CDC Report Points to Missed Opportunity in ADHD Care

Despite Recommendations, Young Children More Likely to Get Drugs Than Behavioral Therapy

May 25, 2016 01:50 pm Cindy Borgmeyer

More than 6 million children in the United States were reported by their parents to have been diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2011-2012, making it the most common neurodevelopmental disorder among those ages 4 to 17 years. These most recent figures represent a 42 percent rise in the prevalence of the condition since 2003, according to a 2014 article(www.jaacap.com) in the Journal of the American Academy of Child and Adolescent Psychiatry.

[Graph showing percentages of young children being treated for ADHD by treatment type]

Notably, more than half (53 percent) of children in that age range who are diagnosed with ADHD first receive that diagnosis(www.cdc.gov) from a primary care physician, followed by psychiatrists, psychologists and other physicians (e.g., neurologists) at 18 percent, 14 percent and 15 percent of cases, respectively.

Once an ADHD diagnosis is made, says a 2011 American Academy of Pediatrics (AAP) guideline that the AAFP endorsed, the first line of treatment for young children (preschool-aged) should be behavioral therapy administered by the child's parents. Physicians should resort to medication only if behavioral interventions fail to achieve significant improvement and patients continue to have moderate to severe functional impairment.

But all too often, that's not happening, say CDC officials in the most recent Vital Signs report.(www.cdc.gov) Rather than leveraging the opportunity to teach young children how to control their own behavior -- which has been shown to have lasting positive effects on how they function at school, at home and in relationships -- these children are more often being prescribed potent drugs to help reduce their impulsive behaviors in the short term.

Story Highlights
  • A new report from the CDC found that young children with attention-deficit/hyperactivity disorder (ADHD) are more likely to be prescribed drugs than behavior therapy for their condition -- despite recommendations to the contrary.
  • More than 6 million children in the United States have been diagnosed with the condition, according to their parents.
  • Use of behavior therapy for ADHD has been shown to have lasting beneficial effects on how these children function in school, at home and elsewhere.

In a May 3 telebriefing(www.cdc.gov) on the report, CDC Principal Deputy Director Anne Schuchat, M.D., laid out the agency's position on appropriate treatment of ADHD in young children.

"In this month's Vital Signs, we're drawing attention to behavior therapy, which is an important and recommended first step for young children with ADHD," said Schuchat. "Behavior therapy is a form of treatment in which parents learn specific ways to improve the behavior of their young child with ADHD.

"This treatment can work as well as medicine, and without the risk of side effects in young children," she added. "And research shows the benefits of behavior therapy can last for years."

Indeed, says a Morbidity and Mortality Weekly Report (MMWR) article(www.cdc.gov) released in conjunction with the Vital Signs report, nearly one-third of children ages 3-5 who take ADHD medication experience adverse effects, "most commonly appetite suppression and sleep problems, but also upper abdominal pain ('stomach ache'), emotional outbursts, irritability, lack of alertness, repetitive behaviors and thoughts, social withdrawal, and irritability when the medication wears off."

Titled "National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among Insured Children Aged 2-5 Years -- United States, 2008-2014," the MMWR report analyzed claims data from both employer-sponsored health plans and Medicaid to determine whether children were receiving clinical care for their condition, what type of care they received and whether the type of care varied by insurer.

The report's authors found that the overall percentage of children who received clinical care for ADHD increased over time. However, during 2008-2011, the percentage of Medicaid beneficiaries who received clinical care was double that of children with employer-sponsored insurance.

Furthermore, although percentages varied by state, no more than 55 percent of children with ADHD overall received psychological services each year, regardless of insurance type. By contrast, about three-fourths received medical therapy.

Perhaps most troubling, the use of psychological services to treat young children with ADHD, as recommended in the 2011 AAP guideline, did not increase after publication of that guidance. In fact, the percentage of children receiving this type of therapy decreased slightly, while the percentage of those being treated medically did not change.

"These data suggest we are missing opportunities for young children with ADHD to receive behavior therapy," Schuchat observed. "Increasing referrals and the availability of appropriate services could help many families with young children who have ADHD."

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, heartily agreed with Schuchat's assessment that more access to these services is an important part of reversing the trend toward greater medication use and its sequelae.

"I think that access to behavioral therapy is a big issue, especially in smaller communities," Frost told AAFP News. But even in larger cities, she added, it can take months to get an appointment with a behavioral therapist.

"It is a big challenge, and a reason why so many of these kiddos are on medications," Frost noted.

Family physicians may be able to get some help from the CDC website, which provides information about behavior therapy for ADHD,(www.cdc.gov) including resources to aid physicians and parents in locating therapists who offer this type of training.

Related AAFP News Coverage
AAFP Joins Diverse Coalition That Aims to Prevent ADHD Medication Misuse
CPAMM Focuses on Reaching College Students

(9/2/2014)

Analysis of Survey Results
Parent-reported Cases of ADHD on the Rise, But Treatment Still Lags

(1/8/2014)

More From AAFP
American Family Physician
AFP by Topic: Attention-Deficit/Hyperactivity Disorder

American Family Physician
Diagnosis and Management of ADHD in Children

(Oct. 1, 2014)


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