Are ADHD medications overprescribed or underprescribed? (Quick answer: both)

Although med­ica­tion treat­ment for ADHD has been shown to sig­nif­i­cant­ly reduce core ADHD symp­toms in hun­dreds of stud­ies, impor­tant con­cerns remain about it being pre­scribed inap­pro­pri­ate­ly to chil­dren and teens who do not have ADHD. There is also evi­dence that many youth with ADHD who could poten­tial­ly ben­e­fit from med­ica­tion treat­ment do not receive it, and may real­ize poor­er out­comes in as a result.

Esti­mat­ing the rate of the over- and under-use of ADHD med­ica­tion is chal­leng­ing, and a recent study pro­vides the most com­pre­hen­sive exam­i­na­tion to date of this impor­tant issue: Assess­ing under-treat­ment and over-treat­ment of ADHD med­ica­tions in chil­dren and ado­les­cents across con­ti­nents: A sys­tem­at­ic review and meta-analy­sis. [Neu­ro­science and Behav­ioral Reviews, 128, 64–73.]

The Study:

The authors began by iden­ti­fy­ing all pub­lished stud­ies of com­mu­ni­ty sam­ples, i.e., rep­re­sen­ta­tive com­mu­ni­ty mem­bers and not sam­ples of those seek­ing treat­ment, in which ADHD diag­noses and ADHD med­ica­tion treat­ment sta­tus was obtained. Over 25,000 poten­tial­ly rel­e­vant stud­ies were screened and a final sam­ple of 36 stud­ies meet­ing rig­or­ous selec­tion cri­te­ria were ulti­mate­ly select­ed for review. These stud­ies includ­ed over 100,000 par­tic­i­pants and were con­duct­ed in mul­ti­ple continents.

Because these were com­mu­ni­ty sam­ples, some par­tic­i­pants had been pre­vi­ous­ly been diag­nosed with ADHD (based on par­ent report of a pri­or diag­no­sis) and some did not have a pri­or diag­no­sis but were iden­ti­fied as hav­ing ADHD in the study. Because par­tic­i­pants were drawn from the com­mu­ni­ty, how­ev­er, rather than from those specif­i­cal­ly seek­ing treat­ment, most would not have had either ADHD or any oth­er diagnosis.

Three groups were iden­ti­fied based on the infor­ma­tion obtained: 1) youth with ADHD who were receiv­ing med­ica­tion treat­ment; 2) youth with ADHD who were not receiv­ing med­ica­tion treat­ment; and, 3) youth with­out ADHD who were nonethe­less receiv­ing med­ica­tion treatment.

Those in group 1 would be con­sid­ered appro­pri­ate­ly treat­ed, i.e., diag­nosed with ADHD and receiv­ing an empir­i­cal­ly sup­port­ed med­ica­tion treat­ment. Those in group 2 would rep­re­sent an ‘under-treat­ed’ group in that they were diag­nosed with ADHD but not receiv­ing an evi­dence-based treat­ment. Final­ly, group 3 par­tic­i­pants reflect an ‘over-treat­ed’ group in that they were not diag­nosed with ADHD but were still receiv­ing med­ica­tion treatment.

(Note that many would argue that the above cat­e­go­riza­tion over­sim­pli­fies things in that not all youth with ADHD nec­es­sar­i­ly require med­ica­tion and some believe that oth­er treat­ments should be tried first. From this per­spec­tive, not every­one in Group 1 would be ‘appro­pri­ate­ly treat­ed’ and not every­one in group 2 would be ‘under-treat­ed’.)

Results:

The pri­ma­ry analy­ses were restrict­ed to stud­ies where diag­no­sis was estab­lished using DSM cri­te­ria or val­i­dat­ed rat­ing scales, and not parental report of a pri­or diag­no­sis. Of over 3300 diag­nosed youth across 18 stud­ies, only 19% were receiv­ing ADHD med­ica­tion treat­ment. That leaves over 80% of diag­nosed youth who were not being treat­ed with medication.

In terms of over-treat­ment, of over 25,500 youth across 14 dif­fer­ent stud­ies, under 1% were receiv­ing ADHD medication.

When stud­ies were restrict­ed to those con­duct­ed in the US, where ADHD med­ica­tion pre­scrip­tion rates are high­est, 33% of diag­nosed youth that were being treated.

Summary and implications:

The main take­away from this study is that a only a minor­i­ty of chil­dren and teens with ADHD receive med­ica­tion treat­ment for the con­di­tion. And, rel­a­tive­ly few youth who don’t meet ADHD diag­nos­tic cri­te­ria are receiv­ing ADHD med­ica­tion. While rec­og­niz­ing that the actu­al num­bers pre­sent­ed are only esti­mates, it is there­fore rea­son­able to con­clude that under-treat­ment is sub­stan­tial­ly more com­mon than over-treatment.

Giv­en con­cerns that ADHD med­ica­tion is fre­quent­ly pre­scribed to youth with­out ADHD, Find­ing that that this is rel­a­tive­ly uncom­mon (under 1%) is reas­sur­ing. Nonethe­less, even 1% of the youth pop­u­la­tion in the US is still a lot of indi­vid­u­als and it it is impor­tant not to min­i­mize this.

One’s per­spec­tive on these find­ings will depend on how one per­ceives the val­ue of med­ica­tion treat­ment for ADHD. For instance, those who ques­tion the util­i­ty of med­ica­tion treat­ment would be less con­cerned that only a minor­i­ty of diag­nosed youth receive this treat­ment. Because med­ica­tion treat­ment has per­haps the strongest evi­dence base as an ADHD treat­ment, how­ev­er, many would find this to be high­ly problematic.

Final­ly, it should be empha­sized that because these find­ing are based on com­mu­ni­ty sam­ples and not on youth whose par­ents were seek­ing evaluation/treatment, they do not apply to the over- or under-use of ADHD med­ica­tion for help seek­ing sam­ples. Thus, when par­ents have their child eval­u­at­ed by a health pro­fes­sion­al because of behav­ioral con­cerns, far more than 1% may be incor­rect­ly diag­nosed with ADHD and then inap­pro­pri­ate­ly treat­ed with med­ica­tion. That is an entire­ly dif­fer­ent issue which this inter­est­ing study was not designed to address.

– 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.

The Study in Context:

• Does ADHD treat­ment enable long-term aca­d­e­m­ic suc­cess? (Yes, espe­cial­ly when phar­ma­co­log­i­cal and non-phar­ma treat­ments are combined)
• Sur­vey of 2500 fam­i­lies finds what ADHD treat­ments seem to work/ not work as applied in the real world
• Hav­ing ADHD costs $1.1 mil­lion in low­er life­time earn­ings, even when “treat­ed”
• What are cog­ni­tive abil­i­ties and how to boost them?