Is Ritalin Over prescribed?

Richard E. Ruhrold, Ph.D., HSPP

Vice President, Outpatient Managed Care

Rarely does a week go by that we don’t see or hear a news report about the use of Ritalin or other psycho stimulant drug in the treatment of disruptive behavior in children. While there indeed has been an increase in the use of Ritalin, is it really over prescribed? What does the evidence show?

Attention Deficit Hyperactivity Disorder (ADHD), characterized by impaired impulse control and developmental deficits in attention, persistence, motivation, and in the control physical activity (i.e. hyperactivity) is widespread among both children and adults. Consensus estimates are that 5%-7% of children and adolescents and 2 ½% to 3 ½ % of adults meet the diagnostic criteria for the disorder. That is about 10 to 20 million people in the United States. ADHD accounts for 30% to 40% of referrals of children and adolescents to behavioral healthcare providers.

In over 700 controlled research studies, it has been clearly demonstrated that psycho stimulants (Ritalin, Dexedrine, Adderall, Cylert), when used properly, are safe and effective in treating symptoms of ADHD. Medication has been shown to improve self-control, attention, learning, persistence, and to reduce excessive physical activity and emotional outbursts in appropriately diagnosed clients.

Psycho stimulants are the only medical consensus treatment that strikes at the heart of ADHD. They increase the level of activity in the frontal brain structures that mediate these key functions. Without such treatment, these structures remain under active and the client continues to struggle with impulsivity in general and the above-noted symptoms, in particular.

I suspect that some of the controversy in the use of these drugs stems from the observation that they are sometimes given to clients who have not undergone an adequate diagnostic assessment. A diagnosis of ADHD has not been well supported, and other issues affecting the patient have not been thoughtfully addressed. In short, there are persons taking psycho stimulants who probably should not be, and there are most certainly persons who are not taking them who would benefit from doing so.

At present about 2 ½ % of the child/adolescent population are taking psycho stimulants Comparing that figure to the rate of ADHD in the child/adolescent population (5% to 7%) reveals that they are not overused. It would be easier to argue that they are underutilized. This is even more apparent among adults. Data indicate that ½% of adults take psycho stimulants for treatment of ADHD. Compare this to the population rate of ADHD among adults (2 ½%), and we clearly see that this disorder is seriously under diagnosed and under treated among adults.

The American Medical Association (AMA) recently published a review of two decades of studies about the use of Ritalin (Goldman, L.S., et al. [1998], Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder in Children and Adolescents. Journal of the American Medical Association, 279, 1100-1107.) The article indicated that studies have found no evidence that doctors are over prescribing psycho stimulants to hyperactive and inattentive children.

As practitioners’ knowledge and diagnostic practices improve, we are likely to see an increase in the use of psycho stimulant drugs as ADHD is more consistently identified. This will be especially true among the adult population. It is only in recent years that we have widely acknowledged that ADHD continues to affect about 50% of sufferers into their adult years. Undiagnosed ADHD among adults contributes to diminished work productivity, continuing patterns of underachievement, and to a host of co-existing conditions such as depression, anxiety, explosive outbursts, and substance abuse.