PEDIATRICS Vol. 109 No. 5 May 2002, pp. 733-739
Psychotropic Medication Use in a Population of Children Who Have Attention-Deficit/Hyperactivity Disorder
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* Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Division of General Pediatrics, University of Washington School of Medicine, Seattle, Washington
Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Washington
|| Department of Health Services, University of Washington School of Public Health and Community Medicine, Seattle, Washington
¶ Center for Attention Deficit Disorders, Group Health Cooperative of Puget Sound, Redmond, Washington
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ABSTRACT |
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Objective. Recent reports suggest a trend of increasing prevalence of psychotropic drug prescriptions among children with attention-deficit/hyperactivity disorder (ADHD); however, reasons for the increased use of such medications is unclear. The objectives of this study were to examine differences in nonstimulant psychotropic medication fills between children with and without identified ADHD and to assess associations with non-ADHD neurobehavioral disorders.
Methods. A population-based retrospective matched cohort study was conducted of a large group model health maintenance organization located in western Washington State. Eligible patients were children who were ages 3 to 17 years and were continuously enrolled and used services from January 1 to December 31, 1997 (N = 57 216). Children with ADHD were identified by a diagnosis of ADHD or a pharmacy fill for a stimulant medication using automated patient files. Children without ADHD were randomly selected and matched 4:1 to children with ADHD on age and gender. Neurobehavioral disorders and pharmacy fills for psychotropic medications were measured.
Results. During 1997, 2992 children were identified as having ADHD (5.2%). These children were more likely to have a diagnosis of a non-ADHD neurobehavioral disorders (adjusted odds ratio: 6.3; 95% confidence interval: 5.4–7.3) than children without ADHD. Although most (78%) were treated with stimulant medications, children who were identified as having ADHD were also more likely to receive pharmacy fills for nonstimulant medications than were children without ADHD. Nonstimulant medications were more often used along with stimulant medications and were frequently prescribed in association with ADHD after controlling for other disorders.
Conclusions. Children who were identified as having ADHD were more likely to have a diagnosis of other neurobehavioral disorders and to receive nonstimulant psychotropic medications than were children without ADHD. Because many of these drugs have little or no empirical basis in the treatment of ADHD, the rationale for their use is less clear. Future research to examine the use, effectiveness, and safety of these medications alone and in combination in children with ADHD is urgently needed.
Key Words: attention deficit disorder with hyperactivity • child • stimulant medications • psychotropic medications
Abbreviations: ADHD, attention-deficit/hyperactivity disorder • TCA, tricyclic antidepressant • GHC, Group Health Cooperative of Puget Sound • HMO, health maintenance organization • ICD-9, International Classification of Diseases, Ninth Revision • ODD, oppositional-defiant disorder • SADD, substance abuse/dependence disorders • SSRI, selective serotonin reuptake inhibitor • OR, odds ratio • CI, confidence interval
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Attention-deficit/hyperactivity disorder (ADHD) is considered to be the most common neurobehavioral disorder among school-aged children.1–3 Children who have ADHD exhibit symptoms of inattention, impulsivity, and hyperactivity that are extreme for age and result in significant impairment across multiple settings.4 In addition, children who have ADHD frequently have diagnoses of other neurobehavioral disorders, which may compound their difficulties.5–8
Psychotropic medications are commonly used to treat the symptoms of ADHD,2,9 and their use seems to be growing, particularly in preschool-aged children.10–12 Stimulants compose the majority of psychotropic medications used in the treatment of ADHD.13,14 Stimulants have been shown to be effective in improving the core symptoms of ADHD15–17 and may also improve aggression, oppositionality, internalizing symptoms, and peer relations.18 The use of other psychotropic medications in children also seems to be growing.11,12,14 Some of these medications, such as tricyclic antidepressants (TCAs) and 
adrenergic agonists, may have some beneficial effects in children who have ADHD, but there are limited data on their efficacy and safety.9,19
Little is known regarding the use of nonstimulant psychotropic medications in a population of children who have ADHD. In this study, we sought to compare differences in practice norms in the diagnosis of neurobehavioral disorders and pharmacy fills for nonstimulant psychotropic medications between children who do and do not have identified ADHD at a large integrated health care system. We also sought to examine psychotropic medication patterns in children who have identified ADHD and to evaluate the rationale for medication usage by linking associations between specific medication classes and neurobehavioral disorders.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Setting
Group Health Cooperative of Puget Sound (GHC) is a large not-for-profit group model health maintenance organization (HMO) that is located in western Washington State. It serves approximately 500 000 enrollees and is considered to be the country’s largest consumer-governed health care organization. Primary care for children is provided by family practitioners and pediatricians, >95% of whom are board certified. Outpatient mental health care is provided at 6 geographically dispersed clinics. Treatment emphasizes brief psychotherapy, group therapy, and pharmacotherapy. GHC patients are permitted to self-refer directly for specialty mental health care. Inpatient, partial hospitalization, and day treatment are provided by contracted providers throughout the GHC service area. The Center for Attention Deficit Disorders is a referral clinic that conducts initial evaluations, provides follow-up services, and sponsors various educational activities and behavioral interventions. Speech and language services are also offered to patients through referrals from their primary care providers. At the time of this study, there were no system-wide quality improvement initiatives or clinical guidelines in place pertaining to the diagnosis and treatment of ADHD. However, the use of pemoline was discouraged because of reports of hepatotoxicity, and mixed amphetamine salts was subject to pharmacy preapproval because of cost considerations.
GHC maintains automated patient information on multiple databases that are linked through a unique identifier to each GHC enrollee. Summary information on patient demographics, pharmacy fills, and all diagnostic codes for ambulatory and inpatient care was available for each enrollee and was used as the main data source for this study. Verification of computerized data occurs through on-line edits, automatic prompts for incomplete or missing information, and monthly comparison of data from all data input sources.
Patients
Children who were ages 3 through 17 years, were continuously enrolled in the HMO from January 1 to December 31, 1997, and made an ambulatory visit or had a hospitalization were eligible for inclusion in the study. Children who had ADHD were identified as children who made an ambulatory visit or incurred a hospitalization during the study period that included a diagnosis of ADHD by International Classification of Diseases, Ninth Revision (ICD-9) code 314 or who had a pharmacy fill for a stimulant medication. The following stimulant drugs were used to identify children who had ADHD because of their negligible use in other childhood conditions and to identify children who had ADHD and who may not carry an ADHD diagnostic code in the automated files because of provider coding decisions2: methylphenidate, dextroamphetamine, mixed amphetamine salts, and pemoline. Children without ADHD consisted of all children who did not have a diagnosis of ADHD or a pharmacy fill for a stimulant medication during the study period. Children who did not have ADHD were randomly selected as control subjects and matched 4:1 to children who had ADHD on age and gender. Subjects were categorized by age as preschool age (ages 3–6 years), school age (ages 7–12 years), or adolescent (ages 13–17 years). Additional details of subject selection have been presented elsewhere.20 The study protocol was approved by the Human Subjects and Research Committees at GHC and by the institutional review board at the University of Washington.
Medical record review of a random sample of 70 subjects who were identified as having ADHD was conducted to assess the validity of ADHD diagnoses. Subjects were categorized as probable ADHD, possible ADHD, or doubtful ADHD depending on whether encounter data from their medical records affirmed 6 of 9 symptom criteria for hyperactive/impulsive, inattentive, or combined ADHD from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.4 Functional impairment and symptomatology across settings were not assessed. Additional details of the medical record review were provided in a previous publication.20
Outcomes
Children in the cohort were identified as having non-ADHD neurobehavioral disorders using appropriate ICD-9 codes from automated patient files. Providers at GHC were instructed to code only diagnoses for which treatment was rendered. We did not use prescriptions for nonstimulant psychotropic medications to identify non-ADHD disorders because of the low specificity of these medications for identification of disorders. The following non-ADHD neurobehavioral diagnoses were selected for identification: depressive disorders (ICD-9 codes 296.2, 296.3, 300.4, 311), anxiety disorders (ICD-9 codes 300.0–300.2, 313.0), bipolar disorder (ICD-9 code 296), obsessive-compulsive disorder (ICD-9 code 300.3), oppositional-defiant disorder (ODD; ICD-9 code 313.81), conduct disorder (ICD-9 code 312), learning disorders (ICD-9 codes 315.0–315.3), substance abuse and dependence disorders (SADD; ICD-9 codes 303–305), tic disorders (ICD-9 code 307.2), enuresis (ICD-9 code 307.6, 788.3), encopresis (ICD-9 code 307.7, 787.6), and seizure disorders (ICD-9 codes 780.3, 345). For the purposes of analysis, depressive, anxiety, bipolar, and obsessive-compulsive disorders were aggregated into internalizing disorders, and conduct disorder and ODD were aggregated into externalizing disorders.
Pharmacy fills for psychotropic medications were obtained using automated pharmacy data. Pharmacy fills represent the number of prescription medication fills per person per year and do not specify a given length of time on medication. At the time of the study, state-controlled substance regulations limited stimulant medications to 30- to 60-day limits. Other psychotropic medications could be given for up to 90 days without a refill. In addition, subjects could receive more than 1 fill at a time because of medication regimens that incorporated different formulations or prescription strengths. We defined multiple medication users as those who had pharmacy fills for >1 class of psychotropic medication during the study period (eg, stimulants and agonists) either in combination or sequentially.
For the purposes of this study, pharmacy fills were reported both as the proportion of subjects with any fills per year and per capita fills per year. The following categories of psychotropic medications from the GHC formulary were evaluated for pharmacy fills among the study cohort: stimulants (methylphenidate, dextroamphetamine, mixed amphetamine salts, pemoline), TCAs (imipramine, desipramine, nortriptyline, amitriptyline), selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, sertraline, paroxetine), bupropion, buspirone, adrenergic agonists (clonidine, guanfacine), and valproate. We did not select lithium or antipsychotics for identification because of their negligible use in ADHD and ADHD-associated conditions.14,21 Psychotropic medications were divided into stimulant medications and nonstimulant medications.
Analysis
Differences in the proportion of children who had non-ADHD neurobehavioral disorders and pharmacy fills for nonstimulant medications between children who did and did not have identified ADHD were assessed for statistical significance by the 
2 test. Differences in the per capita number of pharmacy fills for nonstimulant medications between children who did and did not have identified ADHD were assessed for statistical significance by the Wilcoxon rank sum test. To account for multiple comparisons, we considered P < 0.01 to be statistically significant.
Conditional logistic regression was used to estimate the probability of a non-ADHD neurobehavioral diagnosis for children who were identified as having ADHD relative to children who did not have ADHD. The odds ratio (OR) with corresponding 95% confidence intervals (CI) was the measure of association. Separate models were fit by category of non-ADHD disorder. To account for a priori matching, we implicitly included the matching variable designating age and gender in all models. Additional adjustment was made for any specialty mental health care use. Conditional logistic regression was also used to estimate the probability of nonstimulant medication fills (TCAs, SSRIs, and adrenergic agonists) for children who were identified as having ADHD relative to children who did not have ADHD and for children who had non-ADHD neurobehavioral disorders (internalizing disorders, externalizing disorders, SADD, tic disorders, and enuresis) relative to those who did not. Separate models were fit for each class of nonstimulant medication and were adjusted implicitly for age and gender and explicitly for any mental health care use and for neurobehavioral disorders by including separate dummy variables for each disorder. Stata Statistical Software, release 6.0 (College Station, TX) was used for all statistical analyses.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Among 57 216 children who were aged 3 to 17 years, were continuously enrolled, and used services in 1997, we identified 2992 children who had ADHD (5.2%). The vast majority were identified on the basis of a diagnosis of ADHD. Children who were identified as having ADHD were primarily male (77.2%). They had a mean age of 11.7 years (standard deviation: 3.2), and a slight majority were school age (52.9%). Only 28 children (0.9%) who were younger than 5 years were identified as having ADHD. There were no differences among the 3 age groups (P = .35) in the proportion who were male.
Children who were identified as having ADHD were more likely to receive a diagnosis for a non-ADHD neurobehavioral disorder during the study period (adjusted OR: 6.3; 95% CI: 5.4–7.3) than children who did not have ADHD (Table 1). Overall, 28.7% of children who had identified ADHD had 1 or more disorders compared with 3.8% of children who did not have ADHD. For most categories of disorders, children who had identified ADHD were more likely to have a diagnosis than were children who did not have ADHD. The only exception was encopresis (adjusted OR: 1.7; 95% CI: 0.9–3.2), but the number of children in each group with this diagnosis was small. Among children who were identified as having ADHD, 19.7% had 1 additional disorder, 6.1% had 2 additional disorders, and 2.9% had 3 or more additional disorders.
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Among children who were identified as having ADHD, ODD and depression were the most prevalent non-ADHD neurobehavioral disorders. Among children without ADHD, depression and SADD were the most prevalent disorders. A greater proportion of preschool-aged children who were identified as having ADHD had a diagnosis of a non-ADHD disorder than were either school-aged children or adolescents who had ADHD (37.2% vs 23.5% and 28.8%; P < .001). The most common disorder among preschool-aged children who had ADHD was ODD (19.6%); the most common disorders among school-aged children who had ADHD were ODD (8.3%) and learning disorders (8.1%); and the most common disorder among adolescents who had ADHD was depression (15.4%). Overall, the proportions of male and female subjects who were identified as having ADHD and received any non-ADHD neurobehavioral diagnosis were similar; however, girls were more likely than boys to receive a diagnosis of depression (13.1% vs 8.4%; P < .001), and boys were more likely than girls to receive a diagnosis of conduct disorder (5.0% vs 2.6%; P = .009).
The majority of children who were identified as having ADHD (82.9%) received at least 1 pharmacy fill for a psychotropic medication during the study period. A slightly greater proportion of boys than girls were prescribed a psychotropic medication (84.3% vs 78.3%; P < .001), whereas a smaller proportion of preschool-aged children than either school-aged children or adolescents were prescribed a psychotropic medication (56.8% vs 82.8% and 86.2%; P < .001).
Stimulant medications were the most commonly prescribed psychotropic medication among children who were identified as having ADHD; 78% of children who had ADHD received at least 1 prescription for a stimulant. Among stimulants, methylphenidate was prescribed most commonly (75.0%), followed by dextroamphetamine (33.2%), pemoline (3.4%), and mixed amphetamine salts (1.2%). The median number of stimulant fills was 6 (mean: 6.8; standard deviation: 5.6), but the distribution of stimulant fills was wide. Although the majority (87.6%) received 12 or fewer stimulant prescriptions, pharmacy fills were highly skewed with 2.7% receiving >20 fills. One third of the latter group received different stimulants (eg, methylphenidate and dextroamphetamine); the rest received the same stimulant.
The majority of children who were identified as having ADHD (64.9%) received only stimulant medications during the year (Table 2). Nonstimulant medications were prescribed less frequently (18.0%) to children who ADHD and were more commonly prescribed along with stimulant medications (12.8%) than alone (5.2%) during the study period. The most prevalent nonstimulants either alone or along with stimulants were agonists, SSRIs, and TCAs. Other nonstimulants were used infrequently. For children who had ADHD and comorbid internalizing disorders, the most prevalent medication regimens were SSRIs alone (18%), stimulants alone (22%), or SSRIs and stimulants as a multiple medication (26%). For children who had ADHD and comorbid externalizing disorders, the most prevalent medication regimens were stimulants alone (37%) or stimulants along with agonists (21%). For children who had ADHD and comorbid SADD, the most prevalent medication regimen was stimulants alone (39%). For children who had ADHD and comorbid tic disorders, the most prevalent regimens were agonists alone (33%) or agonists along with stimulants (34%).
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A greater proportion of children who were identified as having ADHD were prescribed a nonstimulant medication (18% vs 1.5%) than children who did not have ADHD (Fig 1). In each category of medication, a greater proportion of children who had ADHD than children who did not have ADHD received a nonstimulant medication fill during the study period (P < .001). For children who had ADHD,
adrenergic agonists were the most commonly prescribed nonstimulant, followed by SSRIs and then TCAs. For children who did not have ADHD, SSRIs were the most commonly prescribed nonstimulant. Valproate, bupropion, and buspirone were used uncommonly for children in both groups. Among users, the majority of children who had ADHD (79.2%) and did not have ADHD (90.2%) received only a single category of nonstimulant medications during the study period. Among users, there were no differences in the per capita pharmacy fills for nonstimulants between children who did and did not have ADHD: agonists (median: 5 vs 6.5; P < .59), SSRIs (median: 3 vs 3; P = .77), TCAs (median: 4 vs 3; P = .15), bupropion (median: 2 vs 1.5; P = .82), buspirone (median: 3 vs 2; P = .58), and valproate (median: 5 vs 3; P = .28).
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The probability of nonstimulant use by category of neurobehavioral disorder was estimated (Table 3). Among children of the same category of age, gender, mental health service use, and non-ADHD disorder, children who were identified as having ADHD were more likely to receive TCAs (adjusted OR: 12.4; 95% CI: 7.6–20.3), SSRIs (adjusted OR: 4.3; 95% CI: 2.7–6.9), and
adrenergic agonists (adjusted OR: 32.0; 95% CI: 17.3–59.4) than were children who did not have ADHD. Similarly, children who had internalizing disorders were more likely to receive TCAs (adjusted OR: 25.3; 95% CI: 6.1–104.2) and SSRIs (adjusted OR: 75.2; 95% CI: 26.7–211.7) than were children who did not have internalizing disorders. Children who had tic disorders were more likely to receive adrenergic agonists (adjusted OR: 215.2; 95% CI: 21.5–2157.9) than were children who did not have tic disorders. Children who had enuresis were more likely to receive TCAs (adjusted OR: 54.0; 95% CI: 14.2–205.0) than were children who did not have enuresis. Finally, children who had SADD were more likely to receive TCAs (adjusted OR: 44.7; 95% CI: 7.2–275.9) than were children who did not have SADD. However, the number of children who had non-ADHD disorders and received medications was relatively small and resulted in large CIs. The probability of adjusted use of bupropion, buspirone, and valproate was not reported because of the extremely small numbers of patients who were prescribed these medications.
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From the medical record review of 70 randomly selected children who were identified as having ADHD, 50 (71%) were determined to have probable ADHD. In 15 (22%), it was not possible to determine the validity of their ADHD diagnoses because of incomplete or missing information from their medical records regarding the diagnostic evaluation. These children were categorized as having possible ADHD. There was no difference between children who had probable and possible ADHD in the proportion who received stimulant and nonstimulant medications. Five children (7%) were determined to have doubtful ADHD. None of these children was prescribed psychotropic medications.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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In this population-based study conducted at a large HMO, we found that children who were identified as having ADHD were more likely than children who did not have ADHD to have a diagnosis for a non-ADHD neurobehavioral disorder, in particular ODD and depressive disorders. Children who were identified as having ADHD were also more likely than those who did not have ADHD to receive nonstimulant psychotropic medications. Although stimulant medications were the most commonly prescribed class of psychotropic medication,
agonists, SSRIs, and TCAs were the most commonly prescribed classes of nonstimulant medications. These latter medications were prescribed in association with ADHD after adjustment for non-ADHD disorders and were more commonly used along with stimulants. Few children who had ADHD received nonstimulant medications alone during the study period.
The finding in this population that stimulants compose the majority of psychotropic medications prescribed to children who have ADHD is not surprising and is consistent with a number of previous studies.13,14,22,23 What has been less clear is how frequently stimulants are used with other psychotropic medications and which regimens are most prevalent. In this study, we found that stimulants were used alone 84% of the time but were used along with nonstimulants 16% of the time. The most prevalent multiple regimens were stimulants with adrenergic agonists, SSRIs, or TCAs. These findings are consistent with results reported by Zito et al14 using data from the National Ambulatory Medical Care Survey and Zarin et al21 using data from a survey of psychiatric practices. However, children in the latter study had higher rates of multiple medication therapy and may not be representative of all children who have ADHD. Combination therapy involving simultaneous use of stimulants and other psychotropic medications for children who have ADHD may be growing,12 but the rationale for such therapy is unclear given the absence of controlled studies to document the efficacy and safety of combined therapy.19 Wilens et al24 proposed that the increasing use of multiple psychotropic agents for children may be arising out of a need to treat multiple symptoms associated with a single disorder, to treat comorbid disorders, and/or to elicit a synergistic effect of combined agents for certain disorders.
Recent data have documented an increasing prevalence of nonstimulant psychotropic medication prescriptions among children who have ADHD, particularly among preschool children.11,12 Because many nonstimulant medications are used off-label in the pediatric population, it has not been clear why the prevalence of these medications is increasing. Our data suggest that certain nonstimulant medications ( agonists, TCAs, and SSRIs) are used to treat symptoms associated with ADHD. Although there seems to be general consensus that agonists and TCAs may be effective for symptoms of ADHD,2,9 the data are limited by the few studies that evaluated their safety and efficacy in this population.19 Moreover, it is unclear why we found SSRIs prescribed in association with ADHD. This peculiar finding is consistent with findings from a study by Rushton et al.25 In this survey of family physicians and pediatricians in a southeastern state, 36% of physicians reported prescribing SSRIs for the treatment of ADHD. Because data on the effectiveness of SSRIs in the treatment of ADHD is lacking,9 it is unclear why practitioners in these 2 studies were prescribing SSRIs in association with ADHD. Possible reasons are that physicians are using SSRIs to treat symptoms of subclinical depression, to treat depression but avoid the label of depression, or to treat symptoms of ADHD in the belief that SSRIs are effective for this purpose. Additional research to clarify reasons for the use of SSRIs in children who have ADHD is needed.
This study on the use of psychotropic medications in children who do and do not have ADHD has particular strengths. First, we used a population-based data set to identify all children who did and did not have ADHD, were continuously enrolled, and used services. Studies that restrict subjects to either referral-based or primary care populations may not be representative of all children who have ADHD. Second, we used automated pharmacy data to obtain information on psychotropic medications. Studies that use surveys to obtain this information may be limited by subjects’ recall of the specific medications used. Third, we captured additional neurobehavioral diagnoses that may have an impact on medication treatments and adjusted our analyses for these disorders. Previous studies that reported only on psychotropic medications without associated diagnoses may not be able to identify target disorders for which these medications are being prescribed. Fourth, we examined a random sample of medical records of subjects who had ADHD to validate ADHD diagnoses. Our review suggested that >93% of children who were identified as having ADHD in our cohort had probable or possible ADHD, whereas only 7% probably did not have ADHD.20
Our study is subject to certain limitations. First, the use of automated patient files may result in misclassification of subjects (eg, subjects labeled as ADHD when in fact they do not meet criteria for ADHD and vice versa). Any misclassification would be expected to be nondifferential and bias differences in psychotropic medication use toward the null. In addition, medical record reviews of a random sample of children who had ADHD suggested that the majority of children who were identified as having ADHD in this data set had a valid diagnosis. Few children who were identified as having ADHD were determined to have a doubtful diagnosis. Second, our study population and their treatments may not be representative of all children who have ADHD. This study population has been previously described as white and middle income, similar to the population of Puget Sound but with a slightly higher educational level.26 In addition, the treatment practices of providers at this HMO may not be representative of all providers nationwide. However, the medication regimens used by providers in this study to treat children who have ADHD were similar to the regimens used by providers who participated in a nationally representative survey.14 Third, we were unable to identify the specific symptoms for which psychotropic medications were prescribed. However, we were able to make associations between diagnosed disorders and specific medication classes using multivariate methods that suggest target disorders for these medications. Fourth, we were unable to link prescriptions to specific provider types (eg, psychiatry versus pediatrics versus family medicine). Because previous studies have shown differences in treatment practices by provider type,14,25,27 this additional data would be of interest in discerning treatment practices of various providers in this study. Fifth, the reported prevalence of non-ADHD neurobehavioral disorders may be an underestimate of the actual prevalence of these disorders. Providers at GHC were instructed to code only for disorders for which treatment was provided at the time of the encounter. Additional disorders for which treatment was not rendered would therefore not be coded and entered into the automated files. In addition, we did not independently validate these disorders in the medical record. Sixth, we were unable to determine whether those subjects with fills for multiple classes of medications were using those medications concurrently in combination or sequentially one after another. Data from other studies suggest that they are being used in combination.14,21
Our findings have implications for clinical practice and future research initiatives. First, the results from this study are consistent with previous studies that have identified stimulants as the most prevalent psychotropic medications used in the treatment of ADHD. The short-term efficacy and adverse effects of stimulants are well published, and this knowledge may have influenced prescribing preferences at this HMO. Second, nonstimulants were used along with stimulants fairly often without reliable data on safety and efficacy. Additional research to determine the safety and efficacy of these medications alone and in combination is needed. Third, our results suggest that SSRIs are prescribed frequently in association with the diagnosis of ADHD. Little empirical evidence exists for the effectiveness of these medications in the treatment of ADHD. Additional research to determine the rationale for the use of SSRIs by clinicians is required to inform clinical practice better. Fourth, from this and other studies, it is apparent that non-ADHD neurobehavioral problems are more common among children who have ADHD than children who do not have ADHD. Initiatives to improve the recognition and evidence-based treatment of these comorbid disorders may help to improve the long-term outlook for children who have ADHD.
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ACKNOWLEDGMENTS |
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This project was supported by funds from the Center for Health Studies, Group Health Cooperative of Puget Sound.
We are grateful to the Center for Health Studies at Group Health Cooperative of Puget Sound and to Robert Davis, MD, MPH, for support of this project. We thank Julie M. Zito, PhD, and Martin T. Stein, MD, for critical reviews of the manuscript.
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FOOTNOTES |
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Received for publication Jul 12, 2001; Accepted Dec 13, 2001.
Reprint requests to (J.G.), Division of General Pediatrics, Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104. E-mail: guevara{at}email.chop.edu
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