Study Finds Gaps in the Consistent Treatment of Childhood ADHD

May 16, 2023

ADHD treatment rates are staggeringly low for children, according to a study recently published by JAMA Network that found only 12.9% of 9- and 10-year-olds with parent-reported symptoms had taken ADHD medication during the preceding two weeks. ¹ Children who received treatment for their ADHD were more commonly boys, white children, and from families with a lower socioeconomic status. These findings expose treatment gaps that span the boundaries of a clinical ADHD diagnosis.

This study comprised a self-administered, semi-structured computerized parent interview used to identify 1,206 children aged 9 to 10 with ADHD using the Kiddie Schedule for Affective Disorders and Schizophrenia for DSM-5 (KSADS). Treatment groups included ADHD medication; outpatient mental health care; and both (“any treatment”).

“…A focus on the increasing numbers of children treated for ADHD does not give a sense of what fraction of children in the population with ADHD receive treatment,” the researchers wrote. “To estimate the unmet need for ADHD treatment, it is necessary to ascertain children from outside of clinical settings, evaluate them for ADHD, and assess their treatment use.”

Gaps in Treatment

ADHD Medication

According to the survey findings, twice as many boys (15.7%) as girls (7%) took medication for their ADHD after adjustment for ADHD subtype, comorbid disruptive behavior disorders, and other common psychiatric comorbid conditions. Stimulant use was significantly higher among boys than it was among girls.

Additionally, among children with parent-reported ADHD who were currently receiving ADHD medication:

• a significantly higher percentage were children of parents without a high school education compared to children of parents with at least a bachelor’s degree (32.2% v. 11.5%)
• a significantly higher percentage had combined type ADHD compared to inattentive ADHD (17% v. 9.5%)
• a significantly higher percentage were White children compared to Black children (14.8% v. 9.4%)

More than half of all children receiving ADHD medication did not have parent-reported ADHD at the time of the study (57%).

Outpatient Mental Health Care

Outpatient mental health care was more commonly used to treat parent-reported ADHD in adolescents than was ADHD medication. Slightly over one quarter (26.2%) of children in the ADHD group had ever received this course of treatment.

The difference between girls and boys was insignificant, however, among children with parent-reported ADHD and a history of outpatient mental health care:

• a significantly higher percentage were children of parents with a high school education or some college compared to children of parents with at least a bachelor’s degree (36.2% or 31% v. 21.3%)
• a significantly higher percentage were children with family incomes of less than $25,000 or $25,000 to $49,999 compared to $75,000 or more (36.5% or 27.7% v. 20.1%)
• a significantly higher percentage had combined type ADHD vs. inattentive ADHD or hyperactive/impulsive ADHD (33.6% v. 20% or 22.4%)

Children who received either treatment (medication or mental health care) accounted for 34.8% of the parent-reported ADHD group.

Treatment Disparities

The study’s findings conflict with data reported by the CDC in 2016. It found that 77% of children in the U.S. with parent-reported ADHD received treatment, and 69% aged 6 to 11 received medication. ² A survey conducted by ADDitude in 2017 similarly found that 67% of children with ADHD were currently taking ADHD prescription medication.

But unlike the current study, where ADHD was based on results from parent interviews, the CDC relied on clinical diagnoses, and in turn, access to mental health care professionals.

“Low treatment rates among children with parent-reported ADHD suggest a need to increase mental health service availability; enhance knowledge of ADHD symptoms among parents, teachers, and primary care clinicians; and develop accessible care pathways,” the researchers wrote. “Local shortages of child mental health clinicians also hinder care access in many communities.”

Accessible care pathways must address diagnostic biases and under-referral for treatment related to ADHD symptom presentation in girls, who often go misdiagnosed or underdiagnosed. Pathways should also address disparities in care received by minority racial and ethnic groups that can be attributed to structural racism-related issues, including implicit bias by prescribers, mistrust of clinicians, and stimulant medication safety.

“Physician efforts to recognize and manage their own implicit biases, together with patient-centered clinical approaches that promote shared decision-making, including open explorations of Black parents’ knowledge, attitudes, and beliefs concerning ADHD and its management, might help reduce these treatment disparities.”

According to researchers, lower treatment rates among higher socioeconomic groups could be related to a reliance on non-conventional methods or greater concern about side effects of treatment. In the ADDitude treatment survey, 20% of caregivers tried other treatment options before turning to medication and 14.5% called it a “last resort.” When it came to other treatment options, insurance, cost, and availability were most often cited as concerns.

“The side effects were not worth it,” wrote one survey respondent. “We preferred to adjust diet, household routine, treat sibling and parental relationships and involvement, add more exercise, and did genetic testing.”

Another respondent wrote about the “terrifying experience” of medicating a child, stating: “It would be helpful if doctors provided more information about the emotional expectations. They were pretty good at listing the possible physical side effects. It’s a very hard decision for a parent to stick with medication in the beginning when you’re constantly questioning yourself: ‘Am I doing the right thing for this child, when he feels awful?’”

Additional Considerations

A total of 11,723 children were recruited between 2016 and 2018 via the Adolescent Brain Cognitive Development (ABCD) Study. Parents were asked to complete a self-administered, computerized parent version of the KSADS. Teacher ratings were collected using the Brief Problem Monitor teacher-version attention scale and shared in a secondary analysis. Recruiters surveyed 21 public and private schools across the U.S.

Participation was voluntary and response rates were not available; therefore, researchers state that the full sample used in the study is not representative of the selected school systems or the nation. Parents were asked to report on medication use in the previous two weeks, which may have impacted medication rates. For the full summary of study limitations, click here.

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