ADHD and psychostimulants — overdiagnosis and overprescription

Careful assessment and universal precautions are necessary

Attention deficit hyperactivity disorder (ADHD) is the most widely studied child and adolescent mental health disorder, yet it remains the subject of ongoing debate, both about the validity of the diagnosis and its treatment. Increasing rates of psychostimulant prescription highlight the possibility of overprescription and overdiagnosis with the implication that disorders of children in particular are being “medicalised”. There are risks for children that the use of stimulant medication is a simplistic attempt to find solutions to more complex problems underlying behavioural and emotional difficulties1, and risks in adolescents and adults prescribed or exposed to stimulants, including poisonings, as identified in this issue of the MJA.2

Several factors appear to contribute to the increasing diagnosis of ADHD since the 1970s, before which the diagnosis was relatively rare. On the positive side, there is increasing awareness of the associated developmental morbidity and implications of early attentional disorders and related neurodevelopmental problems; increasing scientific understanding of the risk factors for neurodevelopmental difficulties such as ADHD, which are very broad and include in utero, peripartum and postpartum factors, with genetic and environmental components; and increasing recognition of the coordinated educational and family support needs for children with this spectrum of difficulties and evidence from a range of randomised control trails about the importance of comprehensive intervention. Despite this, the controversies around ADHD persist without consensus as to whether increases in diagnosis and treatment result in symptom reduction and improved long-term outcomes.3

The controversy around ADHD and its treatment has contributed to emotive and highly polarised discussions, with proponents of both over- and underdiagnosis positions. As is often the case, the complexity of this situation means that there are many developmental pathways to the condition commonly diagnosed as ADHD, and a major issue remains in the need for comprehensive assessment, which excludes other conditions. ADHD may be confused with other conditions, such as trauma-related neurodevelopmental difficulties, autistic spectrum disorder, and fetal alcohol spectrum disorders. In these instances, stimulants may be of benefit. The use of medication in various neurodevelopmental conditions may be quite appropriate but should not be seen as the sole treatment approach. It is therefore important that diagnosis includes a clear differential approach and that it is not made in a perfunctory fashion. It is also crucial that attention is paid to the needs of families, including parenting interventions and other strategies to support the development of positive emotional relationships and security of attachment in children who have major challenges in both behavioural and emotional regulation.

The issues related to the prescription of stimulant medications are also complex. There are increasing rates of prescription, especially of methylphenidate and an associated increase in poisonings.2 The proportion of deliberate overdoses and associated suicidal behaviour is of particular concern. Given concerns about the use of stimulant medication across the community in general, it is in some ways unsurprising that psychostimulants that may be appropriately prescribed can be misused. This pattern of greater rates of prescribing of psychoactive medications being associated with greater rates of misuse has also been dramatically and tragically seen with opioids.4

In the absence of national guidelines, the Royal Australian and New Zealand College of Psychiatrists5 supports the use of Canadian6 or United Kingdom 7 guidelines for ADHD treatment. Both highlight the need for comprehensive assessment of ADHD and substance use disorders. An approach supported by specialist Australian medical colleges that has been suggested for opioid prescription could be adapted for stimulant prescribing for ADHD.8 The concept of “universal precautions” implies routinely assessing all patients for risk of diversion, misuse or overdose, both before and on an ongoing basis while prescribing psychoactive drugs.

With regard to prescribing stimulants for ADHD, this approach could include ensuring comprehensive assessment with alternative diagnoses considered. These include multimodal non-pharmacological approaches to ADHD treatment; assessing all patients (including parents of children) for current and past history of substance use disorders; clinical assessment and drug toxicology to assess medication adherence and exclude substance use disorders; treatment agreements including informed consent; and addressing assessment of non-medical use. If substance use disorders are identified, they warrant concurrent specialist treatment.

In addition, prescription monitoring programs may have a role;9 however, with the exception of Tasmania, this has not occurred to date in Australia. While careful assessment and universal precautions will not stop all non-medical use of prescription stimulants, including poisonings, they remain practical and feasible approaches to limit misuse.