ADHD medication rates vary between regions. Are restrictive or liberal ADHD prescription practices better for long-term prognosis?

It is well documented in many randomized controlled trials (experiments) that stimulant medication is helpful for patients with ADHD. This is no controversy in child- and adolescent psychiatry. However, patients referred to psychiatric services often have some symptoms indicating ADHD, but there may be circumstances which also can explain the symptoms. For example, the children may live in chaotic families, they may find school boring, or they may simply have a lot of energy. Based on clinical judgement the psychiatrist must determine if ADHD diagnosis is appropriate, and if medication should be started. This clinical judgement varies between psychiatrists and between hospitals. The consequence is that the rate of ADHD diagnosis and medication for ADHD varies considerably between regions and hospitals. Similarly, the rate varies between countries. The restrictive attitude is characterized with a concern about medicalization, side-effects of medicine, and over-treatment. The liberal position is characterized by a belief that diagnosis and medication in ADHD may prevent the adverse trajectory in ADHD. ADHD is associated with an elevated risk of school dropout, poor educational attainment, accidents, crime and mortality (Lyhmann et al 2022). We have found a 10-fold variation in ADHD diagnosis between the most restrictive CHAMS and the most liberal ones (Widding-Havneraas et al 2022). There is a similar variation in and between other countries. The many trials do not settle this controversy in child and adolescent psychiatry. The trails are based on children and adolescents with clear ADHD diagnosis. We will explore if the liberal or the restrictive approach to ADHD diagnosis and treatment produces the best prognosis for patients. We will use registry data and the naturally occurring variation in ADHD treatment rates in this project.

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The 185 RCTs supporting the efficacy of stimulant medication in ADHD do not address this ADHD-controversy. The RCTs are largely based on patients with clear-cut ADHD, where there will be consensus on diagnosis and treatment. However, many patients referred to child psychiatry have only some symptoms of ADHD or the symptoms may be better explained by another condition than ADHD, and psychiatrists differ in their policy on ADHD-diagnosis and medication in this large group. This is where the controversy occurs between the liberal and the restrictive ADHD-treatment position. Consequently, large variations in ADHD medication rates exist, even within a country like Norway with a universal public specialist health system. Patients are generally unaware of this lottery-like situation regarding ADHD-diagnosis and treatment. Further, the 185 RCTs have on average only 75 days follow-up. Clinicians, patients, and their parents are interested in treatment effects in terms of years rather than months. They are also interested in functional outcomes, like the chance of school dropout, crime, employment and survival, generally not reported in the current literature. The aim of this study is to provide empirical evidence to inform this international controversy in child psychiatry. Does a liberal or the restrictive ADHD medication practice produce better long-term prognoses? The proposed research project further aims to innovate psychiatric epidemiology. Current observational psychiatric epidemiology is rightfully criticized for being unable to address causality due to residual confounding and bias. This project is enabled by the lottery-like variation in ADHD diagnosis and medication, world-class longitudinal population registry data, the presence of a universal health system catering for the entire population, absence of competition within and with a private sector, and a cross-disciplinary team at the forefront of clinical psychiatry, epidemiology and causal modelling.