Medications prescribed or continued in 80% of visits.
Office visits during 2012-2013 by children with a primary diagnosis of ADHD reached an annual average of 6.1 million, equating to a rate of 105 per 1,000 children ages 4 to 17, data from a large federal survey indicated.
The majority of these visits were not with a psychiatrist: 48% were performed by pediatricians and 12% by family practitioners. Only slightly more than a third of visits (36%) were with psychiatrists.
The rate was especially high among boys: 147 per 1,000 population, according to the analysis of data from the 2012-2013 National Ambulatory Medical Care Survey, reported in a National Center for Health Statistics databrief.
Girls had less than half that rate, at 62 per 1,000, according to investigators led by Michael Albert, MD, MPH, of the CDC.
These disparities persisted when broken down by age group: For children ages 4 to 12 years, there were 156 visits per 1,000 boys versus 59 visits per 1,000 girls, and for children ages 13 to 17, there were 130 visits per 1,000 boys compared with 67 visits per 1,000 girls.
Jeff Epstein, PhD, director of the Center for ADHD at Cincinnati Children’s Hospital in Ohio, who was not involved in the study, said the disparity may be due to the fact that boys with ADHD tend to display behaviors such as impulsivity, so they “are more likely to be referred for assessment and treatment.” In contrast, “girls with ADHD are more likely to just have problems with inattention.”
The low rate of psychiatrist involvement may be traced to unequal distribution of specialists around the country, Epstein suggested.
“In many regions of the U.S., particularly in rural areas, there is often decreased access to mental health specialists … Even in areas where mental health specialists, like psychiatrists, are available, it is often the case that these providers cannot support the demand. Hence, many children with ADHD rely on primary care pediatricians for ADHD care.”
Using ICD diagnoses codes, the researchers determined that about 29% of children who had ADHD office visits had any additional mental health disorder, including episodic mood disorder (7%); anxiety, dissociative, and somatoform disorder (7%); and disturbance of emotions specific to childhood and adolescence (4%).
Thomas Power, PhD, of Children’s Hospital of Philadelphia, who also wasn’t involved in the study, said this is likely an underestimate, given that most ADHD visits are not with psychiatrists, “who are more attuned to investigate other mental health comorbidities.”
When looking at the use of CNS stimulant medications, they found these drugs were mentioned — either provided, prescribed, or continued — at 80% of all visits.
The most commonly mentioned were methylphenidate (Ritalin, Concerta, Daytrana) or dexmethylphenidate (Focalin) at 47%, followed by amphetamine/dextroamphetamine combinations, at 13%.
Power noted that CNS medications are commonly prescribed because “they [have been] repeatedly demonstrated to manage symptoms of ADHD in children and adults. Overall, about 75-80% of children will respond to one or both classes of stimulants mentioned in the article.”
He noted that the disparity in use of the two classes of medications, methylphenidate and amphetamines, “is most likely a result of embedded prescribing patterns among physicians and marketing and does not reflect differences in effectiveness.”
If these medications are not effective, doctors will use second-line medications such as atomoxetine (Strattera), Power said, adding that non-pharmacological treatments such as behavioral therapy “can be used in combination with pharmacological treatments and even alone in milder cases of ADHD.”
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