Over-prescribed ADHD

ADHD specialists not following clinical guidelines for preschoolers

/ Author:  / Reviewed by: Chris Galloway, M.D.

(RxWiki News) Clinical guidelines recommend treating preschool aged kids that have ADHD with behavioral therapy before trying medication. But few doctors may be following these guidelines.

In a recent study, researchers asked pediatric specialists how they approached treating attention deficit/hyperactivity disorder (ADHD) in preschool children.

The vast majority of the specialists did not follow the American Academy of Pediatrics clinical guidelines that recommend behavioral therapy before prescribing medication.

"Talk to a therapist about behavioral modification therapy."

Researchers from the Cohen Children’s Medical Center of New York, led by Jaeah Chung, MD, presented research results at the American Academy of Pediatrics annual conference on the prescribing practices of healthcare specialists for preschool aged children with ADHD.

The American Academy of Pediatrics has a set of clinical guidelines for healthcare professionals to follow when prescribing medications to manage ADHD in preschool-aged children.

According to the study authors, current clinical guidelines recommend that preschoolers with ADHD generally be treated with behavioral modification therapy before medication. As a secondary line of treatment, the guidelines recommend that the first medication prescribed should be methylphenidate, brand name Ritalin.

For this study, the researchers set out to investigate whether healthcare professionals follow those guidelines when prescribing medications.

The researchers sent surveys to a random sample of 3,000 pediatric specialists to ask questions about their treatment practices. Only 714 of the surveys were filled out and only 560 were completed by board-certified pediatricians or child psychiatrists.

Out of these 560 specialists, 322 were developmental behavioral pediatricians, 170 were child psychiatrists and 68 were child neurologists.

A total of 21 percent said they prescribed medication first and 70 percent said they prescribed both medication and behavioral therapy first.

Of the doctors that prescribed medication as the first or secondary form of treatment, 38 percent said they started patients with something other than methylphenidate.

Half of those doctors said they prescribed amphetamines and half said they prescribed non-stimulants.

About 91 percent of doctors said they “often or very often” recommended behavioral modification therapy at all.

No significant differences were found among prescribing patterns between specialties or between doctors who treated primarily Medicaid or privately insured patients.

While the researchers defined the American Academy of Pediatrics guidelines as behavioral modification without medication as the first line of treatment and medication therapy specifically with methylphenidate as the second line of treatment, only 12 percent of child psychiatrists, 8 percent of developmental behavioral pediatricians and 9 percent of child neurologists followed the guidelines.

Nearly one in five (19 percent) of the doctors said they expected a future increase in the number of children that they will prescribe medication to.

“It is unclear why so many physicians who specialize in the management of ADHD—child neurologists, psychiatrists and developmental pediatricians—fail to comply with recently published treatment guidelines,” said Andrew Adesman, MD, senior investigator involved with the study.

“At a time when there are public and professional concerns about over-medication of young children with ADHD, it seems that many medical specialists are recommending medication as part of their initial treatment plan for these children,” said Dr. Chung.

The diagnosis of ADHD in children less than 6 years of age is difficult to make since the usual symptoms associated with the diagnosis are often seen in children without the disorder but may have slightly delayed development. Furthermore the symptoms often overlap with other disorders such as anxiety and pervasive developmental delay," Dr. Thomas Seman told dailyRx.

"Many pediatricians and family practice primary care physicians do not handle this in their office and therefore rely on the psychiatrist and mental health providers to help them out. Their expertise generally over runs their schedules and they try to do their best. They are pressed for time and therefore jump straight to the next phase. As a primary care physician we always try to find a common denominator and therefore will often try behavioral therapy before trying to use drugs," Dr. Seman continued. 

"In regards to what they choose, for a while there was no good form of methylphenidate that could be used in children who did not swallow pills, so the other forms of medications were used. This "habit" then perpetuates itself most likely not purposely or to necessarily rebuke the studies," said Dr. Seman, who was not involved with this study.

Methylphenidate is available in generic form and costs vary based on dosage. A one-month supply for the generic without insurance coverage could run around $100. Therapy sessions vary based on insurance coverage and provider. One session could run around $100 to $150 without insurance coverage.

This research was presented at the Pediatric Academic Societies annual meeting held in Washington, D.C. May 4-7, 2013. This study has not yet been published in a peer-reviewed journal.

Reviewed by: 
Review Date: 
May 3, 2013
Last Updated:
November 4, 2013