Education World examines the rise in the number of prescriptions written for stimulant medication to treat ADHD -- an increase of 500 percent since 1991, according to the Drug Enforcement Administration. Included: Highlights of research tracking the rise of childhood ADHD and medication use.
Recent research investigations confirm what school administrators and teachers have realized for many years: The number of kids taking psychotropic medication has increased substantially in recent years. That increase is consistent with the rising number of kids diagnosed with ADHD.
Psychotropic medications treat a variety of behavior, emotional, and mental disorders, including ADHD.
The increase in the number of prescriptions doctors write for treating ADHD is staggering. According to the Congressional Testimony of Terrance Woodworth, a deputy director of the Drug Enforcement Administration, the number of prescriptions written for methylphenidate has increased by a factor of five since 1991. About 80 percent of the 11 million prescriptions doctors write for that medication each year treat childhood ADHD, he said. In addition, production of Adderall and Dexedrine, also used to treat ADHD, has risen 2,000 percent in nine years.
The increasing use of stimulant medication to treat ADHD in the United States differs significantly from practices in the rest of the world, according to United Nations data, Woodworth said. The U.S. produces and consumes about 85 percent of the world's production of methylphenidate.
The significant increase in stimulant medication prescribed to children has raised concerns that our society is choosing quick-fix remedies to treat ADHD. "How we deal with our kids' problems reflects our thinking and a much larger problem in our culture," said Lawrence H. Diller, who practices behavioral pediatrics in California and is author of Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill.
Although Diller prescribes stimulant medication for children with ADHD, he questions the large number of children currently on the medication in the United States.
The use of stimulant medication is not seen just in school-aged children. The number of preschool children using stimulant medication for ADHD has increased significantly as well. A study, Trends in the Prescribing of Psychotropic Medications to Preschoolers, published in the Journal of the American Medical Association, found that psychotropic medication use tripled in preschool children ages two to four over a five-year span.
The researchers also stated that though the use of methylphenidate had significantly increased among all age groups, it had increased by 311 percent for 15- through 19-year-olds during the past 15 years. Use among children ages 5 to 14 increased by approximately 170 percent.
According to Mental Health: A Report of the Surgeon General (Chapter 3), methylphenidate is manufactured today at two and a half times the rate it was a decade ago. The report also notes that though the overall numbers are up, treatment rates are lower for some groups, including girls, minorities, and children receiving care through public service systems.
The report sites a 1998 study by researchers Adrian Angold and E. Jane Costello, who found that the majority of children and adolescents who receive stimulants for ADHD do not fully meet the criteria for ADHD. They also found that many children who do meet the criteria for ADHD are not being treated.
Peter Jensen, who has headed major National Institute of Mental Health (NIMH) studies on ADHD and is an assistant professor of psychiatry at Columbia University, agrees with Angold and Costello's findings that the majority of children receiving stimulant medication may not fully meet the criteria.
"It's likely there is a bit of both [under diagnosis and over diagnosis]," Jensen told Education World. "This always happens when public awareness increases that there could be some over diagnosis. But under diagnosis and under treatment are still happening."
The large increases in the use of psychotropic medications are consistent with the rise in the number of children being diagnosed with emotional and behavioral problems. Another study, Increasing Identification of Psychosocial Problems: 1979-1996, published in the journal Pediatrics in June 2000, found the number of children identified with psychosocial problems nearly tripled between 1979 and 1996. The number of children diagnosed with emotional or behavioral problems jumped from 6.8 percent to 18.7 percent among four- to 15-year-olds. Attention problems showed the greatest increase, consistent with a significant rise in the number of prescriptions for ADHD, up from 32 percent to 78 percent.
The disparity of treatment noted by the surgeon general was further confirmed in a study funded by the Maryland Department of Education. The researchers found that white, suburban elementary school children are using medication for ADHD more than twice the rate of African American students. The study, Stimulant Treatment in Maryland Public Schools, was published in the September 2000 issue of the journal Pediatrics.
Of the 3 percent of the Maryland students who use medication to treat ADHD, the study found that more boys are treated for the disorder than girls. The study also found that about half the children receiving methylphenidate had special education status, also consistent with the Angold and Costello study cited by Surgeon General Satcher.
"You don't have to be ADHD to be on stimulants," said Daniel Safer, who wrote the report for the Maryland Department of Education. "Other kids may benefit from stimulants, which are quite safe."
Safer, adjunct associate professor of pediatrics and psychiatry at the Johns Hopkins Medical Institutions, said the Maryland data also raise questions about access to medical systems and how cultural attitudes play a role in whether parents agree to put their child on medication.
Safer explains that the expanded criteria of symptoms for ADHD along with increased awareness of those symptoms are why more children are being diagnosed with ADHD. The criteria were broadened in 1994 by the American Psychiatric Association.
Howard Abikoff, the Pevaroff Cohn professor of child and adolescent psychiatry and director of research at the New York University Child Study Center, agrees with Safer that there are a number of factors why more kids are being diagnosed with ADHD. However, he defends the broader APA criteria for ADHD. Although the criteria for ADHD have been expanded, lots of work went into pinpointing the appropriate symptoms for ADHD, he said.
"Those criteria didn't just pop out of our heads," he said. "There were a number of field trials during the late 1980s and 1990s to study the disorder. The criteria that were chosen are based on comprehensive research and data. The bottom line is that it was not done by the seat of our pants, but by evaluating data collected on large samples of children."
Diane Weaver Dunne
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