By Kathryn Doyle
New York, Thu Sep 25, 2014 4:54pm EDT

(Reuters Health) – Most kids in the U.S. who take medication for attention deficit hyperactivity disorder (ADHD) are not getting behavioral counseling therapy as well, according to a new study.

The analysis, based on a commercial insurance database, also found the proportion of kids with ADHD who do get therapy varies widely from region to region.

“Although I expected rates of psychotherapy to differ across counties, I was surprised by the amount by which they differed,” said Dr. Walid F. Gellad, lead author of the new research letter.

“In some counties, it’s less than 10 percent of kids, and in other counties it’s almost 50 percent,” said Gellad, an adjunct scientist at the RAND corporation and a physician and researcher at the VA Pittsburgh Healthcare System and University of Pittsburgh.

“For some kids, medication alone may be best, and for others, combination (therapy) may be better,” he said.

Guidelines don’t require behavioral therapy for treating children with ADHD. For teens, the American Academy of Pediatrics (AAP) recommends that doctors prescribe approved medications, like Adderall or Ritalin, says they may also prescribe behavior therapy, and suggests that combining the two is preferable. For elementary school-age kids, AAP recommends medication and/or therapy.

With the ideal treatment still so uncertain, and a lack of data about current practices, the study team writes in JAMA Pediatrics, they set out to see how many kids are getting the combined treatment versus medication alone.

They also looked at whether those rates have anything to do with the local supply of psychologists available to deliver behavioral therapy.

For the study, Gellad and his colleagues used insurance claims data to identify kids under age 18 who filled a prescription for an ADHD medication in 2010, excluding those with autism or other developmental disorders. They looked for additional claims for at least one outpatient therapy visit for an individual, group or family.

The final tally included more than 300,000 kids in 1,516 counties in the U.S., and showed that 25 percent of them had at least one appointment with a therapist in addition to their ADHD medication prescription.

About half of those kids who got therapy visited at least four times, and half of those went at least eight times.

In almost 200 counties, less than one in ten kids saw a therapist.

Researchers also used a database of licensed psychologists in each county to see if the supply of therapists was linked to how often kids went to therapy.

In counties with fewer therapists, kids were less likely to go to therapy, but that didn’t explain all of the variation, Gellad said.

For example, 20 percent of kids in Miami, Florida, saw a therapist compared to almost 50 percent of kids in Sacramento, California, even though both areas have about three licensed psychologists for every 10,000 residents.

“It is very likely that both parental preference and pediatrician preference/habit/comfort also play a role in addition to the supply of specialty mental health care,” Gellad told Reuters Health by email.

The research did not include therapy services delivered by a pediatrician, or those offered in the community that were not billed to commercial insurance, and did not address publicly insured children, the authors note.

It is unlikely that “need” for therapy differs so much by region, Gellad said.

We can’t say for certain based on this data how little therapy is too little, he said.

“I will say it is highly likely that in counties where fewer than 1 in 10 kids on medications have received psychotherapy, many children who could benefit from therapy are not receiving it,” Gellad said.

Adding therapy to medication can help some kids perform better in school, make parents more satisfied and actually lower the dose of stimulant medication kids need, he said.

SOURCE: JAMA Pediatrics, online September 22, 2014.


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