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PEDIATRICS Vol. 106 No. 3 September 2000, pp. 533-539
From the * Departments of Psychiatry and Pediatrics, Johns Hopkins
Medical Institutions, and the Maryland State Department of
Education, Baltimore, Maryland.
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ABSTRACT |
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Abstract
Methods
Results
Discussion
Conclusion
References
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Objective. A statewide school survey was performed to provide naturalistic data on the prevalence of medication administered to Maryland public school students for the treatment of attention deficit hyperactivity disorder (ADHD) to clarify the concern of some state legislators about stimulant treatment for youths.
Methods. In April 1998, school nurses supervised a survey of all Maryland public school students medicated during school hours for ADHD. The data collected on these students included: type of medication administered, gender, school level, race/ethnicity, special education and Section 504 status, and the specialist of the prescriber.
Results. Of the 816 465 students surveyed, 20 050 (2.46%) received methylphenidate and 3721 (0.46%) received other medications for ADHD. Other major findings were: 1) methylphenidate constituted 84% of all the medication administered for ADHD; 2) the male:female ratio of the medication's recipients was 3.5:1 and 4.3:1 in elementary and secondary school, respectively; 3) black and Hispanic students received methylphenidate at approximately half the rate of their white counterparts; 4) 45% of all students receiving methylphenidate had special education status and an additional 8% had Section 504 status; and 5) nurse practitioners were the prescribers of 3% of the methylphenidate prescribed to Maryland students.
Conclusions. This large, population-based, point prevalence study of medication administered to students for ADHD adds new and updated findings on prevalence variations, rates for minority and special education/Section 504 students, and specialty prescriber rates. Key words: attention deficit hyperactivity disorder, methylphenidate, stimulant medication, pharmacoepidemiology.
In 1997, the Maryland General Assembly passed House Bill
971, which created a task force to "study the uses of methylphenidate and other drugs on school children." One charge of the task force was
to "determine the prevalence of use of methylphenidate among school-aged children in the state." The responsibility for carrying out this school survey was given to the Maryland State Department of
Education, which assigned school nurses within each of the state's 24 school districts to supervise the completion of a comprehensive survey
on all public school students recorded as receiving medication for
attention deficit hyperactivity disorder (ADHD) during school hours.
The model for this prevalence study was the biennial survey used in
Baltimore County, Maryland from 1971 through 1997 to record medication
treatment patterns for students with ADHD.1,2 That survey
was modified in this instance to include only public school students
administered medication for ADHD during school hours. Furthermore, some
additional information was requested. When finalized, the requested
student data included, in addition to the name of the
school-administered medication, the following: gender, race/ethnicity,
school level, and special education and Section 504 status. The
specialty of the medication prescriber was also recorded.
The sociodemographic factors included in this medication survey
were viewed as at least as important the total prevalence. Recent
studies of US youths have revealed that drug treatment prevalence for
ADHD varies substantially in relation to: 1) the child's
characteristics: age, gender, comorbid disorders,
socioeconomic status, race/ethnicity, special education or
regular education status 2) treatment factors: physician
specialty, medical payment source 3) temporal factors: duration
of the reporting period, year of the study 4) societal factors:
adverse or positive media influences, geographic area, pharmaceutical
promotion, and 5) changing diagnostic boundaries: the expansion
of the category of hyperkinesis/attention deficit disorder
(ADD)/ADHD which began in 1980.1 Consequently,
total medication prevalence and differences by subpopulation
are detailed and discussed herein and are related to the findings of
previous surveys.
The Maryland State Department of Education, under legislative
mandate, contacted all school districts in the state (n = 24) and instructed school nurses in each district to obtain complete information on students who, during school hours, were
receiving methylphenidate or other medications for the treatment of
ADHD. The recording of medications other than methylphenidate for the treatment of ADHD was listed separately on the survey form so that it
is possible In the 24 jurisdictions of the state, school health suites are managed
by registered nurses, licensed practical nurses, and/or health
aides In the statewide survey of students administered medication treatment
for ADHD, .3% were uncoded (missing) for special education status,
.6% were uncoded for race/ethnicity, and the prescribing provider
specialty was not known in 6.4%. In Maryland State Department of
Education enrollment data, 1.6% of students were not assigned to
specific grade levels. School enrollment in Maryland public schools was
obtained from the Maryland State Department of Education figures for
September and December 1997.
The data were analyzed using primarily descriptive statistics and a
nonparametric test. The data were collected in summary form, which did
not permit the use of multivariate techniques. Individual
school district rate differences in student medication treatment for ADHD were evaluated in relation to school district student race/ethnicity patterns and in relation to 1998 median household income by county/jurisdiction.3 Where
appropriate, these data comparisons were analyzed using the Spearman
rank order statistic.
The estimate of youths who were given medication for ADHD only at
home was based on data from 2 sources, both of which found it
to be approximately 20% of the total on medication. The first estimate
came from a 1997 consumer survey of parents in an ADD support
group,4 and the second came from a 1993 school nurse
survey in Baltimore County which separately tabulated in-school and
home-administered medication for ADHD.5
Percent of Public School Students Receiving Medication for ADHD
During School Hours
Table 1 presents the data on the
prevalence of medications administered for ADHD to Maryland public
school students. The prevalence of methylphenidate and of other
medications administered to treat ADHD during school hours was 2.46%
and .46%, respectively. In all, 2.92% of all public school students
were administered a medication for ADHD in school. The male:female
ratio for students administered medication was 3.5:1 in elementary and
4.3:1 in secondary schools.
TABLE 1
METHODS
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Methods
Results
Discussion
Conclusion
References
though not likelythat a student could be recorded twice
if receiving both methylphenidate and other medications for ADHD. The
survey was performed in April 1998 and focused on youths receiving
medication at the time of the survey. In addition to gathering data on
the medication administered for ADHD, the following relevant data were
recorded: 1) gender; 2) school level (grouped as elementary
[grades K-5], middle [6-8], and high [9-12]); 3)
race/ethnicity (white, black, Hispanic, Asian, Native-American); 4)
special education status (determined by having an Individualized Education Program [IEP]); 5) Section 504 status; and 6)
prescriber specialty (pediatrician, family practitioner, psychiatrist,
nurse practitioner, other).
depending on the school district. All school districts have at
least 1 registered school nurse and registered school nurses in each
district were responsible for gathering the survey data.
RESULTS
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Abstract
Methods
Results
Discussion
Conclusion
References
Prevalence of Enrolled Students Receiving Medication for ADHD by School
Level
Estimated Total Prevalence of Medication Treatment for ADHD in Maryland Public Schools
The statewide public school survey recorded only medication administered for ADHD during school hours, which was 2.92%. Because 2.92% was determined to approximate 80% of the total, 3.65% was calculated to be the overall estimate of the point prevalence of medication treatment for ADHD in Maryland public schools in April 1998. This disaggregates by school level to rates of 4.5% in elementary, 4.3% in middle, and 1.3% in high school. The male:female gender ratio is 3.76:1, indicating a medication rate for ADHD of 5.75% for boys and 1.53% for girls.
Types of Medications Administered During School Hours
The medications administered for ADHD in school were of the following proportions: 84.2% methylphenidate, 11.6% amphetamines, 1.7% clonidine, .4% pemoline, and .4% tricyclic antidepressants. Of the medications `other than methylphenidate' administered for ADHD in school, 73% belonged to the amphetamine class.
Influence of Race/Ethnicity
Table 2 focuses on the variation in school administered methylphenidate by race/ethnicity. Comparing the treatment and enrollment proportions, it is apparent that non-white students had a proportional rate of methylphenidate treatment nearly half that of their proportional school enrollment (23.76% vs 44.09%). When methylphenidate prevalence data are presented in relation to school level, one race/ethnicity disparity widens with advancing grade levels. The white/black methylphenidate prevalence ratio increases as follows: 2.0:1 in the elementary school, 2.6:1 in the middle school, and 5.2:1 in high school. The pattern was not attributable to a declining enrollment by blacks and was not present for Hispanics or other minorities (Tables 2 and 3).
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Special Education Status
In Maryland public schools, 13% of the students enrolled were receiving special education services during the 1997-1998 school year.6 Table 4 presents the rate of school-administered methylphenidate treatment for students with ADHD receiving special education services compared with those in regular education. Overall, 1.55% of regular education students received this ADHD treatment compared with 8.70% of students who had an IEP, a marker for special education. This represents a 5.6-fold higher medication rate for students receiving special education services compared with students in regular education. In high school, students with an IEP were 10-fold more likely than their regular education counterparts to be receiving methylphenidate in school (Table 4).
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Table 5 presents the percent of special education students and students with a Section 504 plan who were administered methylphenidate for ADHD in school. Overall, 45% of the students receiving methylphenidate were in special education and an additional 8.3% had a 504 plan. Thus, 53% of all students receiving methylphenidate during school hours had an official school-documented impairment.
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Geographic Variations
The school district rates of methylphenidate treatment for ADHD varied fivefold geographically, from a low of 1.18% to a high of 6.02%. Race/ethnicity demographics were not uniform throughout the state and appeared to dramatically influence the prevalence variability. The jurisdictions with the lowest rate of methylphenidate treatment, Prince George's County and Baltimore City, had the highest minority student enrollment rates in the state, 84.7% and 87.2%, respectively. At the opposite extreme, the jurisdictions with the highest ADHD medication prevalence rates, Allegany and Garrett Counties, had among the lowest rates of minority student enrollment, 4.0% and .7%, respectively.6 A second possible geographic influence is the presence locally of a large clinic specifically treating children with ADHD. Only 3 such clinics reportedly exist in the Maryland area, and the 3 counties that are served by these clinics are among the highest 4 in methylphenidate prevalence.
Medical Specialty Prescribers of Methylphenidate for ADHD
The prescribers of methylphenidate for ADHD were reported in 94% of cases. Their rank order of prescribing by specialty (where known) is as follows: pediatricians, 63%; family practitioners, 17%; psychiatrists, 11%; behavioral clinic, 5%; nurse practitioners, 3%; and others, 2%. Pediatricians prescribed 67% of the medication for elementary school youths with ADHD, whereas family practitioners and psychiatrists together prescribed equally as much as did pediatricians for high school youths with ADHD (47% vs 46%). The proportion of medications other than methylphenidate prescribed by psychiatrists was nearly threefold greater than the proportion of methylphenidate that they prescribed (29% vs 11%).
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DISCUSSION |
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Comparative Rates of Medication Treatment for ADHD Among School-Aged Youths
In addition to the 1997 Baltimore County public school survey of medication for ADHD,1 there are 2 other recent school medication surveys. LeFever et al7,8 reported on a methylphenidate treatment survey covering 2 school districts in eastern Virginia during the 1995-1996 school year. The point prevalence of methylphenidate treatment in the second through the fifth grades was 10.8% for white and 5.4% for black students. In a central Wisconsin school district in 1996, Musser et al9 surveyed all public and parochial school students who received stimulant medication treatment for ADHD during school hours. She and her colleagues reported that 3.7% of the entire student body were administered stimulant medication then.
Generalizations from these school district surveys to the state as a whole or to other school districts are quite difficult because of differences in school subpopulations and wide variations in the prevalence of medication treatment for ADHD from one school district to another.
Survey Inclusiveness
In assessments of the prevalence of stimulant medication treatment for youths, the most inclusive study was done by Rappley et al.10 She and her colleagues obtained complete methylphenidate prescription information from the entire state of Michigan using controlled substances triplicate prescription data. The research team found that 1.96% of all 5- to 14-year-old youths and 1.6% of all 5- to 17-year-old youths in that state (as determined by census figures) had been prescribed methylphenidate in February or March 1992.
A slightly less comprehensive survey of youths receiving stimulant treatment would include all public school students in 1 or more school districts. Virtually all youths aged 5 to 18 years would then be covered in such a survey except high school drop-outs and students enrolled in private or parochial schools. (In Maryland, 4.66% of public high school students dropped out of school during the 1996-1997 school year and 17% of all enrolled students matriculated in nonpublic schools in the fall of 1997.6) Another limitation of a school-based medication survey is that it could less accurately record exclusively home-administered medication for ADHD. School surveys of ADHD drug treatment nonetheless have an advantage over prescription based surveys in that they can assess a greater range of factors relevant to the initiation and administration of the medication.
Treatment-based surveys have their own set of limitations. Nationally stratified surveys based on data from office-based physicians underrepresent clinic medical coverage and are limited frequently by low reliability.11 Data-based records of treatment from health maintenance organization enrollees include few with low incomes, and Medicaid datasets focus primarily on low-income recipients.12
State-by-State Comparisons
There are no state-by-state population-based methylphenidate treatment comparisons. The only state-by-state comparison is based on a crude measure, kilograms of methylphenidate shipped to retail registrants in the United States by zip code. This measure is reported in a US Drug Enforcement Administration13 database whose acronym is ARCOS. In 1994, Maryland had the fourth lowest methylphenidate shipment rate among the 50 states, .83 g per 100 population.14 In 1997, Maryland ranked 17th among the 50 states with 3.78 g of methylphenidate shipped per 100 population (DEA, 1998). The markedly increased shipment rate to Maryland from 1994 to 1997 is at variance with the 1995 to 1997 population-based increase in the number of students receiving methylphenidate in Baltimore County public schools, an increase of <10% over 2 of those 3 years (3.75%-4.10%) (Safer, unpublished data, 1998). Consequently, an accurate state-by-state comparative analysis awaits additional population-based research.
Variations in Treatment Prevalence: Replications of Previous Research
A number of the findings of the Maryland 1998 statewide public school survey match those reported previously. A 4:1 male:female ratio of students receiving stimulant medication has been regularly noted.10,15,16 The peak age range of stimulant medication during the 1990s has been reported to be ages 8 to 11 years.10,16 The medication prevalence rate for middle schools now nearly equals that of elementary schools.15 The fivefold stimulant medication variation across school districts in Maryland is similar to findings previously reported by Zito et al,16 and these mirror the 10-fold methylphenidate variation across Michigan counties reported by Rappley et al.10
The medical specialty prescriber patterns are also similar to those reported previously. In surveys and in studies assessing prevalence, the proportion of medical specialists prescribing medication for youths with ADHD is as follows: pediatricians (40%-69%), family practitioners (15%-37%), psychiatrists (6%-25%), and neurologists (5%-15%).10,17-21
The twofold lower prevalence of medication treatment for ADHD of black compared with white youths has been previously reported by Cullinan et al,22 Bussing et al,23 Le Fever et al,8 and Zito et al.16
New Findings on Treatment Variations
Nurse Practitioners Not previously reported is the finding that nurse practitioners in Maryland now prescribe 3% of the stimulant medication administered to students with ADHD. Most states in the United States now grant prescribing privileges to nurse practitioners and in Maryland, this includes the right to prescribe controlled substances.24
Race/Ethnicity The statewide Maryland public school survey now provides enough data on all non-white student groups (black, Hispanic, Asian and Native-American) to reveal that all have a comparatively lower treatment prevalence for ADHD medication than white students based on their proportional enrollment (Table 2). It is particularly noteworthy that the black versus white medication rate disparity increased substantially at higher school levels, that this school level disparity was not present for Hispanic or other minority students, and that the proportion of white students administered methylphenidate for ADHD increased from elementary to high school (Tables 2 and 3).
Studies based on teacher ratings suggest that compared with white youths, black youths have the same or a greater likelihood of exhibiting the features of ADHD,25-28 and there is good evidence that cultural differences explain at least some of the comparatively low level of stimulant treatment by youths from black families.29-32 Possibly these cultural factors have their greatest impact on black students at the high school level where their relative rate is lowest (Table 3). Comparing Maryland school districts, there was a significant inverse relationship between the in-school rate of methylphenidate administration and the public school percentage of black students (Spearman rank order Correlation =
.454;
P < .05). At the extremes of the ranking, Prince
George's County and Baltimore City had the lowest in-school rates of
methylphenidate treatment (1.18% and 1.20%, respectively), but the
highest percentages of black public school enrollment (75% and 86% of
the total, respectively). Nonetheless, it is of interest that these 2 jurisdictions were considerably different in their 1998 state-ranked
median annual household income (Prince George's County = sixth highest, $44 655; Baltimore City = fourth lowest,
$26 878).3 This suggests that race/ethnicity is more
associated with the disparity in medication prevalence than is median
household income.
The relatively very low medication treatment prevalence for ADHD among
Asian students is also striking (Table 2). Some reports suggest that
Asian youths are less likely than whites to exhibit the characteristics
of ADHD,33 although cross-national studies using
standardized teacher-rating scales generally show more interpopulation
similarities than differences.34,35
Special Education The finding that 45% of all students in Maryland public schools who received methylphenidate for ADHD during school hours were officially in a special education category reflects a sizable increase in this group's share of medication compared with the 25% reported in 1987 by Safer and Krager.2 One must consider though that those counted in the 1987 Baltimore County survey were for the most part in special education classes or schools and that the 1998 Maryland study included all those with an IEP, most of whom were mainstreamed.
The close relationship between special education status and ADHD has now been even more clearly demonstrated. Of course, this relationship has been known for some time. In numerous clinic studies, an average of 45% of all students diagnosed with ADHD receive (or received) special education services.20,36,37 Likewise, Forness38 after reviewing the literature reported that an average of 29% of all special education students have ADHD, and that 74% of all ADHD youths receiving special education services have a documented learning disability. The finding that 8.7% of public school special education students receive methylphenidate for ADHD during school hours is difficult to compare with previous reports. Cullinan et al22 reported that 6.6% of 6- to 18-year-old public school special education students in northern Illinois were being treated with stimulant medication in 1985. These students averaged 12 years of age and 83% were mainstreamed. Bussing et al23 studying public school special education students in the second through the fourth grades in southeastern Florida reported that 20% were receiving medication therapy for ADHD in 1995.Section 504 of the Rehabilitation Act of 1973
Although 55% of students medicated in school for ADHD had not been qualified for special education services, a sizable number of these students were still eligible for Section 504 services because they exhibited an impairment that substantially limited their major life activities.28 In the Maryland medication survey, it was found that 8.3% of all students receiving methylphenidate during school hours had been qualified by school officials for Section 504 services. Thus, students with a school-identified impairment/handicap comprised a total of 53% of all those receiving methylphenidate. The 504 category has not previously been assessed in relation to medication treatment.
Limitations of the Study
It is possible that the total prevalence of medicated students is an overcount because students could be counted twice if they were administered more than 1 type of medication for ADHD during school hours. That number, however, must be small because 2.46% were administered methylphenidate and .35% were administered other stimulants (nearly all amphetamines). It is unlikely that students were administered 2 different stimulants during school hours. Thus, only the remaining .11% could have reasonably received 2 different types of medications for ADHD during school hours.
An undercount is more likely. In the late 1990s, the proportion of youths treated with stimulants who were prescribed amphetamine compounds substantially increased.39 Amphetamines have a longer duration of action than methylphenidate and thus are more likely to be administered only at home.40 The estimate of 20% for the out-of-school administration of medication may therefore be somewhat higher. It is also possible that a few students were receiving medications for ADHD, such as atypical neuroleptics, which had not been listed for nurses as applicable for the treatment of ADHD.
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CONCLUSION |
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The Maryland public school survey of medication for ADHD administered to students during school hours provides detail on the statewide prevalence and the variability of this treatment. The rate of medication treatment for ADHD was found to vary fourfold by gender (male vs female), twofold by ethnicity/race (white vs minority), threefold by school level (elementary vs high school), sixfold by educational category (special education vs regular education), and fivefold by school district (highest vs lowest rate). Thus, a given finding for one age group or one geographic locale may be misleading if applied generally.
The inclusion of both sociodemographic and educational variables as part of a medication survey clearly adds depth to the prevalence findings and to some extent clarifies the circumstances related to the prescribing of medication for ADHD. Of the variables researched, the educational category was found to be important in that a majority of public school students administered medication for ADHD were receiving special education or Section 504 services. Consequently, future medication prevalence studies for the treatment of ADHD will need to include this dimension when such data are available.
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FOOTNOTES |
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Received for publication Jul 29, 1999; accepted Jan 7, 2000.
Reprint requests to (D.J.S.) 7702 Dunmanway, Baltimore, MD 21222. E-mail: dsafer{at}jhmi.edu
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ABBREVIATIONS |
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ADHD, attention deficit hyperactivity disorder; Section 504, Section 504 of the Rehabilitation Act of 1973; ADD, attention deficit disorder; IEP, Individualized Education Program.
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REFERENCES |
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