When Is Enough Enough? ADHD and Overprescribing

George Fouras, MD

In a previous article regarding Attention Deficit Hyperactivity Disorder (ADHD), I made the assertion that medications may be either overprescribed, appropriate or underprescribed based on numerous personal and social factors. The focus of this article will be on the concept of medication-predominantly psychostimulants-being overprescribed for children and adolescents in this country.

To be sure, there is no available data that, in fact, medications are being overprescribed, which implies a situation of inappropriateness. This past year, there has been a large increase in media attention regarding psychotropic medication prescriptions in general for children. Perhaps the most significant article on this topic occurred with the JAMA article by Zito, et al, which noted a roughly three-fold increase in methylphenidate use from 1991 to 1995 in both the public and private sector in the 2-4 year-old-population. What is happening? Why such a huge increase? Could we, indeed, be seeing the overprescribing of medications for ADHD and, thus, inappropriate treatment of our youth?

Assessment is Key to Proper Diagnosis

At the very core of this issue is the assessment of the patient. A thorough evaluation should be conducted using the biopsychosocial model. This requires an interview of not only the child, but also the caretakers and important people in the child's life such as teachers or therapists. A physical exam with appropriate lab studies are also needed. Finally, in most cases, some form of objective testing is also useful. Needless to say, this type of evaluation may take several hours to perform and collate into a meaningful differential diagnosis. The diagnosis itself should be based on scientifically grounded criteria, such as the DSM IV. The diagnosis is made based on criteria that have been grouped into inattention and hyperactivity impulsivity categories.

In addition, there must be functional impairment in two or more settings. Some symptoms must be present before the age of seven and, finally, there are exclusion criteria, so that a diagnosis can not be made if another diagnosis can account for the symptoms. The resulting differential can include such disparate diagnoses such as: bipolar disorder, conduct disorder, specific learning disability, anxiety, hyperthyroidism, intracranial disease (either infectious or neoplastic), or boredom from lack of academic challenge.

From the differential, one can surmise that the evaluation for ADHD can be tedious. Most physicians do not have the time in their schedule to conduct such an interview, and often have to rely on other professionals to gather the necessary information. Or, the physician is simply not reimbursed for the time it takes to perform the evaluation. As a result, there is pressure for the physician to make a decision based on minimal information. Another factor that may contribute to the phenomenon of overprescription is that there is a subtle pressure that is applied to physicians to "do something."

For example, how many physicians prescribe an antibiotic for a viral syndrome? Patients may feel that the visit to the physician was a waste of time if they do not leave with a prescription in hand. In addition, most people wait until their situations have gotten out of hand or when they are in crisis, thus hoping to find a quick fix. Physicians, who I believe are kind at heart, empathize with the need and try hard to accommodate the patient even though they know it may not be the best choice. It is hard for anyone to say no.

There is also subtle pressure from third party payers, who will not reimburse for the time needed to complete a thorough evaluation. Nor will they often pay for the psychological testing that is required, nor will they pay for behavioral therapy interventions. It seems that only medication management meets their idea of "medically necessary" intervention.

Arguably, one of the most pernicious forces that may be contributing to the situation is that of our schools. Of course, complex problems rarely have simple solutions. But can anyone not argue that our schools have been grossly mismanaged? They are overcrowded, lack sufficient, well-trained staff, and lack appropriate resources to meet the challenges presented by our modern society. It is amazing to me that with a simple signature on a form, a child can be expelled from school-usually in one day. When I went to school, this was a major event requiring a hearing before the school board. And where is this child to go? Ladies and gentlemen, we now have the situation of musical schools instead of musical chairs! While schools are often the venue where behavior problems manifest themselves-and the schools acknowledge that there are mental health issues with a number of their pupils-the level of resistance to collaborating with community mental health services is alarming. So what is their solution? Medication. It's quick. It's efficient. For example, I was asked to evaluate a child that the school had suspended because of his behavior. He was told not to return unless he was on medication. Gee, I thought I was the MD?

Social factors also play a role. The use of illicit drugs and alcohol during pregnancy continues to be a major public health problem. We are only beginning to explore how these chemicals affect the developing brain. Is it possible that drugs, such as cocaine, may induce changes which present as ADHD later in life? It is interesting to note that both cocaine and psychostimulants have dopaminergic activity and I wonder if there is a correlation. Strictly speculation on my part.

I will leave you with one final thought. What is overprescribing? How do we even know whether it is occurring, when we are not even sure of the prevalence rates? Could the prevalence rates be changing over time, given factors such as drug use in pregnancy? Are we getting better at recognizing the syndrome and thus improving access to treatment? We do know that rates of medication use are increasing. But is this wrong? The best thing for physicians to do is to return to what we know.

The concept of overprescribing refers to the masses. We must focus on the individual. Resist the urge to perform a cursory exam. Keep an open mind. Apply our training and knowledge to the facts and derive a logical conclusion. Seek consultation when we have doubts. Be open to the possibility that we are wrong. Educate our patients and society as to what is happening and why we practice as we do. If we strive to hone our skills of diagnosis and treatment, then overprescribing will become what it should be. . . an interesting philosophical topic.

Dr. Fouras is a child psychiatrist and medical director of the Foster Care Mental Health Program (FCMHP), a city/county community mental health agency. He is a member of the SFMS Psychiatric Services Committee and is an alternate delegate to the California Medical Association. Dr. Fouras also chairs the Child and Adolescent committee for the California Psychiatric Assoc.

Resources:

1. Zito, J., Safer, D., dosReis, S., etal. "Trends in the Prescribing of Psychotropic Medications in Preschoolers" JAMA, Vol 283(8), p. 1025-30
2. DSM-IV, American Psychiatric Assoc., Washington, DC 1994. Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults With Attention-Deficit/ Hyperactivity Disorder, J. Am. Acad. Child Adolescent Psychiatry 36(10) supplement. Oct. 1997.