Use of psychostimulant medication for ADHD in South Australia

Prescription patterns and medication adherence in preadolescent children with attention deficit hyperactivity disorder

BACKGROUND

Nonadherence in attention deficit hyperactivity disorder (ADHD) can be as high as 80%, yet studies on adherence to medications in preadolescent children are few. Recent Indian trends in prescription patterns are lacking.

AIM

The present study assesses prescription patterns and adherence to medications in preadolescent children with ADHD.

MATERIALS AND METHODS

Fifty children aged 5-12 years with ADHD, who were on medications for at least 6 months, were enrolled. Their sociodemographic factors and prescription details were noted. Vanderbilt ADHD Diagnostic Parents Rating Scale and Compliance Rating Scale were administered.

RESULTS

Sixty-two percent of the children had good compliance, whereas 38% showed reluctance. Adherence was better in children with shorter duration of illness, lesser severity, absence of side effects, and stimulant prescription. Non-stimulant-based combination (40%) was more common compared to stimulants (28%), with atomoxetine and risperidone being the most commonly prescribed medications.

CONCLUSIONS

Adherence to medications in preadolescent children with ADHD is good. Associated factors and implications are discussed.

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder During Adolescence in the Primary Care Setting: A Concise Review

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school-age children. This review is intended to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents. PubMed, PsychInfo, and Science Citation Index databases were searched from March 1990 to 2015 with the keywords: ADHD, primary care/pediatrics, and children/adolescents. Abstracts addressing diagnosis and/or treatment with 105 citations were identified including supplementary treatment guidelines/books. Adolescent ADHD presents with significant disturbances in attention, academic performance, and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis, and limited training and time for PCPs to conduct thorough evaluations. The evidence base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification, and treatment of conditions associated with ADHD that emerge during adolescence such as substance use disorders. Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care psychiatric models, to assist in determining the optimal care for patients at this critical period.

Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by age-inappropriate levels of inattention, impulsivity and hyperactivity. School can be particularly challenging for children with ADHD. Few reviews have considered non-pharmacological interventions in school settings.

OBJECTIVES

To assess the effectiveness of non-pharmacological interventions delivered in school settings for pupils with, or at risk of, ADHD and to explore the factors that may enhance, or limit, their delivery.

DATA SOURCES

Twenty electronic databases (including PsycINFO, MEDLINE, EMBASE, Education Resources Information Centre, The Cochrane Library and Education Research Complete) were searched from 1980 to February-August 2013. Three separate searches were conducted for four systematic reviews; they were supplemented with forward and backwards citation chasing, website searching, author recommendations and hand-searches of key journals.

REVIEW METHODS

The systematic reviews focused on (1) the effectiveness of school-based interventions for children with or at risk of ADHD; (2) quantitative research that explores attitudes towards school-based non-pharmacological interventions for pupils with ADHD; (3) qualitative research investigating the attitudes and experiences of children, teachers, parents and others using ADHD interventions in school settings; and (4) qualitative research exploring the experience of ADHD in school among pupils, their parents and teachers more generally. Methods of synthesis included a random-effects meta-analysis, meta-regression and narrative synthesis for review 1, narrative synthesis for review 2 and meta-ethnography and thematic analysis for reviews 3 and 4.

RESULTS

For review 1, 54 controlled trials met the inclusion criteria. For the 36 meta-analysed randomised controlled trials, beneficial effects (p < 0.05) were observed for several symptom and scholastic outcomes. Mean weighted effect sizes ranged from very small (d + < 0.20) to large (d + ≥ 0.80), but substantial heterogeneity in effect size estimates across studies was reported. Moderator analyses were not able to clarify which intervention features were linked with effectiveness. For review 2, 28 included studies revealed that educators' attitudes towards interventions ranged in positivity. Most interventions were rated positively or neutrally across different studies. The only intervention that consistently recorded positive attitudes from educators was daily report cards. For review 3, 33 studies met the inclusion criteria. Key findings included tensions regarding the preferred format of interventions, particularly how structured interventions were and the extent to which they are tailored to the child with ADHD. There were mixed views about the impact of interventions, although it was clear that interventions both influence and are influenced by the relationships held by children with ADHD and participants' attitudes towards school and ADHD. For review 4, 34 studies met the inclusion criteria. Key findings included the importance of causal attributions that teachers, parents and pupils made about ADHD symptoms, the decisions teachers made about treatment, the self-perceptions pupils developed about themselves, the role of the classroom environment and stigma in aggravating ADHD symptoms, and the significant barrier to treatment posed by the common presence of conflict in relationships between pupils-teachers, parents-teachers and pupils-peers in relation to ADHD. An overarching synthesis of the four reviews highlighted the importance of the context affecting interventions. It suggested that ADHD psychoeducation and relationship-building skills are potential implications for interventions.

LIMITATIONS

The breadth of both interventions and outcomes in the reviewed studies presented a challenge for categorisation, analysis and interpretation in reviews 1-3. Across reviews, relatively few studies were conducted in the UK, limiting the applicability of findings to UK education. In reviews 1 and 2, the poor methodological quality of some included studies was identified as a barrier to establishing effectiveness or comparing attitudes. In review 3 the descriptive analysis used by the majority of studies constrained theorising during synthesis. Studies in review 4 lacked detail regarding important issues like gender, pupil maturity and school level.

CONCLUSION

Findings suggest some beneficial effects of non-pharmacological interventions for ADHD used in school settings, but substantial heterogeneity in effect sizes was seen across studies. The qualitative reviews demonstrate the importance of the context in which interventions are used. Future work should consider more rigorous evaluation of interventions, as well as focus on what works, for whom and in which contexts. Gaps in current research present opportunities for the development and testing of standardised tools to describe interventions, agreement on gold-standard outcome measures assessing ADHD behaviour and testing a range of potential moderators alongside intervention trials.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001716.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A Survival Analysis of Psychostimulant Prescriptions in New South Wales from 1990 to 2010

OBJECTIVE

Psychostimulant medication is considered a mainstay in the treatment of attention-deficit/hyperactivity disorder (ADHD); however, research suggests that the typical duration of medication treatment for children and youth may be <3 years. The purpose of this study was to evaluate the psychostimulant treatment persistence for children and adolescents in New South Wales, Australia.

METHODS

This study used survival analysis to assess duration of medication treatment on a large administrative database of children and youth from New South Wales, Australia. Several models were fit to evaluate differences in survival rates among decades (1990-1999 vs. 2000-2010), gender, and age.

RESULTS

Results showed that: 1) Overall median treatment time (i.e., median survival time) was 1.96 years (99% CI=1.93, 1.99); 2) there were small, but significant changes over time in duration of treatment; 3) females had shorter treatment duration than males; and 4) there were relatively large differences in treatment duration across age groups.

CONCLUSIONS

These results indicate that the majority of children and youth receive medication treatment for only a small portion of childhood/adolescence, and that there are differential patterns in treatment duration across age groups.

Differences in ADHD medication usage patterns in children and adolescents from different cultural backgrounds in the Netherlands

PURPOSE

Differences in incidence and prevalence of ADHD medication use between ethnic groups have been reported. Goal of this study was to determine whether there are also differences in usage patterns of ADHD medication among native Dutch children and adolescents and those with a Moroccan, Turkish and Surinam cultural background in the Netherlands between 1999 and 2010.

METHODS

In a cohort of ADHD patients <19 years (N = 817) incident use and discontinuation of ADHD medication were measured for ethnicity and adjusted for age, gender and socio-economic status.

RESULTS

A significant higher proportion of ADHD-diagnosed patients from Moroccan (32 %) and Turkish (42 %) cultural background never used ADHD medication compared to Dutch natives (21 %). One-fifth of native Dutch and Turkish patients already used ADHD medication before the ADHD diagnosis date. Discontinuation of ADHD medication within 5 years was significantly higher in Moroccan [HR 2.4 (95 % CI 1.8-3.1)] and Turkish [HR 1.7 (95 % CI 1.1-2.6)] patients. A sensitivity analysis with a zip code-matched comparison between Dutch natives and non-natives showed similar results, suggesting this effect is probably not explained by socio-economic status (SES).

CONCLUSION

Differences are found in prescribing and use of ADHD medication between patients with a different cultural background. Native Dutch and Turkish patients start more frequently with ADHD medication before the ADHD diagnose date, which can be an indication of differences in either referral patterns and/or access to care. A higher percentage of patients with a Moroccan and Turkish cultural background never start using ADHD medication at all and discontinuation rate is higher compared to Dutch natives and Surinamese.

Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for children with ADHD, to reduce symptoms and improve function. In this study we investigated the factors that influence paediatricians' decisions about prescribing stimulant medications.

METHOD

In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who were purposively recruited so as to sample a broad demographic of paediatricians working in diverse clinical settings. Paediatricians were recruited from public outpatient and private paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their demographic and practice characteristics.

RESULTS

Our findings showed that the decision to prescribe is a dynamic process involving two key domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along the journey to prescribing. Five themes relating to this process emerged from data analysis: comprehensive assessments that include history, examination and information from others; influencing factors such as functional impairment and social inclusion; previous success; facilitating parental understanding including addressing myths and parental confusion; and decision-making model.

CONCLUSIONS

Paediatricians' decisions to prescribe stimulant medications are influenced by multiple factors that operate concurrently and interdependently. Paediatricians do not make decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients, to arrive at a collective, well-informed decision.

Association between ADHD drug use and injuries among children and adolescents

To study the association between attention deficit hyperactivity disorder (ADHD) drug use and the incidence of hospitalization due to injuries. A random sample of 150,000 persons (0-18 years) was obtained from the Dutch PHARMO record linkage system. An ADHD medication cohort as well as an up to six age/sex/index date sampled control cohort with no history of ADHD drug use was formed. Differences in incidence of hospitalization due to injuries were stratified for age and sex and compared prior, during and after exposure on ADHD drugs. The overall incidence of hospital admissions for injuries was two times higher in the ADHD medication cohort [incidence rate ratios (IRR) 2.2 (95 % CI 1.6-2.9)]. The incidence rate for injuries during exposure to ADHD drugs was lower in the exposed period compared to the period prior to ADHD drug use, although the difference was not statistically significant [IRR 0.68 (95 % CI 0.29-1.60)]. The relative risk for injuries was almost five times higher in the ADHD medication cohort among those who concomitantly used other psychotropics [IRR 4.8 (95 % CI 1.4-16.9)]. Risk for injuries was highest in 12-18 years olds. Children and adolescents using ADHD medication showed a twofold risk for hospital admissions for injuries. ADHD drug use might diminish the increased injury risk, but still overall risk is higher than in age/sex sampled children and adolescents without treatment with ADHD drugs. Use of ADHD and concomitant psychotropics increases the risk for injuries compared to only ADHD drug use.

The strengths and difficulties questionnaire as a predictor of parent-reported diagnosis of autism spectrum disorder and attention deficit hyperactivity disorder

The Strengths and Difficulties Questionnaire (SDQ) is widely used as an international standardised instrument measuring child behaviour. The primary aim of our study was to examine whether behavioral symptoms measured by SDQ were elevated among children with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) relative to the rest of the population, and to examine the predictive value of the SDQ for outcome of parent-reported clinical diagnosis of ASD/ADHD. A secondary aim was to examine the extent of overlap in symptoms between children diagnosed with these two disorders, as measured by the SDQ subscales. A cross-sectional secondary analysis of data from the Millennium Birth Cohort (n = 19,519), was conducted. Data were weighted to be representative of the UK population as a whole. ADHD or ASD identified by a medical doctor or health professional were reported by parents in 2008 and this was the case definition of diagnosis; (ADHD n = 173, ASD n = 209, excluding twins and triplets). Study children's ages ranged from 6.3-8.2 years; (mean 7.2 years). Logistic regression was used to examine the association between the parent-reported clinical diagnosis of ASD/ADHD and teacher and parent-reported SDQ subscales. All SDQ subscales were strongly associated with both ASD and ADHD. There was substantial co-occurrence of behavioral difficulties between children diagnosed with ASD and those diagnosed with ADHD. After adjustment for other subscales, the final model for ADHD, contained hyperactivity/inattention and impact symptoms only and had a sensitivity of 91% and specificity of 90%; (AUC) = 0.94 (95% CI, 0.90-0.97). The final model for ASD was composed of all subscales except the 'peer problems' scales, indicating of the complexity of behavioural difficulties that may accompany ASD. A threshold of 0.03 produced model sensitivity and specificity of 79% and 93% respectively; AUC = 0.90 (95% CI, 0.86-0.95). The results support changes to DSM-5 removing exclusivity clauses.

Prediction of 7-year psychopathology from mother-infant joint attention behaviours: a nested case-control study

BACKGROUND

To investigate whether later diagnosis of psychiatric disorder can be predicted from analysis of mother-infant joint attention (JA) behaviours in social-communicative interaction at 12 months.

METHOD

Using data from a large contemporary birth cohort, we examined 159 videos of a mother-infant interaction for joint attention behaviour when children were aged one year, sampled from within the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Fifty-three of the videos involved infants who were later considered to have a psychiatric disorder at seven years and 106 were same aged controls. Psychopathologies included in the case group were disruptive behaviour disorders, oppositional-conduct disorder, attention-deficit/hyperactivity disorder, pervasive development disorder, anxiety and depressive disorders. Psychiatric diagnoses were obtained using the Development and Wellbeing Assessment when the children were seven years old.

RESULTS

None of the three JA behaviours (shared look rate, shared attention rate and shared attention intensity) showed a significant association with the primary outcome of case-control status. Only shared look rate predicted any of the exploratory sub-diagnosis outcomes and was found to be positively associated with later oppositional-conduct disorders (OR [95% CI]: 1.5 [1.0, 2.3]; p = 0.041).

CONCLUSIONS

JA behaviours did not, in general, predict later psychopathology. However, shared look was positively associated with later oppositional-conduct disorders. This suggests that some features of JA may be early markers of later psychopathology. Further investigation will be required to determine whether any JA behaviours can be used to screen for families in need of intervention.

Parent-infant vocalisations at 12 months predict psychopathology at 7 years

This study investigated the utility of adult and infant vocalisation in the prediction of child psychopathology. Families were sampled from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Vocalisation patterns were obtained from 180 videos (60 cases and 120 randomly selected sex-matched controls) of parent-infant interactions when infants were one year old. Cases were infants who had been subsequently diagnosed aged seven years, with at least one psychiatric diagnostic categorisation using the Development and Wellbeing Assessment. Psychopathologies included in the case group were disruptive behaviour disorders, oppositional-conduct disorders, Attention Deficit Hyperactivity Disorder, pervasive development disorder, and emotional disorders. Associations between infant and parent vocalisations and later psychiatric diagnoses were investigated. Low frequencies of maternal vocalisation predicted later development of infant psychopathology. A reduction of five vocalisations per minute predicted a 44% (95%CI: 11-94%; p-value=0.006) increase in the odds of an infant being a case. No association was observed between infant vocalisations and overall case status. In sum, altered vocalisation frequency in mother-infant interactions at one year is a potential risk marker for later diagnosis of a range of child psychopathologies.

A review of geographic variation and Geographic Information Systems (GIS) applications in prescription drug use research

BACKGROUND

While understanding geography's role in healthcare has been an area of research for over 40 years, the application of geography-based analyses to prescription medication use is limited. The body of literature was reviewed to assess the current state of such studies to demonstrate the scale and scope of projects in order to highlight potential research opportunities.

OBJECTIVE

To review systematically how researchers have applied geography-based analyses to medication use data.

METHODS

Empiric, English language research articles were identified through PubMed and bibliographies. Original research articles were independently reviewed as to the medications or classes studied, data sources, measures of medication exposure, geographic units of analysis, geospatial measures, and statistical approaches.

RESULTS

From 145 publications matching key search terms, forty publications met the inclusion criteria. Cardiovascular and psychotropic classes accounted for the largest proportion of studies. Prescription drug claims were the primary source, and medication exposure was frequently captured as period prevalence. Medication exposure was documented across a variety of geopolitical units such as countries, provinces, regions, states, and postal codes. Most results were descriptive and formal statistical modeling capitalizing on geospatial techniques was rare.

CONCLUSION

Despite the extensive research on small area variation analysis in healthcare, there are a limited number of studies that have examined geographic variation in medication use. Clearly, there is opportunity to collaborate with geographers and GIS professionals to harness the power of GIS technologies and to strengthen future medication studies by applying more robust geospatial statistical methods.

Predictors of diagnosis of child psychiatric disorder in adult-infant social-communicative interaction at 12 months

To establish which social interactive behaviours predict later psychiatric diagnosis, we examined 180 videos of a parent-infant interaction when children were aged one year, from within the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Sixty of the videos involved infants who were later diagnosed with a psychiatric disorder at seven years, and 120 were a randomly selected sex-matched control group. Interactive behaviours for both the caregiver and the one year old infant were coded from the videos according to eight holistic categories of interpersonal engagement: Well-being, Contingent Responsiveness, Cooperativeness, Involvement, Activity, Playfulness, Fussiness, and Speech. Lower levels of adult activity and speech in interaction at one year significantly predicted overall diagnosis of child psychiatric disorder.

Parental and professional beliefs on the treatment and management of ADHD

OBJECTIVE

This study examined parental and professional beliefs about the efficacy of various treatment strategies for ADHD.

METHOD

Parents of children with and without ADHD and seven medical and nonmedical professional groups (N = 673) completed a questionnaire examining their beliefs about the efficacy of various treatment regimes.

RESULTS

Principle component analysis identified four factors-school-based interventions, medical and allied health interventions, parent interventions, and nontraditional interventions. Although there were some group differences in the level of endorsement for these factors, there was a high degree of concordance between the groups. The school-based interventions factor was the most highly endorsed, whereas the nontraditional interventions factor was the least endorsed by the sample as a whole.

CONCLUSION

The results suggest that the low level of interdisciplinary interaction that has been reported in the literature is not due to differences in beliefs about the efficacy of various treatment strategies for ADHD.

Less discontinuation of ADHD drug use since the availability of long-acting ADHD medication in children, adolescents and adults under the age of 45 years in the Netherlands

Treatment options for ADHD in the Netherlands have increased with the introduction of the extended-release formulations of methylphenidate (MPH ER, Concerta^®) in 2003 and atomoxetine (ATX, Strattera^®) in 2005, but data on the effect on drug usage patterns are scarce. The objective of the present study was to describe changes in the patterns of ADHD medication use and determinants thereof among children, adolescents and adults (<45 years) starting ADHD medication since the introduction of MPH ER and ATX. Data were obtained from Dutch community pharmacies as collected by the Foundation for Pharmaceutical Statistics, covering 97% of all dispenses for prescription medicines to outpatients in the Netherlands. Usage patterns (continuation, discontinuation, switching and addition) of ADHD drugs were evaluated at 3, 6 and 12 months after initiation for three separate time cohorts (patients starting ADHD medication in Jan-Dec 2002, Jan 2003–June 2004, respectively July 2004–Dec 2005). It was found that between 2002 and 2006, most ADHD drug users were initiated on methylphenidate IR. Discontinuation of any ADHD drug treatment decreased over time partly in favour of switching and addition. Discontinuation at 3 months decreased from around 33% to around 25%, at 6 months from less than 50% to almost 35%, and at 12 months from just fewer than 60% to less than 45%. Discontinuation was higher among females and in adults >18 years. After the introduction of MPH ER and ATX (time cohort III), 16.5% of the incident ADHD drug users switched their medication and almost 9% added an ADHD drug to the prior ADHD drug. In conclusion, discontinuation of incident ADHD drug use is high after 3, 6 and 12 months. During the study period, the incidence of discontinuation decreased because of the availability of extended-release methylphenidate and atomoxetine.

Trends in incidence and characteristics of children, adolescents, and adults initiating immediate- or extended-release methylphenidate or atomoxetine in the Netherlands during 2001-2006

BACKGROUND

Previous Dutch studies showed increasing psychostimulant use, especially methylphenidate immediate-release (MPH-IR), between 1995 and 2003. In 2003 the extended-release (ER) formulation of MPH and in 2005 atomoxetine (ATX) were introduced in The Netherlands, which increased treatment options.

OBJECTIVE

The aim of this study was to describe the change in incidence of attention-deficit/hyperactivity disorder (ADHD) drugs and the prescription profiles of patients younger than 45 years starting treatment with these medicines between 2001 and 2006.

METHODS

Data were obtained from Dutch community pharmacies as collected by the Foundation for Pharmaceutical Statistics, covering 97% of all dispenses for prescription medicines to outpatients in The Netherlands.

RESULTS

The overall incidence of ADHD drugs use increased 6.5-fold from 2001 to 2006 in men as well as in women. The absolute incidence was highest among 6- to 11-year-old boys. The percentage of first-time MPH-IR users decreased from 98.3% in 2001 to 75.9% in 2006. Likewise, MPH-ER use increased from 0% in 2001 to 18.9% in 2006, and ATX use increased from 0% in 2001 to 3.9% in 2006. The new nonstimulant drug ATX was prescribed more often to adults if they had been previously treated with selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, or antipsychotics. Youngsters <17 years initiated on ATX were often previously treated with antipsychotics or clonidine/guanfacine.

CONCLUSION

These findings demonstrate an increase in incidence in use of ADHD drugs between 2001 and 2006 in The Netherlands. The major proportion of all treated patients comprised boys, 6-11 years old; most of them were treated with MPH-IR. In a few years time, the use of extended-release drugs as part of all ADHD drug prescriptions increased considerably, despite the lack of full reimbursement of these extended-release drugs. Psychostimulants and atomoxetine in children, adolescents, and adults are probably used to address different treatment needs.

Co-morbidity and patterns of care in stimulant-treated children with ADHD in the Netherlands

This study aimed at investigating the use of psychosocial interventions and psychotropic co-medication among stimulant-treated children with attention-deficit hyperactivity disorder (ADHD) in relation to the presence of psychiatric co-morbidity. Stimulant users younger than 16 years were identified in 115 pharmacies and a questionnaire was sent to their stimulant prescribing physician. Of 773 questionnaires sent out, 556 were returned and were suitable for analysis (72%). The results are based on 510 questionnaires concerning stimulant-treated children for whom a diagnosis of ADHD was reported. Of the 510 children diagnosed with ADHD, 31% had also received one or more other psychiatric diagnoses, mainly pervasive developmental disorder or oppositional defiant disorder/conduct disorder. We found an association between the presence of co-morbidity and the use of psychosocial interventions for the child (P < 0.001) and the parents (P < 0.001). In the ADHD-only group, 26% did not receive any form of additional interventions, while psychosocial interventions varied from 8 to 18% in children with ADHD and psychiatric co-morbidity. The presence of diagnostic co-morbidity was also associated with the use of psychotropic co-medication (overall, P = 0.012) and antipsychotics (P < 0.001). Stimulant-treated youths with ADHD and psychiatric co-morbidity received more psychosocial interventions and psychotropic co-medication than children with ADHD-only. The type of psychosocial interventions and psychotropic co-medication received by the children and their parents, depended on the specific co-morbid psychiatric disorder being present.

Current issues around the pharmacotherapy of ADHD in children and adults

Background New drugs and new formulations enter the growing market for ADHD medication. The growing awareness of possible persistence of ADHD impairment beyond childhood and adolescence resulting in increased pharmacotherapy of ADHD in adults, is also a good reason for making an inventory of the what is generally known about pharmacotherapy in ADHD. Aim To discuss current issues in the possible pharmacotherapy treatment of ADHD in children, adolescents and adults with respect to the position of pharmacotherapy in ADHD treatment guidelines, the pharmacoepidemiological trends, and current concerns about the drugs used. Methods A search of the literature with an emphasis on the position of pharmacotherapy in ADHD treatment guidelines, the pharmacoepidemiological trends, and current concerns about the drugs used in pharmacotherapy. Results According to the guidelines, the treatment of ADHD in children consists of psychosocial interventions in combination with pharmacotherapy when needed. Stimulants are the first-choice drugs in the pharmacological treatment of ADHD in children despite a number of well known and frequently reported side effects like sleep disorders and loss of appetite. With regard to the treatment of adults, stimulant treatment was recommended as the first-choice pharmacotherapy in the single guideline available. Both in children and adults, there appears to be an additional though limited role for the nonadrenergic drug atomoxetine. The increase of ADHD medication use, in children, adolescents and in adults, can not only be interpreted as a sign of overdiagnosis of ADHD. Despite the frequent use of stimulants, there is still a lack of clarity on the effects of long-term use on growth and nutritional status of children. Cardiovascular effects of both stimulants and atomoxetine are rare but can be severe. The literature suggests that atomoxetine may be associated with suicidal ideation in children. Conclusion Although pharmacotherapy is increasing common in the treatment of ADHD in both children and adults, there are still a lot of questions about side effects and how best to counter them. This suggests an important role for close monitoring of children and adults treated with stimulants or atomoxetine.

Changes in use of psychostimulant medication for ADHD in South Australia (1990-2006)

OBJECTIVE

The aim of the present study was to undertake a retrospective analysis of archival data on psychostimulant prescriptions from South Australia for the periods 1990-2000 and 2001-2006 for 7849 youths aged from birth to 18 years.

METHOD

A person-based data set was used to assess: (i) rate of new prescriptions by age group; (ii) demographic characteristics (age of psychostimulant start, male: female ratio); (iii) duration of psychostimulant use; and (iv) geographic variation in psychostimulant prescription.

RESULTS

Four major findings were observed: (i) the rate of new prescriptions was highly variable both for 1990-2000 and 2000-2006; (ii) demographic characteristics such as start age and male:female ratio declined over both periods; (iii) the duration of psychostimulant use was approximately 2.5 years for 1990-2000 and 2.0 years for 2000-2006; and (iv) there was geographic variation in both periods with a significant correlation between socioeconomic status and prescription rate per region.

CONCLUSIONS

The patterns of psychostimulant use in Australia closely parallel the USA. Physicians' prescribing practice may be extremely volatile. Duration of psychostimulant treatment should receive increased attention. There is pronounced geographic variability in prescription rates, which may be related to socioeconomic status.

Assessing the diagnostic accuracy of the identification of hyperkinetic disorders following the introduction of government guidelines in England

BACKGROUND

Previous studies have suggested that both underdiagnosis and overdiagnosis routinely occur in ADHD and hyperkinesis (hyperkinetic disorders). England has introduced governmental guidelines for these disorders' detection and treatment, but there has been no study on clinical diagnostic accuracy under such a regime.

METHODS

All open cases in three Child and Adolescent Mental Health Services (CAMHS) in the South East of England were assessed for accuracy in the detection of hyperkinetic disorders, using a two-stage process employing the Strengths and Difficulties Questionnaire (SDQ) for screening, with the cut-off between "unlikely" and "possible" as the threshold for identification, and the Development And Well-Being Assessment (DAWBA) as a valid and reliable standard.

RESULTS

502 cases were collected. Their mean age 11 years (std dev 3 y); 59% were clinically diagnosed as having a hyperkinetic disorder including ADHD. Clinicians had missed two diagnoses of hyperkinesis and six of ADHD. The only 'false positive' case was one that had become asymptomatic on appropriate treatment.

CONCLUSION

The identification of children with hyperkinetic disorders by three ordinary English CAMHS teams appears now to be generally consistent with that of a validated, standardised assessment. It seems likely that this reflects the impact of Governmental guidelines, which could therefore be an appropriate tool to ensure consistent accurate diagnosis internationally.

Academic and educational outcomes of children with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is associated with poor grades, poor reading and math standardized test scores, and increased grade retention. ADHD is also associated with increased use of school-based services, increased rates of detention and expulsion, and ultimately with relatively low rates of high school graduation and postsecondary education. Children in community samples who show symptoms of inattention, hyperactivity, and impulsivity with or without formal diagnoses of ADHD also show poor academic and educational outcomes. Pharmacologic treatment and behavior management are associated with reduction of the core symptoms of ADHD and increased academic productivity, but not with improved standardized test scores or ultimate educational attainment. Future research must use conceptually based outcome measures in prospective, longitudinal, and community-based studies to determine which pharmacologic, behavioral, and educational interventions can improve academic and educational outcomes of children with ADHD.

Medication prescribing practices in a child and adolescent psychiatry outpatient clinic

BACKGROUND

The aim of this study was to evaluate the medication prescribing practices for children who had attended a child and adolescent psychiatry outpatient clinic in Turkey.

METHODS

A retrospective chart review of consecutive new patients admitted to a child and adolescent psychiatry outpatient clinic of university hospital within 6 months was performed.

RESULTS

Male/female ratio of 822 charts examined was 1.75. Over activity and/or distractibility were the most common presenting complaints and attention-deficit hyperactivity disorder was the most common disorder. Approximately one-fourth (24.0%) of children were prescribed psychotropic medications. Initiation time of psychotropic medication was one of the first two visits in 65% of the children who were prescribed medication. The most commonly prescribed medications were in descending order of prescribing frequency: selective serotonin reuptake inhibitors, tricyclic antidepressants, atypical antipsychotics and psychostimulants. About 54.2% of depressed children were prescribed selective serotonin reuptake inhibitors and 24.3% of children with attention-deficit hyperactivity disorder were prescribed psychostimulant treatment. Among children who used at least one psychotropic medication, the rate of co-prescription was 10.7%.

CONCLUSION

It was found that the use of selective serotonin reuptake inhibitors and methylphenidate in children has become widespread. The results of our study may be helpful in improving treatment services in child and adolescent psychiatry.

Use of double-blind placebo-controlled N-of-1 trials among stimulant-treated youths in The Netherlands: a descriptive study

OBJECTIVES

An N-of-1 trial is a double-blind placebo-controlled randomized trial to objectively and systematically evaluate the individual's response. This approach seems extraordinarily suitable for assessing the efficacy of stimulants in the treatment of attention deficit hyperactivity disorder (ADHD). The aim is to examine the use of N-of-1 trials among youths in the Netherlands, the protocols used, and the continuation of stimulant treatment thereafter.

METHODS

Physicians requesting N-of-1 trials with stimulants were interviewed about their rationale and protocol. Prevalence and continuation were investigated by extracting N-of-1 trials among youths <20 years of age from a large pharmacy dispensing database for 2000-2004.

RESULTS

The main purpose of N-of-1 trials mentioned by physicians was the assessing of individuals' response and dose-finding. Trial length, dosing schedule and efficacy assessment differed per physician. Trials consisted of a maximum of two treatment periods per dose. The annual percentage of youths starting stimulant treatment with an N-of-1 trial fluctuated between 0.6% (3/462) and 3.3% (10/301). No statistical significant difference could be detected between the continuation of stimulant treatment with or without an N-of-1 trial (p = 0.71).

CONCLUSIONS

N-of-1 trials with stimulants are infrequently and not optimally used in the Netherlands. The results of N-of-1 protocols described by physicians are of questionable value, due to the small number of treatment periods per dose. More uniformity in the protocols would make it easier to encompass the N-of-1 methodology in physicians' daily practice.

The incidence of methylphenidate use by Canadian children: what is the impact of socioeconomic status and urban or rural residence?

OBJECTIVE

To examine socioeconomic, demographic, and behavioural factors that influence the incidence of methylphenidate use among children aged 4 to 13 years.

METHOD

A total of 11,316 children, aged 2 through 11 years, from Cycle 1 (1994-95) of the National Longitudinal Survey of Children and Youth were followed up 2 years later in Cycle 2 (1996-97). The outcome measure was methylphenidate use in Cycle 2. Individual-level explanatory variables included sex, age, socioeconomic status (SES), mother's age at birth of child, lone-parent family status, parental working status, and hyperactivity-impulsivity and inattention probabilities. Area-level explanatory variables included income and rural or urban residence. We used hierarchical linear modelling to examine individual- and area-level factors that predicted methylphenidate use.

RESULTS

The strongest predictors of methylphenidate use were behavioural: children with high hyperactive-impulsive and (or) inattention behaviours in 1994, compared with children low on these behaviours, were 4.5 to 6 times more likely to use methylphenidate 2 years later. SES remained a significant predictor of the incidence of methylphenidate use, even when other significant predictors were held constant, with lower SES being associated with higher use. Area-level income also predicted methylphenidate use.

CONCLUSION

Even when children with similar behavioural symptoms and demographic characteristics were compared, socioeconomic factors had a significant impact on incidence of methylphenidate use.

Attention-deficit/hyperactivity disorder: are we medicating for social disadvantage? (Against)

The functional impairments seen in attention deficit hyperactivity disorder (ADHD) are the result of a complex interplay between biological vulnerability and environmental influences. In children with ADHD from social disadvantaged families the latter often appear to predominate. Stimulant medication is the intervention with the largest demonstrable effect size in decreasing the core symptoms of ADHD, irrespective of social context. However, medication alone will not effectively treat common comorbidities, such as oppositional behaviour, anxiety, or learning disabilities. Nor can medication be expected to diminish major family discord or psychosocial adversity. Stimulant medication is one key therapy modality in children with ADHD. Data on prescribing rates do not support the assertion that there is systematic overprescribing of stimulants in Australia. There is, however, a serious problem with access to family support and appropriate services in schools for children with ADHD. Paediatricians have a responsibility to provide evidence-based medical treatment for children with ADHD (i.e. stimulant medication), while advocating across sectors for services to enhance family resilience and function.

Attention-deficit/hyperactivity disorder: are we medicating for social disadvantage? (For)

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) is based on well defined criteria, which describe a number of symptoms. It is important to consider the context of the symptoms, in terms of the influence of the child's family and school. Although stimulant medications benefit selected children they may not benefit all children with symptoms of ADHD. The incidence of ADHD increases with social disadvantage. There is a potential danger of using stimulant medication alone to treat children with complex psychosocial problems, associated with social disadvantage, including Aboriginal children. We desperately need better training in the management of ADHD and better access to child psychiatrists.

Parents report on stimulant-treated children in the Netherlands: initiation of treatment and follow-up care

OBJECTIVES

The aim of this study was to describe current practices around initiation and follow-up care of stimulant treatment among stimulant-treated children in a nationwide survey among parents.

METHODS

A total of 115 pharmacies detected current stimulant users <16 years old in their pharmacy information system and sent parents a questionnaire regarding their child's stimulant treatment.

RESULTS

Parents returned 924 of 1,307 questionnaires (71%). The median age of the stimulant users was 10 years and 85% were boys. In all, 91% were diagnosed with attention-deficit/hyperactivity disorder (ADHD). In 77% of the cases, the child or parents received other therapies besides stimulants-21% received psychotropic co-medication, with melatonin (11%) and antipsychotics (7%) being mentioned most frequently. Stimulant use was primarily initiated by child psychiatrists (51%) and pediatricians (32%), but most children received repeat prescriptions from general practitioners (61%). Of these 924 children, 19% did not receive any follow-up care, and transfer of prescribing responsibility increased the risk of not receiving follow-up care. The 732 children (79%) who were monitored visited a physician approximately twice a year. During follow-up visits, pediatricians performed physical check ups significantly more often.

CONCLUSION

Stimulant treatment in The Netherlands is initiated mainly by specialists such as child psychiatrists and pediatricians. In the current study, follow-up care for stimulant-treated children in The Netherlands appeared to be poor, suggesting an urgent need for improvement.

Attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a disorder of inattention, impulsivity, and hyperactivity that affects 8-12% of children worldwide. Although the rate of ADHD falls with age, at least half of children with the disorder will have impairing symptoms in adulthood. Twin, adoption, and molecular genetic studies show ADHD to be highly heritable, and other findings have recorded obstetric complications and psychosocial adversity as predisposing risk factors. Converging evidence from animal and human studies implicates the dysregulation of frontal-subcortical-cerebellar catecholaminergic circuits in the pathophysiology of ADHD, and molecular imaging studies suggest that abnormalities of the dopamine transporter lead to impaired neurotransmission. Studies during the past decade have shown the safety and effectiveness of new non-stimulant drugs and long-acting formulations of methylphenidate and amfetamine. Other investigations have also clarified the appropriate role of targeted psychosocial treatments in the context of ongoing pharmacotherapy.

Health state utilities for childhood attention-deficit/hyperactivity disorder based on parent preferences in the United kingdom

OBJECTIVES

The purpose of this study was to use standard gamble (SG) utility interviews to assess parent preferences for health states of childhood attention-deficit/hyperactivity disorder (ADHD).

METHODS

The study was conducted in August 2003 in London, England. Parents (N=83) of children diagnosed with ADHD completed SG utility interviews, rating their child's current health and 14 hypothetical health states describing untreated ADHD and ADHD treated with a nonstimulant, immediate-release stimulant, or extended-release stimulant. Raw temporary utilities ranging from 0 (worst health) to 1 (best health) were adjusted to a chronic utility scale ranging from 0 (death) to 1 (best health) using a linear transformation. Parents rated the severity of their children's ADHD symptoms using the Attention-Deficit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS) and their children's health-related quality of life using the EuroQol EQ-5D.

RESULTS

Raw and adjusted SG ratings of hypothetical health states ranged from 0.63-0.90 and 0.88-0.96, respectively. Parents' raw SG scores of their child's current health state (mean=0.72) were significantly correlated with inattentive, hyperactive, and overall ADHD symptoms (r=-0.25, -0.27, -0.27; P <0.05) and the EQ-5D visual analogue scale (r=0.26; P <0.05).

CONCLUSION

This UK-based study suggests that parent SG interviews are a valid method for obtaining utilities for child ADHD-related health states. The utilities obtained in this study would be appropriate for use in a cost-utility analysis evaluating the costs and benefits of childhood ADHD treatments in the United Kingdom.

Psychotropic co-medication among stimulant-treated children in The Netherlands

OBJECTIVES

The aim of this study was to examine stimulant use from 1998 to 2002 among children in the Dutch pediatric population with emphasis on psychotropic co-medication.

METHODS

A drug utilization study was based on community pharmacy-dispensing data from 1998 to 2002 for children aged 0-19 years in the northern and eastern part of The Netherlands.

RESULTS

The prevalence of stimulant use increased from 0.6% in 1998 to 1.2% in 2002. Duration of stimulant treatment was longest in children aged 5-14 years. The use of any psychotropic co-medication in stimulant users increased from 12% in 1998 to nearly 15% in 2002. Of those youths who were prescribed stimulant medication in 2002, the most co-prescribed class was the antipsychotics (7.9%). In 1998, none of the stimulant-treated children received antidepressants for co-medication; in 2002, this was 1.8%.

CONCLUSION

The prevalence of stimulant use among children in The Netherlands has increased in recent years, mainly as a result of the duration of stimulant treatment. Psychotropic co-medication among stimulant-treated children increased moderately.

Prediction of childhood pulmonary function using ulna length

Pulmonary function is important in neuromuscular weakness. In children, height determines normal values. Height measurement is unreliable when neuromuscular weakness or spinal deformity is present. The aim of this study was to accurately predict pulmonary function from a limb segment measurement that is precise and reproducible. Normal males (n = 1,144) and females (n = 1,199), 5.3 to 19.6 years old, were recruited from Melbourne schools. Height, weight, ulna, forearm, tibia, and lower leg lengths were measured using a Harpenden stadiometer and calipers, and electronic scales. Three maximal expiratory maneuvers were performed. Limb measurements were highly reproducible. Linear regression on log-transformed FEV1 and FVC was used to develop prediction equations from limb measurements and age. In males FEV1 = exp (0.071 x U + 0.046 x A - 1.269), r2 = 0.86; FVC = exp (0.77 x U + 0.041 x A - 1.285), r2 = 0.86 and in females FEV1 = exp (0.072 x U + 0.041 x A - 1.272), r2 = 0.84; FVC = exp (0.078 x U + 0.037 x A - 1.315), r2 = 0.83 (U refers to ulna length and A refers to age). Precision is similar to equations using height. Ulna measurement is accessible in wheelchair-bound children. Using ulna length to predict pulmonary function should facilitate respiratory assessment in children whose height is difficult to measure.

Economic implications of attention-deficit hyperactivity disorder for healthcare systems

Attention-deficit hyperactivity disorder (ADHD) is one of the most common chronic conditions of childhood, with adverse consequences that persist through adolescence into adulthood. Thus, the burden of illness associated with ADHD is high for affected individuals, their families, and society at large. This article reviews available information about ADHD-associated utilisation of healthcare resources, direct medical costs, and the costs or cost effectiveness of pharmacological interventions. Published estimates suggest that direct medical costs for youth with ADHD are approximately double those for youth without ADHD. Cross-sectional studies suggest that ADHD-associated incremental costs are highest for mental health services and pharmaceutical costs, and are greatest for youth with comorbid psychiatric conditions and for those being treated with stimulant medication. To guide relevant clinical and health policy, additional research is warranted on the following: source of increased costs observed among persons with ADHD; patient characteristics of those accruing high medical costs; and the long-term effect of ADHD treatment on direct and indirect costs.