Healthcare use by children with attention deficit/hyperactivity disorder with and without psychiatric comorbidities

Healthcare utilisation in the United Arab Emirates for children with attention-deficit hyperactivity disorder and comorbidities

The prevalence of attention-deficit hyperactivity disorder is consistent worldwide. Psychiatric comorbidities are common, although less is known about how those comorbidities affect utilisation of healthcare services. Access to paediatric mental healthcare is a challenge in many regions. However, access to care in the United Arab Emirates (UAE) is supported by a well-established healthcare infrastructure with widely available primary care physicians. A review of diagnosis codes suggests that a clear correlation exists between the number of comorbidities and increased utilisation of available mental health services. Infrastructure in the UAE may represent a successful model for paediatric mental healthcare.

Health system utilization before age 1 among children later diagnosed with autism or ADHD

Children with autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) have 2-3 times increased healthcare utilization and annual costs once diagnosed, but little is known about their utilization patterns early in life. Quantifying their early health system utilization could uncover condition-specific health trajectories to facilitate earlier detection and intervention. Patients born 10/1/2006-10/1/2016 with ≥ 2 well-child visits within the Duke University Health System before age 1 were grouped as ASD, ADHD, ASD + ADHD, or No Diagnosis using retrospective billing codes. An additional comparison group was defined by later upper respiratory infection diagnosis. Adjusted odds ratios (AOR) for hospital admissions, procedures, emergency department (ED) visits, and outpatient clinic encounters before age 1 were compared between groups via logistic regression models. Length of hospital encounters were compared between groups via Mann-Whitney U test. In total, 29,929 patients met study criteria (ASD N = 343; ADHD N = 1175; ASD + ADHD N = 140). ASD was associated with increased procedures (AOR = 1.5, p < 0.001), including intubation and ventilation (AOR = 2.4, p < 0.001); and outpatient specialty care, including physical therapy (AOR = 3.5, p < 0.001) and ophthalmology (AOR = 3.1, p < 0.001). ADHD was associated with increased procedures (AOR = 1.41, p < 0.001), including blood transfusion (AOR = 4.7, p < 0.001); hospital admission (AOR = 1.60, p < 0.001); and ED visits (AOR = 1.58, p < 0.001). Median length of stay was increased after birth in ASD (+ 6.5 h, p < 0.001) and ADHD (+ 3.8 h, p < 0.001), and after non-birth admission in ADHD (+ 1.1 d, p < 0.001) and ASD + ADHD (+ 2.4 d, p = 0.003). Each condition was associated with increased health system utilization and distinctive patterns of utilization before age 1. Recognizing these patterns may contribute to earlier detection and intervention.

Variation in Rate of Attention-Deficit/Hyperactivity Disorder Management by Primary Care Providers

OBJECTIVE

To describe variation in rates of attention-deficit/hyperactivity disorder (ADHD) management by pediatrics primary care providers (PCPs) and to assess influence of clinician characteristics on variation.

METHODS

Retrospective cohort study of electronic health records from all office visits of patients aged 4 to 17 years seen at least twice between 2015 and 2017 by 73 clinicians in 9 pediatrics practices of a community-based primary health care network in California. Outcomes per clinician: 1) percent patients seen for ADHD management; (2) percent ADHD patients with diagnosed comorbid conditions. Logistic random-effects regression models examined practice- and clinician-level variation.

RESULTS

Of 40,323 patients in the cohort, 2039 (5.1%) carried an ADHD diagnosis, of which 1142 (56%) received ADHD medication. Percent of patients seen for ADHD management varied by clinician from 0.0% to 8.3% (median 3.0%). After accounting for practice-level variation and patient characteristics (ie, sex, age, insurance), clinician characteristics explained 28% of clinician variation in ADHD management. ADHD management rate was associated with high-percent full-time equivalent (odds ratio 1.17; 95% confidence interval 1.07-1.27). Percent of ADHD patients with diagnoses of comorbidities varied by clinician from 0.0% to 100% (median 35%). Association between ADHD management rate and comorbidity diagnosis was minimal (R = 0.10).

CONCLUSIONS

Objective electronic health records measures showed that PCPs in this network varied widely in their involvement in ADHD management. For most PCPs, percent of patients with ADHD and diagnosis of comorbidities was lower than estimated prevalence rates. Exploration of modifiable factors associated with PCP variation is needed to inform strategies for implementation of evidence-based practices.

Influence of Surgical Procedures and General Anesthesia on Child Development Before Primary School Entry Among Matched Sibling Pairs

IMPORTANCE

Substantial preclinical evidence suggests that the developing brain is susceptible to injury from anesthetic drugs. Findings from clinical studies of the neurotoxic effects of anesthesia are mixed, but these effects can be influenced by unmeasured confounding from biological and environmental risk and protective factors on child development.

OBJECTIVE

To examine the association between surgical procedures that require general anesthesia before primary school entry and child development in biological siblings.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective sibling-matched cohort study included sibling pairs aged 5 to 6 years with the same birth mother who had Early Development Instrument (EDI) data completed. The EDI is a population-based measure of child development that assesses children's readiness to learn in 5 major domains (physical health and well-being, social knowledge and competence, emotional health and maturity, language and cognitive development, and communication skills and general knowledge). All eligible children in public and Catholic schools in Ontario, Canada, from 2004 through 2012 were included. Data were analyzed from December 13, 2017, through July 27, 2018.

EXPOSURES

Surgical procedures that require general anesthesia from the date of birth to EDI completion.

MAIN OUTCOMES AND MEASURES

Early developmental vulnerability, defined as any major domain of the EDI in the lowest 10th percentile of the Ontario population.

RESULTS

Of the 187 226 eligible children for whom the EDI was completed, a total of 10 897 sibling pairs (21 794 children; 53.8% female; mean [SD] age, 5.7 [0.3] years) were subsequently identified, including 2346 with only 1 child exposed to surgery. No significant differences were found between exposed and unexposed children in early developmental vulnerability (697 of 3080 [22.6%] vs 3739 of 18 714 [20.0%]; adjusted odds ratio [aOR], 1.03; 95% CI, 0.98-1.14; P = .58) or for each of the 5 major EDI domains (aOR for language and cognitive development, 0.96 [95% CI, 0.80-1.14]; aOR for physical health and well-being, 1.09 [95% CI, 0.96-1.24]; aOR for social knowledge and competence, 0.98 [95% CI, 0.84-1.14]; aOR for emotional health and maturity, 0.98 [95% CI, 0.84-1.14]; and aOR for communication skills and general knowledge, 0.90 [95% CI, 0.77-1.05]), after adjusting for confounding factors (age at EDI completion, sex, mother's age at birth, and eldest sibling status).

CONCLUSIONS AND RELEVANCE

In this provincial cohort study, children who had surgical procedures that require general anesthesia before primary school entry were not found to be at increased risk of adverse child development outcomes compared with their biological siblings who did not have surgery. These findings further support that anesthesia exposure in early childhood is not associated with detectable adverse child development outcomes.

Accuracy of Electronic Health Record-Derived Data for the Identification of Incident ADHD

OBJECTIVE

To assess the accuracy of electronic health record (EHR)-derived diagnoses in identifying children with incident (i.e., newly diagnosed) ADHD.

METHOD

In 10 large health care organizations, electronic diagnoses data were used to identify all potential cases of incident ADHD among 3- through 9-year-old children. A random sample of records was manually reviewed to determine whether a diagnosis of ADHD was documented in clinician notes.

RESULTS

From electronic diagnoses data, a total of 7,362 children with incident ADHD were identified. Upon manual review of 500 records, the diagnosis of incident ADHD was confirmed in clinician notes for 71.5% (95% confidence interval [CI] = [56.5, 86.4]) of records for 3- through 5-year-old children and 73.6% (95% CI = [65.6, 81.6]) of records for 6- through 9-year-old children.

CONCLUSION

Studies predicated on the identification of incident ADHD cases will need to carefully consider study designs that minimize the likelihood of case misclassification.

Toward Effective Utilization of the Pediatric Emergency Department: The Case of ADHD

This project's purpose was to characterize attention-deficit/hyperactivity disorder (ADHD)-related emergency department (ED) visits compared with other psychiatric visits made by children with Medicaid and to determine whether any visits were avoidable. Medicaid claims of children who visited the ED for mental health services were analyzed. Logistic regression was used to examine whether demographic, ED-, and system-level variables increased the odds of an ED visit for children with Medicaid, comparing those with ADHD to other psychiatric diagnoses. Children who were African American, arrived during the daytime, and lived in counties with mental health professional shortages had greater odds of an ED visit for ADHD compared to other psychiatric visits. Approximately 24% of all ED visits were for ADHD and about 30% of these visits may have been avoidable. ADHD-related ED visits comprise a sizeable proportion of all ED visits. Some visits appeared to be emergent but possibly treatable in primary care.

Teletherapy delivery of caregiver behavior training for children with attention-deficit hyperactivity disorder

BACKGROUND

Preliminary studies suggest that videoteleconferencing (VTC) may be an effective means to deliver behavioral interventions to families. Subjects consisted of a subsample of children (n=37) and caregivers who participated in the Children's Attention-Deficit Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS) (n=223), a randomized trial testing the effectiveness of delivering treatments for ADHD to families residing in their home communities using distant technologies. Families randomized to the CATTS intervention arm received pharmacotherapy and caregiver behavior training.

MATERIALS AND METHODS

Thirty-seven families from the CATTS intervention arm participated. All families received pharmacotherapy through VTC. Twelve families received the caregiver behavior training through VTC, or teletherapy, and 25 received the intervention in-person. We assessed children's outcomes at 25 weeks with the Vanderbilt ADHD Parent Rating Scale and the Columbia Impairment Scale. We assessed caregivers' outcomes using measures of distress in caring for a child with ADHD, including depression, stress, strain, and empowerment. We used analysis of covariance to assess outcomes from baseline to 25 weeks.

RESULTS

Families in the two conditions showed comparable attendance at sessions and satisfaction with their care. Caregivers in both conditions reported comparable outcomes for their children's ADHD-related behaviors and functioning, but caregivers in the teletherapy group did not report improvement in their own distress.

CONCLUSIONS

Findings support the feasibility, acceptability, and effectiveness of treating children with ADHD through teletherapy. Future work should investigate how teletherapy may improve caregivers' distress. Teletherapy is a promising modality for delivering behavioral interventions for children with ADHD.

Attention-deficit/hyperactivity disorder and telemental health

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders diagnosed in children and adolescents (youth). ADHD is equally distributed geographically, but services are not. Access to expert evaluation and treatment remains limited for youth with ADHD living in rural areas, as well as for ethnic and racial minority youth. Telepsychiatry is a service delivery model with the potential to reach these youth and to develop collaborative models of care among local primary care physicians, remote telepsychiatrists, and local families. Care delivered through telepsychiatry can readily adhere to the practice parameters of the American Academy of Child and Adolescent Psychiatry. Work to date indicates that ADHD is the most common disorder treated through telepsychiatry. This article reviews the status of child and adolescent telepsychiatry, with particular focus on its potential to improve the care and outcomes of underserved populations of youth diagnosed with ADHD.

The evolution of hyperactivity, impulsivity and cognitive diversity

The evolutionary status of attention deficit/hyperactivity disorder (ADHD) is central to assessments of whether modern society has created it, either physically or socially; and is potentially useful in understanding its neurobiological basis and treatment. The high prevalence of ADHD (5-10%) and its association with the seven-repeat allele of DRD4, which is positively selected in evolution, raise the possibility that ADHD increases the reproductive fitness of the individual, and/or the group. However, previous suggestions of evolutionary roles for ADHD have not accounted for its confinement to a substantial minority. Because one of the key features of ADHD is its diversity, and many benefits of population diversity are well recognized (as in immunity), we study the impact of groups' behavioural diversity on their fitness. Diversity occurs along many dimensions, and for simplicity we choose unpredictability (or variability), excess of which is a well-established characteristic of ADHD.Simulations of the Changing Food group task show that unpredictable behaviour by a minority optimizes results for the group. Characteristics of such group exploration tasks are risk-taking, in which costs are borne mainly by the individual; and information-sharing, in which benefits accrue to the entire group. Hence, this work is closely linked to previous studies of evolved altruism.We conclude that even individually impairing combinations of genes, such as ADHD, can carry specific benefits for society, which can be selected for at that level, rather than being merely genetic coincidences with effects confined to the individual. The social benefits conferred by diversity occur both inside and outside the 'normal' range, and these may be distinct. This view has the additional merit of offering explanations for the prevalence, sex and age distribution, severity distribution and heterogeneity of ADHD.

Change in the direct cost of treatment for children and adolescents with hyperkinetic disorder in Germany over a period of four years

BACKGROUND

In many developed countries, the treatment of hyperkinetic disorder (or ADHD) consumes a considerable amount of resources. The primary aim of this study was to determine change in the direct cost of treatment for children and adolescents with hyperkinetic disorder in Germany over time, and compare the cost with the cost of treatment for two physical disorders: epilepsy and asthma.

METHODS

The German Federal Statistical Office provided data on the direct cost of treating hyperkinetic disorder, epilepsy and asthma in Germany for 2002, 2004, and 2006. The direct costs of treatment incurred by hyperkinetic disorder in these years were compared with those incurred by epilepsy and asthma.

RESULTS

The total direct cost of treatment for the hyperkinetic disorder was euro 177 million in 2002, euro 234 million in 2004, and euro 341 million in 2006. The largest proportion of the cost was incurred by the age group < 15 years: euro 158 million in 2002, euro 205 million in 2004, and euro 287 million in 2006. The direct cost of treatment for epilepsy in this age group was a total of euro 157 million in 2002, euro 155 million in 2004, and euro 155 million in 2006. For asthma, the total direct cost of treatment in this age group was euro 266 million in 2002, euro 257 million in 2004, and euro 272 million in 2006.

CONCLUSION

The direct cost of treatment for hyperkinetic disorder in the age group < 15 years increased considerably between 2002 and 2006. Over the same period of time and for the same age group, expenditure for epilepsy and asthma was more or less constant. The increase in expenditure for the treatment of hyperkinetic disorder may be due to increasing demand for diagnostic and therapeutic services and improved availability of such services. The study is limited by the difficulty of obtaining consistent data on the direct cost of treatment for both physical and psychiatric disorders in Germany.

Mothers of children diagnosed with attention-deficit/hyperactivity disorder: health conditions and medical care utilization in periods before and after birth of the child

BACKGROUND

Analyzing health conditions and medical utilization of mothers of children with attention-deficit/hyperactivity disorder (ADHD) can shed light on biologic, environmental, and psychosocial factors relating to ADHD.

OBJECTIVE

To examine health conditions, health care utilization, and costs of mothers of children with ADHD in periods before the child was diagnosed.

METHODS

Using automated data from Northern California Kaiser Permanente we identified mothers of children with ADHD, mothers of children without ADHD, and mothers of children with asthma. Mothers' diagnostic clusters, health care utilization, and costs were compared. Mothers of children with ADHD were compared with mothers of children without ADHD and, separately, to mothers of children with asthma.

RESULTS

Compared with mothers of children without ADHD, mothers of children with ADHD were more likely to be diagnosed with numerous medical and mental health problems in the 2 years after birth of their child, including depression [odds ratio (OR): 1.88], anxiety neuroses (OR: 1.64), obesity (OR: 1.70), and musculoskeletal symptoms (OR: 1.51). Results were similar for the year before delivery. Mothers of children with ADHD also had higher total health care costs per person in the year before ($1,003) and the 2 years after ($953) the birth of their child. Mothers of children with ADHD also were diagnosed with more health conditions and had higher health care costs than mothers of children with asthma.

CONCLUSIONS

Our findings suggest that the likelihood of being diagnosed with ADHD is related to maternal conditions and use of health services that precede the child's diagnosis. Future studies are needed to clarify whether this is due to biologic, psychosocial, or environmental factors, or a combination.

ADHD service use patterns in youth

OBJECTIVE

To review what is currently known about service use by youth with attention-deficit/hyperactivity disorder (ADHD) and discuss research and policy implications.

METHODS

Literature review.

RESULTS

The primary care, mental health, and educational service system sectors all play an essential role in caring for youth with ADHD. Recent studies also suggest increasing use of stimulants and other psychoactive medication for youth with ADHD, decreasing mental health visits for ADHD unassociated with medication use, increased use of other psychotropic medications, and a number of barriers to care coordination across primary care, mental health, and schools.

CONCLUSIONS

Four important services, research, and policy areas that need to be addressed over the next decade include: 1) delving deeper into current service use, 2) paying attention to the context in which service use occurs, 3) operationalizing evidence-based care for real-world settings, and 4) learning what changes clinician and educator behavior.

The interdependence of behavioral and somatic health: implications for conceptualizing health and measuring treatment outcomes

PURPOSE

The interdependence of behavioral and somatic aspects of various health conditions warrants greater emphasis on an integrated care approach.

THEORY

We propose that integrated approaches to health and wellness require comprehensive and empirically-valid outcome measures to assess quality of care.

METHOD

We discuss the transition from independent to integrated treatment approaches and provide examples of new systems for integrated assessment of treatment outcome.

RESULTS

Evidence suggests that support for an independent treatment approach is waning and momentum is building towards more integrated care. In addition, research evidence suggests integrated care improves health outcomes, and both physicians and patients have favorable impressions of integrated care.

CONCLUSIONS

As treatment goals in the integrated perspective expand to take into account the intimate relationships among mental illness, overall health, and quality of life, clinicians need to develop outcome measures that are similarly comprehensive.

DISCUSSION

Increased recognition, by researchers, providers, and insurers, of the interdependence between behavioral and physical health holds great promise for innovative treatments that could significantly improve patients' lives.

Patterns of psychostimulant prescribing to children with ADHD in Western Australia: variations in age, gender, medication type and dose prescribed

OBJECTIVE

To examine treatment with psychostimulant medicines for attention deficit hyperactivity disorder (ADHD) in children (3-17 years) within Western Australia (WA) during 2004.

METHODS

Using whole-population-based administrative pharmacy data for 2004, age-specific prevalence of children treated with dexamphetamine and methylphenidate was determined. Treatment with immediate-action and sustained-release stimulants was also examined. Average daily dose (absolute and relative to body weight) of dexamphetamine, methylphenidate and total stimulant medication was also calculated.

RESULTS

9,658 children from 3-17 years (23.5 per 1,000 child population) were treated with stimulant medication for ADHD during 2004. Age-specific prevalence of treatment increased rapidly from three to eight years to peak at 14 years. The male-to-female ratio of stimulant treatment was 4.1. Child prevalence of treatment with dexamphetamine, methylphenidate or combined therapy was 16.4, 8.9 and 1.7 per 1,000 children, respectively. Most children were treated with immediate-action stimulants (16.9 per 1,000 child population), with fewer using sustained-release medicines (4.0 per 1,000 child population).

CONCLUSIONS

The prevalence of stimulant medication use for the treatment of ADHD in WA children is 2.4%, with males accounting for the majority of treated patients. Most children were treated with dexamphetamine. Prescribing of methylphenidate, sustained-release stimulants or combined medication therapy was less common. Age-related trends in prescribed daily dose differed for dexamphetamine and methylphenidate.

Emergency department use and costs for youth with attention-deficit/hyperactivity disorder: associations with stimulant treatment

OBJECTIVE

To investigate whether, among youth with attention-deficit/hyperactivity disorder (ADHD), stimulant treatment is associated with reduced emergency department (ED) use and medical costs.

METHODS

We previously reviewed the complete and detailed school and medical records of all individuals born 1976-1982 in Rochester, Minn, to identify those who met criteria for ADHD between age 5 years and emigration from the area. Stimulant treatment (all start/stop dates, dosages) was also abstracted. This study followed birth cohort members with ADHD in provider-linked billing data from January 1, 1987 (billing data first available), to age 18 for outcomes: ED visits, ED costs, and medical costs. For each outcome, we analyzed associations with 1) any stimulants (yes/no), 2) proportion of follow-up time on stimulants, and 3) among those treated with stimulants, periods on versus off stimulants.

RESULTS

Of 313 youth with ADHD, 231 (74%) received any stimulants; treatment duration ranged from 14 days to 11.8 years. Treated and untreated youth were similar with respect to median annual ED visits (0.5 vs 0.5) and medical costs (661 US dollars vs 741 US dollars) (P > .05); however, increasing proportion of follow-up on stimulants was associated with fewer ED visits (P= .02) and higher medical costs (P< .001). The 231 treated youth experienced an average of 3.7 periods on and off stimulants; while receiving stimulants, they exhibited fewer ED visits (P= .02), lower ED costs (P = .03), and higher medical costs (P< .001) compared with periods off stimulants.

CONCLUSIONS

Among youth with ADHD, extended stimulant treatment is associated with decreased ED visits and ED costs, but higher total medical costs.

Effect of methylphenidate formulation on treatment patterns and use of emergency room services

PURPOSE

The treatment patterns of and use of emergency room services by patients with attention-deficit/hyperactivity disorder (ADHD) who initiated therapy with thrice-daily, immediate-release (IR) methylphenidate versus once-daily, extended-release (ER) oral system methylphenidate were studied.

METHODS

Using a large claims database, patients who were newly initiated on either ER methylphenidate or IR methylphenidate were retrospectively identified. Analysis of covariance was used to examine differences in treatment patterns between individuals who initiated therapy on ER methylphenidate and those who initiated therapy on IR methylphenidate. Multivariate regressions were used to examine the probability of visiting the emergency room and the number of visits to the emergency room.

RESULTS

Of the 5939 patients who met the inclusion criteria, 4785 were initiated on ER methylphenidate and 1154 were initiated on IR methylphenidate. Significantly fewer patients initiated on ER methylphenidate had a 15- or 30-day gap in therapy or switched to another ADHD medication (p < 0.0001 for all comparisons). In addition, patients initiated on the ER formulation had a significantly longer duration of therapy than did those who received IR methylphenidate (p < 0.0001). Patients who received initial treatment with ER methylphenidate were also significantly less likely to visit an emergency room (odds ratio, 0.79; p = 0.01) and had, on average, 0.21 fewer visit to the emergency room (p = 0.0101).

CONCLUSION

A retrospective analysis of a patient database demonstrated that initial treatment with ER methylphenidate for patients with ADHD was associated with longer treatment periods, fewer switches in therapy, increased patient adherence, and a lower usage rate of emergency room services compared with initial treatment with IR methylphenidate.

Bildgebende Darstellung neurokognitiver Dysfunktionen bei der Aufmerksamkeitsdefizit-/Hyperaktivit�tsst�rung

Attention Deficit Hyperactivity Disorder (ADHD) is a neurobiological disorder of early childhood onset. Defining symptoms are chronic impairments of attention, impulse control and motor hyperactivity that frequently persist until adulthood. Miscellaneous causes of the disorder have been discussed. Accumulating evidence from imaging- and molecular genetic studies strengthened the theory of ADHS being a predominantly inherited disorder of neurobiological origin. In the last 15 years, non-invasive brain imaging methods were successfully implemented in pediatric research. Functional magnetic resonance imaging studies gave major insight into the neurobiological correlates of executive malfunction, inhibitory deficits and psychomotoric soft signs. These findings are in good accordance with brain morphometric data indicating a significant volumetric decrease of major components of striato-thalamo-cortical feedback loops, primarily influencing prefrontal executive functioning (e.g. basal ganglia). Empirical evidence points to a broad array of associated behavioral disturbances like deficient visuomotor abilities and oculomotor dysfunctions. This paper reviews the current empirical evidence derived from prior imaging studies. Special emphasis is given to the relevance of oculomotor dysfunctions in clinical and research settings, as well as their assessment in the MR environment.