Receipt of Medication and Behavioral Therapy Among a National Sample of School-Age Children Diagnosed With Attention-Deficit/Hyperactivity Disorder

ADHD Prevalence Rose, Yet Disparities Remain: Commentary on the 2022 National Survey of Children's Health

This is a commentary on Danielson and colleagues' report entitled "ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment," which provides updated prevalence rates related to ADHD diagnosis and treatment utilization using data from the 2022 National Survey of Children's Health (NSCH). This timely article is among the first to report on ADHD prevalence rates since the COVID-19 pandemic, and highlights important patterns related to ADHD diagnosis and treatment utilization. In this commentary, we contextualize these findings with consideration to the COVID-19 pandemic and within the existing literature on health disparities among youth with ADHD and their families. We end with recommendations for future work involving researchers, clinicians, and policymakers with the intention of reducing disparities in ADHD diagnosis and treatment in the U.S.

Measuring quality-of-care in treatment of young children with attention-deficit/hyperactivity disorder using pre-trained language models

OBJECTIVE

To measure pediatrician adherence to evidence-based guidelines in the treatment of young children with attention-deficit/hyperactivity disorder (ADHD) in a diverse healthcare system using natural language processing (NLP) techniques.

MATERIALS AND METHODS

We extracted structured and free-text data from electronic health records (EHRs) of all office visits (2015-2019) of children aged 4-6 years in a community-based primary healthcare network in California, who had ≥1 visits with an ICD-10 diagnosis of ADHD. Two pediatricians annotated clinical notes of the first ADHD visit for 423 patients. Inter-annotator agreement (IAA) was assessed for the recommendation for the first-line behavioral treatment (F-measure = 0.89). Four pre-trained language models, including BioClinical Bidirectional Encoder Representations from Transformers (BioClinicalBERT), were used to identify behavioral treatment recommendations using a 70/30 train/test split. For temporal validation, we deployed BioClinicalBERT on 1,020 unannotated notes from other ADHD visits and well-care visits; all positively classified notes (n = 53) and 5% of negatively classified notes (n = 50) were manually reviewed.

RESULTS

Of 423 patients, 313 (74%) were male; 298 (70%) were privately insured; 138 (33%) were White; 61 (14%) were Hispanic. The BioClinicalBERT model trained on the first ADHD visits achieved F1 = 0.76, precision = 0.81, recall = 0.72, and AUC = 0.81 [0.72-0.89]. Temporal validation achieved F1 = 0.77, precision = 0.68, and recall = 0.88. Fairness analysis revealed low model performance in publicly insured patients (F1 = 0.53).

CONCLUSION

Deploying pre-trained language models on a variable set of clinical notes accurately captured pediatrician adherence to guidelines in the treatment of children with ADHD. Validating this approach in other patient populations is needed to achieve equitable measurement of quality of care at scale and improve clinical care for mental health conditions.

The Impact of Stimulant Medications on Blood Pressure and Body Mass Index in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

To describe changes in blood pressure (BP) and body mass index (BMI) associated with stimulant medication fills in children.

METHODS

Observational, retrospective matched cohort study of children 6-17.9 years initiating stimulant medication between 7/1/2010-6/30/2017 matched 1:3 by age, race, ethnicity, and sex to children with no stimulant use during this period. All BPs and BMIs recorded during ambulatory visits were identified. Generalized linear models were used to estimate differences in change in systolic BP (SBP), diastolic BP (DBP), and BMI over time.

RESULTS

The 686 children with stimulant prescription fills and 2048 matched controls did not differ by baseline SBP or BMI. The matched control group (30.5% female, mean age 11.2 ± 3.4 years 79.7% white) was more likely to be publicly insured (35% vs. 21%, P < .01). After adjusting for baseline values, over a mean follow-up of 144 days change in SBP or DBP did not differ significantly between patients with stimulant medication fills and matched controls. Stimulant use was associated with a 4.7 percentile decrease in BMI percentile compared to matched controls (95% CI: 3.69, 5.71; P < .01).

CONCLUSIONS

In a pediatric primary care cohort, stimulant prescription fills were associated with marked decreases in BMI but no significant changes in BP over time.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

The effect of cognitive training on children with attention deficit and hyperactivity disorder: A meta-analysis

OBJECTIVE

This document is a meta-analysis of randomized controlled trials that evaluated the effect of cognitive training interventions on attention deficit and hyperactivity disorder (ADHD) symptoms.

METHODS

A systematic literature search was conducted using databases such as PubMed, Web of Science, and Embase from the inception of each database to April 28, 2022. Data were analyzed using Stata 15 software. The risk of bias assessment was conducted using five domains from the Cochrane Collaborations tool.

RESULTS

A total of 10 studies with 446 children with ADHD were included. The results showed that cognitive training was effective in improving attention symptoms [SMD= -0.78 (95% CI: -1.46, -0.1)] and executive function [SMD = -0.3 (95% CI: -0.56, -0.05)] in children with ADHD compared to controls. No significant difference in the degree of improvement in hyperactivity/impulsivity with cognitive training compared to the control group [SMD = -0.65 (95% CI: -1.35, 0.05)]. In addition, subgroup analyses also found that cognitive training significantly improved attention in children with ADHD <10 years of age [SMD = -1.3 (95% CI: -2.58, -0.02)] and children with ADHD with length of training >30 days [SMD = -0.94 (95% CI: -1.81, -0.07)] compared to controls.

CONCLUSION

This meta-analysis found that the beneficial effects of cognitive training on attention (particularly for children with ADHD <10 years old and >30 days of training) and executive function in children with ADHD, but not on hyperactivity/impulsivity.

Racial and Ethnic Disparities for Unmet Needs by Mental Health Condition: 2016 to 2021

OBJECTIVES

Racial and ethnic minority children receive less care and inferior care in the United States, but less is known about how these disparities vary by mental health conditions. We examined unmet mental health needs by condition types to identify potentially hidden racial and ethnic inequities.

METHODS

We used data from the nationally representative National Survey of Children's Health, from 2016 to 2021 (n = 172 107). Logistic regression analyses were applied to mental health conditions in aggregate and individually and adjusted for individual and household characteristics.

RESULTS

Relative to non-Hispanic white children with any mental health condition, non-Hispanic Black children had greater odds of unmet needs (adjusted odds ratio [aOR] = 1.56, 95% confidence interval [CI]: 1.18-2.05). Models disaggregated by specific mental health conditions revealed heterogeneous patterns. Specifically, relative to non-Hispanic white children, non-Hispanic Black children displayed elevated odds of unmet needs for behavioral problems (aOR = 1.41, 95% CI: 1.00-2.02), whereas Asian and Hispanic children displayed elevated odds for anxiety (aOR = 2.60, 95% CI: 1.20-4.29 and aOR = 1.41, 95% CI: 1.05-1.90, respectively).

CONCLUSIONS

Racial and ethnic minority children are disproportionately affected by unmet treatment needs. These disparities vary by individual mental health conditions and persist after controlling for socioeconomic characteristics. Results reveal clinically underserved racial and ethnic groups across different mental health conditions.

A Narrative Review of the Association between Prematurity and Attention-Deficit/Hyperactivity Disorder and Accompanying Inequities across the Life-Course

Preterm birth is associated with an increased risk of neurodevelopmental and neurobehavioral impairments including attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioral disorder of childhood. In this narrative review, we examine the known associations between prematurity and ADHD and highlight the impact of both prematurity and ADHD on multiple domains across the pediatric life-course. We develop a framework for understanding the health services journey of individuals with ADHD to access appropriate services and treatments for ADHD, the "ADHD Care Cascade". We then discuss the many racial and ethnic inequities that affect the risk of preterm birth as well as the steps along the "ADHD Care Cascade". By using a life-course approach, we highlight the ways in which inequities are layered over time to magnify the neurodevelopmental impact of preterm birth on the most vulnerable children across the life-course.

Treatment of US Children With Attention-Deficit/Hyperactivity Disorder in the Adolescent Brain Cognitive Development Study

Importance

Characterizing the extent and pattern of unmet needs for treatment of children with attention-deficit/hyperactivity disorder (ADHD) could help target efforts to improve access to ADHD medications and outpatient mental health care.

Objective

To describe current ADHD medication use and lifetime outpatient mental health care among a large national sample of children with ADHD.

Design, Setting, and Participants

This study uses cross-sectional survey data from the first wave of the Adolescent Brain and Cognitive Development Study (n = 11 723), conducted from June 1, 2016, to October 15, 2018, among 1206 school children aged 9 and 10 years who met parent-reported Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for current ADHD. Statistical analysis was performed from March 23, 2022, to March 10, 2023.

Main Outcomes and Measures

Current ADHD medications including stimulants and nonstimulants, lifetime outpatient mental health care, or either treatment. Weighted results are reported.

Results

Among a sample of 11 723 children, 1206 had parent-reported ADHD (aged 9-10 years; 826 boys [68.2%]; 759 White, non-Hispanic children [62.2%]), 149 (12.9%) were currently receiving ADHD medications. Children receiving ADHD medications included a significantly higher percentage of boys (15.7% [121 of 826]) than girls (7.0% [28 of 108]), White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), children of parents without a high school education (32.2% [9 of 36]) than of parents with a bachelor's degree or higher (11.5% [84 of 715]), and children with the combined subtype of ADHD (17.0% [83 of 505]) than with the inattentive subtype (9.5% [49 of 523]). Approximately 26.2% of children (301 of 1206) with parent-reported ADHD had ever received outpatient mental health care. Children receiving outpatient mental health care included a significantly higher percentage of children whose parents had a high school education (36.2% [29 of 90]) or some college (31.0% [109 of 364]) than a bachelor's degree or higher (21.3% [153 of 715]), children with family incomes of less than $25 000 (36.5% [66 of 176]) or $25 000 to $49 999 (27.7% [47 of 174]) than $75 000 or more (20.1% [125 of 599]), and children with the combined subtype of ADHD (33.6% [166 of 505]) than with the predominantly inattentive subtype (20.0% [101 of 523]) or the hyperactive-impulsive subtype (22.4% [34 of 178]) of ADHD.

Conclusions and Relevance

This cross-sectional study of children with parent-reported ADHD suggests that most were not receiving ADHD medications and had never received outpatient mental health care. Gaps in treatment, which were not directly associated with socioeconomic disadvantage, underscore the challenges of improving communication and access to outpatient mental health care for children with ADHD.

Racial-Ethnic Disparities in Outpatient Mental Health Care in the United States

OBJECTIVE

The authors aimed to compare national rates and patterns of use of outpatient mental health care among Hispanic, non-Hispanic Black, and non-Hispanic White individuals.

METHODS

Data from the 2018-2019 Medical Expenditure Panel Survey, a nationally representative survey of U.S. households, were analyzed, focusing on use of any outpatient mental health care service by non-Hispanic White (N=29,126), non-Hispanic Black (N=7,965), and Hispanic (N=12,640) individuals ages ≥4 years (N=49,731). Among individuals using any mental health care, analyses focused on those using psychotropic medications, psychotherapy, or both and on receipt of minimally adequate mental health care.

RESULTS

The annual rate per 100 persons of any outpatient mental health service use was more than twice as high for White (25.3) individuals as for Black (12.2) or Hispanic (11.4) individuals. Among those receiving outpatient mental health care, Black (69.9%) and Hispanic (68.4%) patients were significantly less likely than White (83.4%) patients to receive psychotropic medications, but Black (47.7%) and Hispanic (42.6%) patients were significantly more likely than White (33.3%) patients to receive psychotherapy. Among those treated for depression, anxiety, attention-deficit hyperactivity disorder, or disruptive behavior disorders, no significant differences were found in the proportions of White, Black, or Hispanic patients who received minimally adequate treatment.

CONCLUSIONS

Large racial-ethnic gaps in any mental health service use and smaller differences in patterns of treatment suggest that achieving racial-ethnic equity in outpatient mental health care delivery will require dedicated efforts to promote greater mental health service access for Black and Hispanic persons in need.

Health Disparities in the Treatment of Supraventricular Tachycardia in Pediatric Patients

Supraventricular tachycardia (SVT) is a common pediatric arrhythmia. The objective of this investigation was to investigate the existence and degree of the health disparities in the treatment of pediatric patients with supraventricular tachycardia based on sociodemographic factors. This was retrospective cohort study at a large academic medical center including children ages 5-18 years old diagnosed with SVT. Patients with congenital heart disease and myocarditis were excluded. Initial treatment and ultimate treatment with either medical management or ablation were determined. The odds of having an ablation procedure were determined based on patient age, sex, race, ethnicity, and insurance status. There was a larger portion of non-White patients (p = 0.033) within the cohort that did not receive an ablation during the study period. Patients that were younger, female, American Indian/Alaskan Native, unknown race, and had missing insurance information were less likely to receive ablation therapy during the study period. In this single center, regional evaluation, we demonstrated that disparities in the treatment of pediatric SVT are present based on multiple patient sociodemographic factors. This study adds evidence to the presence of inequities in health care delivery across pediatric populations.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Adherence to Child Attention-Deficit/Hyperactivity Disorder Treatment Guidelines in Medical Homes-Results from a National Survey

OBJECTIVE

Having primary care delivered through a medical home is believed to improve mental health care delivery to children. Children with attention-deficit/hyperactivity disorder (ADHD) are commonly treated in pediatric practices, yet little is known about ADHD treatment patterns in medical homes. Our objective was to assess for treatment variation depending on parent-perceived medical home (PPMH) status. We hypothesized that having a PPMH would be associated with receiving ADHD treatments recommended by clinical guidelines.

METHODS

We used the 2016 National Survey of Children's Health-a nationally representative cross-sectional survey of children in the United States. Analyses included an unweighted sample of 4,252, representing 5.4 million children aged 3 to 17 years with parent-reported ADHD. Child characteristics were analyzed using descriptive statistics. Associations between ADHD treatment types and PPMH status were assessed using a multinomial logistic regression, adjusting for child characteristics.

RESULTS

Having a PPMH was associated with increased prevalence odds of children's receipt of medications alone for ADHD (vs no treatment). The prevalence odds of receiving behavioral treatment alone (vs medications alone) for ADHD decreased by 43% when children had a PPMH (95% confidence interval, 0.38-0.85, p = 0.01). PPMH status was not associated with a statistically significant difference in prevalence odds of receiving combination treatment (vs medications alone) for pediatric ADHD.

CONCLUSION

Having a PPMH was associated with children's receipt of ADHD medications alone, but not behavioral treatments. Our findings suggest that medical homes may need further improvement to ensure that children with ADHD receive treatments as recommended by clinical guidelines.

Diagnostic and Medication Treatment Disparities in African American Children with ADHD: a Literature Review

BACKGROUND

Despite a national focus on achieving health equity, limited attention has been paid to behavioral and pediatric health disparities. As the most common pediatric neurobehavioral disorder, attention-deficit/hyperactivity disorder (ADHD) provides an opportunity to assess the status of pediatric behavior health disparities. The purpose of this literature review is to provide a synthesis of existing research on ADHD diagnostic and treatment disparities between African American and White children.

METHODS

Studies were systematically identified through searches in PubMed, CINAHL, and APA PsycInfo using the terms attention-deficit/hyperactivity disorder, disparity, race, ethnicity, diagnosis, medication, and treatment. Summary calculations were conducted to report the proportions of studies with statistically significant differences in ADHD diagnosis and treatment between White and African American children, and to describe trends in disparities over time.

RESULTS

Forty-one studies were included in this review. The majority of studies identified significant disparities in ADHD diagnosis and medication treatment between African American and White children. While diagnostic disparities show a trend toward reduction over time, a similar trend was not observed in medication treatment disparities. This synthesis provides a critique of the existing literature and recommendations for practice and future research.

Assessing undertreatment and overtreatment/misuse of ADHD medications in children and adolescents across continents: A systematic review and meta-analysis

A controversy exists on whether there is an over or underuse of medications for Attention-Deficit/Hyperactivity Disorder (ADHD). We conducted the first meta-analysis to estimate the rate of ADHD pharmacological treatment in both diagnosed and undiagnosed individuals. Based on a pre-registered protocol (CRD42018085233), we searched a broad set of electronic databases and grey literature. After screening 25,676 abstracts, we retained 36 studies including 104,305 subjects, from which 18 studies met our main analysis criteria. The pooled pharmacological treatment rates were 19.1 % and 0.9 % in school-age children/adolescents with and without ADHD, respectively. We estimated that for each individual using medication without a formal ADHD diagnosis, there are three patients with a formal diagnosis who might benefit from medication but do not receive it in the US. Our results indicate both overtreatment/misuse of medication in individuals without ADHD and pharmacological undertreatment in youths with the disorder. Our findings reinforce the need for public health policies improving education on ADHD and discussions on the benefits and limitations of ADHD medications.

The Mechanism, Clinical Efficacy, Safety, and Dosage Regimen of Atomoxetine for ADHD Therapy in Children: A Narrative Review

Atomoxetine, a selective norepinephrine (NE) reuptake inhibitor, was approved for attention deficit/hyperactivity disorder (ADHD) treatment in children, adolescents and adults. We searched the database PubMed/MEDLINE (2000 to October 1, 2021). Only publications in English were considered. Atomoxetine inhibits the presynaptic norepinephrine transporter (NET), preventing the reuptake of NE throughout the brain along with inhibiting the reuptake of dopamine in specific brain regions such as the prefrontal cortex (PFC). The novel mechanism of atomoxetine also includes several new brain imaging studies and animal model studies. It is mainly metabolized by the highly polymorphic drug metabolizing enzyme cytochrome P450 2D6 (CYP2D6). Atomoxetine is effective and generally well tolerated. ADHD is often accompanied by multiple comorbidities. A series of studies have been published suggesting that atomoxetine is effective in the treatment of ADHD symptoms for children with various types of comorbidity. In some cases, it is possible that atomoxetine may have a positive influence on the symptoms of comorbidities. Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses, and has a negligible risk of abuse or misuse. The latest guideline updated that clinical dose selection of atomoxetine was recommended based on both CYP2D6 genotype and the peak concentration. To have a more comprehensive understanding of atomoxetine, this review sets the focus on the mechanism, clinical efficacy and dosage regimen in detail, and also touches on those studies regarding adverse reactions of atomoxetine.

Tantrum Tool: Development and Open Pilot Study of Online Parent Training for Irritability and Disruptive Behavior

Objectives: Parent management training is an effective treatment for disruptive behavior disorders but it is often underutilized in clinical settings. Access to care is limited due to logistical barriers as well as limited service availability. This study examines in an open trial the acceptability, feasibility, and clinical effects of a digital parent management training intervention that includes videoconference coaching, called "Tantrum Tool." Methods: Fifteen children, ages 3-9 years, participated in an open trial of an 8-week intervention. The primary symptom measure was the Disruptive Behavior Rating Scale (DBRS), and the secondary outcome measure was the Affective Reactivity Index (ARI) completed by the primary caregiver before and after treatment. Results: Treatment retention was high (80%), and parents reported a high level of satisfaction with the program. There was a significant reduction in the mean DBRS score from 13.5 ± 5.5 at baseline to 7.3 ± 3.4 at endpoint, p < 0.001. There was also a significant reduction in the mean ARI irritability score from 7.2 ± 2.6 at baseline to 3.75 ± 2.1 at endpoint, p < 0.01. Conclusions: This open pilot study supports the feasibility and acceptability of a digital parent training program for young children with disruptive behavior. Findings provide preliminary support for a clinically meaningful reduction of both disruptive behavior and irritability. Using the Tantrum Tool to deliver online treatment for children could increase access to first-line treatments for disruptive behavior and irritability in young children. ClinicalTrials.gov: NCT03697837.

Disparities in Childhood Attention Deficit Hyperactivity Disorder Symptom Severity by Neighborhood Poverty

OBJECTIVE

To determine the association between neighborhood poverty and Attention Deficit Hyperactivity Disorder (ADHD) severity among children in a large metropolitan area.

METHODS

This is a secondary analysis of data collected April 2016 to July 2017 at the Children's Hospital of Philadelphia Care Network. We attributed 2015 American Community Survey census tract poverty, defined as percent of individuals with income below poverty level, to each child's residential address. Tracts were grouped from low to high poverty. ADHD severity was determined by Vanderbilt Parent Rating Scale (VPRS) symptom score. We also recorded parent-reported child ADHD medication use.

RESULTS

A total of 286 children were linked to 203 unique census tracts. The majority of children from high poverty tracts were black and from disadvantaged households. Higher neighborhood poverty was associated with higher VPRS scores and decreased medication use in bivariate analysis. Poverty was no longer associated with VPRS scores in multivariate analysis, but medication use still had a significant negative association with VPRS score. Post hoc stratification by medication use revealed that neighborhood poverty and VPRS score were significantly associated for children on medication, but not for those off medication.

CONCLUSIONS

Neighborhood poverty was not associated with ADHD severity in multivariate analysis. This suggests other factors, including medication use, confound the relationship between neighborhood poverty and ADHD severity. Lack of medication treatment was significantly associated with higher symptom burdens for children with access to primary care. Decreased medication use in higher poverty communities warrants exploration and public health interventions to ensure adequate ADHD management for all children.

The Association Between Race/Ethnicity and Socioeconomic Factors and the Diagnosis and Treatment of Children with Attention-Deficit Hyperactivity Disorder

OBJECTIVE

Assessing race/ethnicity and socioeconomic status (SES) relationships with Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis, treatment, and access to care has yielded inconsistent results often based only on parent-report. In contrast, this study used broader ADHD diagnostic determination including case-definition to examine these relationships in a multisite elementary-school-based sample.

METHOD

Secondary analysis of children with and without ADHD per parent and teacher-reported Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria evaluated SES, race/ethnicity, and other variables through simple bivariate/multivariable models within and across: parent-reported diagnosis, medication treatment, and meeting ADHD study case-definition.

RESULTS

The total sample included 51.9% male, 51.3% White, and 53.1% with private insurance; 10% had parent-reported ADHD diagnoses while 8.3% met ADHD study case-definition. In multivariable models, White children had higher odds of parent-reported diagnoses than Black, Hispanic, and Other Race/Ethnicity children (p < 0.05), but only Hispanic children had lower odds of being case-positive (<0.05); males and children in single-parent households had higher odds of parent-reported diagnoses and being case-positive (p < 0.05); and children who were White, male, and had health insurance had higher odds of taking medication (p < 0.05). Among children who were case-positive, those with Medicaid, White, and 2-parent statuses had higher odds of parent-reported diagnoses (p < 0.05).

CONCLUSION

Children with underlying ADHD appear more likely to have assessment/medication treatment access if they are White, male, have health insurance (particularly Medicaid), and live in 2-parent households. While boys and children raised by single parents may have higher rates of ADHD diagnoses, false-positive diagnostic risk also appeared higher, inviting further investigation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Commercial Insurance Claims Analysis of Correlates of Behavioral Therapy Use Among Children With ADHD

OBJECTIVE

The study examined factors associated with uptake of behavioral therapy among children with attention-deficit hyperactivity disorder (ADHD).

METHODS

Insurance claims data from 2008-2014 (MarketScan) were reviewed to examine associations between behavioral therapy use and demographic, patient, family, and provider factors. The association between ADHD medication use and future uptake of behavioral therapy was examined with logistic regression adjusted for covariates found to affect behavioral therapy use.

RESULTS

Among 827,396 youths with ADHD, under 50% received any billable behavioral therapy services over the 7 years. ADHD severity, gender, region of residence, assessment year, comorbid behavioral disorders, and behavioral therapy use by siblings were significantly associated with behavioral therapy use (p<0.001). Parent psychopathology and sibling medication use was not. Children prescribed ADHD medication were 2.5 times less likely than those not prescribed medication to use behavioral therapy, even after adjustment for severity of behavioral health symptoms and other covariates (odds ratio [OR]= 0.41, 95% confidence interval [CI]=.40-.41, p<0.001). Effects of medication use were stronger for future uptake of behavioral therapy (OR=0.25, 95% CI =0.24-0.25, p<.001). The impact of medication use on behavioral therapy use was equally strong for children under age 6 and for older children and did not weaken after release of 2011 guidelines recommending behavioral therapy as the initial ADHD treatment for young children.

CONCLUSIONS

Multiple systems, family, patient and provider factors affected behavioral therapy uptake. ADHD medication was a robust and potentially modifiable factor. It may be advisable to engage families in behavioral therapy prior to initiation of ADHD medication.

Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings

OBJECTIVES

To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training).

STUDY DESIGN

A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations.

RESULTS

Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription.

CONCLUSIONS

We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.

Influence of Psychopharmacotherapy on the Quality of Life of Children with Attention-Deficit/Hyperactivity Disorder

Objective: Attention-deficit/hyperactivity disorder (ADHD) may have a lasting effect on the quality of life (QoL) of children and their parents. Children with ADHD as well as their parents report a lower QoL compared with healthy children and children with chronic diseases such as bronchial asthma. The primary objective of this study was to investigate the changes of QoL of children with ADHD and their parents' subjective well-being before and after starting pharmacotherapy. We used the appropriate KINDL questionnaire for assessing the children's QoL and the World Health Organization (WHO) Big Five Questionnaire for assessing parental well-being. Methods: We assessed the QoL and the parental well-being in 60 children and adolescents with ADHD between the ages of 6 and 12 years [mean age 8.7 years, (standard deviation = 1.8)], treated at the Department of Child and Adolescent Psychiatry of the Medical University of Vienna. QoL was rated using the KINDL questionnaires, and parental well-being was assessed using the WHO Big Five Questionnaire (WHO-5) before and after starting pharmacotherapy. We used t-tests and three-way GLM-ANOVA (SPSS, version 22; IBM Corp.) for evaluating the statistical significance of pre-post differences. Results: The QoL of the children with ADHD and the subjective well-being of the parents improved significantly after introducing pharmacotherapy. Conclusions: Pharmacotherapy is recommended in children with clinically significant ADHD not only because it helps to improve the symptoms of ADHD, but also their QoL and the well-being of their parents.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid

OBJECTIVES

To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care.

STUDY DESIGN

Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016.

RESULTS

More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016.

CONCLUSIONS

Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

Collaborative Care of Attention Deficit Hyperactivity Disorder: An Innovative Partnership to Serve Rural Pediatric Patients

Attention deficit hyperactivity disorder (ADHD) is a common behavioral health disorder in childhood that causes significant impairments in quality of life, home relationships, and school success. Despite a substantial evidence base and corresponding practice guidelines established by the American Academy of Pediatrics that support use of behavioral therapy to treat ADHD, affected patients infrequently receive therapy. This article will review the causes of underuse of behavioral therapy and methods to overcome these barriers such as integrating behavioral health care, thereby creating a pediatric patient-centered medical home. Additionally, a novel practice model of a behavioral health care collaboration being piloted in a rural pediatric office will be presented, including methods to screen, assess, and treat ADHD patients and families within the comfort of the primary care office.