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Study: Rates of ADHD diagnosis and medication treatment continue to increase substantially

Begin­ning in about 1990, sub­stan­tial increas­es in the rates of ADHD diag­no­sis and med­ical treat­ment were found in sev­er­al nation­al­ly rep­re­sen­ta­tive sam­ples of US physi­cian office vis­its. For exam­ple, between 1995–96 and 2007-08, the num­ber of office vis­its at which an ADHD diag­no­sis was made increased by over 400% in adults — from 3.1 per 1000 vis­its to 14.5 per 1000 vis­its. And, the per­cent of adult office vis­its includ­ing both ADHD diag­no­sis and med­ica­tion increased from 1.9 to 11.4 per 1000 vis­its.

Among chil­dren aged 5 to 18, between 1991–92 and 2008-09, rates of ADHD diag­no­sis increased near­ly 4-fold among boys — from 39.5 to 144.6 per 1000 — and near­ly 6-fold for girls — from 12.3 and 68.5 per 1000 vis­its. Dur­ing this time, the rate of vis­its that also involved med­ica­tion treat­ment increased by sim­i­lar rates.

These sub­stan­tial increas­es in ADHD diag­no­sis and med­ica­tion treat­ment raise the ques­tion of whether these trends have con­tin­ued. Sev­er­al recent devel­op­ments in the field sug­gest this may be the case. First, the intro­duc­tion of new ADHD med­ica­tions and asso­ci­at­ed may con­tribute to increas­es in med­ica­tion treat­ment sim­ply because addi­tion­al options are avail­able. Sec­ond, changes in ADHD diag­nos­tic cri­te­ria in DSM-V, i.e., required age of onset of symp­toms increas­ing from 6 to 12 and reduc­ing the num­ber of symp­toms required in teens and adults from 6 to 5, could con­tribute to an increase in indi­vid­u­als meet­ing a some­what broad­er set of diag­nos­tic cri­te­ria.

The New Study

In a study recent­ly pub­lished online in the Jour­nal of Atten­tion Dis­or­ders, Diag­no­sis and treat­ment of ADHD in the Unit­ed States: Update by gen­der and race (2017) exam­ines this ques­tion using date from the Nation­al Ambu­la­to­ry Med­ical Care Sur­vey over 3 time peri­ods: 2008-09, 2010-11, and 2012–13. This sur­vey pro­vides data on a nation­al­ly rep­re­sen­ta­tive sam­ple of US com­mu­ni­ty-based physi­cian office vis­its. Counts of vis­its in which an ADHD diag­no­sis was made are based on diag­no­sis codes includ­ed for each vis­it. Sim­i­lar­ly, infor­ma­tion on pre­scribed med­ica­tion enables the deter­mi­na­tion of the num­ber of vis­its dur­ing which one of eight ADHD med­ica­tions was pre­scribed. Demo­graph­ic infor­ma­tion, e.g., age, gen­der, race, are also avail­able for each vis­it. With these data, trends in ADHD diag­no­sis and med­ica­tion treat­ment over this time peri­od, and how that may have var­ied in rela­tion to demo­graph­ic vari­ables, can be deter­mined.

The Findings

1. Rates of ADHD diag­no­sis con­tin­ue to riseBetween 2008-09 and 2012–13, vis­its to a com­mu­ni­ty-based physi­cian that involved an ADHD diag­no­sis increased by 36% among adults — from 18.5 to 25.3 per 1000 vis­its. For youth, the increase was 18.5%, from 93.1 to 110.3 vis­its per thou­sand. Thus, rates of ADHD diag­no­sis dur­ing physi­cian office vis­its increased faster in adults but the num­ber of diag­nosed youth remains far greater.

2. Rates of ADHD med­ica­tion treat­ment con­tin­ue to rise — Among adults, the num­ber of office vis­its where ADHD med­ica­tion was pre­scribed increased by 21%, from 15.1 to 18.2 vis­its per thou­sand adults. For youth, the increase was 16%, from 74.3 to 86 per thou­sand youth. Thus, near­ly 9% of all youth vis­its to com­mu­ni­ty-based physi­cians dur­ing 2012–13 involved a pre­scrip­tion for ADHD med­ica­tion.

3. The increase in diag­no­sis rates vary by gen­der — Among adults, the increase in rate of diag­no­sis was greater in males than in females, increas­ing by 52% in males and only 23% for females. For youth, the increase in the per­cent of office vis­its that involved an ADHD diag­no­sis was more sim­i­lar, increas­ing by 22% in females and 17% in males.

4. The increase in med­ica­tion treat­ment rates vary by gen­der — Among adult males, the num­ber of office vis­its that involved pre­scrib­ing ADHD med­ica­tion increased by 30%; for adult females, the increase was only 13%. Among youth, the trend was reversed as office vis­its involv­ing ADHD med­ica­tion increased by 29% females and by only 10% in males.

5. There were a num­ber of inter­est­ing find­ings relat­ed to age and race — Increas­es in the pro­por­tion of office vis­its that involve ADHD diag­no­sis and med­ica­tion treat­ment are most rapid among those over 50, espe­cial­ly adults over 65. Between 2008-09 and 2012–13, the rate of increase among adults 65 and above was 348%; the absolute num­ber of old­er adults receiv­ing an ADHD diag­no­sis remained very low, how­ev­er.

For youth, there was actu­al­ly a sig­nif­i­cant decline in vis­its involv­ing an ADHD diag­no­sis (down 24%) and med­ica­tion treat­ment (down 51%) in chil­dren under 5. Rates increased in every oth­er age group with the largest increas­es occur­ring in youth between 15 and 19.

Vis­its involv­ing a diag­no­sis increased sub­stan­tial­ly more for black youth than for white youth — 69% vs. 23%. Sim­i­lar trends were observed for vis­its involv­ing the pre­scrip­tion of med­ica­tion.

Summary and implications

Results from this study clear­ly indi­cate that oth­er than for chil­dren under 5, the upward trend in ADHD diag­no­sis and med­ical treat­ment that began over 25 years ago remains firm­ly in place. The decline in treat­ment for youth under 5 may reflect recent AAP guide­lines that high­light com­pli­ca­tions with estab­lish­ing the diag­no­sis in young chil­dren and that rec­om­mend clin­i­cians ini­ti­ate a tri­al of behav­ior ther­a­py before pre­scrib­ing med­ica­tion.

For adults, rates of diag­no­sis increased more rapid­ly dur­ing the 6-year study peri­od for males than for females. For youth, diag­no­sis is increas­ing a bit more quick­ly in females but the rate of “…pop­u­la­tion-adjust­ed growth in ADHD diag­no­sis cou­pled with phar­ma­cother­a­py for females was near­ly triple than that for males over the 6-year study peri­od.” The lat­ter may reflect greater vig­i­lance on the part of physi­cians to iden­ti­fy­ing prob­lems with atten­tion, which tend to be more promi­nent in females with ADHD rel­a­tive to hyper­ac­tive-impul­sive symp­toms.

While find­ings indi­cate that the rates of ADHD diag­no­sis and med­ica­tion con­tin­ue to increase sig­nif­i­cant­ly, these data pro­vide no infor­ma­tion on the rea­sons that these upward trends con­tin­ue. It may be that the broad­en­ing of diag­nos­tic cri­te­ria in DSM-V has result­ed in more indi­vid­u­als being diag­nosed and treat­ed med­ical­ly than was pre­vi­ous­ly the case. The intro­duc­tion of new med­ica­tions and asso­ci­at­ed mar­ket­ing efforts by phar­ma­ceu­ti­cal com­pa­nies may also play a role. Such ques­tions can not be addressed by the sur­vey data reviewed here, how­ev­er.

It should also be not­ed that the study pro­vides no infor­ma­tion as to whether the accu­ra­cy of ADHD diag­noses has improved, i.e., are physi­cians just doing a bet­ter job of rec­og­niz­ing ADHD and diag­nos­ing it appro­pri­ate­ly. Results from a recent­ly pub­lished study on pedi­a­tri­cians’ prac­tices for diag­no­sis and treat­ing ADHD sug­gest, how­ev­er, that this is not like­ly to be the case — see Dis­cour­ag­ing new find­ings about pedi­atric care for chil­dren with ADHD: Often, best-prac­tice guide­lines are not fol­lowed for a review of this study. This con­cern, cou­pled with find­ings that the rates of ADHD diag­no­sis vary sig­nif­i­cant­ly in dif­fer­ent parts of the coun­try, and are sub­stan­tial­ly low­er in oth­er devel­oped coun­tries, raise impor­tant ques­tions about the need to bet­ter under­stand why the diag­no­sis and med­ica­tion treat­ment of ADHD has con­tin­ued to rise at a fair­ly rapid rate.

Rabiner_David– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and helped pre­pare the self-paced, online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

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