[The health economics of attention deficit hyperactivity disorder in Germany. Part 1: Health care utilization and cost of illness]

Does helping mothers in multigenerational ADHD also help children in the long run? 2-year follow-up from baseline of the AIMAC randomized controlled multicentre trial

ADHD often affects multiple generations in a family. Previous studies suggested that children with ADHD benefit less from therapy if parents are also affected, since ADHD symptoms interfere with treatment implementation. This two-group randomised controlled trial examined whether targeting maternal ADHD boosts the efficacy of parent-child training (PCT) for the child's ADHD. Here, we report follow-up results 2 years from baseline. Mothers of 144 mother-child dyads (ADHD according to DSM-IV) were examined for eligibility (T1) and randomised to 12 weeks of intensive multimodal treatment comprising pharmacotherapy and DBT-based cognitive behavioural group psychotherapy (TG, n = 77) or clinical management comprising non-specific counselling (CG, n = 67) for Step 1 (concluded by T2). Subsequently, all dyads participated in 12 weekly PCT sessions for Step 2 (concluded by T3). In Step 3, participants received maintenance treatments for 6 months (concluded by T4). At 24 months after baseline (T5), we performed follow-up assessments. The primary endpoint was child ADHD/ODD score (observer blind rating). Outcomes at T5 were evaluated using ANCOVA. Assessments from 101 children and 95 mothers were available at T5. Adjusted means (m) of ADHD/ODD symptoms (range 0-26) in children did not differ between TG and CG (mean difference = 1.0; 95% CI 1.2-3.1). The maternal advantage of TG over CG on the CAARS-O:L ADHD index (range 0-36) disappeared at T5 (mean difference = 0.2; 95% CI - 2.3 to 2.6). Sensitivity analyses controlling for medication and significant predictors of follow-up participation showed unchanged outcomes. Within-group outcomes remained improved from baseline. At the 24-month follow-up, TG and CG converged. The superiority of intensive treatment regarding maternal symptoms disappeared. In general, cross-generational treatment seems to be effective in the long term. (BMBF grant 01GV0605; registration ISRCTN73911400).

Prevalence of ADHD in Accident Victims: Results of the PRADA Study

Background: Recent research has shown an increased risk of accidents and injuries in ADHD patients, which could potentially be reduced by stimulant treatment. Therefore, the first aim of our study was to evaluate the prevalence of adult ADHD in a trauma surgery population. The second aim was to investigate accident mechanisms and circumstances which could be specific to ADHD patients, in comparison to the general population. Methods: We screened 905 accident victims for ADHD using the ASRS 18-item self-report questionnaire. The basic demographic data and circumstances of the accidents were also assessed. Results: Prevalence of adult ADHD was found to be 6.18% in our trauma surgery patient sample. ADHD accident victims reported significantly higher rates of distraction, stress and overconfidence in comparison to non-ADHD accident victims. Overconfidence and being in thoughts as causal mechanisms for the accidents remained significantly higher in ADHD patients after correction for multiple comparison. ADHD patients additionally reported a history of multiple accidents. Conclusion: The majority of ADHD patients in our sample had not previously been diagnosed and were therefore not receiving treatment. The results subsequently suggest that general ADHD screening in trauma surgery patients may be useful in preventing further accidents in ADHD patients. Furthermore, psychoeducation regarding specific causal accident mechanisms could be implemented in ADHD therapy to decrease accident incidence rate.

Cost effectiveness of optimal treatment of ADHD in Israel: a suggestion for national policy

OBJECTIVES

There are well known behavioral complications of ADHD at adulthood such as learning difficulties resulting in lower education attainments; increased rate of car and other accidents; substance abuse; misconduct and imprisonment. These complications can be prevented or alleviated by effective treatment. In this study we calculated the economic burden of ADHD among adults in Israel and the cost of diagnosing and treating ADHD from childhood to adulthood. We then obtained the cost-benefit ratio of the treatment.

METHODS

The data were calculated using accepted estimations of prevalence and cost for the Israeli population assuming a prevalence of 4% among adults which is based on the ADHD prevalence among school age children.

RESULTS

The estimated cost per person with ADHD due to lower education attainment, higher involvement in crime and car accidents and more drug abuse is 289,969 USD and the estimated cost for optimal treatment is 41,667 USD. Hence, the benefit cost ratio is 7.02 and, assuming only 50% success of treatment, it is 3.51, still a very high cost benefit ratio.

CONCLUSIONS

Since early diagnosis and appropriate treatment of ADHD is very effective in reducing the various symptoms and complications at adulthood thus enabling a better education and higher income, it seems important to diagnose and offer comprehensive treatment to children with ADHD. Moreover, it seems equally important to continue treatment at adulthood.

Accident patterns in trauma surgery patients with and without self-reported ADHD

Attention deficit/hyperactivity disorder (ADHD) has been associated with a higher risk for accidents and injuries, leading to increased mortality. The objective of this study was to identify the types and mechanisms of accidents in a group of adult trauma victims with self-reported ADHD compared to a control group, based on Adult ADHD Self-Report Scale Version 1.1 (ASRSv1.1). A semi-open/qualitative accident questionnaire was conducted with 116 recruited patients from three trauma surgery units. The adult ADHD (aADHD) group differed significantly from the control group in self-reported psychiatric co-morbidities (p = 0.012), regular psychotropic medication use (p = 0.005), other accidents in the past year (p = 0.002), substance use before the accident (p = 0.007), and overconfidence in relation to the accident (p = 0.033). Most interestingly, we found significantly greater subjective ratings for stress (p = 0.002) and stressful/pressurising events before the accident (p = 0.026) in the adult ADHD group, as well as for self-reported stress at the time when conducting the interview (p = 0.016). The data demonstrate that special attention should be paid to interventions in stress reduction and sufficient treatment of ADHD in terms of preventing accidents and injuries in aADHD. Therefore, we suggest, in addition to pharmaceutical therapy, the integration of stress-management and coping strategies into aADHD management.

The cost incurred by victims of bullying from a societal perspective: estimates based on a German online survey of adolescents

Being a victim of bullying is linked to various social, emotional and behavioral problems potentially leading to a reduced quality of life. Furthermore, victims of bullying may cause extensive costs for society, for example by an above-average need for healthcare services. The present study was designed to quantify the costs and the loss of quality of life attributable to bullying by comparing victims with a control group of non-bullied students. A cross-sectional sample of 1293 adolescents (mean age 14.07, SD = 1.36) and their parents reported on bullying victimization, quality of life (adolescents' self-report), and annual direct (medical and non-medical) as well as indirect costs (parents' self-report) from a societal perspective (all expressed in €, year 2014 and 2015). For frequent (20.6% of our sample; costs: €8461.80 p.a.) but not occasional (13.3%; costs: €2850.06) bullying, victimization was associated with significantly higher costs compared to non-bullied adolescents (costs: €3138.00; annual difference between frequently bullied students and controls: €5323.01 p.a.; p = 0.008). Cost drivers included increased direct medical costs, but mostly indirect costs caused by productivity losses of the parents. Self-reported quality of life of frequent victims was considerably reduced (T = - 10.96; p < 0.001); also occasional bullying showed significantly reduced values in global quality of life (T = - 5.73; p < 0.001). The present findings demonstrate that frequent bullying is associated with substantial cost to society and reduced quality of life of victims. This observation underscores the need for effective school-based bullying prevention and suggests a high potential of effective programs to be cost effective as well.

Individualised short-term therapy for adolescents impaired by attention-deficit/hyperactivity disorder despite previous routine care treatment (ESCAadol)-Study protocol of a randomised controlled trial within the consortium ESCAlife

BACKGROUND

Despite the high persistence rate of attention-deficit/hyperactivity disorder (ADHD) throughout the lifespan, there is a considerable gap in knowledge regarding effective treatment strategies for adolescents with ADHD. This group in particular often shows substantial psychosocial impairment, low compliance and insufficient response to psychopharmacological interventions. Effective and feasible treatments should further consider the developmental shift in ADHD symptoms, comorbidity and psychosocial adversity as well as family dysfunction. Thus, individualised interventions for adolescent ADHD should comprise a multimodal treatment strategy. The randomised controlled ESCAadol study addresses the needs of this patient group and compares the outcome of short-term cognitive behavioural therapy with parent-based telephone-assisted self-help.

METHODS/DESIGN

In step 1, 160 adolescents aged 12 to 17 years with a diagnosis of ADHD will undergo a treatment as usual (TAU) observation phase of 1 month. In step 2, those still severely affected are randomised to the intervention group with an Individualised Modular Treatment Programme (IMTP) or a telephone-assisted self-help programme for parents (TASH) as an active control condition. The IMTP was specifically designed for the needs of adolescent ADHD. It comprises 10 sessions of individual cognitive behavioural therapy with the adolescents and/or the parents, for which participants choose three out of 10 available focus modules (e.g. organisational skills and planning, emotion regulation, problem solving and stress management, dysfunctional family communication). TASH combines a bibliotherapeutic component with 10 counselling sessions for the parents via telephone. Primary outcome is the change in ADHD symptoms in a clinician-rated diagnostic interview. Outcomes are assessed at inclusion into the study, after the TAU phase, after the intervention phase and after a further 12-week follow-up period. The primary statistical analysis will be by intention-to-treat, using linear regression models. Additionally, we will analyse psychometric and biological predictors and moderators of treatment response.

DISCUSSION

ESCAadol compares two short-term non-pharmacological interventions as cost-efficient and feasible treatment options for adolescent ADHD, addressing the specific needs and obstacles to treatment success in this group. We aim to contribute to personalised medicine for adolescent ADHD intended to be implemented in routine clinical care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), Current Controlled Trial DRKS00008974, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00008974 ; http://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008974 ; Registered on 28 December 2015.

Health Care Costs Associated With Parent-Reported ADHD: A Longitudinal Australian Population-Based Study

OBJECTIVE

To examine the health care costs associated with ADHD within a nationally representative sample of children.

METHOD

Data were from Waves 1 to 3 (4-9 years) of the Longitudinal Study of Australian Children ( N = 4,983). ADHD was defined by previous diagnosis and a measure of ADHD symptoms (Strengths and Difficulties Questionnaire [SDQ]). Participant data were linked to administrative data on health care costs. Analyses controlled for demographic factors and internalizing and externalizing comorbidities.

RESULTS

Costs associated with health care attendances and medications were higher for children with parent-reported ADHD at each age. Cost differences were highest at 8 to 9 years for both health care attendances and medications. Persistent symptoms were associated with higher costs ( p < .001). Excess population health care costs amounted to Aus$25 to Aus$30 million over 6 years, from 4 to 9 years of age.

CONCLUSION

ADHD is associated with significant health care costs from early in life. Understanding the costs associated with ADHD is an important first step in helping to plan for service-system changes.

Italian regional health service costs for diagnosis and 1-year treatment of ADHD in children and adolescents

The main aim of this study was to estimate the costs associated with diagnostic assessment and 1-year therapy in children and adolescents enrolled in 18 ADHD reference centres. Data concerning 1887 children and adolescents from the mandatory ADHD registry database during the 2012–2014 period were analysed. The overall diagnostic and treatment costs per patient amounts to €574 and €830, respectively. The ADHD centre, the school as sender, and the time to diagnosis constitute cost drivers. Non-pharmacological therapy resulted as being more expensive for patients concomitantly treated with drugs (€929) compared to those treated with psychological interventions alone (€590; p = 0.006). This study gives the first and reliable estimate of the costs associated with both diagnosis and treatment of ADHD in Italy. Although costs associated with mental disorders are difficult to estimate, continuing efforts are need to define costs and resources to guarantee appropriate care, also for ADHD.

The Risk of Hospitalizations with Injury Diagnoses in a Matched Cohort of Children and Adolescents with and without Attention Deficit/Hyperactivity Disorder in Germany: A Database Study

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is a common neuropsychiatric disorder in children and adolescents worldwide, and children with ADHD have elevated risk of injuries. Our aim was to assess the risk of hospitalizations with injury diagnoses and their various subtypes in children and adolescents with newly diagnosed ADHD compared to those without ADHD, as well as to study sex effects on this risk in the setting of the German health care system.

METHODS

The German Pharmacoepidemiological Research Database, in which 20 million insured from four statutory health insurances in Germany are included, was used to set up a matched cohort study of 3- to 17-year-old children and adolescents with and without ADHD. We calculated age-specific incidence rates and used Cox regression to obtain hazard ratios (HRs) for hospitalizations with injury diagnoses. We used the injury mortality diagnosis matrix for classification of injuries.

RESULTS

The matched cohort comprised a total of 75,300 children. The age-specific incidence rates for hospitalization with injury diagnosis for males with ADHD displayed a u-shaped form with highest incidences in the in the age groups 3-6 years [26.2 per 1,000 person-years; 95% confidence interval (CI) 20.5-33.0] and 18-21 years (28.6; 22.4-36.0). Girls with ADHD were less affected in younger age-groups, but the incidence rate for 18-21 year olds was similar to boys with ADHD (26.4; 17.4-38.4). The adjusted HR for children with ADHD was 1.40 (95% CI 1.30-1.49) compared to non-affected children. With respect to nature of injury, ADHD was associated with hospitalization with injury diagnoses of the internal organs, open wounds, and contusions but not with other injuries. With respect to body regions, children with ADHD were more prone to hospitalizations with injuries of the abdomen, traumatic brain injuries, other head injuries, and system-wide injuries such as poisoning and intoxication. No significant associations were seen for the other body regions. Differences between sexes were only seen for system-wide injuries.

CONCLUSION

Children and adolescents with ADHD are at an increased risk for hospitalizations with diagnoses of injuries compared to non-affected children. Despite differences in health-care systems, the risk increase is at a similar level in Germany as in other countries.

Prevalence of medically treated children with ADHD and type 1 diabetes in Germany - Analysis of two representative databases

BACKGROUND

The aim of this study was to analyze the prevalence of attention deficit hyperactivity disorder (ADHD) in children and adolescents with type 1 diabetes mellitus (T1DM) in Germany.

METHODS

Two different representative German databases - IMS®-Disease Analyzer, a database that includes diagnoses as well as other information, and IMS®-LRx, a database that documents prescriptions - were used to conduct a retrospective analysis. We searched the LRx database for patients who received both insulin and ADHD-specific medication.

RESULTS

In 2014, 677,587 children and adolescents aged 0-18 years were treated by a pediatrician and documented in the Disease Analyzer database. Of these patients, 16,833 received the International Statistical Classification of Diseases and Related Health Problems (ICD-10) diagnosis of ADHD (2.5%) and 3668 patients were treated for T1DM (0.1%). Of these 3668 patients, a total of 153 children were also diagnosed with ADHD (4.2%; p<0.05). In the LRx database, the overall prevalence of children in Germany who received both drugs for the treatment of ADHD and insulin in 2014 amounted to 2.9%. Diagnosis of ADHD is 2.4-3.3 times more frequent in boys than in girls. The highest prevalence was seen in the age group of 12-15 years (3.5%) and the lowest in the age group of 6-11 years (2.5%).

CONCLUSIONS

Children with diabetes suffer from ADHD significantly more frequently than children without diabetes. The prevalence of medically treated children with ADHD and diabetes is similar to that documented in a recent report by the Barmer GEK health insurance body. However, it is possible that children with T1DM are much more frequently seen by medical care providers and are thus more likely to be evaluated and receive an appropriate diagnosis.

Preschool hyperactivity is associated with long-term economic burden: evidence from a longitudinal health economic analysis of costs incurred across childhood, adolescence and young adulthood

BACKGROUND

Preschool hyperactivity is an early risk factor for adult mental health problems and criminality. Little is known about; (a) the patterns of long-term service costs associated with this behavioural marker in the general population and (b) the specific factors predicting hyperactivity-related costs. We undertook a prospective study investigating associations between preschool hyperactivity and average individual annual service costs up to late adolescent and young adulthood.

METHODS

One-hundred and seventy individuals rated as hyperactive by their parents and 88 nonhyperactive controls were identified from a community sample of 4,215 three years olds. Baseline information about behaviour/emotional problems and background characteristics were collected. At follow-up (when individuals were aged between 14 and 25 years) information was obtained on service use, and associated costs since the age of three. Based on this information we calculated the average cost per annum incurred by each individual.

RESULTS

Compared to controls, preschoolers with hyperactivity had 17.6 times higher average costs per annum across domains (apart from nonmental health costs). These were £562 for each hyperactive individual compared with £30 for controls. Average annual costs decreased as a function of age, with higher costs incurred at younger ages. The effects of hyperactivity remained significant when other baseline factors were added to the model. Effects were fully mediated by later psychiatric morbidity. When the hyperactive group were examined separately, costs were consistently predicted by male gender and, for some cost codes, by conduct problems.

CONCLUSIONS

Preventative approaches targeting early hyperactivity may be of value. Services should be targeted towards high-risk individuals with careful consideration given to the cost-to-benefit trade-off of early intervention strategies.

Computer-based cognitive training for ADHD: a review of current evidence

There has been an increasing interest in and the use of computer-based cognitive training as a treatment of attention-deficit/hyperactivity disorder (ADHD). The authors' review of current evidence, based partly on a stringent meta-analysis of 6 randomized controlled trials (RCTs) published in 2013, and an overview of 8 recently published RCTs highlights the inconsistency of findings between trials and across blinded and nonblinded ADHD measures within trials. Based on this, they conclude that more evidence from well-blinded studies is required before cognitive training can be supported as a frontline treatment of core ADHD symptoms.

Annual research review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders

BACKGROUND

Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses.

SCOPE AND METHODS

The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012.

FINDINGS

Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8).

CONCLUSION

Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.

Treatment costs of attention deficit hyperactivity disorder in Germany

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most common behavioural disorders among children and adolescents. The number of patients as well as prescriptions to treat this disease has continuously increased over the past few years. The aim of the present study was to analyse the costs for treating ADHD patients from the perspective of a major German health insurance fund.

METHODOLOGY

Anonymised administrative claims data were available for the study. All services reimbursed by the health fund for the selected ADHD patients were recorded. Apart from the resource use attributed directly to ADHD, co-morbidities as well as incremental costs were described based on a control group design.

RESULTS

A total of 30,264 ADHD patients were diagnosed in 2008. The total costs for these patients were euro 3,888, and the incremental costs were euro 2,902. The largest proportions of incremental costs were due to therapeutic devices and remedies like occupational therapy amounting to euro 1,270. Proportionate costs of euro 263 have been settled for pharmacotherapy with Methylphenidate and Atomoxetine. However, 41% of the patients were not treated with ADHD-related pharmaceuticals.

CONCLUSIONS

ADHD costs are relevant from health insurance perspective. The expenses for occupational therapy constitute the cost driver. Compared to the findings of studies from the United States and contrarily to the backdrop of public discussions about considerably increased prescriptions of ADHD-specific drugs, the significantly higher additional expenses for occupational therapy services are impressing. This kind of therapy is internationally rather unknown and is therefore not acknowledged as a therapeutic standard.

Molecular genetics research in ADHD: ethical considerations concerning patients' benefit and resource allocation

Immense resource allocations have led to great data output in genetic research. Concerning ADHD resources spent on genetic research are less than those spent on clinical research. But there are successful efforts made to increase support for molecular genetics research in ADHD. Concerning genetics no evidence based conclusive results have significant impact on prevention, diagnosis or treatment yet. With regard to ethical aspects like the patients' benefit and limited resources the question arises if it is indicated to think about a new balance of resource allocation between molecular genetics and non-genetics research in ADHD. An ethical reflection was performed focusing on recent genetic studies and reviews based on a selective literature search. There are plausible reasons why genetic research results in ADHD are somehow disappointing for clinical practice so far. Researchers try to overcome these gaps systematically, without knowing what the potential future benefits for the patients might be. Non-genetic diagnostic/therapeutic research may lead to clinically relevant findings within a shorter period of time. On the other hand, non-genetic research in ADHD may be nurtured by genetic approaches. But, with the latter there exist significant risks of harm like stigmatization and concerns regarding data protection. Isolated speeding up resources of genetic research in ADHD seems questionable from an ethical point of view. There is a need to find a new balance of resource allocation between genetic and non-genetic research in ADHD, probably by integrating genetics more systematically into clinical research. A transdisciplinary debate is recommended.

[Survey of attention deficit hyperactivity disorder in adults]

Attention deficit hyperactivity disorder (ADHD) represents a serious illness which involves impairments in childhood and adolescence that are of considerable importance for the process of social adaptation and thus the development of social competence. If left untreated this leads in a high percentage of cases to disturbances which seriously affect all areas of life reaching into adulthood. Hence, it makes sense and is necessary that adequate treatment is carried out preferably during childhood and adolescence and also at an adult age. Due to the persistence of the disorder in adults with ADHS, various problems arise in formulating expert opinions in conjunction with criminal, social and civil law, in road traffic law and within the scope of conscription. They result from the essential symptoms of ADHS like inattentiveness, overactivity and impulsiveness, but also particularly from the diverse comorbidities.

[The health economics of attention deficit hyperactivity disorder in Germany. Part 2: Therapeutic options and their cost-effectiveness]

Attention deficit hyperactivity disorder (ADHD) has been associated with a continuous increase of health care utilization and thus expenditures. This raises the issue of cost-effectiveness of health care provided for patients with ADHD. Comparative health economic evaluations generate relevant insights and typically report incremental cost-effectiveness ratios (ICERs) of alternatives versus an established standard. Typically, results of cost-effectiveness analyses (CEAs) are reported in terms of incremental cost-effectiveness ratios (ICERs). International evaluations, as well specific adaptations to Germany, indicate an acceptable to attractive cost-effectiveness--according to currently used international benchmarks--of an intense medication management strategy based on stimulants, primarily methylphenidate, with ICERs ranging from 20,000 EUR to 37,000 EUR per quality-adjusted life year (QALY) gained. Economic modeling studies also suggest cost-effectiveness of long-acting modified-release preparations of methylphenidate, owing to improved treatment compliance associated with simplified once daily administration schemes. Atomoxetine, in contrast, appears economically inferior compared to long-acting stimulants, given its higher acquisition costs and at best equal clinical effectiveness. There are currently no data supporting the cost-effectiveness of psychotherapeutic or behavioral interventions. Economic evaluations, which have been published to date, are generally limited by time horizons of up to 1 year and by their prevailing focus on ADHD core symptom improvement only. Therefore, further research into the cost-effectiveness of ADHD treatment strategies seems warranted.