Trends in attention deficit hyperactivity disorder ambulatory diagnosis and medical treatment in the United States, 2000-2010

Attention-deficit/hyperactivity disorder in pregnancy and the postpartum period

Attention-deficit/hyperactivity disorder is a childhood-onset neurodevelopmental disorder that frequently persists into adulthood with 3% of adult women having a diagnosis of attention-deficit/hyperactivity disorder. Many women are diagnosed and treated during their reproductive years, which leads to management implications during pregnancy and the postpartum period. We know from clinical practice that attention-deficit/hyperactivity disorder symptoms frequently become challenging to manage during the perinatal period and require additional support and attention. There is often uncertainty among healthcare providers about the management of attention-deficit/hyperactivity disorder in the perinatal period, particularly the safety of pharmacotherapy for the developing fetus. This guideline is focused on best practices in managing attention-deficit/hyperactivity disorder in the perinatal period. We recommend (1) mitigating the risks associated with attention-deficit/hyperactivity disorder that worsen during the perinatal period via individualized treatment planning; (2) providing psychoeducation, self-management strategies or coaching, and psychotherapies; and, for those with moderate or severe attention-deficit/hyperactivity disorder, (3) considering pharmacotherapy for attention-deficit/hyperactivity disorder, which largely has reassuring safety data. Specifically, providers should work collaboratively with patients and their support networks to balance the risks of perinatal attention-deficit/hyperactivity disorder medication with the risks of inadequately treated attention-deficit/hyperactivity disorder during pregnancy. The risks and impacts of attention-deficit/hyperactivity disorder in pregnancy can be successfully managed through preconception counselling and appropriate perinatal planning, management, and support.

[Pharmacological management of attention-deficit/hyperactivity disorders (ADHD) by generalists and specialists in Germany: a secondary data analysis]

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental health disorders among children, and it is rapidly surging among adults as well. The aim of this study was to investigate the role of community neurologists and psychiatrists as well as general practitioners and paediatricians in prescribing ADHD medications in Germany and whether their role has changed over the 10-year period from 2008 and 2018.

METHODS

In this secondary analysis of anonymized prescribing data, we calculated the absolute and relative frequencies of ADHD prescriptions by neurologists and psychiatrists, summarized as specialists, and family physicians and paediatricians, summarized as generalists, and how it has changed during the years 2008 to 2018.

RESULTS

A total of 620 practices delivered data on 77,504 patients diagnosed with ADHD, 38% (29,396/77,504) of them had received a prescription for ADHD medicine at least once in the study period. Over time, we observed a shift from generalists to specialists. While 59% of patients received their prescription from a generalist and 41% from a specialist in 2008, there was reverse in the ratio in 2018: only 37% received their medication from a generalist and the vast majority (63%) from a specialist. This trend was particularly evident among adults: 58% of them received their ADHD medication from a specialist in 2008, but 80% in 2018. The proportion of children and adolescents who received their prescriptions from a specialist rose from 38% to 51% over the same period.

CONCLUSION

There is a shift in drug prescription away from generalists to specialists, without any discussion of advantages or disadvantages so far. However, this would be desirable, not least because specialists alone may not have sufficient resources to care for all ADHD patients.

Prescription Stimulant Medical and Nonmedical Use Among US Secondary School Students, 2005 to 2020

Importance

Recent information on the prevalence of prescription stimulant therapy for attention-deficit/hyperactivity disorder (ADHD) and nonmedical use of prescription stimulants (NUPS) at the school-level among US secondary school students is limited.

Objective

To investigate the school-level prevalence of and association between stimulant therapy for ADHD and NUPS among US secondary school students.

Design, Setting, and Participants

This cross-sectional study used survey data collected between 2005 and 2020 as part of the Monitoring the Future study (data collected annually via self-administered survey in schools from independent cohorts). Participants were from a nationally representative sample of 3284 US secondary schools. The mean (SD) response rates were 89.5% (1.3%) for 8th-grade students, 87.4% (1.1%) for 10th-grade students, and 81.5% (1.8%) for 12th-grade students. Statistical analysis was performed from July to September 2022.

Main Outcome and Measure

Past-year NUPS.

Results

The 3284 schools contained 231 141 US 8th-, 10th-, and 12th-grade students (111 864 [50.8%, weighted] female; 27 234 [11.8%, weighted] Black, 37 400 [16.2%, weighted] Hispanic, 122 661 [53.1%, weighted] White, 43 846 [19.0%, weighted] other race and ethnicity). Across US secondary schools, the past-year prevalence of NUPS ranged from 0% to more than 25%. The adjusted odds of an individual engaging in past-year NUPS were higher at secondary schools with higher proportions of students who reported stimulant therapy for ADHD, after controlling for other individual-level and school-level covariates. Students attending schools with the highest rates of prescription stimulant therapy for ADHD had approximately 36% increased odds of past-year NUPS compared with students attending schools with no medical use of prescription stimulants (adjusted odds ratio, 1.36; 95% CI, 1.20-1.55). Other significant school-level risk factors included schools in more recent cohorts (2015-2020), schools with higher proportions of parents with higher levels of education, schools located in non-Northeastern regions, schools located in suburban areas, schools with higher proportion of White students, and schools with medium levels of binge drinking.

Conclusions and Relevance

In this cross-sectional study of US secondary schools, the prevalence of past-year NUPS varied widely, highlighting the need for schools to assess their own students rather than relying solely on regional, state, or national results. The study offered new evidence of an association between a greater proportion of the student body that uses stimulant therapy and a greater risk for NUPS in schools. The association between greater school-level stimulant therapy for ADHD and other school-level risk factors suggests valuable targets for monitoring, risk-reduction strategies, and preventive efforts to reduce NUPS.

Type of medication therapy for ADHD and stimulant misuse during adolescence: a cross-sectional multi-cohort national study

Background

Attention-deficit/hyperactivity disorder (ADHD) is associated with higher substance use rates. Stimulant and non-stimulant pharmacotherapy improve adolescent ADHD, but their associations with prescription stimulant misuse (PSM), cocaine, and methamphetamine use are unclear. Using 2005-2020 US Monitoring the Future data, we investigated relationships between ADHD pharmacotherapy history and PSM, cocaine, or methamphetamine use.

Methods

Secondary students (13-19 years) provided data on pharmacotherapy history (N = 199,560; 86.3% of total sample) between January 1, 2005 and May 31, 2020 in a cross-sectional multi-cohort study; weights assured a nationally representative sample. Participants were grouped by ADHD pharmacotherapy history: none (88.7%; principally non-ADHD controls); stimulant-only (5.8%); non-stimulant-only (3.3%); both stimulant and non-stimulant (2.1%). Outcomes were past-year PSM, cocaine, and methamphetamine use. Logistic regressions examined relationships between pharmacotherapy history and outcomes, controlling for sociodemographics, recent substance use, and stimulant treatment cessation.

Findings

Past-year outcome rates were lowest in adolescents with no pharmacotherapy history: 4.7% for PSM [8310/174,561], 1.6% for cocaine [2858/174,688], and 0.7% for methamphetamine [1036/148,378]. A history of both stimulant and non-stimulant treatment was associated with the highest rates: 22.3% for PSM [940/4098], 10.4% for cocaine [450/4110], and 7.8% for methamphetamine [275/3427]. Adolescents who received monotherapy (stimulant- or non-stimulant-only) had intermediate rates, with no differences between monotherapy groups.

Interpretation

While elevated PSM and illicit stimulant use rates are likely influenced by ADHD, our findings suggested adolescents with a history of both stimulant and non-stimulant pharmacotherapy are at highest risk for these stimulant outcomes. Adolescents receiving ADHD pharmacotherapy should be monitored for PSM and illicit stimulant use.

Funding

National Institute on Drug Abuse/National Institutes of Health (USA) and Food and Drug Administration (USA).

Effects of Training on Use of Stimulant Diversion Prevention Strategies by Pediatric Primary Care Providers: Results from a Cluster-Randomized Trial

Pediatric primary care is a promising setting for reducing diversion of stimulant medications for ADHD. We tested if training pediatric primary care providers (PCPs) increased use of diversion prevention strategies with adolescents with ADHD. The study was a cluster-randomized trial in 7 pediatric primary care practices. Participants were pediatric PCPs (N = 76) at participating practices. Practices were randomized to a 1-h training in stimulant diversion prevention or treatment-as-usual. At baseline, 6 months, 12 months, and 18 months, PCPs rated how often they used four categories of strategies: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes, implementation climate, knowledge/skill, and resource constraints. Generalized Estimating Equations estimated differences in outcomes by condition. Mediation analyses tested if changes in knowledge/skill mediated training effects on strategy use. PCPs in the intervention condition reported significantly greater use of patient/family education strategies at all follow-up time points. There were no differences between conditions in medication management, assessment of mental health symptoms/functioning, or assessment of risky behaviors. At 6 months, PCPs in the intervention condition reported more positive attitudes toward diversion prevention, stronger implementation climate, greater knowledge/skill, and less resource constraints. Differences in knowledge/skill persisted at 12 months and 18 months. Brief training in stimulant diversion had substantial and enduring effects on PCPs' self-reported knowledge/skill and use of patient/family education strategies to prevent diversion. Training had modest effects on attitudes, implementation climate, and resource constraints and did not change use of strategies related to medication management and assessment of mental health symptoms/functioning and risky behaviors. Changes in knowledge/skill accounted for 49% of the total effect of training on use of patient/family education strategies. Trial registration This trial is registered on ClinicalTrials.gov (NCT03080259). Posted March 15, 2017.

Trazodone Prescribing for Children With Attention Deficit Hyperactivity Disorder on Medicaid in Oregon

OBJECTIVE

To examine trazodone prescribing to Medicaid-insured children with a diagnosis of attention deficit hyperactivity disorder (ADHD) from 2012 to 2016 for patient-level factors, including coexisting diagnoses associated with trazodone prescriptions.

METHODS

A retrospective cohort study used de-identified claims data from the Oregon Health Authority to analyze associations, frequency, and likelihood of new trazodone fills.

RESULTS

A total of 16,547 trazodone prescriptions were identified, representing 8.4% (n = 2,705) of 32,134 children. Most were filled for children ages 10 years and older. Children with ADHD were predominantly male (70.7%); however, more female children had a filled trazodone prescription compared with males (10.1% vs 7.7%). Female and male children with a filled trazodone prescription shared common diagnoses in the top 10 rank, although episodic mood disorders, such as bipolar disorder (International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 296) were only noted for female children. Female children were significantly older at the time of the first filled trazodone prescription (12.5 years; 95% CI, 12.3–12.7) compared with male children (12.0 years; 95% CI, 11.8–12.1). Modified Poisson regression models found children with ADHD and a filled trazodone prescription were 3 times more likely to have a sleep-related diagnosis as their most common diagnosis (excluding ADHD), compared with those of the same age and sex without a trazodone prescription (RR, 2.94; 95% CI, 2.44–3.54).

CONCLUSIONS

Children with ADHD are prescribed trazodone off label and for conditions with no national guidelines or clinical evidence of efficacy. Female children on Medicaid may be prescribed trazodone for concurrent mental health conditions, and further research is warranted regarding potential correlates.

Use of Stimulant Diversion Prevention Strategies in Pediatric Primary Care and Associations With Provider Characteristics

PURPOSE

Diversion of stimulant medications for ADHD is a prevalent problem. Pediatric primary care providers (PCPs) are well-positioned to reduce diversion risk among adolescents prescribed stimulants, but little is known about their use of prevention strategies. The objectives of this study were to describe the frequency with which pediatric PCPs use diversion prevention strategies and examine potential determinants (facilitators and barriers) of strategy use.

METHODS

Participants were pediatric PCPs (N = 76) participating in a randomized controlled trial of stimulant diversion prevention strategies. At baseline, before randomization, PCPs rated the frequency with which they used specific strategies in each of four categories: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes toward diversion prevention, subjective norms (i.e., implementation climate), and perceived behavioral control (i.e., knowledge/skill, resource constraints). Associations between determinants and strategy use were tested with correlational and regression analyses.

RESULTS

PCPs used strategies for assessing mental health symptoms/functioning most frequently and patient/family education strategies least frequently. Attitudes about the effectiveness of diversion prevention, implementation climate, knowledge/skill, and resource constraints were positively correlated with the use of at least one category of strategies. In regression analysis, PCP knowledge/skill was positively associated with patient/family education, medication management, and risk assessment strategies.

CONCLUSIONS

Findings suggest that improving knowledge and skill may increase the use of diversion prevention strategies by PCPs. Identifying provider-level determinants of strategy use informs implementation efforts in pediatric primary care and can facilitate efforts to prevent stimulant diversion among adolescents.

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review

IMPORTANCE

Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services.

OBJECTIVE

To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions.

EVIDENCE REVIEW

This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality.

FINDINGS

Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.

CONCLUSIONS AND RELEVANCE

This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy.

Referral Trends in Two Pioneering Developmental-Behavioral Pediatric Centers in Turkey

OBJECTIVE

To inform professionals pioneering developmental-behavioral pediatrics (DBP) services in low- and middle-income countries (LMICs), we aimed to examine referral trends in 2 pioneering DBP centers at different locations in Turkey and to ascertain whether the official establishment of DBP as a subspecialty affected these trends.

METHOD

This longitudinal observational study included all children referred to Ankara (AUDPD) and Inonu (IUDPD) Universities' Developmental Pediatrics Divisions between 2010 and 2018. We examined the sources of referrals and the independent effects of time and the establishment of DBP as a subspecialty on referral volume using Negative Binomial Regression (NBR) models.

RESULTS

Of 8,051 children, most were boys (58%) and under 24 months of age (72%). Most referrals were from the pediatric and pediatric surgery department clinics (85%); less than 1% were from child and adolescent psychiatry, and none were from family physicians. The NBR models showed that yearly, the referral volume increased significantly, 1.18-fold (95% confidence interval [CI] = 1.09-1.28) and 1.48-fold (95% CI = 1.20-1.82) for AUDPD and IUDPD, respectively. Compared with the trend of referrals before, the trend after the establishment of DBP as a subspecialty increased significantly at AUDPD, but not IUDPD.

CONCLUSION

The increase in referrals to DBP over time is encouraging to professionals working to advance DBP services and training in LMICs even if DBP is not officially established as a subspecialty. Additional efforts may be needed to improve recognition and use of DBP services by community physicians and allied disciplines that provide services to children.

Creativity in ADHD: Goal-Directed Motivation and Domain Specificity

Objective: This research aimed to provide explanations for the inconsistent findings regarding creativity in ADHD. Method: In Study 1, we assessed real-world creative achievements and intrinsic motivation during idea generation in adults with ADHD and compared these with controls. In Study 2, we manipulated competition during idea generation to investigate effects on idea originality in adults with ADHD versus controls, and assessed creativity in specific domains. Results: Adults with ADHD reported more real-world creative achievements. We did not observe differences in intrinsic motivation during idea generation between groups, but adults with ADHD generated more original ideas when competing for a bonus. Moreover, adults with ADHD rated themselves as more creative in specific creative domains. Conclusion: Our findings suggest that goal-directed motivation may drive the enhanced real-world creative achievements of people with ADHD. Moreover, people with ADHD may selectively engage and excel in creative domains that fit their skills and preferences.

Clinical Effects of Pediatric Clonidine Exposure: A Retrospective Cohort Study at a Single Tertiary Care Center

BACKGROUND

Pediatric clonidine ingestions frequently result in emergency department visits and admission for cardiac monitoring. Detailed information on the clinical course and specifically time of vital sign abnormalities of these patients is lacking.

OBJECTIVE

The objective of this study was to provide descriptive analysis of the rates and times to vital sign abnormalities, treatment, disposition, and outcomes in a single-center cohort of pediatric patients with report of clonidine poisoning.

METHODS

We performed a retrospective cohort study of patients younger than 21 years who presented to a large, urban, tertiary care center with a report of single substance clonidine exposure between January 2004 and November 2017. Patients were dichotomized into younger (≤9 years or younger) and older (10-21 years) groups based on the expected physiologic and psychologic differences between older and younger children.

RESULTS

Eighty-eight patients met our inclusion criteria. Younger patients (≤9 years or younger; n = 47) were more likely to be exposed to someone else's medication (53%) and older patients (10-21 years; n = 41) overwhelmingly (85%) were exposed to their own medication. Thirty-nine (45%) became bradycardic, 27 (32%) became bradypneic, and 38 (44%) became hypotensive. Eighty percent of patients had depressed mental status. Thirty-three (38%) patients received at least one dose of naloxone (median 0.07 mg/kg; interquartile range 0.03-0.11 mg/kg). Of those who received naloxone, 50% had a documented clinical response.

CONCLUSIONS

In this study of patients at a pediatric tertiary referral center, pediatric patients with report of clonidine exposures were likely to exhibit altered mental status and frequently develop vital sign abnormalities. Naloxone exhibited some effectiveness; given its wide safety margin, high-dose naloxone should be used in critically poisoned non-opioid-dependent patients. Because adolescents are much more likely to ingest their own clonidine medication, counseling with parents and other caregivers regarding safe medication storage is paramount.

Investigative interviewing of youth with ADHD - recommendations for detective training

Attention deficit hyperactivity disorder (ADHD) in youth can lead to a trajectory of early and repeated contact with the criminal justice system (CJS), where such youth face significant challenges due to the nature of their diagnosis and the lack of specialized detective training in this area. This article reviews Australian detectives' perceptions regarding contact with ADHD-affected youth, ongoing contact of such youth with the CJS, and the impact of ADHD on interviewing time efficiency and quality of information gathered. It explores detectives' perceived impact of ADHD on components of the Cognitive Interview (CI). It overviews detectives' perceptions regarding their own skill/ability, training availability and future training preferences regarding the interviewing of ADHD-affected youth. The authors highlight best practice in specialized detective training, as well as in working with ADHD-affected youth. Recommendations are made regarding the design features of a potential specialized training programme for detectives interviewing ADHD-affected youth.

Trends in Pediatric Primary Care Visits Among Commercially Insured US Children, 2008-2016

IMPORTANCE

Primary care is the foundation of pediatric care. While policy interventions have focused on improving access and quality of primary care, trends in overall use of primary care among children have not been described.

OBJECTIVE

To assess trends in primary care visit rates and out-of-pocket costs, to examine variation in these trends by patient and visit characteristics, and to assess shifts to alternative care options (eg, retail clinics, urgent care, and telemedicine).

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of claims data from 2008 to 2016 for children 17 years and younger covered by a large national commercial health plan. Visit rate per 100 child-years was determined for each year overall, by child and geographic characteristics, and by visit type (eg, primary diagnosis), and trends were assessed with a series of child-year Poisson models. Data were analyzed from November 2017 to September 2019.

MAIN OUTCOMES AND MEASURES

Visits to primary care and other settings.

RESULTS

This cohort study included more than 71 million pediatric primary care visits over 29 million pediatric child-years (51% male in 2008 and 2016; 37% between 12-17 years in 2008 and 38% between 12-17 years in 2016). Unadjusted results for primary care visit rates per 100 child-years decreased from 259.6 in 2008 to 227.2 in 2016, yielding a regression-estimated change in primary care visits across the 9 years of -14.4% (95% CI, -15.0% to -13.9%; absolute change: -32.4 visits per 100 child-years). After controlling for shifts in demographics, the relative decrease was -12.8% (95% CI, -13.3% to -12.2%). Preventive care visits per 100 child-years increased from 74.9 in 2008 to 83.2 visits in 2016 (9.9% change in visit rate; 95% CI, 9.0%-10.9%; absolute change: 8.3 visits per 100 child-years), while problem-based visits per 100 child-years decreased from 184.7 in 2008 to 144.1 in 2016 (-24.1%; 95% CI, -24.6% to -23.5%; absolute change: -40.6 visits per 100 child-years). Visit rates decreased for all diagnostic groups except for the behavioral and psychiatric category. Out-of-pocket costs for problem-based primary care visits increased by 42% during the same period. Per 100 child-years, visits to other acute care venues increased from 21.3 to 27.6 (30.3%; 95% CI, 28.5% to 32.1%; absolute change: 6.3 visits per 100 child-years) and visits to specialists from 45.2 to 53.5 (16.4%; 95% CI, 14.8% to 18.0%, absolute change: 8.3 visits per 100 child-years).

CONCLUSIONS AND RELEVANCE

Primary care visit rates among commercially insured children decreased over the last decade. Increases in out-of-pocket costs and shifts to other venues appear to explain some of this decrease.

Time to Stable Dose of Psychostimulants in Pediatric Patients With ADHD

OBJECTIVES The prevalence of attention-deficit/hyperactivity disorder (ADHD) is increasing and psychostimulants are the pharmacological standard of care. Patients benefit most when there is efficient titration to a stable dose of medication as defined by maintaining that same dose for 6 months. The aims of this study were to describe time to stable dose in a cohort of children with ADHD and examine the impact of demographic factors.

METHODS A list of pediatric patients with a diagnosis of ADHD in the electronic health record was generated, and a retrospective chart review of stimulant use was conducted on 500 patients randomly selected from 2010 to 2015 who met inclusion criteria. Time to stable dosing and its association with demographic characteristics were assessed.

RESULTS Patients were predominantly male (72%), white (81%), and privately insured (67%). Fifty-five percent of patients achieved a stable dose of medication on first attempt; therefore, the median time to stable dosing for the cohort was 0 days with the interquartile range being 0 to 133.8 days. There was significant increase in time to stable dose for patients younger than 10 years compared with those ≥10 years of age (p = 0.01). Time to stable dose was not significantly associated with race (p = 0.13), sex (p = 0.72), type of insurance (p = 0.56), or formulation being immediate or extended release (p = 0.56).

CONCLUSIONS Many patients had long titration periods when trying to reach a stable dose. Given that medication switching can be challenging for patients and families, more frequent contact with providers during titration may be necessary.

Drug Prescriptions for Children With ADHD in Japan: A Study Based on Health Insurance Claims Data Between 2005 and 2015

Objective: The aim of this study is to investigate the trend of prescription drugs for children with ADHD in Japan. Method: Using health insurance claims data of 3,672,951 people between January 2005 and December 2015, we investigated the trend of prescription drugs for 7,856 children with ADHD. Results: After approval in 2007, the proportion of prescriptions for methylphenidate-osmotic-controlled release oral delivery system tablets was 31.4% in 2009 (adjusted odds ratio [AOR] = 2.72; 95% confidence interval [CI] = [2.12, 3.51]) and reached a plateau approximately after 2009 (AOR = 0.96; 95% CI = [0.94, 0.98]). The proportion of prescriptions for atomoxetine increased from 6.1% in 2008 to 21.8% in 2014 (AOR = 1.12; 95% CI = [1.13, 1.18]). The proportion of prescriptions for aripiprazole and ramelteon increased (all trend p < .001). Conclusion: Prescriptions of drugs for children with ADHD have changed. We need to monitor the safety of ADHD medications among children with ADHD.

Impact of a behavioral intervention, delivered by pediatricians or psychologists, on sleep problems in children with ADHD: a cluster-randomized, translational trial

BACKGROUND

We have demonstrated the efficacy of a brief behavioral intervention for sleep in children with ADHD in a previous randomized controlled trial and now aim to examine whether this intervention is effective and cost-effective when delivered by pediatricians or psychologists in community settings.

METHODS

Translational, cluster-randomized trial of a behavioral intervention versus usual care from 19th January, 2015 to 30th June, 2017. Participants (n = 361) were children aged 5-13 years with ADHD and parent report of a moderate/severe sleep problem who met criteria for American Academy of Sleep Medicine criteria for chronic insomnia disorder, delayed sleep-wake phase disorder, or were experiencing sleep-related anxiety. Participants were randomized at the level of the pediatrician (n = 61) to intervention (n = 183) or usual care (n = 178). Families in the intervention group received two consultations with a pediatrician or a psychologist covering sleep hygiene and tailored behavioral strategies.

RESULTS

In an intention-to-treat analysis, at 3 and 6 months respectively, the proportion of children with moderate to severe sleep problems was lower in the intervention (28.0%, 35.8%) compared with usual care group (55.4%, 60.1%; 3 month: risk ratio (RR): 0.51, 95% CI 0.37, 0.70, p < .001; 6 month: RR: 0.58; 95% CI 0.45, 0.76, p < .001). Intervention children had improvements across multiple Children's Sleep Habits Questionnaire subscales at 3 and 6 months. No benefits of the intervention were observed in other domains. Cost-effectiveness of the intervention was AUD 13 per percentage point reduction in child sleep problem at 3 months.

CONCLUSIONS

A low-cost brief behavioral sleep intervention is effective in improving sleep problems when delivered by community clinicians. Greater sample comorbidity, lower intervention dose or insufficient clinician supervisions may have contributed to the lack benefits seen in our previous trial.

Unintended Effects of Communicating About Drug Safety Issues: A Critical Review of the Literature

Communications about the safety and effectiveness of human drugs can influence patients' and prescribers' perceptions and behaviors, which in turn can affect the public's health more broadly. We conducted a critical review of the literature on the unintended effects from communicating information to the public about safety issues with prescription and over-the-counter drugs. We searched PubMed for peer-reviewed studies published from 1990 to 2017 where study authors reported probable unintended effects of communicating drug safety. The types of communications included in these studies were news reports, direct-to-consumer advertisements, and those released by government agencies. Among the 26 studies identified, the most commonly reported unintended effects were decreased drug use or discontinuation. Other unintended effects included spillover to populations not targeted by the communications (e.g., discontinuation of antidepressants among adults following communications concerning use among youth), shifts in clinical diagnoses (e.g., fewer diagnoses of depression), increased use of alternative therapies, and other undesirable behaviors (e.g., possible increased suicide attempts because antidepressants were discontinued). Limitations to the literature include the inability to establish causation or to isolate the effects of multiple communication sources and messages. Further, because the intended effect of many communications was not known, our study was limited by challenges in defining some effects as unintended. Most studies used health insurer claims data to identify unintended effects of communications, which provide an incomplete picture; few used self-reported or other methodologies that could help illuminate the reasons underlying the effects observed in the claims data. Best practices for communicating about the potential benefits and harms of drugs in a manner that minimizes negative unintended effects are needed to protect and improve public health.

A Quantitative Comparison Approach for Methylphenidate Drug Regimens in Attention-Deficit/Hyperactivity Disorder Treatment

OBJECTIVE

Different methylphenidate (MPH) formulations, immediate release (IR) or extended release (ER), have been developed to treat Attention-Deficit/Hyperactivity Disorder (ADHD). A better use of these formulations, with a proper choice of their timing, dosage, and combination, can help to attain optimal therapeutic effect while maintaining a good quality of life. In this study, we aim at presenting a quantitative comparison approach to help identify drug regimens that provide best therapeutic performances and respect patients' specific needs.

METHODS

Using pharmacokinetic (PK) models of various MPH formulations constructed with data in hand and a formerly developed performance metric for MPH regimens, we proposed a statistical integral strategy for regimen comparison, which comprises a sequential, a relative, and a probability-over-threshold method. The first is hierarchical in nature and sequentially compares the regimen performance, the total daily dose, and the administration frequency. The second compares two regimens by quantifying their similarity. The third computes the probability of an incremental regimen performance over a specified threshold. The first two comparison approaches are used for naive patients, whereas the third one is for patients under treatment.

RESULTS

PK models of one compartment effectively describe both the IR and ER data. Applied to three frequent MPH clinical situations, the three-methods strategy is able to distinguish the regimens proposed for each. A combined regimen of IR and ER taken at the same time performs better than a single ER dose.

CONCLUSION

The proposed statistical strategy is able to differentiate ADHD regimens in various clinically relevant situations, and adapt the use of MPH drugs to a patient's daily routine. Since it does not compare fixed doses and formulations but rather any MPH regimen, our approach generalizes the current context of bioequivalence study and provides an accessible computational tool for objectively selecting MPH regimens.

Prevalence and Predictors of Medication Use in Children with Attention-Deficit/Hyperactivity Disorder: Evidence from a Community-Based Longitudinal Study

OBJECTIVES

To determine, in a community-based sample of primary school-aged children meeting diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD), (1) the proportion of children with ADHD treated with medication; (2) predictors of medication use; and (3) the association between medication use and psychological service utilization.

METHODS

Grade 1 children with ADHD were recruited through 43 schools in Melbourne, Australia, using a two-stage screening and case confirmation procedure. Parent report of medication treatment, clinician diagnosis, and psychological service use were collected at ages 7 and 10 years. Medication use was analyzed by ADHD subtype. Predictors of medication treatment examined included ADHD symptom severity and persistence, externalizing comorbidities, poor academic performance, and social disadvantage. Unadjusted and adjusted logistic regression were used to identify the predictors of medication status.

RESULTS

One hundred seventy-nine children with ADHD were recruited. At baseline, 17.3% had been clinically diagnosed with ADHD, increasing to 37.7% at age 10 years. At baseline, 13.6% were taking ADHD medications, increasing to 25.6% at age 10. Children with the combined and hyperactive-impulsive subtypes were more likely to be taking medication than those with inattentive subtype (age 7: p = 0.002; age 10: p = 0.03). ADHD symptom severity (Conners 3 ADHD Index) at baseline was concurrently and prospectively associated with medication use at both ages (both p = 0.01), and ADHD symptom severity at age 10 was also associated with medication use at age 10 (p = 0.01). Baseline area-level disadvantage was associated with medication use at age 7 (p = 0.04). At 10 years, children receiving medication were more likely, compared with those who were not, to be receiving psychological services (p = 0.001).

CONCLUSIONS

In this study, only a minority of children meeting diagnostic criteria for ADHD were diagnosed clinically or treated with ADHD medication by age 10. The strongest predictors of medication treatment were ADHD symptom severity and area disadvantage.

Police perceptions of the impact that ADHD has on conducting cognitive interviews with youth

Attention deficit hyperactivity disorder (ADHD) in youth witnesses, victims and suspects can significantly impact the investigative interviewing process. In this study, 102 Child Protection Investigation Unit (CPIU) detectives were asked to read four vignettes of adolescents being interviewed by police, two as witnesses and two as suspects, in which one witness and one suspect display ADHD-type behaviour. The detectives rated the degree to which the behaviour in each vignette would impact the interviewer's ability to use the 10 key components of the cognitive interview (CI). They perceived ADHD-type interviewee behaviour as significantly hampering the use of all 10 CI components. There is also a significant difference between the detectives' rated severity of each CI component; they rated Encourage Concentration, Mentally Recreate and Change Order as exerting the strongest impact on the interview process. Implications for police perceptions of training options, needs and preferences regarding interviewing youth with ADHD are discussed.

The Prevalence of Attention Deficit/Hyperactivity Disorder among Chinese Children and Adolescents

Updating the worldwide prevalence estimates of attention-deficit hyperactivity disorder (ADHD) has significant applications for the further study of ADHD. However, previous reviews included few samples of Chinese children and adolescents. To conduct a systematic review of ADHD prevalence in Mainland China, Hong Kong, and Taiwan to determine the possible causes of the varied estimates in Chinese samples and to offer a reference for computing the worldwide pooled prevalence. We searched for PubMed, Embase, PsycINFO, Web of Science, China National Knowledge Infrastructure, VIP, WANFANG DATA, and China Science Periodical Database databases with time and language restrictions. A total of 67 studies covering 642,266 Chinese children and adolescents were included. The prevalence estimates of ADHD in Mainland China, Hong Kong, and Taiwan were 6.5%, 6.4%, and 4.2%, respectively, with a pooled estimate of 6.3%. Multivariate meta-regression analyses indicated that the year of data collection, age, and family socioeconomic status of the participants were significantly associated with the prevalence estimates. Our findings suggest that geographic location plays a limited role in the large variability of ADHD prevalence estimates. Instead, the variability may be explained primarily by the years of data collection, and children's socioeconomic backgrounds, and methodological characteristics of studies.

Psychotropic medication in children and adolescents in the United States in the year 2004 vs 2014

BACKGROUND

There is a global perception that psychotropic utilization in children and adolescents is increasing in the US.

METHODS

We present prevalent estimates for all psychotropics prescribed in the US (using commercial claims from Medicare and Medicaid) to children and adolescents in 2004 (total population N = 6,808,453) and in 2014 (total population N = 11,082.260). Further we evaluated if there has been a statistically significant change in prevalence during this time period. Analyses were stratified for the 6 major drug classes, all individuals' psychotropics (87 drugs), age and sex.

RESULTS

The prevalence of psychotropic drug prescription was 8.55% in 2004 and 9.00% in 2014 (age stratified in 2004 and 2014 toddlers: 3.08 and 2.63%, children: 8.74 and 8.73%, adolescents: 10.89% and 12.11). The prevalence for each drug class in 2004 and 2014 was: stimulants/other ADHD drugs 5.0 and 5.8%; antidepressants 2.8 and 2.7%; anxiolytic-hypnotic-sedative 2.2 and 2.3%; mood stabilizers 0.1 and 0.1%; antipsychotics 1.3 and 1.1%; and for drugs treating drug dependence 0.02 and 0.02%.

CONCLUSIONS

The perception that psychotropic utilization in children and adolescents is increasing in the US, derived from the 2 to 3 fold increase seen from the mid 80's to the mid 90's is not valid anymore. There has been a slowdown in the increase of prescribing psychotropics. In the last 10 years, in toddlers there was a decrease in the prescription; in children there was no change; and in adolescents there was a slight increase. The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall. Graphical abstract In the last 10 years there has been a slowdown in the increase of prescribing psychotropics. In toddlers there was a decrease in the prescription (3.08 and 2.63%); in children (8.74 and 8.73%) there was no change; and in adolescents there was a slight increase (10.89% and 12.11). The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall.

Is ADHD Really Increasing in Youth?

OBJECTIVE

It would be useful to compare temporal changes in the diagnostic prevalence of ADHD obtained from identical population surveys with time-trend survey findings based on individual ADHD features.

METHOD

Changes in the diagnostic prevalence of ADHD over time were recorded from parent reports and from physician office visit data. Associated features of ADHD were temporally recorded from standardized teacher, parent, and youth surveys.

RESULTS

Time-trend diagnostic findings on ADHD prevalence based on 6 parent surveys and 12 outpatient physician office visit surveys revealed consistent rate increases. By contrast, 26 sets of standard ratings of the primary and associated features of ADHD assessed systematically by different teachers, parents, and students during different years indicated little change.

CONCLUSION

Time-trend national surveys of ADHD in youth over the last two decades reveal consistent increases in its diagnostic prevalence, whereas time-trend findings for individual ADHD-related symptoms remained relatively stable.

The Alternative Quality Contract: Impact on Service Use and Spending for Children With ADHD

In 2009, Blue Cross-Blue Shield of Massachusetts (BCBSMA) implemented the alternative quality contract (AQC), which pays provider organizations a global payment for all services used by enrollees. BCBSMA claims for 2006-2011 were used to compare youths enrolled in provider organizations participating in the AQC (7,407 person-years [PYs]) with those not participating (45,398 PYs). Difference-in-differences models estimated changes in mental health and substance abuse treatment service utilization and spending attributable to the AQC. The AQC was associated with small increases in the probability of any outpatient visits and in the probability and number of medication management visits among children with attention-deficit hyperactivity disorder (ADHD). Spending did not change, and there was no evidence of reductions in service utilization or spending for children with ADHD in the first three years of AQC implementation.

Prevalence rates of youths diagnosed with and medicated for ADHD in a nationwide survey in Taiwan from 2000 to 2011

AIMS

Public controversy regarding the potential overdiagnosis and overmedication of children with attention-deficit/hyperactivity disorder (ADHD) has continued for decades. This study used the National Health Insurance Research Database of Taiwan (NHIRD-TW) to explore trends in ADHD diagnosis in youths and the proportion of those receiving medication, with the aim of determining whether ADHD is overdiagnosed and overmedicated in Taiwan.

METHOD

Youths (age ≤18 years) who had at least two NHIRD-TW claims records with ADHD diagnosis between January 2000 and December 2011 were selected as the subject cohort. In total, the study sample comprised 145 018 patients with ADHD (mean age at a diagnosis of ADHD: 7.7 ± 3.1 years; 21.4% females). The number of cases of ADHD were calculated annually for each year (from 2000 to 2011), and the number of cases per year who received medication was determined as those with at least one record of pharmacotherapy (immediate-release methylphenidate, osmotic controlled-release formulation of methylphenidate, and atomoxetine) in each year.

RESULTS

The prevalence rates of a diagnosis of ADHD in the youths ranged from 0.11% in 2000 to 1.24% in 2011. Compared with children under 6 years of age, the ADHD diagnosis rates in children aged between 7 and 12 years (ratio of prevalence rates = 4.36) and in those aged between 13 and 18 years (ratio of prevalence rates = 1.42) were significantly higher during the study period. The prevalence in males was higher than that in females (ratio of prevalence rates = 4.09). Among the youths with ADHD, 50.2% received medications in 2000 compared with 61.0% in 2011. The probability of receiving ADHD medication increased with age. More male ADHD patients received medications that females patients (ratio of prevalence rates = 1.16).

CONCLUSIONS

The rate of ADHD diagnosis was far lower than the prevalence rate (7.5%) identified in a previous community study using face-to-face interviews. Approximately 40-50% of the youths with ADHD did not receive any medications. These findings are not consistent with a systematic public opinion about overdiagnosis or overmedication of ADHD in Taiwan.

Association of Risk of Suicide Attempts With Methylphenidate Treatment

IMPORTANCE

Patients with attention-deficit/hyperactivity disorder (ADHD) are at an increased risk of attempting suicide. Stimulants, such as methylphenidate hydrochloride, are the most common treatment for ADHD, but the association between their therapeutic use and suicide is unclear.

OBJECTIVE

To investigate the association between methylphenidate and the risk of suicide attempts.

DESIGN, SETTING, AND PARTICIPANTS

A population-based, electronic medical records database from the Hong Kong Clinical Data Analysis & Reporting System was used to identify 25 629 individuals aged 6 to 25 years who were treated with methylphenidate between January 1, 2001, and December 31, 2015. Those who had attempted suicide were included in the analysis. A self-controlled case series design was used to control for time-invariant characteristics of the patients.

MAIN OUTCOMES AND MEASURES

Relative incidence of suicide attempt during periods when patients were exposed to methylphenidate compared with nonexposed periods.

RESULTS

Among 25 629 patients with methylphenidate prescriptions, 154 had their first recorded suicide attempt within the study period; of these individuals, 111 (72.1%) were male; mean (SD) age at baseline was 7.15 (2.19) years. The overall incidence of suicide attempts during methylphenidate treatment was 9.27 per 10 000 patient-years. An increased risk of suicide attempts was detected during the 90-day period before methylphenidate was initiated, with an incidence rate ratio (IRR) of 6.55 (95% CI, 3.37-12.72). The IRR remained elevated during the first 90 days of treatment (IRR, 3.91; 95% CI, 1.62-9.42) before returning to baseline levels during ongoing treatment (IRR, 1.35; 95% CI, 0.77-2.38). When the risk during the first 90 days of treatment was compared with the 90 days preceding first treatment, the incidence of suicide attempts was not elevated (IRR, 0.78; 95% CI, 0.26-2.35).

CONCLUSIONS AND RELEVANCE

The incidence of suicide attempts was higher in the period immediately before the start of methylphenidate treatment. The risk remained elevated immediately after the start of methylphenidate treatment and returned to baseline levels during continuation of methylphenidate treatment. The observed higher risk of suicide attempts before treatment may reflect emerging psychiatric symptoms that trigger medical consultations that result in a decision to begin ADHD treatment. Therefore, this study's results do not support a causal association between methylphenidate treatment and suicide attempts.

ADHD: Insurance and Mental Health Service Use

We describe mental health service use by insurance among children aged 4 to 17 with diagnosed attention-deficit/ hyperactivity disorder (ADHD). Using parent reports from 2010-2013 National Health Interview Survey, we estimate the percentage that received services for emotional and behavioral difficulties (EBD): medication, other nonmedication services, and none (neither medication nor other nonmedication services). Among children with diagnosed ADHD, 56.0% had used medication for EBD, 39.8% had contact with a mental health professional, 32.2% had contact with a general doctor about the child's EBD, and 20.4% received special education services for EBD. Medication use was more often reported for privately or publicly insured children than uninsured children ( P < .001), and uninsured children more often received no services ( P < .001). Publicly insured children were more likely than privately insured children to receive other nonmedication services ( P < .001). Less than a third (28.9%) of all children received no services as compared to almost half (48.8%) of uninsured children.

An Evaluation Approach for the Performance of Dosing Regimens in Attention-Deficit/Hyperactivity Disorder Treatment

OBJECTIVE

Stimulant medications, with methylphenidate as the main agent, are the most prescribed for the treatment of attention-deficit/hyperactivity disorder. Nevertheless, real challenges still remain for clinicians concerned with adaptation of the therapeutic regimens, in terms of doses and timing, to children's daily activities. The aim of this study was to optimize short-acting methylphenidate regimens according to specific children's needs by evaluating the performance of a particular regimen through a web-based application.

METHODS

In this article, accounting for day-to-day children's activities and using up-to-date pharmacokinetic knowledge of methylphenidate, we propose a computational approach for the identification of the most suitable dosing regimens of immediate-release formulations of methylphenidate based on constraints on drug concentration and time frame of activities, defined through therapeutic boxes. To assess the performance of these regimens, time- and concentration-based therapeutic indicators, as well as a roller coaster effect, are proposed.

RESULTS

A web-based interface that can serve as an educational tool for clinicians and patients has been developed based on the proposed approach for the evaluation of dosing regimens. Comparison of those optimal regimens identified by our method with the well-accepted regimens defined in the NIMH Collaborative Multisite Multimodal Treatment study of Children with attention-deficit/hyperactivity disorder indicates that there is still room for improvement in the current practice especially for the last dose administration to avoid side effects such as sleep disturbance.

CONCLUSION

The developed approach and its associated web-based interface provide an efficient way to evaluate and adapt the methylphenidate regimens to children's daily activities. In addition, this approach could be used as proof of concept to further implement combination of short- and long-acting methylphenidate.

Adolescents' Prescription Stimulant Use and Adult Functional Outcomes: A National Prospective Study

OBJECTIVE

To assess the prospective 17-year relationship between the medical and nonmedical use of prescription stimulants during adolescence (age 18 years) and educational attainment and substance use disorder (SUD) symptoms in adulthood (age 35 years).

METHOD

A survey was self-administered by nationally representative probability samples of US high school seniors from the Monitoring the Future study; 8,362 of these individuals were followed longitudinally from adolescence (age 18, high school senior years 1976-1996) to adulthood (age 35, 1993-2013).

RESULTS

An estimated 8.1% reported medical use of prescription stimulants, and 16.7% reported nonmedical use of prescription stimulants by age 18 years. Approximately 43% of adolescent medical users of prescription stimulants had also engaged in nonmedical use of prescription stimulants during adolescence. Among past-year adolescent nonmedical users of prescription stimulants, 97.3% had used at least one other substance during the past year. Medical users of prescription stimulants without any history of nonmedical use during adolescence did not differ significantly from population controls (i.e., non-attention-deficit/hyperactivity disorder [ADHD] and non-stimulant-medicated ADHD during adolescence) in educational attainment and SUD symptoms in adulthood. In contrast, adolescent nonmedical users of prescription stimulants (with or without medical use) had lower educational attainment and more SUD symptoms in adulthood, compared to population controls and medical users of prescription stimulants without nonmedical use during adolescence.

CONCLUSION

Nonmedical use of prescription stimulants is common among adolescents prescribed these medications. The findings indicate youth should be carefully monitored for nonmedical use because this behavior is associated with lower educational attainment and more SUD symptoms in adulthood.

Critical assessment of the research outcomes of European birth cohorts: linking environmental factors with non-communicable diseases

OBJECTIVES

The objective of this review paper was to stimulate collaborative discussions toward the development of a general concept of an open source protocol for a feasible and efficient longitudinal birth cohort study exploring non-communicable diseases (NCDs), their multifactorial etiology and relations between various risk factors.

STUDY DESIGN

The present paper systematically reviews the design of existing birth cohorts in Europe containing environmental exposure data, and assesses a quantity and quality of their research outcomes as their potential to be an effective tool for studying non-communicable diseases and their risk factors.

METHODS

European birth cohorts with more than 3000 participants have been included in the study. A total number of scientific papers published in the internationally recognized journals and their impact factors and citation records were evaluated for all cohorts as surrogates for their efficiency to contribute to NCDs understanding and thus their prevention.

RESULTS

The birth cohorts contributing most significantly to the NCD understanding shared common features: (i) study size between 10,000 and 15,000 mother-child pairs; (ii) repeated assessment of children from prenatal into adulthood; and (iii) availability of biological samples. Smaller cohorts and cohorts with a specific focus generated a lower number of publications; however, these often received considerably a higher number of citations.

CONCLUSIONS

General cohort studies with 10,000-15,000 mother-child pairs allow a broader context interpretation, publish a higher number of articles, and often lead to the formation of infrastructures for 'spin-off (nested) studies'.

Methylphenidate and the risk of psychotic disorders and hallucinations in children and adolescents in a large health system

Previous studies have suggested that risk of psychotic events may be increased in children exposed to methylphenidate (MPH). However, this risk has not been fully examined, and the possibility of confounding factors has not been excluded. Patients aged 6-19 years who received at least one MPH prescription were identified using Hong Kong population-based electronic medical records on the Clinical Data Analysis and Reporting System (2001-2014). Using the self-controlled case series design, relative incidence of psychotic events was calculated comparing periods when patients were exposed to MPH with non-exposed periods. Of 20,586 patients prescribed MPH, 103 had an incident psychotic event; 72 (69.9%) were male and 31 (30.1%) female. The mean age at commencement of observation was 6.95 years and the mean follow-up per participant was 10.16 years. On average, each participant was exposed to MPH for 2.17 years. The overall incidence of psychotic events during the MPH exposure period was 6.14 per 10,000 patient-years. No increased risk was found during MPH-exposed compared with non-exposed periods (incidence rate ratio (IRR) 1.02 (0.53-1.97)). However, an increased risk was found during the pre-exposure period (IRR 4.64 (2.17-9.92)). Results were consistent across all sensitivity analyses. This study does not support the hypothesis that MPH increases risk of incident psychotic events. It does indicate an increased risk of psychotic events before the first prescription of MPH, which may be because of an association between psychotic events and the behavioural and attentional symptoms that led to psychiatric assessment and initiation of MPH treatment.

Stimulant Treatment of Young People in the United States

OBJECTIVE

To describe national stimulant treatment patterns among young people focusing on patient age and prescribing specialty.

METHODS

Stimulant prescriptions to patients aged 3-24 were analyzed from the 2008 IMS LifeLink LRx Longitudinal Prescription database (n = 3,147,352), which includes 60% of all U.S. retail pharmacies. A subset of young people from 2009 with service claims (n = 197,654) were also analyzed. Denominators were adjusted to generalize estimates to the U.S.

POPULATION

Population percentages filling ≥1 stimulant prescription during the study year by sex and age group (younger children, 3-5 years; older children, 6-12 years; adolescents, 13-18 years; and young adults, 19-24 years) were determined. Percentages prescribed stimulants by psychiatrists, child and adolescent psychiatrists, pediatricians, and other physicians were also determined along with percentages that were treated for a long or short duration; coprescribed other psychotropic medications; used psychosocial services; and received clinical psychiatric diagnoses.

RESULTS

Population percentages with any stimulant use varied across younger children (0.4%), older children (4.5%), adolescents (4.0%), and young adults (1.7%). Among children and adolescents, males were over twice as likely as females to receive stimulants. Percentages of stimulant-treated young people with ≥1 stimulant prescription from a child and adolescent psychiatrist varied from younger children (19.1%), older children (17.1%), and adolescents (18.2%) to young adults (10.1%), and these percentages increased among those who were also prescribed other psychotropic medications: young children (31.0%), older children (37.9%), adolescents (35.1%), and young adults (15.8%). Antipsychotics were the most commonly coprescribed class to stimulant-treated younger (15.0%) and older children (11.8%), while antidepressants were most commonly coprescribed to adolescents (17.5%) and young adults (23.9%).

CONCLUSIONS

Stimulant treatment peaks during middle childhood, especially for boys. For young people treated with stimulants, including younger children, low rates of treatment by child and adolescent psychiatrists highlight difficulties with access to specialty mental health services.

Lifetime nonmedical use of prescription medications and socioeconomic status among young adults in the United States

BACKGROUND

Despite decreases in the use of illicit drugs in the United States, prescription medications have become a major category of substances used by young adults.

OBJECTIVE

This study examines the relationship between the socioeconomic status (SES) of young adult respondents (ages 24-32) and their history of nonmedical use of prescription medications (NUPM).

METHOD

A secondary analysis was conducted with nationally representative data gathered from several waves (n = 15 701) of the National Longitudinal Study of Adolescent Health (Add Health). Four categories of NUPM were examined: (i) sedatives; (ii) tranquilizers; (iii) stimulants; and (iv) pain killers. SES was defined by several measures in the Add Health survey. Given the complex sampling plan of the Add Health, all analyses were weighted appropriately.

RESULTS

Results indicated higher levels of personal SES, such as having health insurance or not experiencing a financial hardship in the past year, decreased the likelihood of reporting lifetime NUPM. In contrast higher levels of parent SES (e.g. parental education) were associated with an increased likelihood of reporting lifetime use of NUPM tranquilizers and stimulants.

CONCLUSIONS

The results of this study suggest parental SES may have a stronger influence over NUPM than personal levels of SES, particularly for the categories of tranquilizers and stimulants. Furthermore, these findings indicate more research is needed on this subject to better understand the NUPM epidemic in order to effectively develop comprehensive clinical, public health, and policy-related intervention and prevention approaches.

Recent Trends in Stimulant Usage

OBJECTIVE

In the last decade, dramatic changes have occurred in stimulant medication prevalence and in patterns of stimulant treatment. The resultant trends merit analysis.

METHOD

Usage patterns of stimulant medication, specifically amphetamine and methylphenidate, were analyzed for trends. The data were obtained from datasets including pharmacy claims, aggregate production quotas, bulk distribution to counties, pharmacy prescription sales, parent surveys, and physician visit surveys. Stimulant medication trends were organized by drug subclass, year, age group, gender, country, prescriber specialty, diagnosis, and expenditures.

RESULTS

Major recent trends are as follows: amphetamine medication usage has prominently surpassed methylphenidate, total stimulant prescription sales to adults have surpassed those for youth, and more adult women are prescribed stimulants than adult men.

CONCLUSION

Stimulant medication treatment-particularly of amphetamines-is rapidly expanding in the United States. Off-label use is reported to be at least 40% of total use and appears to be more common in adults. (J. of Att. Dis. 2016; 20(6) 471-477).

Early exposure to stimulant medications and substance-related problems: The role of medical and nonmedical contexts

BACKGROUND

The age of onset (early vs. late) and context (medical vs. nonmedical) of exposure to stimulant medications for attention-deficit/hyperactivity disorder (ADHD) have been identified as important factors in the addictive potential of these controlled medications. This study examines the role of medical and nonmedical contexts in the association between early exposure to stimulant medications and substance use and substance-related problems among adolescents.

METHODS

A Web-based survey was self-administered by Detroit-area secondary school students (N=4755) between the 2009-10 and 2012-13 school years. The sample consisted of 51% females, 62% Whites, 32% African-Americans, and 6% from other racial categories.

RESULTS

During the study period, an estimated 11.7% of respondents were ever diagnosed with ADHD. Approximately 6.7% (n=322) of respondents indicated lifetime medical use of prescription stimulants while 2.6% (n=124) indicated lifetime nonmedical use. The odds of substance use and substance-related problems were significantly lower among those who initiated earlier medical use of stimulant medications relative to later medical initiation. In contrast, the odds of substance use and substance-related problems were significantly greater among those who initiated earlier nonmedical use of stimulant medications relative to later nonmedical initiation.

CONCLUSIONS

More than one in every ten adolescents in this epidemiologically-derived community-based sample was diagnosed with ADHD. This is the first investigation to demonstrate that context (medical vs. nonmedical) plays a critical role in the relationship between early exposure to stimulant medications and the subsequent risk of substance-related problems during adolescence within the same diverse youth sample.

Age of Onset, Duration, and Type of Medication Therapy for Attention-Deficit/Hyperactivity Disorder and Substance Use During Adolescence: A Multi-Cohort National Study

OBJECTIVE

To examine whether age of onset, duration, or type of medication therapy for attention-deficit/hyperactivity disorder (ADHD) is associated with substance use during adolescence.

METHOD

Nationally representative samples of high school seniors were surveyed via self-administered questionnaires. The sample consisted of 40,358 individuals from 10 independent cohorts (2005-2014) and represented a population that was 52% female, 62% white, 10% African American, 14% Hispanic, and 14% other race/ethnicity. Design-based logistic regression analyses were used to test the associations between age of onset, duration, and type of ADHD medication therapy and recent substance use, controlling for potential confounding factors.

RESULTS

Individuals who initiated stimulant medication therapy for ADHD later (aged 10-14 years and 15 years and older) and for shorter duration (2 years or less and 3-5 years) as well as those who reported only nonstimulant medication therapy for ADHD had significantly greater odds of substance use in adolescence relative to individuals who initiated stimulant medication therapy for ADHD earlier (aged 9 years or less) and for longer duration (6 or more years). The odds of substance use generally did not differ between population controls (youth without ADHD and unmedicated youth with ADHD) and individuals who initiated stimulant medication for ADHD early (aged 9 years or less) and for longer duration (aged 6 or more years).

CONCLUSION

Relative to later onset and shorter duration of stimulant treatment for ADHD, early onset and longer duration of stimulant treatment for ADHD was associated with a risk of substance use during adolescence that is lower than and similar to that in the general population.

Prescriptions, nonmedical use, and emergency department visits involving prescription stimulants

OBJECTIVE

Little is known regarding the temporal trends in prescriptions, nonmedical use, and emergency department (ED) visits involving prescription stimulants in the United States. Our aim was to examine these 3 national trends involving dextroamphetamine-amphetamine and methylphenidate in adults and adolescents.

METHOD

Three national surveys conducted between 2006-2011 were used: National Disease and Therapeutic Index, a survey of office-based practices; National Survey on Drug Use and Health, a population survey of substance use; and Drug Abuse Warning Network, a survey of ED visits. Ordinary least squares regression was used to examine temporal changes over time and the associations between the 3 trends.

RESULTS

In adolescents, treatment visits involving dextroamphetamine-amphetamine and methylphenidate decreased over time; nonmedical dextroamphetamine-amphetamine use remained stable, while nonmedical methylphenidate use declined by 54.4% in 6 years. ED visits involving either medication remained stable. In adults, treatment visits involving dextroamphetamine-amphetamine remained unchanged, while nonmedical use went up by 67.1% and ED visits went up by 155.9%. These 3 trends involving methylphenidate remained unchanged. Across age groups, the major source for nonmedical use of both medications was a friend or relative; two-thirds of these friends and relatives had obtained the medication from a physician.

CONCLUSIONS

Trends in prescriptions for stimulants do not correspond to trends in reports of nonmedical use and ED visits. Increased nonmedical stimulant use may not be simply attributed to increased prescribing trends. Future studies should focus on deeper understanding of the proportion of, risk factors for, and motivations for drug diversions.

ADHD Undetected in Criminal Adults

OBJECTIVE

The objective of this study was to assess whether adults with ADHD in a forensic sample had received the diagnosis earlier and to investigate reasons for missing the diagnosis earlier.

METHOD

From December 1, 2007 until March 5, 2009, all patients from an outpatient clinic for forensic mental health care who were suspected of having ADHD were seen by a psychiatrist who assessed presence and severity of ADHD symptoms and other psychiatric disorders in a standardized way.

RESULTS

ADHD diagnosis was missed previously in life in 59 of 106 male adults (56%). ADHD diagnosis was missed more often in older men, in those with hyperactive/impulsive or combined subtype of ADHD, in those who reported fewer symptoms of ADHD in childhood or adolescence, in those with a comorbid mood disorder in adulthood, and in those who had never received mental health care before. Even in those who had previously received mental health care, the diagnosis had been missed in 42% of the cases. Prior contacts with police or court also predicted missing the diagnosis, an effect that was mediated by a lower chance to be referred to mental health care.

CONCLUSION

General and forensic mental health care workers should be alert for the fact that ADHD is missed very often in individuals who have problems with delinquency and should realize that ADHD may be masked by various factors.

Stimulant Medications and Cognition, Behavior and Quality of Life in Children and Youth with HIV

BACKGROUND

Limited empirical investigation exists into longitudinal changes in cognition, behavior or quality of life (QOL) in children with perinatal HIV who are prescribed stimulants.

METHODS

This study was an analysis of longitudinal data from children age 3-19 years, with perinatal HIV infection, with and without prescriptions for stimulant medications [prescription (PG) and comparison (CG) groups, respectively], matched on age, availability of CD4% and outcome measures of cognition, behavior and QOL. Generalized estimating equation models were used to evaluate effects of stimulant exposure on change in measured outcomes over 3 years of follow-up, adjusting for baseline levels of outcomes and relevant covariates.

RESULTS

Children in both the PG (n = 132) and the CG (n = 392) obtained mean verbal and performance (nonverbal) intelligence quotients (VIQ and PIQ, respectively) in the low-average range for age. At baseline, those in PG demonstrated more frequent signs of hyperactivity, impulsivity and conduct and learning problems than those in CG (P ≤ 0.003 in unadjusted analyses). At follow-up, after adjustment for baseline functioning and other relevant covariates, there were no significant changes from baseline in VIQ or PIQ. Stimulant prescription use, however, was associated with worsening symptoms of hyperactivity (P = 0.01), impulsivity (P = 0.04), learning problems (P < 0.001) and worsening of perceived health status (P < 0.001).

CONCLUSIONS

The results suggest expectations for behavioral improvement may not align well with long-term effects of stimulant prescription use on behavior and QOL in children with HIV. Further research is necessary to determine if there are subsets of children who may benefit from stimulant therapy.

A critical appraisal of atomoxetine in the management of ADHD

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder beginning in childhood and often continuing into adulthood. A wealth of data shows that ADHD symptoms respond well to pharmacological treatment. Stimulant medications, including amphetamine and methylphenidate, are most commonly used to treat ADHD. However, with the approval of atomoxetine (Strattera^®, [ATX]) by the US Food and Drug Administration in late 2002, an effective non-stimulant option became available. The US Food and Drug Administration approved ATX for the treatment of ADHD in children, adolescents, and adults. Although the effect size of ATX is generally lower than that of stimulants, the American Academy of Child and Adolescent Psychiatry Practice Parameter for the treatment of ADHD lists ATX as a first-line treatment option. ATX is widely prescribed and accounted for 6% of the prescriptions of ADHD visits in the US in 2010. Numerous trials have found that ATX improves quality of life and emotional lability in addition to core ADHD symptoms. Although some improvement may be seen in a patient as early as one week after the initiation of treatment, ATX generally takes longer to have a full effect. The median time to response using 25% improvement in ADHD symptoms in pooled trials was 3.7 weeks. Data from these trials indicate that the probability of symptom improvement may continue to increase up to 52 weeks after treatment is initiated. ATX has been shown to be safe and effective in combination with stimulants. It has also been studied systematically in subjects with ADHD and comorbid oppositional defiant disorder, anxiety, depression, and substance use disorders. The mechanism of action of ATX, its efficacy, and adverse events reported in trials is reviewed.

Impact of Attention-Deficit Hyperactivity Disorder on School Performance: What are the Effects of Medication?

Attention-deficit hyperactivity disorder (ADHD) affects an estimated 5-7 % of schoolchildren worldwide. School functioning and academic achievement are frequently impaired by ADHD and represent one of the main reasons children start ADHD medication. Multiple potential causal pathways exist between ADHD and impaired school performance. In this review, we decompose school performance into three components and assess the impact of ADHD and its treatments on academic performance (assessed by grade point average [GPA], time on-task, percentage of work completed as well as percent completed correctly), academic skills (as measured by achievement tests and cognitive measures), and academic enablers (such as study skills, motivation, engagement, classroom behavior and interpersonal skills). Most studies examined only the short-term effects of medication on school performance. In these, ADHD medications have been observed to improve some aspects of school performance, with the largest impact on measures of academic performance such as seatwork productivity and on-task performance. In a subset of children, these benefits may translate into detectable improvements in GPA and achievement testing. However, limited data exists to support whether these changes are sustained over years. Optimizing medication effects requires periodic reassessment of school performance, necessitating a collaborative effort involving patients, parents, school staff and prescribers. Even with systematic reassessment, behavioral-based treatments and additional school-based services may be needed to maximize academic performance for the many youth with ADHD and prominent impairments in school performance.

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

OBJECTIVE

To compare the mental health care US children receive from primary care providers (PCPs) and other mental health care providers.

METHODS

Using nationally representative data from the Medical Expenditure Panel Survey (MEPS) from 2008 to 2011, we determined whether children and youth aged 2 to 21 years with outpatient visits for mental health problems in the past year saw PCPs, psychiatrists, and/or psychologists/social workers for these conditions. We compared the proportion of children prescribed psychotropic medications by provider type. Using logistic regression, we examined associations of provider type seen and medication prescribing with race/ethnicity, household income, insurance status, geographical area, and language at home.

RESULTS

One-third (34.8%) of children receiving outpatient care for mental health conditions saw PCPs only, 26.2% saw psychiatrists only, and 15.2% saw psychologists/social workers only. Nearly a quarter (23.8%) of children saw multiple providers. A greater proportion of children with attention-deficit/hyperactivity disorder (ADHD) versus children with anxiety/mood disorders saw a PCP only (41.8% vs 17.2%). PCPs prescribed medications to a higher percentage of children than did psychiatrists. Children seeing a PCP for ADHD were more likely to receive stimulants or α-agonists than children with ADHD seeing psychiatrists (73.7% vs 61.4%). We found only limited associations of sociodemographic characteristics with provider type or medication use.

CONCLUSIONS

PCPs appear to be sole physician managers for care of 4 in 10 US children with ADHD, and one-third with mental health conditions overall. Efforts supporting mental health in primary care will reach a substantial portion of children receiving mental health services.

Age and Cohort Patterns of Medical and Nonmedical Use of Controlled Medication Among Adolescents

OBJECTIVES

We identified peak annual incidence rates for medical and nonmedical use of prescription opioid analgesics, stimulants, sedatives, and anxiolytics (controlled medication), and explored cohort effects on age of initiation.

METHODS

Data were gathered retrospectively between 2009 and 2012 from Detroit area students (n = 5185). Modal age at the last assessment was 17 years. A meta-analytic approach produced age-, year-, and cohort-specific risk estimates of first-time use of controlled medication. Cox regression models examined cohort patterns in age of initiation for medical and nonmedical use with any of 4 classes of controlled medication (opioid analgesics, stimulants, sedatives, or anxiolytics).

RESULTS

Peak annual incidence rates were observed at age 16 years, when 11.3% started medical use, and 3.4% started using another person's prescription for a controlled medication (ie, engaged in nonmedical use). In the more recent birth cohort group (1996-2000), 82% of medical users and 76% of nonmedical users reported initiating such use by age 12 years. In contrast, in the less recent birth cohort group (1991-1995), 42% of medical users and 35% of nonmedical users initiated such use by age 12 years. Time to initiation was 2.6 times less in the more recent birth cohort group (medical use: adjusted hazard ratio [aHR] = 2.57 [95% confidence interval {CI} = 2.32-2.85]; nonmedical use: aHR = 2.57 [95% CI = 2.17-3.03]).

CONCLUSIONS

Peak annual incidence rates were observed at age 16 years for medical and nonmedical use. More recent cohorts reported initiating both types of use at younger ages. Earlier interventions may be needed to prevent adolescent nonmedical use of controlled medication.

Attention Deficit Hyperactivity Disorder Medication Use Among Teens and Young Adults

PURPOSE

The purpose of this study was to determine rates of stimulant/atomoxetine use among teens (aged 12-17 years) and young adults (aged 18-23 years) and to investigate associations in medication use before and after the transition from teen to young adult.

METHODS

Repeated cross-sectional analyses using the nationally representative Medical Expenditure Panel Survey. The sample included all teens and young adults between 2003 and 2012. Within this group, a staggered sample of individuals between 2006 and 2012 born during a 5-year range was used to minimize false positive findings due to temporal trends. The primary outcome was attention deficit hyperactivity disorder (ADHD) medication use (two or more prescriptions and ≥60 tablets). A multivariable logistic regression was utilized to determine associations between ADHD medication use and race/ethnicity and other sociodemographic factors.

RESULTS

A total of 62,699 individuals were included between 2003 and 2012. Rates of ADHD medication use increased for both teens (4.2%-6.0%) and young adults (1.2%-2.6%) between 2003-2004 and 2011-2012. In adjusted analysis, blacks, Hispanics, and Asians had lower rates of use compared with whites. The decrease in use among young adults was more pronounced among blacks compared with whites. A usual source of care and health insurance were less common among young adults, and both were associated with ADHD medication use.

CONCLUSIONS

Although there has been an increase in the use of ADHD medications in both teens and young adults, we found a drop-off in levels of ADHD treatment among young adults when compared with teens. A portion of this decrease appears to be related to race/ethnicity, usual source of care, and health insurance status.

Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Overdiagnosis and underdiagnosis of attention-deficit/hyperactivity disorder (ADHD) are widely debated, fueled by variations in prevalence estimates across countries, time, and broadening diagnostic criteria. We conducted a meta-analysis to: establish a benchmark pooled prevalence for ADHD; examine whether estimates have increased with publication of different editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM); and explore the effect of study features on prevalence.

METHODS

Medline, PsycINFO, CINAHL, Embase, and Web of Science were searched for studies with point prevalence estimates of ADHD. We included studies of children that used the diagnostic criteria from DSM-III, DSM-III-R and DSM-IV in any language. Data were extracted on sampling procedure, sample characteristics, assessors, measures, and whether full or partial criteria were met.

RESULTS

The 175 eligible studies included 179 ADHD prevalence estimates with an overall pooled estimate of 7.2% (95% confidence interval: 6.7 to 7.8), and no statistically significant difference between DSM editions. In multivariable analyses, prevalence estimates for ADHD were lower when using the revised third edition of the DSM compared with the fourth edition (P = .03) and when studies were conducted in Europe compared with North America (P = .04). Few studies used population sampling with random selection. Most were from single towns or regions, thus limiting generalizability.

CONCLUSIONS

Our review provides a benchmark prevalence estimate for ADHD. If population estimates of ADHD diagnoses exceed our estimate, then overdiagnosis may have occurred for some children. If fewer, then underdiagnosis may have occurred.