Doctors are diagnosing children with attention deficit disorder at record rates, and New Hampshire is among the states with the greatest increase in diagnoses from 2008 to 2010, according to a nationwide study by Express Scripts, one of the largest pharmacy benefit management organizations in the country.
Of the 50 states, only Maine, Vermont and Indiana showed greater increases in ADD diagnoses, the study found.
According to the Express Scripts Drug Trend Report, presented last week at an international pharmaceutical conference, the South still leads the nation in percentage of children diagnosed and treated for attention deficit disorders at 11.8 percent, but the Northeast has the highest growth rate for diagnosis, treatment and total associated costs.
New Hampshire saw a 148 percent increase in ADD diagnoses and a 54 percent increase in medical and pharmacy costs for ADD patients. Maine, which topped the list, saw a 464 percent increase in ADD diagnoses.
Several states showed a decrease from 2008 to 2010, with Maryland cases declining by 67 percent and South Dakota by 63 percent. The survey is a continuation of research Express Scripts began last year, when it released data on 2008 and 2009.
ADD, diabetes increases
The drug trend forecast, based in part on prescription insurance claims by private and government sources, suggests that ADD and diabetes will be the only two conditions that will see significant increases in diagnoses and prescription spending over the next three years, according to the study author, Sharon Frazee.
Frazee is responsible for research on drug safety and affordability at Express Scripts, using the company's large database on claims and purchased data on diagnoses. In 2012, the company acquired rival Medco to become one of the largest pharmacy benefit managers in the U.S., with a 40 percent total market share when including mail-order customers.
Frazee said many factors could be contributing to New Hampshire's fourth-place ranking, including the small population. When translated to raw numbers, the 148 percent increase means the number of cases went from 921 in 2008 to 2,280 in 2010. Approximately 8.5 percent of children ages 4 to 17 are being diagnosed and treated, although not all treatments involve medication, she pointed out.
Two contributing factors
The New England region as a whole has two factors contributing to a higher number of ADD diagnoses, she said. The region is fairly affluent, with many children in nursery or pre-school where professionals are trained to identify the condition. And it is home to some of the premiere medical research hospitals and universities in the world.
"New England is often in the forefront of many things because there are so many excellent medical centers there. A lot of new findings and a lot of new guidelines tend to be implemented early in states in the New England area," she said.
One of those new guidelines, issued two years ago by the American Pediatrics Association, lowered the recommended age for ADD testing from 6 to 4.
The projected increase in spending on ADD treatment in the next three years also emerges from a broadening of the age group believed to be affected by the disorder.
"There is much more recognition of ADD as not just being a condition of young children," Frazee said. "So we are getting more older children and young adults, and even some not so young adults. ADD doesn't realize you turned 18 and suddenly it gets turned off."
The increased spending on the condition is not just a matter of concern for those affected. Everyone with health insurance, public or private, shares the cost.
In 2008, expenditures on ADD cost every insured resident of New Hampshire $52, while in 2010, that cost was up to $80 on a per-capita basis, according to the Express Scripts report.
"Despite the availability of generic equivalents for many ADD therapies, the data indicates that spending in the category will increase approximately 25 percent over the next three years, driven by increased use among adults and the geographic variation in diagnosis," the report states.
Ever since ADD emerged as a diagnosis in the 1970s, it has been controversial. Several calls to pediatricians and child psychologists in New Hampshire for comment on the Express Scripts finding went unanswered.
Allen Frances, M.D., former chair of the department of psychiatry at Duke University and now a blogger for Huffington Post, has been involved in several iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association.
In a recent post, titled "Attention Deficit Disorder Is Over-Diagnosed and Over-Treated," he argues that the DSM definition of ADD has been continuously widened over the years.
"The epidemic started precisely when aggressive drug company marketing succeeded in 'educating' and sensitizing doctors, parents, and teachers to spot ADD in kids previously considered to be on the normal side of the spectrum's boundary," he wrote. "Extreme diagnostic exuberance surely picks up previously missed true cases who need medical attention, but it also captures many false positives who have been loosely diagnosed and unnecessarily treated."
He subscribes to the philosophy of Dutch psychologist Laura Batstra, whom he quoted: "A medical approach to ADD type behaviors is warranted only for the minority of kids who have really severe and persistent concentration problems and disruptive behaviors. Most kids respond to simpler methods and don't need an ADD diagnosis. Medical treatment should be offered as the last, not the first step — clearly necessary for those who really need it; but unnecessary and even harmful for those who don't."