Pediatricians and Subspecialists May Need to Up Their ADHD Game

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.

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.

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.”