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Increase in ADHD Medication Misuse in Children

  • Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD, FAAFP
  • CME / ABIM MOC / CE Released: 7/6/2018
  • Valid for credit through: 7/6/2019
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Target Audience and Goal Statement

This article is intended for primary care clinicians, pediatricians, psychiatrists, nurses, pharmacists, and other clinicians who treat and manage children with attention-deficit/hyperactivity disorder.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Evaluate the worldwide prevalence of attention-deficit/hyperactivity disorder among children
  • Assess trends in calls to US poison control centers related to the use of attention-deficit/hyperactivity disorder medications


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News Author

  • Megan Brooks

    Freelance writer, Medscape


    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD, FAAFP

    Health Sciences Clinical Professor of Family Medicine, University of California, Irvine, California


    Disclosure: Charles Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.
    Served as a speaker or a member of a speakers bureau for: Shire Pharmaceuticals

Editor/CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

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Increase in ADHD Medication Misuse in Children

Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD, FAAFPFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/6/2018

Valid for credit through: 7/6/2019


Clinical Context

The prevalence of attention-deficit/hyperactivity disorder (ADHD) among children and adolescents has been a matter of debate for decades. There is substantial geographic variability in the diagnosis and treatment of ADHD, and the prevalence may also have changed based on the very definition of ADHD in different versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Thomas and colleagues assessed research on the prevalence of ADHD among persons younger than age 18 years: 175 studies published between 1975 and 2013 were included in a meta-analysis to determine the pooled estimate prevalence rate, which was 7.2%.[1] The prevalence appeared to be stable regardless of the version of DSM, but there was some increase in the prevalence of ADHD over time. The prevalence values from North American studies were approximately 2% higher than those reported in research from Europe, and the prevalence of ADHD appeared about 3% higher in the Middle East compared with North America.

The number of children and adolescents taking ADHD medications appears to be increasing in the United States, and that increase may affect the risk for drug-related adverse events and overdose. The current study uses the National Poison Data System to assess trends in potentially dangerous exposures to drugs used to treat ADHD.

Study Synopsis and Perspective

Unintentional and intentional pediatric exposures to stimulant medication for ADHD are an increasing problem in the United States and affect children of all ages, new research suggests.

From 2000 through 2014, there were 156,365 calls to US poison control centers related to exposures to ADHD medications among children and adolescents 19 years of age and younger, reports a study published online May 21 in Pediatrics.[2]

"That averaged about 200 calls each week, or about 1 call every 50 minutes," lead investigator Gary Smith, MD, from Nationwide Children's Hospital, Columbus, Ohio, said in a journal podcast.

"Exposures associated with suspected suicide or medication abuse and misuse among adolescents is a particular concern, especially because these result more commonly in serious medical outcomes," added Dr Smith.

The overall rate of ADHD medication exposures increased by 71.2% from 2000 to 2011. This increase was followed by a nonsignificant 6.2% decline from 2011 to 2014. Methylphenidate and amphetamine medications each accounted for roughly 45% of the exposures.

Half of Teenage Exposures Intentional

The majority of exposures involved boys (65.3%) aged 12 years and younger (76.0%).

In children younger than 6 years, exposure to ADHD medications was associated with "exploratory behavior" common in this age group, such as accessing improperly stored medications, Dr Smith said.

Exposures among children aged 6 to 12 years were most often associated with therapeutic errors, such as being given or taking too much medication, or taking a dose too soon after taking the previous dose.

Intentional medication exposures, including suspected suicide and medication abuse or misuse, were reported most often among teenagers aged 13 to 19 years. "In fact, roughly half of reported exposures in teenagers were intentional, and exposures among teens were more likely to result in serious medical outcomes than in younger children," Dr Smith noted.

The vast majority of unintentional or intentional pediatric exposures to ADHD medications happened at home. Most children who experienced exposure (about 60%) did not receive treatment at a healthcare facility. However, about 6% were admitted to a hospital for medical treatment, and there were 3 deaths.

The most common clinical effects involved the cardiovascular or neurologic system and included agitation and/or irritability, tachycardia, and hypertension. These are consistent with the known mechanisms of action of stimulant medication, the researchers note.

"The increasing number and rate of reported ADHD medication exposures during the study period is consistent with the increasing trends in ADHD diagnosis and medication prescribing," Dr Smith said.

Strategies to prevent unintentional and intentional exposure to ADHD medications include educating parents, caregivers, and adolescents, as well as safely storing and disposing medications; use of unit dose packaging, such as blister packs; and increased use of nonpharmacologic interventions for ADHD, said Dr Smith.

He added that there is a need for studies that evaluate the effectiveness of strategies to prevent these pediatric medication exposures.

The researchers point out that it is likely that their study underestimates the frequency of pediatric ADHD medication exposures because clonidine and guanfacine were excluded and because not all exposures are reported to poison control centers.

The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online May 21, 2018.

Study Highlights

  • Researchers evaluated data from 2000 to 2014, with a focus on calls to US poison control centers related to ADHD medications among individuals younger than 20 years. Cases included in the current study required a confirmed exposure to an ADHD drug and a probable adverse effect related to that exposure. Calls related to illicit amphetamine use or drug use for weight loss were excluded from the present analysis.
  • Major effects related to drug use were defined by life-threatening symptoms or a high risk for disability. Moderate effects were less severe symptoms, but usually required treatment. Minor effects were transient symptoms that resolved quickly.
  • There were 156,365 calls to US poison control centers related to the use of ADHD drugs among children and adolescents between 2000 and 2014.
  • 76.0% of calls involved children younger than 12 years, and 65.3% of children were boys.
  • 81.9% of calls were related to unintentional use of ADHD drugs. Therapeutic error was the most common reason for the call (41.6% of cases), followed by unintentional general exposure (39.6%).
  • The majority of cases of therapeutic error involved taking the medication inadvertently or accidentally doubling the dose.
  • However, half of exposures among adolescents between 13 and 19 years of age were intentional and related to self-harm or recreational behaviors.
  • The majority of exposures were related to acute reactions, but more than one third of exposures among older children were among experienced drug users.
  • Methylphenidate and amphetamine medications accounted for 90.7% of exposures.
  • 58.3% of calls did not result in a referral to a healthcare facility.
  • Call volume related to ADHD drugs increased by 76.0% between 2000 and 2011, followed by a nonsignificant decline of 7.0% between 2011 and 2014. The rate of calls increased in particular between 2006 and 2011.
  • The prevalence of calls was highest in the US Midwest and South, and these areas experienced the biggest increases in call volume between 2000 and 2011.
  • Clinical effects were recorded in 28.0% of calls in this sample. The most common symptoms reported were agitation/irritability and tachycardia; 3.1% of calls with noted drowsiness as a symptom.
  • 60.4% of cases were not treated at a healthcare facility, and another 24.6% of cases were treated and released; 2.8% of children required admission to a critical care unit, and 1.8% were admitted to a psychiatric care facility.
  • Serious medical outcomes were reported in 9.4% of all calls. Adolescents in particular experienced double this rate.
  • Three deaths were reported: 2 related to amphetamine products, and 1 from methylphenidate. All deaths were a result of intentional use among adolescents.

Clinical Implications

  • A previous meta-analysis found that the pooled estimate of ADHD among children and adolescents was 7.2%. Prevalence rates were highest among studies conducted in the Middle East, followed by North America.
  • The current study demonstrates that the call volume to US poison control centers related to the use of ADHD drugs among children and adolescents increased markedly between 2000 and 2011, before leveling off through 2014. Half of exposures among adolescents were intentional, but most calls did not result in a referral to a healthcare facility. The most common symptoms reported during calls were agitation/irritability and tachycardia.
  • Implications for the Healthcare Team: The healthcare team should educate children and families regarding the precise dosing and potential adverse effects of treatment for ADHD, and stop treatment when there is evidence of drug misuse.

CME Post Test Questions

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