new low for stimulants

[Igor4sugry]

Anyone see this article on NYTimes. http://www.nytimes.com/2014/05/17/u...rder-diagnoses-in-2-and-3-year-olds.html?_r=0

They decided to look at medicaid data in Georgia and found 10k 2-3yo children prescribed Adderall or Ritalin. I know we had an issue with antipsychotics overprescribed to medicaid population, but this is now way out of line prescribing. I was shocked, but not too surprised, seeing how many kids are on stimulants. I for one feel the driver is related to the way school testing is set-up and in kids who have ADHD diagnosis are not counted in standardized tests. More and more docs are comfortable with stimulants, and the threshhold for risk versus benefit is becoming lower and so they are tried on stimulants in same was as say Ibuprofen or Pepcid.
I also feel that in general antipsychotics and stimulants are prescribed like candy to kids.

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[michaelrack]

I don't know much about kids, but chronic ibuprofen use can cause just as much problems as stimulant use in adults.

 

[shan564]

I don't know much about kids, but chronic ibuprofen use can cause just as much problems as stimulant use in adults.

But ibuprofen isn't addictive.

 

[Shikima]

But ibuprofen isn't addictive.

But the rebound HA prevention is.

 

[freaker]

But ibuprofen isn't addictive.

How many individuals have you seen who are actually addicted to stimulants? I've admitted a grand total of 2 individuals to the inpatient unit who were experiencing hallucinations from prescribed stimulants, but I see them as far more drugs of abuse than of dependence. The number of opiate and benzo addictions dwarfs those who are addicted to stimulants multiple folds over from my personal experience.

No, physicians have no business in my estimation be prescribing stimulants to 2 and 3-year olds. Only rarely in 4-year olds. That said, I see ADHD as a very under-treated illness that has a major societal cost associated with it, and it seems interesting to me that stimulants in general get such a bad rap. Stimulants probably have the largest effects size of any medication we have in psychiatry when used to treat kids with ADHD. There's just nothing that comes close.

 

[MacDonaldTriad]

Most Child and Adolescent psychiatrists I know tell me that ADHD is the most undertreated and over treated illness in psychiatry. This is not a contradiction if we are treating only a small fraction of kids with ADHD, and over half of the children on stimulants don’t have ADHD. It is really quite sad. Parents or teachers decide a child needs a stimulant, if the psychiatrist disagrees, they find one that agrees with them. I don’t know how true this is, really not my field, I’m just repeating what colleagues tell me.

 

[notdeadyet]

Most Child and Adolescent psychiatrists I know tell me that ADHD is the most undertreated and over treated illness in psychiatry.

I've heard this as well.

I worry that stimulant prescriptions has started veering towards the idea of cosmetic psychiatry. I'd be very curious to see the data on prevalence of stimulant prescription by socioeconomic class of patient. I'd also be curious to see prevalence of stimulant prescription by county child folks vs. cash only private pay child folks.

 

[BobbyB]

Anyone see this article on NYTimes. http://www.nytimes.com/2014/05/17/u...rder-diagnoses-in-2-and-3-year-olds.html?_r=0

They decided to look at medicaid data in Georgia and found 10k 2-3yo children prescribed Adderall or Ritalin. I know we had an issue with antipsychotics overprescribed to medicaid population, but this is now way out of line prescribing. I was shocked, but not too surprised, seeing how many kids are on stimulants. I for one feel the driver is related to the way school testing is set-up and in kids who have ADHD diagnosis are not counted in standardized tests. More and more docs are comfortable with stimulants, and the threshhold for risk versus benefit is becoming lower and so they are tried on stimulants in same was as say Ibuprofen or Pepcid.
I also feel that in general antipsychotics and stimulants are prescribed like candy to kids.

who is prescribing them? Psychiatrist/FM/NP?

 

[michaelrack]

But ibuprofen isn't addictive.

agree, but it can cause bleeding ulcers, perforated GI tract, renal failure, htn- as well as increase the risk of Myocardial infarction

 

[shan564]

agree, but it can cause bleeding ulcers, perforated GI tract, renal failure, htn- as well as increase the risk of Myocardial infarction

Yeah, but it's a different issue altogether. Every drug has a risk-benefit ratio that you have to consider.

 

[michaelrack]

Yeah, but it's a different issue altogether. Every drug has a risk-benefit ratio that you have to consider.

While it is true that every drug has risks, I argue that the risk of ibuprofen is as high as that of stimulants (although the risk is of a different type). I was responding to this statement:

"the threshhold for risk versus benefit is becoming lower and so they are tried on stimulants in same was as say Ibuprofen or Pepcid"

 

[shan564]

Oh I see, whoops. I missed that connection.

 

[slappy]

Parents or teachers decide a child needs a stimulant, if the psychiatrist disagrees, they find one that agrees with them.

This. If only we could push for legislature mandating all physicians to report such overbearing parents to CPS so they'd keep track.

 

[whopper]

With the recent FDA approval of EEG-based diagnosis of ADHD, I'm hoping it's going to lead more doctors using more objective methods to diagnose ADHD. I agree it is under-treated/dx'd, but also over-treated/dx'd similarly to what we see with bipolar disorder. We all know very well that when someone has a history of it, we still have a great deal of suspicion if the person truly has it when we don't see them in the manic phase and know that some doctors dx everyone with it whether they have it or not.

As for CPS, they will likely do nothing if we report, or well more realistically it won't amount to much. The problem with CPS, and it's not their fault, is that so many cases reported to them are BS, and they really can only focus on the cases where there's real and actionable data. They are under-funded but even if they got better funding they have such limited evidence to pursue much. Also bear in mind that if they were to take a kid away from their parents that too is highly traumatic and could lead to significant psychological damage for the child.

I don't treat ADHD with stimulants unless there is psychological testing backing it up and I don't mean the tests that have a 1-5 scale and all the person has to do is check off 5 on each one for the scale to suggest they have ADHD.

I have treated one of my patients with a stimulant without testing but I had this guy for 3 years, he always showed signs of hyperactivity in the office, and the reason why I let him go on that is because he doesn't have insurance and the in-depth psychological evaluation would cost hundreds of dollars. Economically, he usually just scrapes by. He was already tried on Wellbutrin, Clonidine, and Guanfacine with no to little benefit.

 

[erg923]

I don't treat ADHD with stimulants unless there is psychological testing backing it up and I don't mean the tests that have a 1-5 scale and all the person has to do is check off 5 on each one for the scale to suggest they have ADHD.

Although you might think I would support this notion since I am a psychologist, I do not.

Although it is nice to attempt to verify and then quantify the disturbance in attention that you think would probably exist in a disorder called "Attention Deficit/Hyperactivity Disorder" the is insufficient literature to support that notion. That is, many kids can fit the (mostly behavioral) criteria and have neuropsychological test findings well WNL. There is little evidence that psychometric cognitive testing serves any diagnostic utility for AD/HD.

That said, a thorough psychological evaluation can certainly identify a host of other issues/disorders (LDs, depression, attachment) that could be behavioral masquerading as AD/HD, that is very true. Psychological testing may or may not be required in order to accomplish the above.

 

[MacDonaldTriad]

Our neuropsychologists say the same thing. They laugh when we attempt to ask them to verify “adult” ADHD. Sometimes I do wish they would pretend; it is useful to see which patients are and are not cooperative with attempts at a workup. I guess I’ll just stick with asking to speak to relatives and see childhood documentation. I’m beginning to believe that a lack of collateral information sources is the number one risk factor for developing adult onset ADHD (joke).

 

[erg923]

Our neuropsychologists say the same thing. They laugh when we attempt to ask them to verify “adult” ADHD. Sometimes I do wish they would pretend; it is useful to see which patients are and are not cooperative with attempts at a workup. I guess I’ll just stick with asking to speak to relatives and see childhood documentation. I’m beginning to believe that a lack of collateral information sources is the number one risk factor for developing adult onset ADHD (joke).

I think a VERY thorough understanding of what this disorder actually is/how it really looks is required in order to be competent in indentifying it via history and current presentation.

 

[whopper]

Although you might think I would support this notion since I am a psychologist, I do not.

Agree. I sometimes have cases where the testing says one thing but I still don't agree with the test, though the test does give more insight.

Something I didn't mention is my outpatient population is heavily addiction-laden because I am a Suboxone provider. I need something more than the patient simply telling me they have symptoms.

In forensic psychology and psychiatry, often times (and I know you already know Erg923, this is more for the students out there), the testing might not support what the clinician believes, and the tests could be wrong. Everything has to be taken within a context of all the data including the testing and the clinical data.

But, IMHO, clinical data alone, especially with a clinician that is weak and whose decision-making algorithm is likely influenced by today's profit models of seeing patients in a short amount of time leads to the phenomenon of kids being over-diagnosed.

 

[TexasPhysician]

With the recent FDA approval of EEG-based diagnosis of ADHD, I'm hoping it's going to lead more doctors using more objective methods to diagnose ADHD. I agree it is under-treated/dx'd, but also over-treated/dx'd similarly to what we see with bipolar disorder. We all know very well that when someone has a history of it, we still have a great deal of suspicion if the person truly has it when we don't see them in the manic phase and know that some doctors dx everyone with it whether they have it or not.

As for CPS, they will likely do nothing if we report, or well more realistically it won't amount to much. The problem with CPS, and it's not their fault, is that so many cases reported to them are BS, and they really can only focus on the cases where there's real and actionable data. They are under-funded but even if they got better funding they have such limited evidence to pursue much. Also bear in mind that if they were to take a kid away from their parents that too is highly traumatic and could lead to significant psychological damage for the child.

I don't treat ADHD with stimulants unless there is psychological testing backing it up and I don't mean the tests that have a 1-5 scale and all the person has to do is check off 5 on each one for the scale to suggest they have ADHD.

I have treated one of my patients with a stimulant without testing but I had this guy for 3 years, he always showed signs of hyperactivity in the office, and the reason why I let him go on that is because he doesn't have insurance and the in-depth psychological evaluation would cost hundreds of dollars. Economically, he usually just scrapes by. He was already tried on Wellbutrin, Clonidine, and Guanfacine with no to little benefit.

Experts in the field disagree with you. ADHD is a clinical diagnosis. Testing may help with other issues, but clinical presentation/concentration/etc is where you make the diagnosis.

 

[whopper]

I'm not disagreeing with you, but what we got in a phenomenon where some clinicians are just very poor in their diagnosis, and we're talking a controlled substance often used to treat the ADHD.

The signs and symptoms in the DSMIV and V are virtually useless. Everyone has had most of the symptoms.

We ought to have a better standard.

 

[billypilgrim37]

I think a VERY thorough understanding of what this disorder actually is/how it really looks is required in order to be competent in indentifying it via history and current presentation.

Exactly the sort of understanding a child psychiatrist should be able to develop in fellowship. I haven't met many adult-trained folks who have really had a clue what they were doing, either under- or over-diagnosing or treating. I think lack of comfort and exposure to developmental processes are the main reason whopper has always supported this non-evidence based approach. (Granted, the population he sees and the context of so many other adult docs doing so poorly drive this as well.) But he and I have had that discussion for the last several years, and it will always be one of the few things we disagree about.

 

[smalltownpsych]

Exactly the sort of understanding a child psychiatrist should be able to develop in fellowship. I haven't met many adult-trained folks who have really had a clue what they were doing, either under- or over-diagnosing or treating. I think lack of comfort and exposure to developmental processes are the main reason whopper has always supported this non-evidence based approach. (Granted, the population he sees and the context of so many other adult docs doing so poorly drive this as well.) But he and I have had that discussion for the last several years, and it will always be one of the few things we disagree about.

I agree very much with what you and Erg are saying, but after years of excellent training and experience, I still struggle with understanding ADHD and when medications should be used. I am comfortable differentiating anxiety disorders and Bipolar Disorder and then treating those with good results. It gets a little more challenging when dealing with learning disorders vs. ADHD, mostly because I don't think we are clear as to what it really is. Some experts emphasizes executive dysfunction whereas others emphasize the effects of stimulants. Sometimes I just want to throw up my hands and just let the GPs keep prescribing stimulants based on the demands of schools and parents to fix these kids.

 

[erg923]

I agree very much with what you and Erg are saying, but after years of excellent training and experience, I still struggle with understanding ADHD and when medications should be used. I am comfortable differentiating anxiety disorders and Bipolar Disorder and then treating those with good results. It gets a little more challenging when dealing with learning disorders vs. ADHD, mostly because I don't think we are clear as to what it really is. Some experts emphasizes executive dysfunction whereas others emphasize the effects of stimulants. Sometimes I just want to throw up my hands and just let the GPs keep prescribing stimulants based on the demands of schools and parents to fix these kids.

I think Barkley has it about as right as anyone has thus far...

 

[smalltownpsych]

I think Barkley has it about as right as anyone has thus far...

I used to think that but then saw some criticisms that made sense. Of course, I haven't really delved into the topic for awhile because most of what I was treating were adolescents with anxiety disorders that had been misdiagnosed as ADHD and then treated with stimulants for a number of years. I really do need to get up to speed with the current research though.

 

[whopper]

But he and I have had that discussion for the last several years, and it will always be one of the few things we disagree about.

Unlike the saying, sometimes some great minds don't think alike. Not that I would consider myself great, but I do respect BillyPilgrim's opinions.

 

[DD214_DOC]

With the recent FDA approval of EEG-based diagnosis of ADHD, I'm hoping it's going to lead more doctors using more objective methods to diagnose ADHD. I agree it is under-treated/dx'd, but also over-treated/dx'd similarly to what we see with bipolar disorder. We all know very well that when someone has a history of it, we still have a great deal of suspicion if the person truly has it when we don't see them in the manic phase and know that some doctors dx everyone with it whether they have it or not.

As for CPS, they will likely do nothing if we report, or well more realistically it won't amount to much. The problem with CPS, and it's not their fault, is that so many cases reported to them are BS, and they really can only focus on the cases where there's real and actionable data. They are under-funded but even if they got better funding they have such limited evidence to pursue much. Also bear in mind that if they were to take a kid away from their parents that too is highly traumatic and could lead to significant psychological damage for the child.

I don't treat ADHD with stimulants unless there is psychological testing backing it up and I don't mean the tests that have a 1-5 scale and all the person has to do is check off 5 on each one for the scale to suggest they have ADHD.

I have treated one of my patients with a stimulant without testing but I had this guy for 3 years, he always showed signs of hyperactivity in the office, and the reason why I let him go on that is because he doesn't have insurance and the in-depth psychological evaluation would cost hundreds of dollars. Economically, he usually just scrapes by. He was already tried on Wellbutrin, Clonidine, and Guanfacine with no to little benefit.

Whopper, do you have a link for more info about the EEG diagnosis? I heard about it but have not really seen anything.

 

[wolfvgang22]

Today I had a parent of a 4 year old complain when I wouldn't increase her child's Adderall just because "he keeps asking me to buy candy every time we go to the store."
I love being a child and adolescent psychiatrist some days...

 

[whopper]

http://www.medicalnewstoday.com/articles/267246.php

http://www.medscape.com/viewarticle/809079

 

[smalltownpsych]

Today I had a parent of a 4 year old complain when I wouldn't increase her child's Adderall just because "he keeps asking me to buy candy every time we go to the store."
I love being a child and adolescent psychiatrist some days...

Parents like that make me wish that we could prescribe placebos. "This is a very effective pill that will make your kid do what you want him to and if it doesn't work we can always double the dosage. "