The Rapid Rise of Stimulant Prescriptions for Children with ADHD: Uncovering the Root Causes of the Epidemic

The opioid epidemic has terrorized the United States for the last three decades. It has taken millions of lives, destroyed tens of thousands of families, and exacerbated social and economic inequalities. The rate of opioid prescription use increased at a staggering rate, and a new category of prescriptions is showing scarily similar patterns of growth. One study suggests that we might soon have another epidemic on our hands. This time, however, it's not with adults and opioids - it's with our children and prescription stimulants for ADHD. Between 2006 and 2019, stimulant prescriptions in the U.S. increased 250%. Stimulant prescriptions are skyrocketing, but the reasons for this increase and the impact it is having on American youth diagnosed with ADHD aren’t fully understood. What is causing this increase in prescription stimulants for children who are diagnosed with ADHD and what effect is it having on children’s wellbeing?

What is ADHD?

ADHD, or Attention-Deficit Hyperactivity Disorder, is the most common neurodevelopmental disorder that is prevalent during childhood and is characterized by impulsivity, inattention, and sometimes, hyperactivity. According to the CDC, it’s estimated that over 6.1 million children (9.4%) in the United States ages 2-17 have been diagnosed with ADHD - 388,000 young children aged 2 to 5 years, 2.4 million school-age children aged 6 to 11 years, and 3.3 million adolescents aged 12 to 17 years.

As outlined by Johns Hopkins Medicine, there are three main types of ADHD: (1) impulsive and hyperactivity, (2) inattentive and distractible, and (3) a combination of the other two. The least common category is the impulsive and hyperactivity form. The second type is the inattentive and distractible form, which is characterized by a lack of attention or a tendency to be distracted without hyperactivity. The third, and most common type, is a combination of the previous two types and is associated with hyperactive behavior, impulsiveness, and distractibility. The exact cause of the disorder is still not fully clear, but there is evidence that suggests some children can have a genetic predisposition to the disorder.

How do Stimulants Treat ADHD?

Stimulants are the first-line medical treatment for ADHD and are the primary reason for the prescription of stimuli to children. About 80% of ADHD visits for children aged 4-17 resulted in the prescription or continued prescription of central nervous system stimulant medication. The four most common stimulates prescribed are methylphenidate, amphetamine, methamphetamine, and lisdexamfetamine. Adderall, a generic name for the combination of amphetamine and dextroamphetamine, is one of the most well-known names in the world of stimulants.

Stimulants work by increasing dopamine levels in the brain. Dopamine is a neurotransmitter, a chemical released at the end of a nerve fiber, that is responsible for regulating attention and executive function. By increasing the level of dopamine, messages in the brain can be more efficiently transmitted and received across synapses, the junctions between neurons in the brain. As Clinical Scientist Keath Low describes, this results in increased attention and reduced impulsivity, causing a reduction in ADHD symptoms.

What is Causing the Increase in Stimulant Prescriptions to Children?

For the last two decades, the number of ADHD diagnoses has increased, yet not proportionally to the increase in population. Adjusted for population growth, the estimated prevalence of diagnosed ADHD in U.S. children and adolescents increased from 6.1% in 1997-1998 to 10.2% in 2016.

What has caused this increase? While there is not one single cause of the increase, my research has found four potential factors that could be contributing to the increase: (1) the subjective nature of the ADHD diagnosis process, (2) increased pressure from the education system to medicate children, (3) a broader and more widespread definition of ADHD, and (4) an increase in the availability of prescription stimulants. 

The Subjective-Nature of the ADHD Diagnosis Process

The diagnosis of ADHD in children is clinical. There is no one clear-cut method to accurately diagnose ADHD. Instead, the diagnosis is a multi-step process composed of testimonials from parents and teachers, clinical evaluations by neurological professionals, and examinations of past and present medical history.

Of these components, significant contributors to the diagnosis are the testimonials. These are typically from parents and teachers who have observed the child exhibiting signs and symptoms of ADHD, such as becoming frequently distracted. Where is the line drawn between a child not sitting perfectly still in a classroom for several hours - a child being a child - and the child having ADHD? One study concluded that potentially as many as 20% - or 900,000 - of the 4.5 million children who were diagnosed with ADHD in 2010 might have been misdiagnosed. According to one study, because 80% of kids with diagnosed ADHD are prescribed stimulants, as the number of children being diagnosed with ADHD - both accurately and not - increases, the number of prescription stimulants goes up.

Pressure from the Education System to Medicate Children

Another potential contributor to the increase in stimulant prescriptions is the education system recommending ADHD diagnoses and medication uptake for students. As previously stated, significant weight of an ADHD diagnosis is placed on the testimonial of a child’s teacher, describing the behavior of the child in a classroom setting. As observed in a 2019 qualitative case study,  a teacher observing a child exhibit ADHD-like symptoms is typically the initial instigator for that child to be tested for ADHD. Teachers and school counselors were also found to be encouraging parents to have children diagnosed and medicated for ADHD.

Additionally, teachers are heavily involved in the parent's decision-making process regarding whether the child should be prescribed medication. The study also concluded that 89% of educators and counselors suggest stimulant prescription as a necessary first step. Another study found that many of these ADHD diagnoses may have been driven by teachers' perceptions of poor behavior. The “symptoms” may simply reflect emotional or intellectual immaturity. In other words, children acting like children. Overall, this leads to an overdiagnosis of ADHD and an overprescribed youth population - children being diagnosed who do not have the disorder and being treated with stimulants.

The Broader Definition of ADHD

A broader definition of ADHD could be causing an increase in ADHD diagnosis and the subsequent increase in adolescent stimulant prescriptions. One study specifically highlights the changes to symptom requirements for an ADHD diagnosis made in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. First, there was a reduction in the minimum number of symptoms from six to five required to be diagnosed. Second, the age range for the onset of symptoms was changed from before 7 years old to before 12 years old, widening the demographic of children who can be diagnosed and medicated for ADHD. Third, the wording of the symptom requirements became more broad. A child’s symptoms now only need to “reduce the quality of social, academic or occupational functioning” instead of requiring that they be “clinically significant.” Finally, Epstein and Richard highlight that the most significant change was the addition of severity levels of ADHD (i.e. mild, moderate, or severe) that allows for a diagnosis even if the full diagnostic criteria are not met. As ADHD is better understood, the American Psychiatric Association is continuing to adapt their definition and symptom qualifications.

Increased Access to Prescription Stimulants

The pharmaceutical industry could also be contributing to the increase in stimulant prescriptions. Pharmaceutical companies are not incentivized to provide the best treatment for children; they are incentivized to sell products and make money. The more children who are diagnosed with ADHD, the larger the market is for prescription stimulants, and thus the potential to make more money. To grow and capture this market, pharmaceutical companies are increasingly direct to consumer advertising, one study found found may account for the high rates of ADHD and ADHD medication use in the US, as compared to other countries.

What’s the Downside of More Children on Prescription Stimulants?

Prescription stimulants are associated with a number of negative side effects. In the short term, children taking prescription stimulants have been found to have trouble sleeping, develop eating issues, experience delayed growth, encounter nausea and headaches, and have mood swings. Research by the Pinelands Recovery Center of Medford has shown that some of these effects, like delayed growth, in the long term do not have an impact, while some symptoms like mood swings that result from the medication wearing off can be quite challenging to navigate. 

Taking stimulants for an extended period can result in the development of dependence. The problem with developing this dependence on stimulants from such a young age is that it puts children at a higher risk for abuse of prescription stimulants in adulthood. A harmless daily treatment can quickly turn into a long-term problem and result in psychosis, anger, paranoia, seizure, and even heart failure when taken in high doses over an extended period. Medicating an increasing number of children is increasing the chances of stimulant abuse in the future and a potential prescription stimulant epidemic.

What Should We Do?

Prescription stimulant use for children is rising at an alarming rate for a combination of reasons that includes the subjective diagnosis process, increased pressure from the education system, a more lenient definition of ADHD, and an increased availability of prescription stimulants. Although keeping some children prescribed stimulants could be the correct treatment method given the severity of the ADHD and duration of the prescription, it could be problematic for the wellbeing of children in the long-run if the number of children being misdiagnosed continues to increase. Alternative treatments for ADHD like dietary changes and emerging game-based digital therapeutics could provide safer alternatives to prescription stimulants, yet these are currently not as effective as the existing stimulant treatments. A study concluded that children can potentially “outgrow” or mask their ADHD symptoms in adulthood, suggesting that it may make sense to simply not place children on stimulant medication. Ultimately, my research shows that while multiple factors can be attributed to the increase in stimulant use, the prescription of stimulants to children with ADHD is a complex and nuanced topic that should be monitored closely during the next decade.

Work Cited

Brumbaugh, Shannon, et al. “Trends in Characteristics of the Recipients of New Prescription Stimulants Between Years 2010 and 2020 in the United States: An Observational Cohort Study.” EClinicalMedicine, vol. 50, 2022, pp. 101524–101524, https://doi.org/10.1016/j.eclinm.2022.101524. 

Gesser-Edelsburg, Anat, and Rasha Hamade Boukai. “Does the Education System Serve as a Persuasion Agent for Recommending ADHD Diagnosis and Medication Uptake? A Qualitative Case Study to Identify and Characterize the Persuasion Strategies of Israeli Teachers and School Counselors.” BMC Psychiatry, vol. 19, no. 1, 2019, pp. 153–153, https://doi.org/10.1186/s12888-019-2120-9. 

“What Is ADHD?” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 9 Aug. 2022, https://www.cdc.gov/ncbddd/adhd/facts.html. 

“Attention-Deficit / Hyperactivity Disorder (ADHD) in Children.” Johns Hopkins Medicine, www.hopkinsmedicine.org/health/conditions-and-diseases/adhdadd. 

Robinson, Lawrence. “ADHD Medications.” HelpGuide.org, 26 Aug. 2022, www.helpguide.org/articles/add-adhd/medication-for-attention-deficit-disorder-adhd.htm#:~:text=Stimulants%20are%20believed%20to%20work,reducing%20hyperactive%20and%20impulsive%20behaviors. 

“Physician Office Visits for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents Aged 4–17 Years: United States, 2012–2013.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Jan. 2017, https://www.cdc.gov/nchs/products/databriefs/db269.htm.  

“2016 National Drug Threat Assessment.” DEA, https://www.dea.gov/documents/2016/2016-11/2016-11-01/2016-national-drug-threat-assessment.

“Dextroamphetamine and Amphetamine: Medlineplus Drug Information.” MedlinePlus, U.S. National Library of Medicine, 2019, https://medlineplus.gov/druginfo/meds/a601234.html#:~:text=The%20combination%20of%20dextroamphetamine%20and%20amphetamine%20(Adderall%2C%20Adderall%20XR%2C,who%20are%20the%20same%20age). 

Low, Keath. “How Can Taking Stimulants Help Your ADHD?” Verywell Mind, Verywell Mind, 13 Jan. 2022, www.verywellmind.com/how-do-stimulants-for-adhd-work-20895. 

Xu, Guifeng, et al. “Twenty-Year Trends in Diagnosed Attention-Deficit/Hyperactivity Disorder Among US Children and Adolescents, 1997-2016.” JAMA Network Open, vol. 1, no. 4, 2018, pp. e181471–e181471, https://doi.org/10.1001/jamanetworkopen.2018.1471. 

Elder, Todd E. “The Importance of Relative Standards in ADHD Diagnoses: Evidence Based on Exact Birth Dates.” Journal of Health Economics, vol. 29, no. 5, 2010, pp. 641–56, https://doi.org/10.1016/j.jhealeco.2010.06.003. 

Pelham, William E., et al. “The Effect of Stimulant Medication on the Learning of Academic Curricula in Children with ADHD: A Randomized Crossover Study.” Journal of Consulting and Clinical Psychology, vol. 90, no. 5, 2022, pp. 367–80, https://doi.org/10.1037/ccp0000725. 

Epstein, Jeffery N., and Richard EA Loren. “Changes in the Definition of ADHD in DSM-5: Subtle but Important.” Neuropsychiatry, vol. 3, no. 5, 2013, pp. 455–58, https://doi.org/10.2217/npy.13.59. 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed.., American Psychiatric Association, 2013. Conrad, Peter. “The Impending Globalization of ADHD: Notes on the Expansion and Growth of a Medicalized Disorder.” Social Science & Medicine, Pergamon, 8 Oct. 2014, https://www.sciencedirect.com/science/article/pii/S0277953614006650. 

Gleeson, Deborah, and David B Menkes. “Trade Agreements and Direct-to-Consumer Advertising of Pharmaceuticals.” International journal of health policy and management vol. 7,2 98-100. 1 Feb. 2018, https://pubmed.ncbi.nlm.nih.gov/29524933/ 

“The Long-Term Consequences of Stimulant Use.” Pinelands Recovery Center of Medford, 7 June 2022, www.pinelandsrecovery.com/the-long-term-consequences-of-stimulantuse/#:~:text=When%20stimulants%20are%20consumed%20in,experiencing%20psychosis%2C%20anger%20or%20paranoia. 

Moss, Cierra M., et al. “Chronic Care for Attention-Deficit/Hyperactivity Disorder: Clinical Management from Childhood Through Adolescence.” Journal of Developmental and Behavioral Pediatrics, vol. 41 Suppl 2S, no. 2S, 2020, pp. S99–S104, https://doi.org/10.1097/DBP.0000000000000772. 

Ridaeus, Diane. “ADHD Medication Withdrawal, Side Effects, Addiction, Treatment.” Alternative to Meds, 26 Aug. 2022, https://www.alternativetomeds.com/blog/adhd-drug-withdrawal/.