Cost-Effectiveness and Cost Utility of Treatment of Attention-Deficit/Hyperactivity Disorder: A Systematic Review

Integrating Structural and Experiential Family Therapy in Neurodivergent Families: A Case Study

Autism Spectrum Disorder (ASD) is widely regarded as the most severe childhood behavioral disorder. However, society's lack of awareness regarding neurodevelopmental disorders, like autism, has led to a limited understanding of their profound impact on children and their families. Challenges include unique sensory experiences, communication and social interactions, strain on familial relationships, emotional toll on parents, and educational hurdles, which can significantly impact the well-being of individuals and their families. This case study explores the integration of Structural and Experiential Family Therapy in a neurodivergent family coping with ASD and Attention-Deficit/Hyperactivity Disorder (ADHD). Structural interventions focus on clarifying roles and redistributing caregiving responsibilities, addressing issues of communication, and power dynamics. Experiential interventions target emotion-focused techniques, empathy building, and cultural sensitivity training. This integration may promote lasting change in family dynamics and a call to empower parents within neurodivergent families through tailored interventions, contributing to a sustainable therapeutic approach.

A systematic meta-review of systematic reviews on attention deficit hyperactivity disorder

BACKGROUND

There are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.

METHODS

We searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.

RESULTS

The prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.

CONCLUSIONS

Despite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.

Stimulant prodrugs: A pharmacological and clinical assessment of their role in treating ADHD and binge-eating disorder

In this review, we critically evaluate the contribution of prodrugs to treating two related psychiatric disorders, attention-deficit hyperactivity disorder (ADHD) and binge-eating disorder (BED). ADHD is characterized by inattentiveness, distractibility, impulsiveness, and hyperactivity. BED is also an impulse-control disorder which leads to frequent, compulsive episodes of excessive eating (binges). Lisdexamfetamine (LDX; prodrug of d-amphetamine) is approved to treat both ADHD and BED. Serdexmethylphenidate (SDX; prodrug of d-threo-methylphenidate) is not clinically approved as monotherapy but, in a fixed-dose combination with immediate release d-threo-methylphenidate (Azstarys™), SDX is approved for managing ADHD in children/adolescents. The pharmacological actions of a stimulant mediate both its efficacy and side-effects. Therefore, daily management of ADHD or BED to maintain optimum efficacy and tolerability places highly restrictive requirements on the pharmacokinetic/pharmacodynamic (PK/PD) characteristics of stimulant medications, especially prodrugs. Prodrugs must have good bioavailability and rapid metabolism to provide therapeutic efficacy soon after morning dosing combined with providing stimulant coverage throughout the day/evening. A wide selection of dosages and linear PK for the prodrug and its active metabolite are essential requirements for treatment of these conditions. The proposed neurobiological causes of ADHD and BED are described. The chemical, pharmacological and PK/PD properties responsible for the therapeutic actions of the prodrugs, LDX and SDX, are compared and contrasted. Finally, we critically assess their contribution as ADHD and BED medications, including advantages over their respective active metabolites, d-amphetamine and d-threo-methylphenidate, and also their potential for misuse and abuse.

Medical Expenditures Associated with Attention-Deficit/Hyperactivity Disorder Among Adults in the United States by Age, 2015-2019

BACKGROUND

Attention-deficit hyperactivity disorder is a common disorder that affects both children and adults. However, for adults, little is known about ADHD-attributable medical expenditures.

OBJECTIVE

To estimate the medical expenditures associated with ADHD, stratified by age, in the US adult population.

DESIGN

Using a two-part model, we analyzed data from Medical Expenditure Panel Survey for 2015 to 2019. The first part of the model predicts the probability that individuals incurred any medical costs during the calendar year using a logit model. The second part of the model estimates the medical expenditures for individuals who incurred any medical expenses in the calendar year using a generalized linear model. Covariates included age, sex, race/ethnicity, geographic region, Charlson comorbidity index, insurance, asthma, anxiety, and mood disorders.

PARTICIPANTS

Adults (18 +) who participated in the Medical Expenditure Panel Survey from 2015 to 2019 (N = 83,776).

MAIN MEASURES

Overall and service specific direct ADHD-attributable medical expenditures.

KEY RESULTS

A total of 1206 participants (1.44%) were classified as having ADHD. The estimated incremental costs of ADHD in adults were $2591.06 per person, amounting to $8.29 billion nationally. Significant adjusted incremental costs were prescription medication ($1347.06; 95% CI: $990.69-$1625.93), which accounted for the largest portion of total costs, and office-based visits ($724.86; 95% CI: $177.75-$1528.62). The adjusted incremental costs for outpatient visits, inpatient visits, emergency room visits, and home health visits were not significantly different. Among older adults (31 +), the incremental cost of ADHD was $2623.48, while in young adults (18-30), the incremental cost was $1856.66.

CONCLUSIONS

The average medical expenditures for adults with ADHD in the US were substantially higher than those without ADHD and the incremental costs were higher in older adults (31 +) than younger adults (18-30). Future research is needed to understand the increasing trend in ADHD attributable cost.

Differential costs for the non-adult ADHD population in Catalonia

Attention-Deficit/Hyperactivity Disorder (ADHD) is young children's most common mental health disorder. We aim to provide causal estimates of the differential costs for the non-adult population with ADHD. We used longitudinal administrative data covering the non-adult population over five years and different healthcare providers (general practitioners, hospitalisations and emergency departments, visits to mental healthcare centres-day-care or hospitals) of 1,101,215 individuals in Catalonia (Spain). We also include the consumption of pharmaceuticals and cognitive therapies. We instrumented ADHD diagnosis by the probability of being diagnosed by the most visited healthcare provider based on individual monthly visits to the provider in which this visit was related to ADHD and the density of professionals in the different mental health providers. After using matching procedures to include a proper control group, we estimated two-part and finite mixture models. Our results indicate that ADHD children and adolescents displayed 610€ higher annual health direct costs compared to not diagnosed counterparts. We provide average costs disentangling the sample by age boundaries, gender, and comorbidities to offer values for cost-effective analyses and incremental costs after diagnosis, which is around 400€. A significant differential annual direct health cost for the non-adult population with ADHD is determined, which will be helpful for cost-effectiveness analysis and complete cost-of-illness studies.

Commentary: Why treatment is the best choice for childhood mental disorders - a commentary on Roest et al. (2022)

An important question in mental healthcare for children is whether treatments are effective and safe in the long run. Here, we comment on a recent editorial perspective by Roest et al. (2022), who argue, based on an overview of systematic reviews, 'that there is no convincing evidence that interventions for the most common childhood disorders are beneficial in the long term'. We believe that the available evidence does not justify this conclusion and express our concern regarding the harmful effects of their message. We show that there is evidence to suggest beneficial longer term treatment effects for each of the disorders and explain why evidence-based treatment should be offered to children with mental disorders.

Better characterization of attention and hyperactivity/impulsivity in children with ADHD: The key to understanding the underlying white matter microstructure

The apparent increase in the prevalence of the attention deficit hyperactivity disorder (ADHD) diagnosis raises many questions regarding the variability of the subjective diagnostic method. This comprehensive review reports findings in studies assessing white matter (WM) bundles in diffusion MRI and symptom severity in children with ADHD. These studies suggested the involvement of the connections between the frontal, parietal, and basal ganglia regions. This review discusses the limitations surrounding diffusion tensor imaging (DTI) and suggests novel imaging techniques allowing for a more reliable representation of the underlying biology. We propose a more inclusive approach to studying ADHD that includes known endophenotypes within the ADHD diagnosis. Aligned with the Research Domain Criteria Initiative, we also propose to investigate attentional capabilities and impulsive behaviours outside of the borders of the diagnosis. We support the existing hypothesis that ADHD originates from a developmental error and propose that it could lead to an accumulation in time of abnormalities in WM microstructure and pathways. Finally, state-of-the-art diffusion processing and novel artificial intelligence approaches would be beneficial to fully understand the pathophysiology of ADHD.