HD12 - The Prevalence of Methylphenidate and Amphetamine Prescriptions in the Commonwealth
Following a recommendation of House Joint Resolution 660 (HJ 660) passed by the 2001 General Assembly, the 2002 Virginia General Assembly passed House Joint Resolution 122 (HJ 122) requesting the Virginia Department of Health (VDH) to examine the prevalence of methylphenidate and amphetamine prescriptions in the Commonwealth of Virginia.
Children in Virginia with Diagnosed Attention Deficit Hyperactivity Disorder
In 2001, the Virginia Department of Education (DOE) found that 1.5 percent of the student population took medication for Attention Deficit Hyperactivity Disorder (ADHD) at school.
The National Institutes of Mental Health (NIMH) estimates that 3-5 percent of school age children have ADHD which would translate to 44,253 to 73,755 school age children (ages 5-19) in Virginia based on the 2000 US Census.
Based on data voluntarily provided by the Virginia Association of Health Plans from five members, nearly 24,000 children had an ADHD diagnosis and the Virginia Department of Medical Assistance Services (DMAS) identified over 12,000 children with Medicaid fee for service claims with this disorder. The data are not representative of the whole state and describe only those groups examined. The proportion of children identified with ADHD within insured population groups ranged from 2 percent to 6.5 percent. Demographics of children in the Commonwealth identified with ADHD largely mirrored national patterns.
The Treatment of Attention Deficit Hyperactivity Disorder
Treatment modalities for ADHD include medication treatment and psychosocial interventions such as behavioral modification through parent and teacher training, counseling, and psychotherapy. Stimulant medication treatment has been found to be effective for up to 90 percent of children with ADHD according to studies such as the NIMH sponsored Multimodal Study (MTA). Although the proportion varies by study, roughly three-quarters of children with ADHD receive stimulant therapy.
While methylphenidate (MPH), also known through brand names Ritalin, Metadate, Methylin, and Concerta, remains the most common ingredient used, amphetamine prescriptions are quickly rising for ADHD treatment. Amphetamines (amphetamine salts, dextroamphetamine) used to treat ADHD include trade names Adderall, Dexedrine and Dextrostat. Following their introduction in the past few years, intermediate and long acting versions of stimulants, which are taken every 4-12 hours, are being prescribed most frequently. An additional 10-15 percent of ADHD patients are often treated with other Central Nervous System (CNS) medications such as antidepressants.
Trends in Stimulant Medication Treatment
Increases in stimulant medication use continue to be reported by numerous sources. It is estimated that 5.3 percent of children receive a psychoactive medication, including those used for ADHD. Combination therapies have also increased as has off label use of psychoactive medications and medication use for preschoolers.
Increases have been attributed to children taking medications for longer periods of time through adolescence, more preschoolers and females being diagnosed with ADHD, more adults being diagnosed and treated for ADHD, direct marketing to consumers, increased insurance coverage for visits and drugs, more available medications and wider acceptance of psychosocial medication use.
Methylphenidate And Amphetamine Use Among Children in Virginia
Based on a sample (n = 398,149) of prescription claims data, VDH estimates that 3 percent of children (ages 19 and under) had a prescription filled for a stimulant medication in 2001. In addition, VDH estimates that between 3-4 percent of children had prescriptions filled for medications often used to treat ADHD. This range nears national estimates, such as from the Medical Expenditure Panel Survey, which has shown 3.5 percent of children through age 20 to be taking these medications.
In addition, VDH estimates that less than one percent of children under age 6, between 5 to 6 percent of children ages 6-10, and between 4 to 5 percent of children ages 11-19 take medication for ADHD.
Less than five percent (4.8 percent) of medication patients were under age 6, 40.1 percent were ages 6-10, and 55.1 percent were ages 11-19. Seven out of ten (69.7 percent) patients were male. Regional variations were found with a low of 6.1 percent of ADHD medications out of all medications in Health Planning Region (HPR) 2 (Northern Virginia) up to a high of9.4 percent in HPR 5 (Tidewater).
Three quarters of children (76.1 percent) were taking stimulants only. An additional 10.9 percent were given stimulants plus another drug type, 16.4 percent received an antidepressant and 8.2 percent received clonidine (alone or in combination with other medications). Of all stimulant patients, 47.6 percent had taken an intermediate or long acting amphetamine and 40.8 percent had taken an intermediate or long acting methylphenidate. Less than one half of one percent (n= 83) of medications examined were for pemoline, a drug not currently recommended due to potential liver toxicity.
Virginia Association of Health Plans members providing data on insured groups had from 1.0 percent to 7.9 percent of their child members on ADHD medications.
Populations with Higher Prevalence of Attention Deficit Hyperactivity Disorder
Higher prevalence of ADHD was found among Department of Juvenile Justice admissions, children hospitalized for mental conditions, and children evaluated at VDH Child Development Clinics.
History of stimulant medication use was found in 37. 9 percent of males and 31.8 percent of females among 2001 Department of Juvenile Justice admissions through the Bon Air Diagnostic Center. These rates were triple those observed in 1993. Based on admitting evaluations, 23.9 percent of males and 25.6 percent of females met the Diagnostic and Statistical Manual 4th Edition (DSM IV) criteria for ADHD. Over two-thirds of admitted youth had unmet mental health treatment needs in 2001.
Admission for mental diseases and disorders was the second most common major diagnostic category for resident children ages 1-19 hospitalized in Virginia in 2001. Nearly a quarter (23.9 percent) of admissions related to mental diseases contained either a primary (3.3 percent) or secondary (20.6 percent) diagnosis of ADHD. Among all child hospitalizations, 4.7 percent had a primary or secondary diagnosis of ADHD.
ADHD occurred most frequently with oppositional defiant disorder, bipolar disease, and depression. Average costs for these hospitalizations with ADHD ranged from to $8,188 (primary) to $9,777 (secondary). A higher than average share of admissions (33 percent) with ADHD were under Medicaid.
Eleven Child Development Clinics (CDC) operated by VDH found that ADHD was the most common referral reason and diagnosis made between FY 98 and FY 02. One quarter of all patients had a primary ADHD diagnosis. CDCs diagnosed 405 children with ADHD in FY 02, a small fraction of the estimated cases in Virginia.
These data provide a snapshot about use of methylphenidates and amphetamines among children in Virginia, largely mirroring national trends. The data do not, however, answer questions about appropriateness of medication and/or diagnosis. This type of analysis would likely require longitudinal survey data from subjects, providers, parents and school personnel or other measures such as medical record review.
While the estimated use of methylphenidates and amphetamines among children in Virginia appears to fall within the national ranges according to pharmaceutical claims data, these data do not reflect the magnitude of increases which have taken place in the past two decades. Regional variances were also found in the data, lending some support to prior studies in the Tidewater area suggesting higher levels of ADHD medication use.
With greater use of intermediate and long acting medications, the proportion of children taking ADHD medication while at school will continue decreasing.
High-risk populations demonstrate consistently higher than average prevalence rates for ADHD. The burden from ADHD among these populations appears to be much greater and illustrates the need for early and accurate diagnosis and adequate mental health treatment.
Based on the analysis the following recommendations are made:
1.) Continue surveillance efforts, as resources allow, to monitor ADHD prevalence and medication treatment among children in Virginia through mechanisms such as the Behavioral Risk Factor Surveillance System annual survey sponsored by VDH.
2.) Continue to support the requirement that persons seeking licensure to teach in Virginia complete study in attention deficit disorder (§ 22.1-298).
3.) Continue to support Department of Education State Special Education Advisory Committee efforts to improve joint training of parents and school personnel and continue support of local parent resource centers, which offer information and may also offer training sessions on ADHD.
4.) Monitor community-based pilot efforts such as the Fairfax County Medical Society and Lee's Comer collaborative project between schools, parents, and providers; the Virginia Beach Public School system efforts to provide parent training on ADHD and behavior modification; and the Center for Pediatric Research's community-based ADHD study, which will provide further data on prevalence, risk factors, outcomes and possible management tools which could be replicated in other areas of the state.
5.) Provide training on the Bright Futures Mental Health Tool Kit, including the National Initiative for Children's Healthcare Quality ADHD tool kit, for school personnel, primary care providers and mental and behavioral health providers. Training would be provided under collaboration between DOE, VDH, VDMHMRSAS and the Virginia Chapter of the American Academy of Pediatrics as funding and resources allow.