Diversion of ADHD Stimulants and Victimization Among Adolescents

Factors Associated With Bullying Victimization and Bullying Perpetration in Children and Adolescents With ADHD: 2016 to 2017 National Survey of Children's Health

OBJECTIVE

To identify characteristics associated with bullying involvement in pediatric ADHD.

METHODS

Data from the 2016 to 2017 National Survey of Children's Health for children aged 6 to 17 years with ADHD were evaluated to assess the association between parent-reported bullying victimization or perpetration and the following potential predictors: demographic characteristics, family factors, school factors, and child conditions/behaviors.

RESULTS

Among children with ADHD, 46.9% were bullying victims and 16.2% were perpetrators. Factors associated with victimization included having family financial strain, developmental delay or intellectual disability, friendship difficulties, and school reports about problems. Factors linked to perpetration included being male, receiving government assistance, lack of school engagement, school reports about problems, and having difficulties with friendships, staying calm, and arguing.

CONCLUSIONS

Children with ADHD frequently were bullying victims and sometimes bullying perpetrators. Factors related to family financial strain, developmental disabilities, emotional regulation, peer relationships, and school functioning may help to identify risk for bullying and opportunities for anti-bullying interventions.

Adolescents Treated for Attention-Deficit/Hyperactivity Disorder in Pediatric Primary Care: Characterizing Risk for Stimulant Diversion

OBJECTIVE

To describe the clinical and psychosocial characteristics, and their hypothesized interrelations, as it pertains to risk for stimulant diversion (sharing, selling, or trading) for adolescents in pediatric primary care treatment for attention-deficit/hyperactivity disorder.

METHODS

Baseline data for 341 adolescents in a cluster-randomized controlled trial of stimulant diversion prevention in pediatric primary care (NCT_03080259) were used to (1) characterize diversion and newly measured risk factors, (2) examine their associations with age and sex, and (3) test whether associations among risk factors were consistent with model-implied predictions. Data were collected through multi-informant electronic surveys from adolescents and parents.

RESULTS

Diversion was rare (1%) in this sample (Mage = 15, SD = 1.5, 74% male participants). Older age was associated with being approached to divert (r = 0.25, p < 0.001) and higher risk on variables pertinent to stimulant treatment, such as treatment disclosure (r = 0.12, p < 0.05), tolerance for stimulant misuse and diversion (r = 0.17, p < 0.05), and peer norms favorable to stimulant misuse and diversion (r values = 0.15-0.34, p < 0.001). Sex differences were minimal. Variables from our conceptual model and specific to stimulants (e.g., perceived likelihood of negative consequences from diversion and schoolmate stimulant misuse/diversion) were related in multivariable regressions to hypothesized immediate precursors of diversion (e.g., diversion intentions).

CONCLUSION

Although diversion was rare for these primary care-treated adolescents, risk levels appear to be higher for older adolescents. Prevention may be most effective by capitalizing on current psychosocial strengths and discussing stimulant-specific attitudes, behaviors, and social norms before vulnerability to diversion increases in the final years of high school and into college.

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.

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.

Peer Victimization in Children With ADHD: A Community-Based Longitudinal Study

Objectives: To investigate (a) whether children with ADHD experience higher levels of overt and relational peer victimization (PV) than children without ADHD and (b) child, family, and school predictors of PV in children with ADHD. Method: 173 children with ADHD and 199 non-ADHD controls were recruited through 43 Melbourne schools at mean age 7.3 years. Parent- and teacher-reported PV (Social Experience Questionnaire) data were collected at mean age 8.9 years. Potential child, family, and school predictors of PV were measured at baseline. Results: Children with ADHD experienced higher levels of PV than children without ADHD by both parent- and teacher-report. Child predictors accounted for the greatest variance in PV, and the strongest predictors of PV were teacher-reported conduct problems, and medication use. Conclusion: Children with ADHD are at higher risk of PV compared with non-ADHD controls. Recognizing and addressing PV is important to reduce additional impairment in children with ADHD.

Trends in stimulant dispensing by age, sex, state of residence, and prescriber specialty - United States, 2014-2019

BACKGROUND

Stimulant medications are commonly prescribed for the treatment of attention-deficit/hyperactivity disorder; however, they also have high potential for diversion and misuse. We estimated national stimulant dispensing trends from 2014 to 2019 and differences in dispensing by age, sex, state, prescriber specialty, payor type, patient copay, and stimulant type.

METHODS

We calculated rates of stimulant dispensing using IQVIA National Prescription Audit (NPA) New to Brand, NPA Regional, and NPA Extended Insights data, which provide dispensing estimates from approximately 49,900 pharmacies representing 92 % of prescriptions dispensed in the United States. Average annual percent change (AAPC) from 2014 to 2019 was analyzed using Joinpoint regression.

RESULTS

From 2014 to 2019, the national annual rate of stimulant dispensing increased significantly from 5.6 to 6.1 prescriptions per 100 persons. Rates differed by prescription stimulant type, with increases occurring among both amphetamine-type stimulants and long-acting stimulants. Rates among females (AAPC = 3.6 %; P = 0.001) and adults aged 20-39 years (AAPC=6.7 %; P = 0.002), 40-59 years (AAPC=9.7 %; P < 0.001), and ≥60 years (AAPC = 6.9 %; P = 0.001) increased significantly during the study period. Stimulant dispensing rates varied substantially across states, ranging from 1.0 per 100 in Hawaii to 13.6 per 100 in Alabama.

CONCLUSIONS

National stimulant dispensing rates increased from 2014 to 2019, driven by notable increases among females and adults aged ≥20 years. These trends should be considered when prescribing stimulants given growing concerns over prescription stimulant diversion, misuse, and related health harms.

Is bullying in adolescence associated with the development of depressive symptoms in adulthood?: A longitudinal cohort study

BACKGROUND

Being bullied in adolescence is linked to mental health problems like anxiety, depressive- and somatic symptoms and can have negative consequences on both an individual and a societal level. However, evidence regarding the long-term mental health consequences of bullying in adolescence is limited. The aim of this study was to examine whether being bullied at age 15 or 18 was associated with experiencing depressive symptoms at age 28, and to examine whether being bullied at both ages 15 and 18 increased the risk of experiencing depressive symptoms at age 28.

METHODS

A prospective cohort study, which applied data from the West Jutland Cohort Study, was conducted. Bullying and depressive symptoms were measured on the basis of self-reported data from surveys in 2004, 2007 and 2017. Depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale. A total of 1790 participants were included in the study, and analyzed by multiple logistic regressions.

RESULTS

The results showed associations between being bullied at age 15 or 18 and the reporting of depressive symptoms at age 28 when adjusted for potential confounders. An exposure-response relationship was seen in those who were bullied at both ages 15 and 18. This group had the highest risk of developing depressive symptoms at age 28.

CONCLUSIONS

Being bullied in adolescence was associated with developing depressive symptoms in adulthood and there was an exposure-response relationship between being bullied over time and the later reporting of depressive symptoms. The results highlight the need to provide more detailed information to schools and local communities about the negative consequences of bullying. Such increased awareness may help reduce the risk of young people developing depressive symptoms later in life.

How to say "no" most effectively: Evaluating resistance strategies for prescription stimulant diversion to inform preventive interventions

We evaluated the perceived effectiveness of resistance strategies students could employ if approached to give away, trade, or sell their prescription stimulant medication, a growing concern on college campuses. Participants: We sampled undergraduates (N = 1,521) at three demographically dissimilar institutions between Fall 2017 and Spring 2018. Methods: We administered an anonymous, online survey and used linear mixed models to examine the effects of strategy type, face support (ie, adding politeness), and substance use history on perceived strategy effectiveness. Results: Internal (eg, "I am not comfortable sharing my medication") and external (eg, "My doctor won't prescribe me if I share") explanations were perceived to be most effective. Excuses, direct refusals, and suggesting an alternative (eg, energy drink) were less preferred. Adding face support improved perceived effectiveness for direct refusals and internal explanations. Conclusion: Preventive interventions for stimulant diversion could encourage the use of internal or external explanations or direct refusals with face support.

Systematic Review: Nonmedical Use of Prescription Stimulants: Risk Factors, Outcomes, and Risk Reduction Strategies

OBJECTIVE

To review all literature on the nonmedical use (NMU) and diversion of prescription stimulants to better understand the characteristics, risk factors, and outcomes of NMU and to review risk-reduction strategies.

METHOD

We systematically searched PubMed, PsycINFO, and SCOPUS from inception to May 2018 for studies containing empirical data about NMU and diversion of prescription stimulants. Additional references identified by the authors were also assessed for inclusion.

RESULTS

A total of 111 studies met inclusion criteria. NMU and diversion of stimulants are highly prevalent; self-reported rates among population samples range from 2.1% to 58.7% and from 0.7% to 80.0%, respectively. A variety of terms are used to describe NMU, and most studies have examined college students. Although most NMU is oral, non-oral NMU also occurs. The majority of NMU is associated with no, or minor, medical effects; however, adverse medical outcomes, including death, occur in some individuals, particularly when administered by non-oral routes. Although academic and occupational performance enhancement are the most commonly cited motivations, there is little evidence that academic performance is improved by NMU in individuals without attention-deficit/hyperactivity disorder.

CONCLUSION

NMU of stimulants is a significant public health problem, especially in college students, but variations in the terms used to describe NMU and inconsistencies in the available data limit a better understanding of this problem. Further research is needed to develop methods to detect NMU, identify individuals at greatest risk, study routes of administration, and devise educational and other interventions to help reduce occurrence of NMU. Colleges should consider including NMU in academic integrity policies.

Prescription Stimulants: From Cognitive Enhancement to Misuse

The nonmedical use of prescription stimulants has become increasingly pervasive among transitional age youth (TAY), aged 16 years to 26 years. Although therapeutically administered stimulants are regarded as safe and effective in TAY with attention-deficit/hyperactivity syndrome (ADHD), stimulant misuse is of concern due to prevalence, behavioral health and substance use correlates, and negative short-term and long-term outcomes. Although academic motivations primarily drive misuse, it is unclear whether prescription ADHD stimulants enhance cognition. Providers are advised to exercise precautions when prescribing ADHD medications, enhance surveillance for misuse, and screen those with misuse for ADHD and other psychopathology, executive dysfunction, and substance use disorders.