What percent of doctors have ADHD?
Nearly 50 percent of physicians believe diversion of ADHD stimulant medications among teens is a problem
Date: May 3, 2014 Source: North Shore-Long Island Jewish (LIJ) Health System Summary: Two recent studies examined physicians’ perceptions and knowledge of diversion of stimulant medications for Attention Deficit Hyperactivity Disorder as well as practices physicians use to prevent diversion among their patients prescribed these medications. Share:
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Two recent studies by investigators at the Cohen Children’s Medical Center of New York examined physicians’ perceptions and knowledge of diversion of stimulant medications for Attention Deficit Hyperactivity Disorder (ADHD) as well as practices physicians use to prevent diversion among their patients prescribed these medications.
The results showed that while almost half of all physicians surveyed believe diversion is common among teens with ADHD, the majority never received training on the topic. Furthermore, about one-third of physicians rarely counsel teens about the health and legal consequences of diverting stimulating medication and don’t feel qualified to do so.
«Diversion of stimulation medications for ADHD by high school and college students is widespread as those with ADHD are often sharing pills with their peers, who don’t have the condition, to try to improve their academic performance,» said Andrew Adesman, MD, senior investigator and chief of developmental behavioral pediatrics at Cohen Children’s Medical Center of New York. «Many pediatric colleagues don’t feel adequate in counseling their ADHD patients about diverting stimulant medications or are unfamiliar with some of the legal and health consequences of non-ADHD patients taking an unprescribed controlled substance.» The survey analyzed responses from 815 physicians who specialize in ADHD — child neurologists, child psychiatrists and developmental pediatricians. In the past 12 months, 59 percent of physicians suspected some of their teen ADHD patients were diverting their medications and 54 percent believed some patients were exaggerating symptoms to obtain stimulation medications to divert. When evaluating teens for an initial diagnosis of ADHD, 66 percent of doctors suspected that some patients were trying to obtain stimulant medication to improve academic performance. Surveyed doctors also believed patients wanted the medication to either lose weight (40 percent), get high (38 percent) or divert their stimulant medication to others (39 percent).
The study also showed that the majority of physicians received no training on prevention of prescription drug diversion in medical school (73 percent), residency (57 percent) or fellowship (51 percent).
When physicians were asked if there is a difference in the legal consequence of selling vs. giving away stimulant medication, 19 percent chose the wrong answer and 36 percent were unsure.
Dr. Adesman said that «in the eyes of the law, there is no difference between someone giving away a pill or selling one; they are both prosecuted as unlawful distribution of a controlled substance.»
As far as health risks, he also noted that, «A patient taking an ADHD medication has been titrated up to a certain dose over time. If someone else takes another person’s dose it can be risky because there is no health history and medication naiveté can lead to potential risks, especially if there is an underlying heart condition.
«While many prevention strategies can be used to prevent diversion of stimulant medication- informational brochures, a medication contract, pill counts, limiting pill quantities, counseling and other methods, our research showed that while doctors are encouraged to use many of these strategies, most MDs don’t believe the strategies to be effective,» Dr. Adesman said. «It is important that physicians treating patients with ADHD are continually educated about stimulant diversion problems and become active in mitigating this from happening.»
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OHSU researchers sharpen estimate of true percentage of people with ADHD
A study led by OHSU researchers in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) found that more than half of children with ADHD had a co-occurring mental disorder. (Getty Images)
Researchers at Oregon Health & Science University estimate the true percentage of people with Attention-Deficit/Hyperactivity Disorder, or ADHD, in the United States is approximately 3.5% of the population — substantially lower than many common estimates.
The study, published this month in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), also found that more than half of children with ADHD had a co-occurring mental disorder.
Many previous reports on the frequency, or prevalence, of ADHD have highlighted national survey-based estimates of 8% to 10%, whereas other scientific studies that use sophisticated modeling support the 3% to 5% range. These variations in estimates are believed to be largely due to differences in how ADHD is defined. OHSU’s research aimed to inform the development of more accurate diagnostic criteria so researchers can effectively study the scientific causes of ADHD.
Joel Nigg, Ph.D. (OHSU)
“This research is significant because it underscores the need for neurobiological research using a multi-method way of defining ADHD, which is something that was unclear before,” said Joel Nigg, Ph.D., director of the OHSU Center for ADHD Research, who led the study. “It also demonstrates that many children presenting with what appears to be ADHD, while really in need of care, may not have neurobiologically characterized ADHD but another form of ADHD or some other condition. This opens the door to ask why, and to consider multiple kinds of ADHD.
“Our hope at our center is that an expanded understanding of ADHD will sharpen the effectiveness of our science and ultimately accelerate progress on causes and treatments,” added Nigg, who also is a professor of psychiatry (clinical psychology) in the OHSU School Medicine.
In the study, researchers at OHSU Center for ADHD Research and the University of Minnesota Masonic Institute for the Developing Brain were able to employ a strict definition of ADHD by leveraging the Adolescent Brain Cognitive Development Study, or ABCD, dataset — a groundbreaking study of nearly 12,000 children, ages 9 and 10, that is mapping behavioral, social and brain development over a 10-year period. Access to this dataset provided researchers the opportunity to use a nationwide sample to estimate the frequency of ADHD and correlations with clinical, neurocognitive and genetic measures.
The authors used four tiers to phenotypically define ADHD, meaning they identified the physical or biochemical characteristics that are influenced by both genetic makeup and environment. Tier 1 is the least strict and Tier 4 the strictest. Tier 1 relies on a single informant’s report on one measure, while Tier 4 relies on multiple informants on multiple measures. The study found that when using this stricter definition, the frequency of ADHD is estimated to be 3.53%, of which two-thirds are male. It also confirmed that ADHD often presents with other psychiatric symptoms and conditions.
When using the stricter, Tier 4 definition, ADHD was strongly correlated with irritability, disruptive behavior and difficulty with concentration and executive functioning. A majority of those individuals identified as having ADHD also had co-occurring conditions such as an anxiety, mood or behavior disorder.
While the study provided key epidemiological and clinical analysis, it was not able to conclusively address questions about the potential variation in ADHD frequency and characteristics among racial and ethnic groups, which Nigg and his team say should be a priority in future research efforts. The children in the ABCD study are being followed by a national consortium over a 10-year period, which will provide the team of researchers the opportunity to track long-term change and stability in ADHD.
Funding for this project was provided by the National Science Foundation Graduate Research Fellowship Program 2020239717 (Cordova) and the National Institutes of Health (NIH) grant R37-MH59105 (Nigg)
Adults who claim to have ADHD? 1 in 4 may be faking it
Amid what some claim is a growing epidemic of ADHD diagnoses, a study finds that almost one in four adults who show up in doctors’ offices seeking treatment may be exaggerating — or even faking — their symptoms.
Twenty-two percent of adults in the study who claimed they suffered from attention-deficit/hyperactivity disorder tried to skew test results to make their symptoms look worse, according to a new report based on the medical records of 268 patients and published in the journal The Clinical Neuropsychologist.
Some of those who exaggerated their symptoms actually had ADHD, but embellished their reports to ensure they got diagnosed, said the study’s lead author, Paul Marshall, a clinical neuropsychologist with Hennepin Faculty Associates, a medical group that provides services at Hennepin County Medical Center in Minneapolis.Others didn’t have the disorder at all, but were having a tough time dealing with their workloads and lives.
«A lot of people think they have it because they are struggling, but it’s not because of ADHD,» Marshall said. «Often times, it’s simply depression, anxiety or lack of sleep.»
Other patients may have been faking symptoms to get access to stimulant medications, Marshall said. In some cases, college and graduate school students want to be diagnosed with ADHD in hopes of gaining access to medications that boost concentration and focus, as well as accommodations such as longer times for tests, he added.
And some just want the meds for an inexpensive high, Marshall said.
In poll, doctors suspect faking
Marshall’s findings dovetail with an informal poll of 100 primary care physicians conducted by the group Truth On Call for msnbc.com.
Responding to the text message survey, 38 percent of doctors said they suspected a patient of exaggerating or faking symptoms to get a prescription for ADHD drugs.
Some said that a red flag would go up when patients got the symptoms right, but seemed to be exaggerating their severity.
“I had a patient who was prescribed Adderall by another doctor,” one physician wrote. “I asked her [for] her medical history pertaining to ADD. She explained how she had difficulty concentrating at home and how the meds had helped her maintain the A grades she had been having all along.”
In the United States, between 2 percent and 4 percent of the adult population is estimated to have ADHD, or 4 million to 8 million people, health experts say. Many adults are first diagnosed as children, with up to 60 percent continuing symptoms into later life. About 5.4 million children ages 4 to 17 have ever been diagnosed with ADHD, according to the Centers for Disease Control and Prevention.
But because there is no real test for ADHD, it can be tricky to diagnose the condition in adults, said Dr. L. Eugene Arnold, an ADHD expert unaffiliated with the new report and a professor emeritus of psychiatry at Ohio State University. When it comes to children you have to have two sources — generally parents and teachers — to make a diagnosis. In adults, you just have the patient’s word, he said.
Questionnaires reveal exaggeration
To get an idea of how many people might be trying to game the system to get drugs and other benefits, Marshall and his colleagues scrutinized patient interviews and questionnaires. The questionnaires came with an extra bit of information. Embedded throughout were little tests designed to ferret out people who might be cheating or exaggerating their symptoms.
Ultimately, Marshall and his colleagues found patients who not only exaggerated their symptoms but also scored much more poorly on the embedded tests than people with actual ADHD symptoms would have.
A doctor in the Truth On Call poll summarized the fakers like this:
“Patients try to describe typical symptoms with a request for specific ADHD drugs. With standard symptom questionnaires, they will push the responses to the extreme and try to request specific medications when prescribed alternatives.”
Why would someone want ADHD medications so badly?
“There are big cultural pressures to get these drugs,” said Dr. Anjan Chatterjee, a professor of neurology at the University of Pennsylvania. “That’s because everyone is in an arms race of accomplishment.”
People want the drugs to get an extra edge, Chatterjee said. Just as athletes have sought out steroids, students — especially those at competitive colleges and graduate schools — try to enhance academic performance with drugs like Ritalin and Adderall.
The medications appear to work by stimulating the brain, boosting levels of dopamine and norepinephrine, chemicals associated with attention and behavior, according to the National Institute on Drug Abuse. In people with ADHD, these drugs have a calming effect. However, in people without the disorder, the drugs can be dangerous.
Chatterjee and others are at the forefront of a new field called cosmetic pharmacology, which studies people who take medications not to treat illness, but rather to improve performance.
“As best as we can tell from survey data, there’s a fairly large number of students who are getting Ritalin and Adderall from underground markets at college campuses,” Chatterjee said.
Worrisome trend, experts say
There are several downsides to the trend, not the least of which is that people who actually do have ADHD may encounter difficulty finding treatment as doctors become increasingly suspicious, Arnold said.
Another important issue is the possibility of addiction, said Dr. Karen Miotto, director of the University of California, Los Angeles, Alcoholism and Addiction Medicine Service.
“I see the most tragic cases,” Miotto said. “For example, there was a woman I saw who had been in medical school. She started misusing Adderall, and then she started needing more and more. Then she started doctor-shopping to get more medication.”
Eventually the woman became dependent on the drugs and flunked out of med school.
“She said she was just trying to do better in school,” Miotto said. “Just trying to keep up. There’s a point in time where you need to come to terms with things. I said, ‘Honey, this isn’t about medical school anymore. Now you have a serious illness — it’s called addiction.»’
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