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Prevalence of Methylphenidate Use Among Adolescents in Ontario
Abstract
Despite a growing interest in the use of methylphenidate (Ritalin) to treat attention deficit/hyperactivity disorders, prevalence data has been scarce in Canada. A probability school survey conducted in 1997 among Ontario students in grades 7, 9, 11 and 13 is used to collect data on such use. Overall, 3.4% of students (5.3% of males, 1.7% of females) used methylphenidate in the previous year. Rates and patterns are similar to those found in the United States. Future research needs to examine reasons and correlates of use, extent of medical supervision and possible non-medical use of methylphenidate.
... 5,19,20 However, there is much less data among Canadian children. Several studies have examined psychotropic drug use on a provincial level, including data from BC, 22 Ontario, 23 and MB, 24,25 although most of the studies to date have focused exclusively on methylphenidate use. 3,4,22,23 Despite this growing body of research concerning the use of psychotropics in children, few studies have examined geographical differences in drug use within this population. ...
... Several studies have examined psychotropic drug use on a provincial level, including data from BC, 22 Ontario, 23 and MB, 24,25 although most of the studies to date have focused exclusively on methylphenidate use. 3,4,22,23 Despite this growing body of research concerning the use of psychotropics in children, few studies have examined geographical differences in drug use within this population. Further, studies of regional variation have generally limited their scope of analysis to one province or state, 14,22,24,26 focused only on usage in urban or suburban settings, 27 or have confined their analysis to a narrow population based on insurance coverage. ...
We used population-based administrative prescription medication data to examine regional differences in psychostimulant and antidepressant (AD) use among children from 2 Canadian provinces: British Columbia (BC) and Manitoba (MB).
Using 1997 to 2003 prescription data, annual rates of psychostimulant and AD use were determined for children aged 19 years and under in both provinces. Further comparisons of rates were made according to sex, age group, and specific classes of dispensed medications.
During 1997 to 2003, psychostimulant use rose by 44.9% in MB and 13.3% in BC. Among male children, psychostimulant use increased by 40.2% in MB, compared with an increase of only 8.6% in BC. AD utilization was similar between provinces, with increases of 80% and 75% in MB and BC, respectively. In both provinces, AD use was highest among older children.
Our observations of regional variation in psychotropic medication use potentially reflect provincial differences in drug benefit policies, disease prevalence, and (or) physician diagnosis and treatment.
... CPRS-R (32) and drug side effects were assessed at baseline and by weekly telephone calls thereafter, in the subjects. CSI, CGI, and CGAS were completed at baseline and at the end of the 4 th and 6 th weeks of the study ...
Objective: To compare the effectiveness and safety of the methylphenidate produced in Iran (Stimdate®) with its original brand (Ritalin®) in children with Attention deficit hyperactivity disorder (ADHD).
Methods: In this double-blinded randomized clinical trial, 30 patients with ADHD who were 6 to 16 years old, were divided into two groups: 15 in Stimdate® and 15 in Ritalin® group. The two groups were compared for side effects profile, Conner’s Parent’s Rating Scale-Persion version (CPRS-R), Child Symptom Inventory-4 (CSI-4), Clinical Global Impressions (CGI), and Children’s Global Assessment Scale (CGAS), at baseline and at the 4th and 6th weeks.
Results: The subjects showed significant decreases in the CPRS-Rand CSI-4 scores and significant increase of CGAS scores during the follow-up, but there were no significant difference between Stimdate® and Ritalin® group, regarding the pattern of changes observed. The mean therapeutic dose and the number of side effects were not significantly different between the two studied groups.
Conclusions: Both Stimdate® and Ritalin® had comparable clinical efficacy and safety in children with ADHD.
... These calculated figures are modestly higher than published reports (11)(12)(13)(14) of methylphenidate use in Canadian youth, but the message is quite clear and significant. ...
... Contrary to data used by the newspaper, we found that methylphenidate use in 1998 was either lower than or consistent with numbers previously reported for other North American jurisdictions. 2,3 Overall, methylphenidate was prescribed to 1% of BC residents aged 19 years of age and younger. Use was highest in the 10-to 14-year age group (2.1%). ...
... Methylphenidate (MPH) is commonly prescribed for the treatment of attention deficit hyperactivity disorder (ADHD), with hundreds of trials demonstrating efficacy in managing the disorder in children and adults (Elia et al. 1999; Goldman et al. 1998). Consequent increases in use of MPH in both the USA and other countries have led to significant controversy regarding the abuse, misuse, and diversion of MPH (Berbatis et al. 2002; Fogelman and Kahan 2001; Ivis and Adlaf 1999; Lin et al. 2005; Robison et al. 1999; Romano et al. 2002; Safer et al. 1996; Zito et al. 2000). MPH has high potential for abuse and is considered a schedule II drug by the Drug Enforcement Administration. ...
There has been controversy over the abuse potential of methylphenidate (MPH) in the context of treatment for attention deficit hyperactivity disorder (ADHD).
The objective of this study was to compare the reinforcing and subjective effects of oral MPH in adults with and without ADHD.
Following screening, 33 adults (n = 16 with ADHD; n = 17 free from psychiatric diagnoses) completed four pairs of experimental sessions, each of which included a sampling session and a self-administration session. During sampling sessions, subjects received in randomized order 0 (placebo), 20, 40, and 60 mg MPH. During self-administration sessions, subjects completed a progressive ratio (PR) task to earn portions of the dose received on the corresponding sampling session. Subjective effects were recorded throughout all sessions. The main outcome measure for the study was the number of ratios completed on the PR task. Secondary measures included peak subjective effects and area-under-the-curve values for subjective effects.
Compared to the control group, the ADHD group completed more ratios on the PR task. Both groups showed robust effects of methylphenidate on subjective endpoints. Main effects of group were noted on subjective effects involving concentration and arousal.
Compared to placebo, MPH produced reinforcing effects only for the ADHD group and not for the control group. Increases in stimulant-related subjective effects in non-ADHD subjects were not associated with drug reinforcement.
Using data from the Statistics Canada National Longitudinal Survey of Children and Youth (NLSCY), this paper investigates the impact of school entry age on inattentive/hyperactive behaviours. We employ both an across-provinces and time difference-in-differences approach and a within-province regression discontinuity design. We find that being young in class causes greater inattentive/hyperactive behaviour, exacerbating any inattentive/hyperactive behaviour exhibited prior to school entry. These results also hold in sibling fixed effect models. We do not find gender differences in the effects, although since boys are more likely to be inattentive/hyperactive at school entry, they are more affected. These effects persist into early adolescence. Âge d'entrée à l'école : impact sur les comportements d'inattention et d'hyperactivité des garçons et des filles au Canada. Nous utilisons les données de l'Enquête longitudinale nationale sur les enfants et les jeunes (ELNEJ) pour étudier l'impact de l'âge d'entrée à l'école sur les comportements d'inattention et d'hyperactivité. Nous tirons avantage des différences interprovinciales, qui varient dans le temps, dans le cadre d'une approche de différences-en-différences, et nous utilisons aussi des régressions de discontinuité à l'intérieur des provinces. Nos résultats démontrent qu'être relativement jeune dans la classe augmente les comportements inattentifs et hyperactifs, spécialement chez les jeunes déjà inattentifs/hyperactifs avant l'entrée à l'école. Ces résultats tiennent également dans des modèles à effets fixes familiaux. Bien que les effets ne soient pas différents entre garçons et filles, parce que les garçons sont plus susceptibles d'être inattentifs/hyperactifs avant d'entrer à l'école, ils sont aussi les plus touchés. Ces effets persistent en début d'adolescence.
The action of Ginkgo biloba (Ginkgarom®) was investigated in 50 hyperactive children (attention deficit hyperactivity disorder, ADHD) aged from 2 to 13 years. The diagnosis of ADHD was based on the DSM-IV Criteria of the American Psychiatric Association as well as on a basal value of the Conners Global Index CGI of 14 or more. The CGI was also used as the evaluation instrument and was assessed by the parents of the patients before and at the end of a 4-week treatment period. The evaluation data from 25 ADHD-children treated with Ritalin® were used for comparison of its efficacy with that of methylphenidate (MPH). Results: 28 of the 50 children (56%) responded well to Ginkgo biloba and achieved a mean improvement of 47% in the CGI rating, whereas 18 children (36%) reacted inadequately with a mean 6% improvement of the CGI. In 4 children (8%) there was a deterioration of 15% on average of the CGI. On comparison of the profile of action of Ginkgo biloba and methylphenidate, it was found that Ginkgo biloba had a greater effect on excitability, frustration tolerance and mood than MPH, whereas the latter primarily improved concentration and restlessness. Difficulty in getting to sleep in one patient was the only adverse effect observed in the Ginkgo biloba group. The herbal taste of the drug led to compliance problems in a few children.
This literature review focuses on the use of psychotropic medication among youths. In a global context where psychiatry, genetics and neurosciences are booming, it is imperative to re-examine the policies, guidelines and clinical settings that determine the prescription of psychotropic medication to children and adolescents. The relevant issues are first discussed from an epidemiological standpoint. Official documents exposing the major principles put forth by Québec ministries are then reviewed. Subsequently, the cautions regarding medication and the calls for multimodal/multidisciplinary interventions that characterize these official documents are compared to the incessant growth in the rates of prescription and polyprescription. In order to shed some light on this discrepancy, we refer to the "medication optimal usage" paradigm. To define a larger problem relating to the use of psychotropic medication, three elements are considered: a) the ambiguity of diagnostic markers; b) the tendency to dissociate the pharmacoprescription from the diagnosis of a mental disorder; and c) the growing complexity associated with multimodal treatments. There is also a possible discrepancy between the government's current views, and the significant breakthroughs of the neurosciences in psychiatry and in other areas. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
1) To consider study designs for evaluating how appropriately stimulant medications are prescribed to children. 2) To investigate appropriateness by seeking evidence of consensus around how stimulant management should be undertaken, collecting and reviewing evidence of actual physician practice in relation to use of stimulants, and evaluating the closeness of fit between recommended and actual practice.
Electronic databases and other published and unpublished material were searched for the decade 1987-1997 to identify 1) authoritative recommendations for medical management of attention-deficit hyperactivity disorder (ADHD) and 2) surveys of physician practice. Available information was analyzed qualitatively for commonalities and trends and for concordance between recommendations and practice.
Despite differences in emphasis between experts, common themes were identifiable regarding prerequisites and follow-up for use of stimulants. Overall, it was rare to find physician practice in accordance with expert recommendations more than 70% of the time, suggesting that management may be suboptimal in at least 30% of children treated with medication for ADHD. Across surveys, consistent differences appear in physician practice patterns related to practice type. Management by specialist consultants approximates standards recommended by experts, while management by primary care practitioners diverges from these standards.
There are grounds for concern about the quality and appropriateness of medical management for children with ADHD. The methodology used in this study holds promise for wider application, with planning and refinement. There is a need to find ways to improve care for children with ADHD provided by primary care physicians.
The use of stimulants in the treatment of AD/HD has increased dramatically over the last twenty years. We wanted to assess the prevalence of students treated with stimulants in the elementary schools in the city of Trondheim, Norway.
Fifty of 53 schools (94%), representing 16,141 students, answered two questionnaires. Mentally retarded, autistic and otherwise severely handicapped students attending special groups or schools, were excluded.
In all, 57 students (3.5 per 1,000) were treated with either methylphenidate or racemic amphetamine. Multivariate analysis suggested that the structure of the classroom was an essential risk factor for being treated with stimulants. The risk was higher in so-called "open schools" (no fixed walls between groups of students) than in schools with traditional classrooms (< 30 students in rooms separated by fixed walls). (Odds ratio: 5.5; 95% confidence interval: 1.1-26.4.) More detailed information was obtained from 47 of the 57 students; only one of whom was female. Teaching resources required for optimal pedagogical treatment were available for about one out of two of these 47 students.
Our results do not suggest that an inappropriately high proportion of students in the region are taking stimulants for AD/HD. On the contrary, AD/HD may be underdiagnosed and inadequately treated in girls. It seems likely that students with AD/HD are less likely to be treated with stimulants in schools with traditional classrooms, and our results also suggest a lack of teaching resources for these students.
The sharp increase of the prescription of methylphenidate (MPD) in hyperactive children in recent years is a matter of increasing uneasiness among professionals, parents and politicians. There is little awareness of treatment alternatives. The purpose of this prospective trial was to assess the efficacy of homeopathy in hyperactive patients and to compare it MPD. The study was performed in a paediatric practice with conventional and homeopathic backgrounds. Children aged 3-17 y, conforming to the DSM-IV criteria for attention deficit hyperactivity disorder (ADHD) with a Conners Global Index (CGI) of 14 or higher were eligible for the study. All of them received an individual homeopathic treatment. When clinical improvement reached 50%, the parents were asked to reevaluate the symptoms. Those who did not improve sufficiently on homeopathy were changed to MPD, and again evaluated after 3 months. One hundred and fifteen children (92 boys, 23 girls) with a mean age of 8.3 y at diagnosis were included in the study. Prior to treatment the mean CGI was 20.63 (14-30), the mean index of the homeopathy group 20.52 and of the MPD-group 20.94. After an average treatment time of 3.5 months 86 children (75%) had responded to homeopathy, reaching a clinical improvement rating of 73% and an amelioration of the CGI of 55%. Twenty-five children (22%) needed MPD; the average duration of homeopathic (pre-) treatment in this group was 22 months. Clinical improvement under MPD reached 65%, the lowering of the CGI 48%. Three children did not respond to homeopathy nor to MPD, and one left the study. In cases where treatment of a hyperactive child is not urgent, homeopathy is a valuable alternative to MPD. The reported results of homeopathic treatment appear to be similar to the effects of MPD. Only children who did not reach the high level of sensory integration for school had to be changed to MPD. In preschoolers, homeopathy appears a particularly useful treatment for ADHD.
There are concerns about the frequency and appropriateness of psychostimulant drug prescription to children. In order to identify unusual or unexpected patterns of use or prescribing, we reviewed prescription of methylphenidate (Ritalin) to children and adolescents aged 19 years or less in British Columbia between 1990 and 1996.
We obtained information about patients, physicians and prescriptions from British Columbia's Triplicate Prescription Program database for controlled drugs. Prescription data were available for the period Jan. 1, 1990, to Dec. 31, 1996. Linkage with the BC Linked Health Dataset provided additional demographic and health information.
In 1990, 1715 children received at least 1 prescription for methylphenidate (1.9 per 1000 children). By 1996, the number had increased to 10,881 children (11.0 per 1000). Because some children were prescribed methylphenidate in more than 1 year, we also calculated the frequency with which the drug was prescribed to children who had never received it before. This rate increased from 1.0 per 1000 children in 1990 to 4.7 per 1000 in 1995; the rate fell in 1996 to 3.5 per 1000. The number of children receiving methylphenidate varied across health regions of the province, from 12.0 to 35.4 per 1000. Use also varied by socioeconomic status quintile: in the 2 lowest (least privileged) quintiles, 21.6 per 1000 children received methylphenidate, compared with 18.4 per 1000 in the 3 highest quintiles (relative risk 1.2, 95% confidence interval 1.1-1.2). Pediatricians and psychiatrists wrote 23% and 21% of all prescriptions respectively. General practitioners accounted for 56% of all prescriptions and 41% of initial methylphenidate prescriptions. A claim for prior specialist consultation was found in 30% of such cases. Many of the children who received more than 10 prescriptions had seen 4 or more physicians. The average daily dosage prescribed differed little among general practitioners, pediatricians and psychiatrists, unlike the mean interval between successive prescriptions: 89.9 (standard deviation [SD] 68.2), 99.8 (SD 64.1) and 75.9 (SD 70.2) days respectively. Persistence with therapy was more likely when a psychiatrist provided the initial prescription, or with involvement of more than one specialty.
Many trends and practices in the prescription of methylphenidate to children in British Columbia are consistent with other settings and accepted standards. Some aspects warrant closer investigation, including regional and socio-economic discrepancies in the distribution of patients, the relative involvement of primary and specialist care providers, continuity of care issues and time intervals between prescriptions.
To examine changes in the full spectrum of psychotropic medication treatment for youths from 1987 to 1996.
A population-based analysis of community treatment data on nearly 900,000 youths enrolled in 2 US health care systems included (1) computerized Medicaid data from 2 states (a midwestern state and a mid-Atlantic state) composed of outpatient prescription claims and enrollment records and (2) computerized prescription dispensing records from a group-model health maintenance organization. Ten 1-year cross-sectional data sets from 1987 through 1996 were analyzed.
Total psychotropic medication prevalence for youths increased 2- to 3-fold and included most classes of medication. The rapid growth since 1991 of alpha-agonists, neuroleptics, and "mood stabilizer" anticonvulsants was particularly notable. The 1996 prevalence of any psychotropic medication among youths younger than 20 years was remarkably similar (5.9%-6.3%) across all 3 sites, with stimulants and antidepressants consistently ranked first and second. Medicaid rates almost always exceeded health maintenance organization rates by large margins, particularly for alpha-agonists, neuroleptics, "mood stabilizer" anticonvulsants, and lithium. Youths in health maintenance organizations had rates similar to Medicaid-insured youths for antidepressants and hypnotics. Over the decade, there was a proportional increase in females receiving stimulants and in males receiving antidepressants, particularly for the 10- to 14-year-old group. The prevalence ratios of whites to African Americans narrowed substantially in 1 Medicaid site.
Youth psychotropic treatment utilization during the 1990s nearly reached adult utilization rates. Youth findings can be used to accurately assess the duration of treatment and unforeseen practice pattern changes, and to identify safety concerns.
This study aimed to estimate the prevalence of methylphenidate (MPH) use among Canadian children aged 2 to 11 years, from 1994-1995 to 1998-1999 and to identify sociodemographic, child, and parent-family correlates are identified.
Cross-sectional data collections from the National Longitudinal Survey of Children and Youth (NLSCY) for 1994-1995, 1996-1997, and 1998-1999 were used and samples weighted up to population levels (n=17,814 in 1994-1995, 13,575 in 1996-1997, and 18,980 in 1998-1999). Logistic regression identified correlates of parent-reported MPH use in each time period.
MPH use by Canadian children increased from 1.33% (95% confidence interval [CI], 1.17% to 1.50%) in 1994-1995 to 1.60% (95% CI, 1.42% to 1.78%) in 1998-1999. Use among school children aged 6 to 11 years increased from 1.94% (95% CI, 1.68% to 2.20%) in 1994-1995 to 2.42% (95% CI, 2.14% to 2.71%) in 1998-1999. Use of MPH increased among girls, from 0.52% (95% CI, 0.32% to 0.67%) in 1994-1995 to 0.97% (95% CI, 0.77% to 1.17%) in 1998-1999. For a child with parent-reported hyperactivity, the odds ratios for using MPH were 6.30 (95% CI, 4.94 to 8.90) in 1994-1995 and 12.54 (95% CI, 9.74 to 16.16) in 1998-1999. Age 6 to 11 years, male sex, and absence of parental alcohol use were significant correlates of MPH use in all time periods. Parental smoking correlated with MPH use in 1994-1995 and in 1998-1999.
Less than 2% of Canadian children used MPH between 1994 and 1999. Some increase in use occurred among school-aged children and girls. Parent-reported hyperactivity was the most important correlate of MPH use.
The authors explored parents' perceptions of and everyday experiences with the stimulant medication used to treat their child's attention deficit hyperactivity disorder (ADHD) in this phenomenological study. They elicited experiences through semistructured interviews with 10 Canadian parents of children with ADHD. In the interviews, parents revealed the meaning the stimulant medication had taken on in the context of their everyday lives. Through the interview analysis, dilemma emerged as the dominant theme. Parents were caught in a dynamic balancing act, as they considered the medication's desirable and undesirable effects in various settings. In addition, parents shared their expectations regarding the medication's role in their child's future. The study's findings reinforce the necessity of further qualitative research in this area, given the growing number of families around the globe whose children have been diagnosed with ADHD.
To the Editor: Attention deficit–hyperactivity disorder (ADHD) is considered to be the most common neurobehavioral disorder of childhood,1 but there are no firm estimates of its prevalence. Dramatic increases have been reported in the frequency of the diagnosis of ADHD and the prescription of methylphenidate,2 a stimulant drug used for decades to treat this disorder,3 but these increases have not been verified. We used a commercial data base on physicians' diagnosis and prescription practices4 to estimate the frequency of the diagnosis and treatment of ADHD, and a United Nations report on Schedule II drugs5 to document the production rate of . . .
Objective. To estimate the increased use and the prevalence of methylphenidate (Ritalin) treatment of youth with attention deficit disorder (ADD) during the 1990s.
Design. Using time-trend findings from two large population-based data sources, three pharmaceutical databases, and one physician audit, a best-fit estimate of the usage and the usage trends for methylphenidate treatment over the half decade from 1990 through 1995 was sought.
Setting. Five regions in the United States (US) and the nation as a whole.
Patients. Youths on record as receiving methylphenidate for ADD.
Results. The findings from regional and national databases indicate that on average, there has been a 2.5-fold increase in the prevalence of methylphenidate treatment of youths with ADD between 1990 and 1995. In all, approximately 2.8% (or 1.5 million) of US youths aged 5 to 18 were receiving this medication in mid-1995. The increase in methylphenidate treatment for ADD appears largely related to an increased duration of treatment; more girls, adolescents, and inattentive youths on the medication; and a recently improved public image of this medication treatment.
Conclusion. The database findings presented serve to correct exaggerated media claims of a 6-fold expansion of methylphenidate treatment, although they do not clarify the issue of the appropriateness of this treatment.
Objective.
—To enumerate and evaluate changes in the rate of medication treatment for hyperactive/inattentive students subsequent to negative media publicity about methylphenidate (Ritalin) and related lawsuits threatened or initiated from late 1987 to early 1989.Design.
—Biennial 1971 to 1991 school nurse surveys of medication treatment for hyperactive/inattentive students; a 1989 school nurse questionnaire on parent attitudes about medication; annual 1984 through 1991 hyperkinetic clinic treatment data; annual 1986 through 1990 Drug Enforcement Administration estimates of retail sales of methylphenidate, nationally and locally.Primary Setting.
—All public and private elementary and secondary schools in Baltimore County, Maryland.Patients.
—Students receiving medication for hyperactivity/inattentiveness.Results.
—Whereas the medication rate for the treatment of hyperactive/ inattentive students in Baltimore County doubled every 4 to 7 years from 1971 through 1987, it declined 39% in the 1989 and 1991 surveys from its 1987 peak. This drop occurred after the 1987 through 1989 media blitz against methylphenidate and after a well-publicized threatened lawsuit locally. Parents became fearful of media-reported medication "side effects" and school staff hesitated to refer restless, impulsive, and inattentive students to physicians. Most inhibited from the prospect of medication treatment were less affluent parents and parents of hyperactive/inattentive elementary schoolchildren who had never received medication. Drug Enforcement Administration data revealed that the Baltimore metropolitan area had a far greater decline in methylphenidate use than that which occurred nationally.Conclusion.
—Strong circumstantial evidence suggests that the prominent 1989 and 1991 declines in the initiation of stimulant medication for hyperactive/inattentive students were related to the apprehension of parents and involved professionals generated by the methylphenidate media blitz and the threatened lawsuit.(JAMA. 1992;268:1004-1007)
Attention-deficit hyperactivity disorder (ADHD) represents one of the most common and serious neurobehavioral disorders of childhood, affecting children from early childhood into adult life. The cardinal clinical characteristics of the disorder, inattention and, at times, impulsivity and hyperactivity, may interfere with the child's adjustment in every phase of existence, both through time and across experiences. Though its etiology may involve environmental influences,1 evidence from a number of lines of investigation suggests that biologic factors play an important role in a significant number of cases (S.E.S. and B.A.S., in press).
The entity we today label ADHD has undergone multiple transformations over the past century. Some of these are semantic; others, however, are more substantive and reveal significant changes in our understanding of the disorder. Review of the evolution of these changes provides important insights into the current conceptualizations of the disorder.
The origins of ADHD can be traced to the
Since 1971, the Baltimore County Health Department has conducted nine biannual surveys of school nurses in all of the county's public and private schools to determine the prevalence of medication treatment for hyperactivity/inattentiveness among students. The results reveal a consistent doubling of the rate of medication treatment for hyperactive/inattentive students every four to seven years such that in 1987,5.96% of all public elementary school students were receiving such treatment. Related trends from 1971 to 1987 have been that stimulants increased from 76% to 99% of the medication prescribed; methylphenidate hydrochloride rose from 40% to 93% of the total; the male-female ratio dropped from an average of 8:1 to 5:1; the rate of medication treatment for hyperactive/inattentive students rose faster in secondary than in elementary schools; and 25% of students receiving stimulant medication in 1987 were in special education classes or schools.
(JAMA 1988;260:2256-2258)
To enumerate and evaluate changes in the rate of medication treatment for hyperactive/inattentive students subsequent to negative media publicity about methylphenidate (Ritalin) and related lawsuits threatened or initiated from late 1987 to early 1989.
Biennial 1971 to 1991 school nurse surveys of medication treatment for hyperactive/inattentive students; a 1989 school nurse questionnaire on parent attitudes about medication; annual 1984 through 1991 hyperkinetic clinic treatment data; annual 1986 through 1990 Drug Enforcement Administration estimates of retail sales of methylphenidate, nationally and locally. PRIMARY SETTING: All public and private elementary and secondary schools in Baltimore County, Maryland.
Students receiving medication for hyperactivity/inattentiveness.
Whereas the medication rate for the treatment of hyperactive/inattentive students in Baltimore County doubled every 4 to 7 years from 1971 through 1987, it declined 39% in the 1989 and 1991 surveys from its 1987 peak. This drop occurred after the 1987 through 1989 media blitz against methylphenidate and after a well-publicized threatened lawsuit locally. Parents became fearful of media-reported medication "side effects" and school staff hesitated to refer restless, impulsive, and inattentive students to physicians. Most inhibited from the prospect of medication treatment were less affluent parents and parents of hyperactive/inattentive elementary schoolchildren who had never received medication. Drug Enforcement Administration data revealed that the Baltimore metropolitan area had a far greater decline in methylphenidate use than that which occurred nationally.
Strong circumstantial evidence suggests that the prominent 1989 and 1991 declines in the initiation of stimulant medication for hyperactive/inattentive students were related to the apprehension of parents and involved professionals generated by the methylphenidate media blitz and the threatened lawsuit.
Data are presented from a case series of 22 patients who abused methylphenidate hydrochloride (Ritalin-SR). The abuse pattern and symptoms of toxicity were similar to that seen with cocaine hydrochloride and amphetamine sulfate addiction; yet, the morbidity and mortality seen in this case series were greater than usual for a group of patients involved in intravenous drug abuse. We describe the characteristics of the methylphenidate abuse syndrome in terms of the pharmacology of methylphenidate, the constituents of the Ritalin-SR preparation, and the disease of chemical dependence. We propose solutions to the problem of methylphenidate abuse.
Treatment of attention deficit hyperactivity disorder (ADHD), one of the most common behavioral disorders in children in the United States, remains controversial because of concern about stimulant medication use. Extending a previous study of pediatricians, the present study surveyed a random national sample of family practitioners and then directly screened 457 patients of 10 pediatricians and family practitioners in two small midwestern cities. Responses to the national survey indicated that stimulant medication remains the main treatment prescribed by primary care physicians for children with ADHD. In the direct patient screening, the prevalence of ADHD diagnoses was 5.3% (pediatricians) and 4.2% (family practitioners) of all elementary-school-aged children screened. Eighty-eight percent of these children were treated with methylphenidate. Although medication was considered an effective treatment by the parents of 85% of the children given the medication, efficacy was unrelated to the accuracy of diagnosis. When explicit DSM-III-R criteria were used, only 72% of those assigned a diagnosis of ADHD by the physicians would have received that diagnosis based on a structured psychiatric interview with the parents and only 53% received that diagnosis based on teacher report of symptoms, even when the child was not receiving medication. Although the majority of physicians (in both the surveys and the direct screenings) reported using at least some behavioral treatments with their patients, parents reported infrequent use of nonpharmacologic forms of therapy, such as behavior modification. These data thus indicate a relatively modest rate of stimulant medication use for ADHD, but a serious underuse of systematic behavioral treatments in primary care.(ABSTRACT TRUNCATED AT 250 WORDS)
Since 1971, the Baltimore County Health Department has conducted nine biannual surveys of school nurses in all of the county's public and private schools to determine the prevalence of medication treatment for hyperactivity/inattentiveness among students. The results reveal a consistent doubling of the rate of medication treatment for hyperactive/inattentive students every four to seven years such that in 1987, 5.96% of all public elementary school students were receiving such treatment. Related trends from 1971 to 1987 have been that stimulants increased from 76% to 99% of the medication prescribed; methylphenidate hydrochloride rose from 40% to 93% of the total; the male-female ratio dropped from an average of 8:1 to 5:1; the rate of medication treatment for hyperactive/inattentive students rose faster in secondary than in elementary schools; and 25% of students receiving stimulant medication in 1987 were in special education classes or schools.
The nature and psychophysiological effects of methylphenidate whose metabolism, pharmacokinetics, and effects on human behavior are not well known are the focus of this review. Methylphenidate treatment of attention deficit disorder with hyperactivity is presented summarily.
A WAVE OF ADVERSE publicity involving methylphenidate hydrochloride (Ritalin), a drug that has been used for more than 30 years to treat children and adults with attention-deficit hyperactivity disorder, has created concern that public opinion may eventually affect medical practice.
There appears to be growing belief on the part of some of the public that the drug has dangerous side effects, that schools want to have it prescribed, and that psychiatrists are eager to label children as having a condition that may not even exist. Among the recent developments:
A suit was filed in Georgia against a public school district and against the American Psychiatric Association.
At least eight medical malpractice suits have been filed, five of them recently in Massachusetts.
The defense attorney for a 15-year-old youth convicted of killing a classmate with a baseball bat argued that his client's behavior may have been affected by taking methylphenidate.
All
We studied the six-month prevalence of four child psychiatric disorders (conduct disorder, hyperactivity, emotional disorder, and somatization) and patterns of service utilization for mental health and social services, ambulatory medical care and special education by different regions of Ontario, urban-rural residence, and age and sex groupings. Among children 4 to 16 years of age, the overall six-month prevalence rate of one or more of these disorders was 18.1%. The prevalences of hyperactivity and one or more disorders were significantly higher in urban areas than rural areas. The utilization data indicated that children with these psychiatric disorders, compared with children without these disorders, were almost four times more likely to have received mental health or social services in the six months preceding this study. However, five of six of these children had not received these specialized services in the previous six-month period. Over 50% of the children in the province had received ambulatory medical care in the last six months. Over 15% of the children in the province had received special education services at some time thus far in their school careers. Implications of these findings, especially for the provision of child mental health services, are discussed.
A review of the literature suggests that serious complications are to be expected from frequent abuse of Methylphenidate (Ritalin) particularly if administered I.V. Treatment personnel have also suggested complicating factors surrounding the abuse of Ritalin during outpatient treatment for opiate dependency.
A consecutive series of admissions (n=111) to a comprehensive Drug Services program is examined for their use of Ritalin. Special attention is given to history of use, means of supply, and adverse consequences associated with the abuse of this substance. Adverse reactions (client’s definition) occurred in nearly 30 percent of the user group. Recommendations for treatment and prevention will be summarized based on the project findings.
To examine pediatricians' knowledge and attitudes concerning the diagnosis and treatment of attention deficit disorder (ADD) and attention-deficit hyperactivity disorders (ADHD).
Cross-sectional survey.
United States.
Three hundred eighty pediatricians comprising respondents from a random sample of 1000 members of the American Academy of Pediatrics.
None.
Pediatricians' perceptions of diagnostic modalities, child and family communication concerning ADD and ADHD diagnosis and treatment, and a variety of treatment issues were assessed in this study. Findings indicate that methylphenidate (Ritalin) hydrochloride is the most prescribed medication for treatment of ADD and ADHD. Pediatricians reported common parent and child misperceptions about ADD and ADHD treatment. Results suggest a wide range of reported physician behavior with respect to the diagnosis and treatment of ADD and ADHD.
Greater attention could be paid to providing accurate information in medical and educator training with respect to the cause, diagnosis, and treatment of ADD and ADHD.
To estimate the increased use and the prevalence of methylphenidate (Ritalin) treatment of youth with attention deficit disorder (ADD) during the 1990s.
Using time-trend findings from two large population-based data sources, three pharmaceutical databases, and one physician audit, a best-fit estimate of the usage and the usage trends for methylphenidate treatment over the half decade from 1990 through 1995 was sought.
Five regions in the United States (US) and the nation as a whole.
Youths on record as receiving methylphenidate for ADD.
The findings from regional and national databases indicate that on average, there has been a 2.5-fold increase in the prevalence of methylphenidate treatment of youths with ADD between 1990 and 1995. In all, approximately 2.8% (or 1.5 million) of US youths aged 5 to 18 were receiving this medication in mid-1995. The increase in methylphenidate treatment for ADD appears largely related to an increased duration of treatment; more girls, adolescents, and inattentive youths on the medication; and a recently improved public image of this medication treatment.
The database findings presented serve to correct exaggerated media claims of a 6-fold expansion of methylphenidate treatment, although they do not clarify the issue of the appropriateness of this treatment.
Ontario Child Health Study II. Six-month prevalence of disorder and rates of service utilization
- D R Offord
- M H Boyle
- P Szatmari
- DR Offord
Nova Scotia Student Drug Use
- C Poulin
- B Wilbur
Stimulant medication use by primary care physicians in the treatment of attention deficit hyper-activity disorder
- M L Wolraich
- S Lindgren
- A Stromquist
- ML Wolraich
Ontario Student Drug Use Survey: 1977-1995. Toronto: Addiction Research Foundation
- E M Adlaf
- F J Ivis
- R G Smart
- G W Walsh
Ontario Student Drug Use Survey: 1977-1997. Toronto: Addiction Research Foundation
- E M Adlaf
- F J Ivis
- R G Smart