How many children in your community are on ADHD medications? Do you know how important it is to find out?
It may be time for a new nightly public service announcement. Throughout the 1970s, American TVs warned “It’s 10 o’clock. Do you know where your children are?” Today a more fitting message might be, “Young kids abuse mental health meds. Do you know how many of your child’s schoolmates have an ADHD prescription?”
A national study published earlier this year showed that ADHD drug abuse among U.S. high and middle school students has been rising for the past 20 years. The problem is more than 30 times greater in some schools than others. The main factor affecting the magnitude of the problem is the percent of ADHD-diagnosed students in a school. More children diagnosed equates to more drug abuse.
While ADHD drug abuse may be a problem in school communities around the country, significant risk factors for abuse were schools located in suburban neighborhoods and schools with highly educated and primarily white populations. Like the opioid epidemic, ADHD drug abuse may be most evident outside inner cities but that doesn’t mean it’s not a problem in urban communities too.
ADHD prescribing rates are important because ADHD often represents a gateway diagnosis not only into the mental health system but also into the world of youthful drug experimentation. Once diagnosed, many children experience a cascade of psychotropic prescriptions—drugs used to treat mental health problems. Stimulants like Adderall and Vyvanse are often prescribed first, but tolerance to the drug effects can develop quickly or induce adverse effects. This often leads doctors to switch up and add on various drugs. In the U.S., 40% of ADHD-diagnosed 2- to 24-year-olds are on multiple types of psychotropics concurrently.
Even the use of powerful antipsychotics—the drugs once reserved for treating adults with schizophrenia—has become a common part of ADHD treatment. A diagnosis of ADHD has been implicated in 25 percent of antipsychotic adverse drug reactions.
In the past, access to local ADHD prescribing rates would have required academic professionals to secure grant money to support labor-intensive research. That’s no longer the case. Thanks to the proliferation of electronic health record systems (EHRs), information about a community’s rate of prescribing ADHD drugs and other mental health meds is sitting in databases begging for air.
Without violating patient privacy or confidentiality, it would be relatively easy for a hospital or health system to generate “de-identified” rates of drugs prescribed to children for ADHD or any other mental health conditions. De-identified information does not include names or other personally identifying information. It is limited to 3-level zip codes (except when fewer than 20,000 individuals reside in the specified geographic region). It includes only aggregate information such as the percent of individuals under 18 who have been diagnosed with ADHD. As individuals who spent much of our careers conducting scientific investigations on the prevalence and impact of mental health diagnoses and drug treatment trends, we value the ease with which communities could now learn about their mental health trends.
In the early to mid-2000s, our research documented that ADHD treatment rates were many times higher than nationally recognized ADHD experts insisted were possible. One of the most prominent ADHD authority figures of the time came to southeastern Virginia (SEVA), which includes Virginia Beach, Norfolk, Portsmouth, and several surrounding cities. He told community members to ignore reports of ADHD overdiagnosis. But when SEVA citizens saw how high its rate of ADHD prescribing was, they took decisive action. Through the help of a community coalition of key stakeholders and community movers and shakers, SEVA systematically decreased ADHD treatment by 32 percent while also developing non-drug interventions that improved educational outcomes. Unfortunately, individuals with financial ties to the pharmaceutical industry attacked and derailed the community-based work beyond repair, as first mentioned in Anatomy of an Epidemic by Robert Whitaker and more recently in Deconstructing ADHD, a volume edited by Eric Maisel.
As detailed in Shooting the Messenger: The Case of ADHD, effort was taken to convey to the medical community and the public that the SEVA epidemiologic and intervention research was based on fabricated data to suit an anti-medication agenda and that the research was being conducted without proper informed consent. One of us (Gretchen LeFever Watson) was the lead researcher at the time. Here’s what happened:
The attacks on my credibility culminated in an anonymous false allegation of scientific misconduct. The allegation was leaked to the press and Eastern Virginia Medical School (EVMS) confirmed that one of its faculty members was under investigation for scientific misconduct. A local newspaper reporter began pestering the researcher’s staff and community collaborators and local K-12 school officials about the research and their role in it.
Local pediatricians affiliated with the medical school became increasingly hostile toward me. Pediatric neurologist Dr. Donald Lewis repeatedly threatened me and rebuked me in an email: “repeated news media reports, fueled by your reports, which depict our clinicians as quick-triggered, pill-pushers undermines the credibility of the Children’s Hospital [Children’s Hospital of The King’s Daughters, CHKD, in SEVA] as well as our community partners.” Lewis was one of the principal investigators for an EVMS-affiliated clinical research organization that had contracts with over 40 pharmaceutical companies, including numerous ADHD clinical drug trials. At some point during the investigation, a K-12 school administrator reportedly marched into the medical school dean’s office complaining that they had been misled about consent procedures. This allegation was false, and wholly unsupported by the record.
Fear on the part of medical and school officials of legal action and press scrutiny apparently created an atmosphere in which the self-preservation instinct overcame solid factual analysis. The looming threat of a scandalous newspaper expose about local ADHD research had the potential to become a public relations nightmare. The unsubstantiated claim by a local school administrator was the straw that broke the camel’s back. The medical school placed me on leave without pay, permanently terminated my federally funded research, and promised school officials that my data—which were collected at taxpayer expense and with the expectation of full public dissemination—would never be used for any reason.
Contact with my staff was severed and I was forced to communicate with the medical school through an attorney, which racked up expenses while on leave without pay. Because EVMS terminated my research, the U.S. Centers for Disease Control and Prevention (CDC) asserted that it was forced to severe their cooperative agreement and withdraw grant funding for my portion of a multisite investigation of the prevalence and impact of ADHD—the portion of the study that was also investigating the prevalence and impact of depression, bipolar disorder, obesity, parenting strategies, sleep hygiene, and related health issues. EVMS eventually cleared me of all wrongdoing. However, as an institution that does not offer tenure, it simply failed to renew my contract the following year.
Despite having a copy of official documentation clearing me of scientific misconduct, a local newspaper story was published which implied my ADHD research may have misled the public and “missed the mark.” The ordeal led to the total dismantling of a public health approach to improve ADHD care which had the potential to serve as a national model for reducing overuse of psychotropic drugs while also improving educational and behavioral outcomes among school-aged children. This included cancellation of programs designed to systematically manage behaviorally challenging children, improve school-provider communication, teacher training and education, and parent education and support. It also led to the termination of the nation’s first public health psychology internship—a clinical psychology internship program approved by the American Psychological Association.
That, in a nutshell, is how an originally anonymous, unsubstantiated complaint led to the termination of a very promising line of research.
Imagine if instead of relying on a single faculty member writing and securing grant funding to collect information from research subjects, the work had been overseen by a community task force that monitored data trends captured by EHRs. It would have been much more difficult for people to cancel the work because it conflicted with their financial interests. Today, the latter approach is possible, but first people must be alerted to the fact that there is reason to be concerned about psychotropic overprescription and that EHR data can help to clarify the extent of the problem. This is especially true in places like SEVA, where the healthcare is dominated by one large, integrated healthcare system and a single pediatric hospital and its affiliated practices.
The benefit of hindsight indicates that SEVA was an epicenter, if not the epicenter, for psychotropic overprescription in children. By 2000, data demonstrated that about 19 percent of the region’s elementary school students were medicated for ADHD, with 28 percent of those students on two or more types of psychotropics concurrently. Early on, this unprecedented level of psychotropic prescribing was associated with surprisingly poor educational outcomes. Since then, the most definitive national study of ADHD treatment modalities documented that ADHD drug treatment led to worse outcomes than other options.
In that federally-funded longitudinal study, known as the MTA study, researchers monitored ADHD treatment outcomes among children who were randomly assigned to various treatment modalities. During the initial assessment, stimulant drugs appeared to reduce ADHD symptoms. However, by the 3-year follow-up, children who were taking stimulants had worse outcomes than those who were not.
Stimulants use “was a significant marker […] not of beneficial outcome, but of deterioration. That is, participants using medication in the 24- to 36-month period actually showed increased symptomatology during that interval relative to those not taking medication,” the researchers wrote.
One of the MTA researchers, Dr. William Pelham, has repeatedly sought to convey to the public that, over the long haul, stimulant drugs are not as effective as commonly believed. “We had thought that children medicated longer would have better outcomes. That didn’t happen to be the case. The children had a substantial decrease in their rate of growth, so they weren’t growing as much as other kids in terms of both their height and their weight. And the second was that there were no beneficial effects—none,” he said in a 2007 Daily Telegraph interview.
These results were reinforced by a 2022 study conducted by Pelham and others showing that, while ADHD children taking stimulant medication sat in their seats longer and got more work done in the short run, they did not learn any more academic material than when they were not taking stimulants.
Other research has confirmed the association between stimulant drugs and a deterioration in functioning on both educational and social-emotional measures. Analyzing a massive and longitudinal set of data from children across Canada, a Princeton University professor documented the downside of long-term use of stimulant drugs. Expanding the use of ADHD drug treatment “had little positive benefit and may have had harmful effects given the average way these drugs are used.”
Though not precisely understood, the “mechanism of action of prescription stimulants is not drastically different from that of cocaine and MA [methamphetamine, known also as meth].” Moreover, 70 to 80 percent of all individuals (whether or not they are diagnosed with ADHD) experience an initially favorable response to stimulant medication, according to Dr. Larry Diller, pediatrician, and author of Running on Ritalin. In a PBS interview, Diller explained that people can get a dopamine “rush” from taking a prescription stimulant, cocaine, or methamphetamine. He also noted that few people realized that methamphetamine, which is generally considered dangerously addictive, is listed in Physician’s Desk Reference as a treatment for ADHD, much like stimulants more commonly prescribed (Ritalin, Adderall, Vyvanse, etc.).
“Rates of overdose deaths from psychostimulants [ADHD pills] have been increasing since 2010,” according to the CDC. The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) is now warning of a new wave of addiction stemming from stimulants like Ritalin and Adderall, as well as cocaine and methamphetamine. It is increasingly common for people in drug rehabilitation programs to report that their drug experimentation began with ADHD pills.
In 2018, John Eadie, a project coordinator for the National High Intensity Drug Trafficking Areas, told WebMD, “No one is paying attention to this. Everyone, correctly, is focused on opioids and should be because of the known problem there. But this other problem is catching up with us very rapidly.” According to Eadie, law enforcement agents are seizing fifteen times more kilograms of stimulants than opioids. ADHD prescriptions surged during the COVID-19 pandemic, again raising questions about the appropriateness of ADHD care.
Is it possible that things would have turned out differently for millions of people suffering with substance abuse problems if efforts to publicly report on trends first observed in SEVA had not been quashed by pharmaceutical industry interests? We’ll never know, but the data sitting in EHRs in every U.S. community might offer insights that could make a difference in the future of countless children, families, schools, and communities.
Several organizations have sponsored a petition to raise awareness about the problem of psychotropic overprescription among U.S. children and calls for the potential to use de-identified EHR information to monitor and publicly report psychotropic prescribing rates at the community level. The authors and sponsors of the petition believe community-level reporting could help reverse our society’s tendency to “medicate normal.” An award-winning documentary film with the same title exposes the underappreciated problem of widespread use of psychotropics, especially when used long-term.
How many children in your community are on ADHD drugs or other psychotropics? For those who might be interested, the petition can be found here.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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