overdiagnosed in youths and that stimulants are overprescribed.



What new information does this article provide? This article reviews what is known about the prevalence of ADHD and stimulant prescribing rates in children and adolescents in the United States. While the data do not suggest a general problem withADHD overdiagnosis and stimulant overprescribing, there continues to be variability in diagnosis and

prescribing rates. Reasons for the continued controversy include fears of stimulant abuse and diversion,physician overprescribing, limited managed care carve-out payer resources to support evidence-basedstandards of ADHD evaluation and treatment, and continuing unease as to the legitimacy of the ADHD

diagnosis.

What are the implications for psychiatric practice? Comprehensive physician ADHD evaluation practices are essential for accomplishing evidence-based stimulant prescribing and for reducing unwanted variation in stimulant prescribing rates. This, in turn,

should help reassure the public that management is accomplished consistently and with due expertise.

Stimulant abuse and diversion

Despite more than 250 randomized controlled medication trials attesting to the efficacy and safety ofstimulant use in patients with ADHD, there continues to be controversy, especially regarding abuse anddiversion. It is important to distinguish between these issues. Stimulant abuse refers to the continued useof a drug that leads to significant impairment in daily functioning characterized by recurrent use underhazardous conditions, such as while driving an automobile or operating machinery, and by legal andinterpersonal problems. Diversion is the practice by which legitimate stimulant prescriptions for16

ADHD are diverted for reasons other than treating ADHD.17

Methylphenidate and amphetamine used to treat the core ADHD symptoms of inattention, impulsivity,and hyperactivity have an established potential for abuse. Preclinical and clinical studies show that bothtypes of stimulants have reinforcing effects that are similar to each other and to drugs of abuse, such ascocaine. Findings from a study by Biederman and colleagues indicate that a diagnosis of ADHD16,18 19

increases the risk of early-onset substance use disorders that have an aggressive course. These datasuggest a potential relationship between ADHD, stimulant treatment, and later substance use disorders.

However, despite the established abuse potential of stimulants, the evidence that methylphenidate andamphetamine are readily abused in the ADHD population in the formulations and doses used clinicallyis limited. Rather than abusing stimulants, patients with ADHD frequently take less medication than16

prescribed. The reinforcing effects of stimulants in ADHD patients may be associated more with20

clinical efficacy than with abuse liability.

Neuroimaging research demonstrates both pharmacokinetic and pharmacodynamic differences in theeuphoric and abuse liability effects of methylphenidate and cocaine in humans. Agents such as21

cocaine that demonstrate rapid absorption and rapid turnover at CNS synaptic dopamine(Drug receptors are associated with euphoric and abuse liability effects. The sameinformation on dopamine)

rapid changes in drug concentration can be achieved through intranasal or intravenous, rather than oral,immediate-release (IR) stimulants. Drugs such as oral methylphenidate demonstrate slower absorptionand longer temporal CNS dopamine receptor binding and release properties and are associated morewith therapeutic effects than with abuse liability effects.



The drug release technology of long-acting stimulants that have a beaded or osmotic release mechanismor that are covalently bonded to an amino acid that mimics the pharmacokinetic properties of IRmethylphenidate or IR amphetamine given 2 or 3 times daily makes intranasal and intravenous usedifficult. Thus, while stimulants have properties consistent with abuse liability, their clinical use in17

ADHD patients does not suggest widespread abuse.

Stimulants are not without some abuse risk in clinical populations. Abuse rates rise in persons withADHD comorbid with substance use disorders and/or other disruptive behavior diagnoses, such asoppositional defiant disorder and conduct disorder. Coexisting bipolar disorder increases the risk of22

stimulant abuse. A family history of substance use disorders increases risk. In such cases, carefulmonitoring and follow-up are recommended.

A more pressing and prevalent issue than abuse appears to be diversionof legitimately prescribed stimulants to individuals without ADHD forpurposes other than to treat ADHD or narcolepsy. The results of ameta-analysis involving more than 113,000 patients showed rates of pastyear nonprescribed stimulant use between 5% and 9% in adolescents andbetween 5% and 35% in college students. Risk factors for stimulant17

abuse and diversion are shown in .Table 2

When prescribing stimulants for adolescents or college students withADHD, a detailed discussion of stimulant diversion, abuse, andmedication misuse with the patient and his or her parents is important.Teach the patient how to store the medication safely when he is livingaway from home.

Diagnosis and treatment

Evaluation of the patient with ADHD takes time and should include amulti-informant, multi-method, developmental assessment of symptoms, impairment, course of illness,previous assessments and treatments, school and social functioning, and comorbid conditions. The23,24

evaluation process is essentially a time-consuming cognitive endeavor of pattern matching the patient’ssymptoms and disease course with what is known about the natural history of ADHD and hypothesistesting and integrating all available data. This systematic evaluation establishes that all clinical criteriafor an ADHD diagnosis are met.

Faced with severe payer and clinical time constraints, many physicians diagnose ADHD by emphasizinga present oriented, cross-sectional symptom evaluation. This type of evaluation may result in6,25

overdiagnosing ADHD, or underidentifying ADHD in children with complex and comorbidpresentations. A quick cursory evaluation from a too busy physician reinforces the public’s perceptionthat stimulant medications with abuse potential are too readily prescribed for children who do not meetfull diagnostic criteria for ADHD.

Once the diagnosis of ADHD is established, treatment planning dependson symptom severity and pervasiveness of functional impairment,tempered by the wishes and concerns of the patient and his family.Treatment should be individualized for each patient. Not all children with



ADHD require medication. Behavioral therapy can be helpful for many.Patients with very mild ADHD may initially receive psychosocial

ther-apy and educational support without medications.

Table 3 outlines an ADHD disease management strategy based on symptom severity and impairment.

Conclusions

Continued controversy over whether ADHD is overdiagnosed and stimulants overprescribed despitemuch scientific data to the contrary reflects ongoing public discomfort about ADHD as a valid andlegitimate disorder. For example, the public perceives that children and adults with a medical disordershould look and act sick, whereas many of the core ADHD symptoms are seen in lively, willful, andexuberant persons. Moreover, the general perception is that medications prescribed to treat illness (ie,antibiotics) are supposed to act differently in sick persons than in healthy individuals and that stimulantswork the same way in children and adults to enhance sustained vigilance whether they have a diagnosisof ADHD or not. Furthermore, the definition of ADHD seems to change frequently. If the definition ofADHD keeps changing, is it a genuine medical disorder?

Despite overwhelming scientific evidence of the legitimacy of ADHD as a CNS neurobiologicaldisorder, the general public appears confused about ADHD: is it a medical illness, a psychiatricsyndrome, a mental disorder, a behavioral health disorder, a behavioral problem, a motivationalproblem, or a school-based learning and socialization problem? Doubt and confusion as to where1,7,8

this disorder fits into the general spectrum of illness further feeds the general perception that ADHD is asocially constructed disorder rather than a valid neurobiological disorder. This increases the public’sconcern that ADHD is overdiagnosed and stimulants are overprescribed.

The public’s fear that ADHD is overdiagnosed and that stimulants are overprescribed is not generallysupported by the current scientific research. Reasons for the continued controversy include fears ofstimulant abuse and diversion, physician overprescribing, limited payer resources to supportevidence-based standards of ADHD evaluation and treatment, and continuing unease as to thelegitimacy of the ADHD diagnosis. Comprehensive physician ADHD evaluation practices are essentialto accomplishing evidence-based stimulant prescribing and to reduce unwanted variation in stimulantprescribing rates that should, in turn, reassure the public that management is accomplished consistentlyand with due expertise.

Image: PASIEKA/SPL/Photo Researchers, Inc.

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problems of over diagnosis and over prescribing in adhd

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