There has been quite a buzz in the press about ADHD lately, with many articles suggesting that the diagnosis is overused and that medication treatment is basically a way that affluent parents give their children an edge. In the midst of this debate comes a recent and interesting study that compared the rates of stimulant treatment in children and adults across different regions, states, and counties.
Using a large prescription database from 2008, a total of 24.1 million stimulant prescriptions (things like Ritalin and Adderall) were analyzed across all 50 states, representing over three-quarters of all U.S. pharmacies. The study authors also looked at potential factors that might be related to the variable rates between different areas. It is important to note that the authors looked at sustained stimulant treatment (not just those who tried it briefly) and did not measure other types of ADHD treatment, including medications not categorized at stimulants (Strattera, Intuniv and others) as well as nonpharacological treatment such as behavioral therapy.
Overall, a total of 2.5% of children nationally were being treated with stimulant medications, with the rate being higher in boys (3.5%) than girls (1.5%). In addition, 0.7% of adults over age 17 were also receiving these medications. For children, the highest stimulant rate was in Delaware at 5.1%, followed by Kentucky, South Carolina, Rhode Island, and North Carolina. The lowest rate was in Alaska at 0.4% with California, Hawaii, Colorado and Nevada rounding out the lowest five. Regional differences (South highest, Midwest lowest) were smaller than between neighboring states and counties. Another surprising fact to some is that only about one-third of the prescriptions came from psychiatrists with most being written by primary care physicians. In children, higher rates of treatment was related to an increased supply of pediatricians, lower socioeconomic status of the population, and more funding for special education.
In the discussion, the authors’ took a perspective that focused mainly on access to mental health treatment. While careful to point out that their data could not weigh in directly on the over- versus under-diagnosis debate, they noted that the prevalence of ADHD is generally cited as between 5-10% which would suggest a large number of children not being diagnosed and treated, especially in particular states and counties. To some, that is cause for celebration; to others, it suggests a breakdown in access to mental health care.
Their finding of stimulants generally being related to families with lower socioeconomic status also supports the assertion that these medications are not being used simply as a study booster for well-to-do kids.
The ADHD discussion will continue you can read a recent post on the ADHD debate here. While just one study, it does offer some measure of reassurance that these medications are not being used at rates that outpace even more moderate estimates related to the prevalence of ADHD.
McDonald DC, Jalbert SK. Geographic Variation and Disparity in Stimulant Treatment of Adults and Children in the United States in 2008. Psych Services 2013;64(11):1079-1086.
Image courtesy of David Castillo Dominici and Freedigitalphotos.net
@copyright by David Rettew, MD
David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.