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Research Letter
November 2014

Geographic Variation in Receipt of Psychotherapy in Children Receiving Attention-Deficit/Hyperactivity Disorder Medications

Author Affiliations
  • 1Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
  • 2RAND Corporation, Pittsburgh, Pennsylvania
  • 3Division of General Medicine and Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 4Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 5Express Scripts, St Louis, Missouri
  • 6Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
  • 7Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania

Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Pediatr. 2014;168(11):1074-1076. doi:10.1001/jamapediatrics.2014.1647

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood disorders, affecting an estimated 11% of boys and 4% of girls in the United States.1 Stimulant medications manage ADHD symptoms in most children.2,3 However, many parents prefer that treatment include some nonpharmacologic therapy,4,5 and combination behavioral therapy and pharmacotherapy may improve outcomes over either modality alone for many youth.3,6

Little is known about what proportion of children treated with ADHD medication also receive nonpharmacologic therapy (hereafter referred to as therapy) and how rates of combination therapy vary geographically. We used a large commercial claims database (MarketScan) linked to county-level information on the supply of psychologists to examine variation in receipt of therapy in children receiving ADHD medication.


We identified children 0 to 17 years of age who filled a prescription for an ADHD medication and were continuously enrolled in an insurance plan from January 1, 2010, to December 31, 2010. To ensure adequate sample size in each area, we excluded counties with fewer than 20 children receiving ADHD medication. We also excluded individuals with comorbid autism or pervasive development disorder. County-level data on supply of licensed psychologists was obtained from the Area Resource File.

Our primary outcome was the receipt of at least 1 outpatient therapy visit (individual, group, or family) in 2010, identified using current procedural terminology codes. We also examined receipt of 4 or more therapy visits and 8 or more therapy visits. We measured receipt of therapy by county, adjusting for age, sex, and the presence of comorbid psychiatric conditions using mixed regression models. We examined how receipt of therapy varied across counties based on the supply of licensed psychologists (by quintile).


The 1516 counties in our cohort, which account for more than 90% of the US population, included 301 530 children aged 0 to 17 years receiving ADHD medication. The mean age was 11.6 years and 69.8% were male. Overall, 24.5% of children receiving ADHD medication had some therapy visits in 2010. Unadjusted rates of therapy varied widely across counties, from 6.3% to 38.1% from the 5th to 95th percentile of counties (Table). In fully adjusted analyses, 22.2% of children received therapy in the median county, 13.1% of children had at least 4 therapy visits, and 7.1% had at least 8 visits, with wide variation across counties (Table).

Image not available
County-Level Percentages of Children Aged 0 to 17 Years Receiving ADHD Medication Who Received Therapy Services in 2010

Rates of psychotherapy varied considerably both within and across quintiles of county psychologist supply (Figure). For example, the proportion of children receiving therapy was more than twice as high in Sacramento County (47.8%) compared with Miami-Dade County (19.9%), despite a comparable supply of licensed psychologists (0.32 of 1000 vs 0.30 of 1000 residents, respectively).

Image not available
County-Level Proportion of Children Receiving Attention-Deficit/Hyperactivity Disorder Medication Who Received Therapy by Quintile of Licensed Psychologist Supply

Quintile 1 is the lowest supply of licensed psychologists and quintile 5 is the highest supply of licensed psychologists. Large cities within counties in each quintile are noted for descriptive purposes. County-level data on supply of licensed psychologists was obtained from the 2011-2012 Area Resource File.


We found that only one-quarter of commercially insured children in our sample receiving ADHD medication received any concurrent therapy services. In almost 200 US counties, fewer than 1 in 10 children receiving ADHD medication received therapy. While medication-only treatment is consistent with guidelines for school-aged children, it may not represent the optimal treatment for many patients. The geographic variation in receipt of therapy, despite adjustment for clinical characteristics, may be explained not only by psychologist supply but also by parent, child, or pediatrician preferences for or comfort with nonpharmacologic care.

We acknowledge limitations common to analyses of claims data, including no information on services that were not billed to commercial insurance and a limited ability to determine severity of illness or clinical appropriateness for therapy. We cannot comment on therapy receipt in those smaller and more rural counties that we excluded. Nonetheless, our study is the first, to our knowledge, to document the substantial variation in receipt of therapy services among US children treated with ADHD medications and is directly relevant to the ongoing public discourse about how this common condition should be treated.

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Article Information

Corresponding Author: Walid F. Gellad, MD, MPH, RAND Corporation, 4570 Fifth Ave, Ste 600, Pittsburgh, PA 15213 (

Published Online: September 22, 2014. doi:10.1001/jamapediatrics.2014.1647.

Author Contributions: Dr Gellad and Mr Ruder had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gellad, Henderson, Frazee, Mehrotra, Donohue.

Acquisition, analysis, or interpretation of data: Gellad, Stein, Ruder, Henderson, Frazee, Donohue.

Drafting of the manuscript: Gellad, Stein, Frazee.

Critical revision of the manuscript for important intellectual content: Stein, Ruder, Henderson, Frazee, Mehrotra, Donohue.

Statistical analysis: Ruder.

Obtained funding: Gellad, Frazee, Donohue.

Administrative, technical, or material support: Henderson, Frazee, Mehrotra.

Study supervision: Gellad, Frazee.

Conflict of Interest Disclosures: Drs Henderson and Frazee are employees of and hold equity interest in Express Scripts.

Funding/Support: This work was supported by Express Scripts through a contract to RAND Corporation, focused on examining geographic variation in prescription use. Dr Gellad was additionally supported by grant CDA 09-207 from Veterans Affairs Health Services Research and Development.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This work represents the opinions of the authors alone and does not necessarily represent the views of the funders or the Department of Veterans Affairs or the US Government.

Previous Presentations: This work was presented at the 2013 annual meeting of the American Academy of Child & Adolescent Psychiatry; October 23, 2014; Orlando, Florida.

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