Dr. David Rabiner on Medication for ADHD
* * IS STIMULANT MEDICATION OVER PRESCRIBED?
One of the frequent concerns raised by individuals and groups who oppose the use of stimulant medication for treating children with ADHD is that such medications are grossly over prescribed. In fact, some data about the use of such medications is potentially consistent with this concern. For example, recent data indicates that the number of methylphenidate prescriptions for adolescents increased by over 250% between 1990 and 1995. Does such an increase reflect the misuse and overuse of stimulant medications, or does it reflect that more children who need the assistance that medication can provide are now receiving it?
This important question was addressed in a recently published study (Jensen, et.al. (1999). Are stimulants over prescribed? Treatment of ADHD in four U.S. Communities. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 797-803). In this study, the authors used epidemiological methods to estimate the prevalence of ADHD among 1285 9 to 17 year-old children residing in 4 different communities. They also gathered information on the frequency with which stimulant medications were prescribed to children in these communities, as well as the other types of services that children with ADHD were receiving.
In this study, ADHD was diagnosed based on structured diagnostic interviews that were administered to both a child's parent(s) and the child him or herself. Unfortunately, it was not possible to obtain information from children's teachers. Teachers, of course, are an important source of information in the evaluation process, and the absence of this information is a regrettable limitation of the study.
In any case, the rates of ADHD were found to vary widely across the 4 communities, ranging from a low of 1.6 % for a community in San Juan, Puerto Rico, to a high of 9.4% for Atlanta, Georgia. The average prevalence rate across the 4 communities (the other 3 were Westchester, NY, and New Haven, CT) was 5.8%. Whether the discrepancy in apparent rates of ADHD in the different communities reflects true differences in the rate of the disorder, or different cultural thresholds about what constitutes acceptable vs. deviant behavior is unclear.
What is clear, however, is that despite widespread concerns about the overprescription of stimulant medications, many children who have ADHD are receiving no such treatment. In fact, in this epidemiologic derived sample, only 12% of children who were diagnosed with ADHD were being treated with stimulants. This means that fewer than 1 out of 8 children with ADHD who comprised a representative sample from 4 diverse communities were receiving such treatment. In addition, only 1.4% of children who did not meet diagnostic criteria for ADHD were being treated with stimulants at the time of the study, and these children all showed high levels of ADHD symptoms even though they did not meet full diagnostic criteria.
These data are certainly not consistent with the notion that stimulant medications are being widely over prescribed. In fact, if anything, they argue for the exact opposite conclusion. Here is another concerning aspect of the medication data. Children with ADHD who were being treated with stimulants were showing virtually the same level of ADHD symptoms as those children with ADHD who were not being treated. In other words, there was no indication in the report of parents and children that the medication was producing any observable positive effects on children's symptoms.
These data should not be interpreted as indicating that stimulants don't work. There is simply an abundance of well-designed studies which clearly indicate that they do. Instead, I think these data again underscore the sad truth that medication is frequently not prescribed in the careful and systematic way that is required to produce the maximum possible benefits for each child. Stimulant medication has been shown repeatedly to result in dramatic reductions in ADHD symptoms are related behaviors when it is prescribed carefully and monitored properly. In actual community settings, however, this is often not done, and, in the absence of careful procedures, the expected benefit is often not attained.
What about the other types of treatments that children with ADHD were receiving? About 1/3 were receiving some type of psychosocial treatment (i.e. behavioral treatment or some form of therapy). Less than 25% were receiving any type of special services at school. It is discouraging to note fewer than half of parents who felt their child needed services at school reported that their child was receiving any such services. In addition, under 40% who believed they needed assistance in learning how to manage their child's behavior were receiving any help in this area.
In contrast, when parents believed their child need medication, they were able to obtain this for their child over 85% of the time. Thus, it appears that medication is the easiest type of assistance for parents to obtain for their child with ADHD. Although medication treatment may be relatively easy for parents to obtain for their child, as noted above, it is not easy for parents to find a physician who will provide such treatment in a careful, thorough, and systematic manner. School services, help with behavior management, and counseling for their child are all more difficult for parents to arrange.
This is an important study. Although any study such as this should be replicated so that confidence in the conclusions one draws are strengthened, these data clearly argue against the belief that stimulant medications are widely over prescribed. It appears that the vast majority of children with ADHD are not receiving any such treatment, and for those that are, this treatment is often done in a way that fails to provide the greatest possible benefit. Although other interventions (i.e. behavioral treatment and school-based services) may actually be provided more frequently to children with ADHD, most parents who feel their child needs such service are unable to obtain it. These are generally discouraging conclusions. Hopefully, studies such as these will eventually result in improvements in the services that are readily available for children with ADHD and their families.
(For an introduction to the educational rights for children with ADHD, go to http://www.helpforadd.com/rights.htm).
A note from Dr. Rabiner:
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David Rabiner, PhD
is hearing a student say,
"Thank you for understanding me."