Prescription Drug Trends

How Geography Drives ADHD Diagnosis

  |   Sharon Frazee

This past year, the utilization of medications to treat attention deficit hyperactivity disorder (ADHD) jumped 9.0%. With this increase, the United States now spends more on prescription drugs for Attention Disorders than it does for all but six other conditions.

Currently, an estimated 5.4 million U.S. children are diagnosed with ADHD. And with new guidelines from the American Academy of Pediatrics that now recommend physicians prescribe these medications to children as young as 4 (previous guidelines suggested a lower limit of age 6), the number of total diagnosed children is likely to grow.

Interestingly, the local impact of this national trend depends highly on where you live.

When looking only at Americans with commercial insurance, Express Scripts researchers found that children living in the South are 63% more likely to be diagnosed with ADHD than children living in western states. When broadening to all American children (including those on Medicaid and other government-sponsored plans where ADHD prevalence is higher), those living in a southern state have approximately a 1 in 9 chance of being diagnosed with this condition.  

Percentage of Children with ADHD Diagnosis, by U.S. RegionAt the individual state level, the disparities are even more startling. North Carolina has the highest rate of ADHD diagnosis (16.4% of children) while Nevada has the lowest (6.4%).

So what does this all mean?

Are physicians in the South overdiagnosing ADHD? Are Nevadans simply more tolerant of children who are easily distracted? Are the three most important aspects affecting prevalence of ADHD simply… Location, Location, Location?

Not necessarily. It’s important to note that our research only indicates correlation – not causation – between geography and ADHD diagnosis. We can’t look at this data and suggest that any one region of the United States is more accurate with its diagnoses than the others.

That said, as we study regional disparities for these frequently used medications, we will continue to identify prescription drug trends that lead to better health and value.

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    • http://www.adhdrollercoaster.org Gina Pera

      I’ve heard that said before, that ADHD diagnosis/treatment rates are higher in the southern U.S.

      I’m wonder what other limitations there are to the data. For example, are Express Scripts clients evenly distributed nationwide? Could it be that Western States have more small businesses that don’t offer this type of pharmacy benefit?

      I could hazard a guess as to why NC has higher diagnosis rates if we had more data as to where in the state the children are being diagnosed. Is it around military bases, for example?  Past research indicates that ADHD prevalence is higher around military bases; many people with undiagnosed/untreated ADHD are drawn to the military due to the external structure it provides and lack of academic focus; then, given ADHD’s high heritability, they have children whose ADHD is picked up by pediatricians or the school system but the adults’ ADHD goes undiagnosed. But it could also be that NC schools do a better than average job of screening for ADHD.

      Western states, in general, are behind the curve when it comes to ADHD awareness for kids, teens, and adults. Compared to the northeast and the Atlantic seaboard, California is woefully under-resourced in medical and therapeutic professionals trained in evidence-based strategies. With “liberalism” tends to come certain views towards diagnoses such as ADHD, views that aren’t altogether in keeping with neuroscience but more harkening back to the old hippie admonishment not to “label people.”

      Having grown up in the South, I can tell you that a higher premium is placed on children behaving and showing manners — all of which are more difficult for children with ADHD and thus might lead to questions about why these children are having so much trouble.

    • AugieWeiss

      I agree with Gina. Here comments on limitations of the data were exactly those that I was prepared to make. It would be interesting to see the map broken down by sources of data. CDC, Express Scripts, percentage by population that have insurance with drug benefits and if it might be available from the pharmaceutical companies. 

      I also find it interesting that tolerance of behaviors may be an important determinate of the distribution in the survey. Personally I doubt that over-diagnosing is going on. 

      Under-diagnosing is a much more likely scenario as the population in the western states tend to have a higher population of Hispanic, Native American and rural households than the east and south.  

    • http://lab.express-scripts.com/author/sharon-glave-frazee/ Sharon Frazee

      Thank you AugieWeiss and Gina Pera for the thoughtful comments. The data being used is publicly available, national data (CDC 2007 age 4-17 ADHD Prevalence by state available at: http://www.cdc.gov/ncbddd/adhd/prevalence.html and Census 2010 population data by state available at http://www.census.gov/compendia/statab/cats/population.html) but is limited to those with Commercial insurance. This analysis did not include prescription drug use to treat the symptoms of ADHD, just the diagnosis. We will be posting additional research on prescribing patterns in the near future and would appreciate your comments.The literature and research we have conducted have shown geographic differences in physician prescribing patterns so it is quite feasible that similar trends occur in diagnosis. That being said, Ms. Pera’s comments about ADHD awareness and behavioral expectations by region are important contributions to this complex issue.Thank you again – we hope to keep the dialogue open with thoughtful readers like both of you.