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Pediatricians and Subspecialists May Need to Up Their ADHD Game

October 20, 2016
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From sixth to eighth grade, Stacy Gibson sought out kids he knew had attention-deficit/hyperactivity disorder and bought their Ritalin or Adderall, sometimes by the handful.

“I would party all night,then I’d take the pills to get through class. It gave me a rush of energy that I needed,” says Gibson, now 32 and in his first semester at Columbus State Community College. A former patient at Maryhaven treatment center, he’s in a 12-step program to maintain sobriety.

In his small hometown of Jackson, Ohio, some kids feigned symptoms and got prescriptions. “They’d go into the doctor’s office and give this story like, ‘Oh I do 10 jobs and don’t finish one. I can’t concentrate,'” Gibson says.  “You just have to learn the characteristics of the disorder.”

While college students have made headlines for widely using ADHD stimulants as study drugs, troubles managing the disorder in school-age children and preschoolers and safeguarding them from overmedication and drug misuse are becoming more evident.

A Wide-Spread Problem

Recent studies and annual surveys found that from 5 to 9 percent of grade school and high school students misused ADHD stimulants during the past year and that amphetamine misuse has been prevalent for decades. Children and adolescents with prescriptions are commonly approached to share, sell or trade their drugs and as many as 26 percent did.

Minnesota researchers found one in five adults feigned symptoms to obtain prescriptions and suggest adolescents may be doing the same. Reports indicate that adolescents, like college students, primarily seek pills to boost grades.

"Unfortunately, it seems like some physicians aren't aware that diversion and misuse of these stimulant medications is a common practice, and probably need to be more vigilant when working with teens to try to prevent this behavior." – Sarah Keim, PhD

“Unfortunately, it seems like some physicians aren’t aware that diversion and misuse of these stimulant medications is a common practice, and probably need to be more vigilant when working with teens to try to prevent this behavior,” says Sarah Keim, PhD, an epidemiologist and principal investigator in the Center for Biobehavioral Health at The Research Institute at Nationwide Children’s Hospital.

In a 2016 national study, Dr. Keim and colleagues asked 826 developmental and behavioral pediatricians, child and adolescent psychiatrists and child neurologists, about their suspicions of diversion and misuse by teens prescribed ADHD medications. They found 59 percent of the subspecialists suspected one or more of their patients were diverting stimulants, 74 percent believed one or more patients had feigned symptoms to obtain medications and 66 percent believed one or more patients wanted stimulants to improve academic performance.

“Diversion, misuse and lack of awareness are real problems,” says Andrew Adesman, MD, chief of Developmental and Behavioral Pediatrics at the Cohen Children’s Medical Center of New York, and study co-author. “Children or adolescents who take stimulant medications as ‘study pills’ or otherwise misuse them definitely put themselves at risk in terms of their health. Cardiac arrhythmias are one of the biggest concerns. There are also risks of dependence.”

The federal government classifies ADHD amphetamines such as Adderall or longer lasting Vyvanse, and methylphenidate, sold as Ritalin or longer lasting Concerta, in the same category as cocaine and opium due to their similar potential for misuse and dependency.

When misused, the stimulants can increase the risk of addiction, lead to malnutrition and slowed growth, paranoia and, at high doses, stroke, the National Institute on Drug Abuse (NIDA) says. Using the drugs without a prescription and sharing or selling pills legally obtained are crimes with legal consequences.

Changing Reasons for Abuse

Amphetamines have a history of abuse and dependency going back to World War II, when pilots were issued pills to stay alert.

At Maryhaven, “adolescents have reported the misuse of Adderall to improve high school performance back to 2004,” says Shawn Holt, president and CEO of the center.

“To get into college… it’s all about the scores and the kids are aware of that,” Holt explains. “Taking a pill to stay up all night and which sharpens your focus—it’s an easy thing to do to try to keep yourself competitive and it’s easy to get your hands on.”

During the last 15 years, drug companies developed longer lasting ADHD stimulants that limit the euphoria users feel, says Daniel Coury, MD, chief of the Section of Developmental and Behavioral Pediatrics at Nationwide Children’s.  But “the dynamic has changed from ‘I want to get high’ to ‘I want an edge to study and concentrate to do better on a test.'”

The trend appears to be growing among teens at elite high schools across the United States, The New York Times has reported. Students trying to get into top colleges used ADHD stimulants to power through long nights of studying, keep up with extracurricular activities and increase focus while taking college entrance exams. They found it easy to buy the drugs from others or feign symptoms to get prescriptions.

NIDA warns that the belief stimulants can improve a person’s ability to learn has become widespread among adolescents, despite studies showing students who misuse the drugs have lower grade point averages than those who don’t.

“For those with ADHD, the change in their abilities to concentrate and improve their grades is significant,” said Steve Matson, MD, chief of Adolescent Medicine at Nationwide Children’s. “For those who don’t need the medications, the stimulants may assist with cramming for tests or helping them focus during exams.”

Misuse of ADHD stimulants for athletics is less well-studied but is occurring, says Chris Stankovich, PhD, a professional sports counselor and adjunct professor of sport psychology at Ohio Dominican University and Wittenberg University.

"Probably 75 percent or more of the junior high and high school boys come in already on an ADHD stimulant medication. I see it year in, year out." – Chris Stankovich, PhD

Professionals to junior high athletes he counsels have told him they purposely seek and use the drugs to enhance their performance, he says.  “They are candid…It’s remarkably easy for them to get. And I do believe it does provide a distinct competitive advantage.”

“Probably 75 percent or more of the junior high and high school boys come in already on an ADHD stimulant medication,” Dr. Stankovich says. “I see it year in, year out.”

Most troubling, he says, is that the majority of the student athletes or their parents simply told their pediatrician or family doctor they needed help with their focus and got a prescription for Adderall or Vyvanse or another ADHD medication they’d seen on television and requested.

Increasing Diagnoses, Prescriptions

The number of children diagnosed with ADHD and on medication is growing. While some mental health and health care professionals say these are signs the health care system is doing a better job recognizing and treating the disorder, Dr. Stankovich is among those who believe the definition of ADHD has become too loose, children are being overdiagnosed and too many are prescribed medicines.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which broadened the definition of the disorder in a 2013 update, maintains that 5 percent of children have ADHD while some community studies estimate up to 8 percent.

A 2011 National Survey of Children’s Health, however, shows that parents reported 11 percent of school-age children had ever been diagnosed with ADHD by a health care provider, up from 7.8 percent — or 2 million — in 2003. The figure includes one of every five high school boys. Those taking ADHD medications grew to 6.1 percent in 2011 from 4.8 percent in 2003, a 28 percent increase.

In the past, most pediatricians wouldn’t diagnose kids before they’d begun elementary school. Then, a 2006 National Institutes of Mental Health-funded study concluded that preschoolers with ADHD benefit from methylphenidate. Today, 2 million of the 6 million children with the disorder in the U.S. were diagnosed at ages 2 to 5, the CDC says.

Although the AAP recommends preschool children be placed in behavioral therapy first, less than half are, the CDC reported this year. Three out of four of the youngsters were given drug treatment.

To help physicians diagnose and manage ADHD, the AAP updated consensus guidelines for evidence-based care in 2011. But a 2016 study of 188 pediatricians at 50 community-based practices in Ohio found the physicians fail to consistently adhere to the recommendations.

The guidelines say physicians should include standardized feedback, or questionnaires,from parents and teachers when making the diagnosis of  ADHD, then monitor their progress once they’re on medication.

“During the diagnostic process,  this was really only done about 50 percent of the time,” says Rebecca Baum, MD, a developmental behavioral pediatrician at Nationwide Children’s and study author. “And for monitoring progress once a patient is on medications, only 10 percent of the time.”

The researchers also found the DSM-5 criteria for diagnosis and treatment monitoring were underused and too few children diagnosed with ADHD were receiving psychosocial counseling.

“There really is a lot of room to improve,” Dr. Baum says.

Improvements Start Here

Dr. Adesman says protection against diversion and misuse starts in the doctor’s office.

“Health care providers should repeatedly counsel their patients that these medications pose potentially serious health risks to those who take these medications illicitly and they also pose a potentially profound legal risk to the patient who elects to give or sell their medication to others,” Dr. Adesman says. “Doctors should assess illicit drug use in their patients, should monitor for irregularities in the need for prescription refills and should consider prescribing either stimulant medications that have less misuse potential and/or non-stimulant medications for their ADHD patients about whom they have concerns.”

"At most high schools, kids tend to know who is on these medications. Teens shouldn't manage their own stimulant medications. Parents should give them one long-lasting pill per day and keep the rest out of reach. Otherwise, there's too much temptation for the kid and too much peer pressure." – Steve Matson, MD

“At most high schools, kids tend to know who is on these medications,” Dr. Matson says.”Teens shouldn’t manage their own stimulant medications. Parents should give them one long-lasting pill per day and keep the rest out of reach. Otherwise, there’s too much temptation for the kid and too much peer pressure.”

Dr. Stankovich suggests that beyond following the AAP guidelines, an evaluation by a mental health professional should be included before issuing an ADHD diagnosis.

In a follow-up study, Dr. Baum and colleagues addressed the lack of standardized input from parents and teachers by providing pediatricians quality improvement training and a web portal parents and teachers could use to complete questionnaires.

“The result,” Dr. Baum says, “was the completion of more questionnaires and improved outcomes for kids.”

 

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