Children with attention deficit hyperactivity disorder and attendance at hospital:

Returning to education after childhood acquired brain injury: Learning from lived parental experience

BACKGROUND

Returning to education (RtE) after an acquired brain injury (ABI) can be stressful for children/young people (CYP) and families. While much can be done to support RtE, there has been limited exploration of the lived experience of parents/carers about what can both help and hinder the process.

OBJECTIVE

The aim was to understand more about RtE from parents' perspectives to inform best practice and facilitate improvements in service delivery.

METHODS

A service evaluation explored parent/carer views about the RtE process and the support received from healthcare professionals at a regional centre in the UK. Questionnaires (n = 59) were sent to parents of patients treated for an ABI in the last two years.

RESULTS

31 parents (response rate = 51%) completed the survey. Results highlight the many challenges of RtE. Thematic analysis of responses revealed six key themes: Parental mindset and growth; What do they need know?; Specialist support and information; Talk and share; Challenges of new and hidden needs; and Don't forget them!

CONCLUSION

Parents offer crucial insight into the challenges of the RtE process. Their feedback highlights important factors for service development and reminds professionals of the key components of an effective return.

County-level prevalence estimates of ADHD in children in the United States

PURPOSE

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood disorder often characterized by long-term impairments in family, academic, and social settings. Measuring the prevalence of ADHD is important as treatment options increase around the U.S. Prevalence data helps inform decisions by care providers, policymakers, and public health officials about allocating resources for ADHD. In addition, measuring geographic variation in prevalence estimates can facilitate hypothesis generation for future analytic work. Most U.S. studies of ADHD prevalence among children focus on national or demographic group rates.

METHODS

Using a small area estimation approach and data from the 2016 to 2018 National Survey of Children's Health, we estimated childhood ADHD prevalence estimates at the census regional division, state, and county levels. The sample included approximately 70,000 children aged 5-17 years.

RESULTS

The national ADHD rate was estimated to be 12.9% (95% Confidence Interval: 11.5%, 14.4%). Counties in the West South Central, East South Central, New England, and South Atlantic divisions had higher estimated rates of childhood ADHD (55.1%, 53.6%, 49.3%, and 46.2% of the counties had rates of 16% or greater, respectively) compared to counties in the Mountain, Mid Atlantic, West North Central, Pacific, and East North Central divisions (2.1%, 4%, 5.8%, 6.9%, and 11.7% of the counties had rates of 16% or greater, respectively).

CONCLUSIONS

These local-level rates are useful for decision-makers to target programs and direct sufficient ADHD resources based on communities' needs.

Relationship between Injuries and Attention-Deficit Hyperactivity Disorder: A Population-Based Study with Long-Term Follow-Up in Taiwan

Objective: To investigate the association between various injuries and attention-deficit hyperactivity disorder (ADHD) and distinguish ADHD from non-ADHD with regards to risk of various injuries among children in Taiwan. Method: Using the data from the National Health Insurance Research Database, we selected a total of 1802 subjects under the age of 18 who were diagnosed with ADHD as well as an additional 7208 subjects as a comparison group. Results: Compared with children who were not diagnosed with ADHD, children diagnosed with ADHD were more likely to intentionally injure themselves. During the school year, ADHD children were injured less frequently than were non-ADHD children on traffic-related incidents. The adjusted hazard ratio of injury for the ADHD children was 2.493 times higher than that of comparison subjects. The ADHD children had a greater length of stay and medical cost when compared to those of the non-ADHD children. Age showed a significant inverse relationship with injury. Among the ADHD children, the injury rate was evidently higher for the low-income group than for the non-low-income group. Conclusions: Age, cause of injuries, low-income household status, and school season all have a significant connection to the risk of injury for ADHD children.

ADHD and accidents over the life span - A systematic review

Studies have demonstrated an increased risk of accidents and injuries in children, adolescents and adults with attention-deficit/hyperactivity disorder (ADHD). However, little is known about how accident risk may alter over the lifespan. Additionally, it would be important to know if the most common types of accidents and injuries differ in ADHD patients over different age groups. Furthermore, there is increasing evidence of an ameliorating effect of ADHD medication on accident risk. Lastly, the underlying risk factors and causal mechanisms behind increased accident risk remain unclear. We therefore conducted a systematic review focusing on the above described research questions. Our results suggested that accident/injury type and overall risk changes in ADHD patients over the lifespan. ADHD medication appeared to be similarly effective at reducing accident risk in all age groups. However, studies with direct comparisons of accident/injuries and effects of medication at different age groups or in old age are still missing. Finally, comorbidities associated with ADHD such as substance abuse appear to further increase the accident/injury risk.

Student-Perceived School Climate Is Associated With ADHD Medication Treatment Among Adolescents in Medicaid

OBJECTIVE

The objective of this study was to evaluate the relationship between school climate and ADHD medication treatment among adolescents in Medicaid in Georgia.

METHOD

School climate and Medicaid claims data were aggregated for 159 GA counties. County-level school climate percentile and medicated ADHD prevalence were calculated. The t tests and regression models evaluated the relationship between school climate, medicated ADHD, and demographics, weighted by county population. Poorer 2008 school climate (<25th percentile) was regressed on 2011 medicated ADHD prevalence, controlling for potential confounders.

RESULTS

The prevalence of medicated ADHD was 7.8% among Medicaid-enrolled GA adolescents. The average county-level prevalence of medicated ADHD was 10.0% ( SD = 2.9%). Poorer school climate was associated with lower rates of medicated ADHD ( p < .0001); along with demographics, these factors accounted for 50% of the county variation in medicated ADHD.

CONCLUSION

School climate is associated with medicated ADHD among adolescents in Medicaid. Additional research may reveal whether high medicated ADHD may reflect a lack of access to non-pharmacological therapies in some communities.

Prevalence of Attention Deficit Hyperactivity Disorder Symptoms in Children Who Were Treated at Emergency Service due to Unintentional Injury

AIM

Attention Deficit Hyperactivity Disorder (ADHD) is a developmental disorder characterized by severe inattention, hyperactivity, and impulsivity. This research aims to determine the frequency of ADHD symptoms in children who were treated in emergency paediatric services due to unintentional injuries.

METHOD

This study was carried out with children who were treated due to unintentional injuries in an Emergency Department. ADHD symptoms were evaluated using the DSM-IV-based Screening and Assessment Scale for Behavioural Disorders in Children and Adolescents.

RESULTS

The study sample consisted of 89 girls (40.1%) and 133 boys (59.9%)-a total of 222 children. The participants ranged from 5 to 18 years of age, and the mean age was found to be 11.5±3 years. According to medical evaluations, the most common diagnosis for the unintentional injuries was soft tissue trauma (41.9%). The mean ADHD and ODD (Oppositional Defiant Disorder) scores of our study sample were, respectively, 19.9±12 and 7.7±5.7. The prevalence of children with possible ADHD was as high as 81.6% (179) and, for ODD, was 62.6% (139), according to cut-off values.

CONCLUSION

Our results pointed out very high levels of ADHD and ODD symptoms among children who were treated at emergency services for accidental injuries. Appropriately screening for ADHD in children with accidental injuries and referring them to child psychiatry units may prevent later accidents and injuries.

Traumatic Brain Injury, Sleep Disorders, and Psychiatric Disorders: An Underrecognized Relationship

Traumatic brain injury (TBI) is commonplace among pediatric patients and has a complex, but intimate relationship with psychiatric disease and disordered sleep. Understanding the factors that influence the risk for the development of TBI in pediatrics is a critical component of beginning to address the consequences of TBI. Features that may increase risk for experiencing TBI sometimes overlap with factors that influence the development of post-concussive syndrome (PCS) and recovery course. Post-concussive syndrome includes physical, psychological, cognitive and sleep-wake dysfunction. The comorbid presence of sleep-wake dysfunction and psychiatric symptoms can lead to a more protracted recovery and deleterious outcomes. Therefore, a multidisciplinary evaluation following TBI is necessary. Treatment is generally symptom specific and mainly based on adult studies. Further research is necessary to enhance diagnostic and therapeutic approaches, as well as improve the understanding of contributing pathophysiology for the shared development of psychiatric disease and sleep-wake dysfunction following TBI.

The Association Between Hospital-Treated Injuries and ADHD Symptoms in Childhood and Adolescence: A Follow-Up Study in the Northern Finland Birth Cohort 1986

OBJECTIVE

We examined the risk of hospital-treated injuries related to the symptoms/diagnosis of ADHD.

METHOD

The study population (N = 6,111) was composed from the Northern Finland Birth Cohort 1986. At the age of 8, symptoms of hyperactivity and at the age of 15, symptoms of ADHD were assessed by the parents while the clinical diagnoses of ADHD were set in adolescence. Information on injuries was obtained from national register.

RESULTS

The risk for hospital-treated injuries during ages 0 to 7 was 1.7-fold increased among those with symptoms of hyperactivity assessed at age 8. Also, injuries during ages 7 to 15 years were more common among those with symptoms of ADHD at age 15 with respect to any injury, fractures, and intracranial injuries, and among those with the diagnosis of ADHD with respect to any injury.

CONCLUSION

The present study shows an association between hospital-treated injuries and symptoms of ADHD in a large epidemiological sample of 0- to 15-year-old children.

Methylphenidate and the risk of trauma

BACKGROUND AND OBJECTIVE

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate (MPH) can reduce ADHD symptoms and may thus theoretically reduce the risk of trauma-related ED admission, but previous studies do not make this association clear. This study examines this association.

METHODS

A total of 17 381 patients aged 6 to 19 years who received MPH prescriptions were identified by using the Clinical Data Analysis & Reporting System (2001-2013). Using a self-controlled case series study design, the relative incidence of trauma-related ED admissions was compared with periods of patient exposure and nonexposure to MPH.

RESULTS

Among 17 381 patients prescribed MPH, 4934 had at least 1 trauma-related ED admission. The rate of trauma-related ED admission was lower during exposed periods compared with nonexposed periods (incidence rate ratio [IRR]: 0.91 [95% confidence interval (CI): 0.86-0.97]). The findings were similar only when the incident trauma episode was assessed (IRR: 0.89 [95% CI: 0.82-0.96]). A similar protective association was found in both genders. In validation analysis using nontrauma-related ED admissions as a negative control outcome, no statistically significant association was found (IRR: 0.99 [95% CI: 0.95-1.02]). All sensitivity analyses demonstrated consistent results.

CONCLUSIONS

This study supports the hypothesis that MPH is associated with a reduced risk of trauma-related ED admission in children and adolescents. A similar protective association was found in both male and female patients. This protective association should be considered in clinical practice.

Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011

OBJECTIVE

Data from the 2003 and 2007 National Survey of Children's Health (NSCH) reflect the increasing prevalence of parent-reported attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment by health care providers. This report updates these prevalence estimates for 2011 and describes temporal trends.

METHOD

Weighted analyses were conducted with 2011 NSCH data to estimate prevalence of parent-reported ADHD diagnosis, current ADHD, current medication treatment, ADHD severity, and mean age of diagnosis for U.S. children/adolescents aged 4 to 17 years and among demographic subgroups. A history of ADHD diagnosis (2003-2011), as well as current ADHD and medication treatment prevalence (2007-2011), were compared using prevalence ratios and 95% confidence intervals.

RESULTS

In 2011, 11% of children/adolescents aged 4 to 17 years had ever received an ADHD diagnosis (6.4 million children). Among those with a history of ADHD diagnosis, 83% were reported as currently having ADHD (8.8%); 69% of children with current ADHD were taking medication for ADHD (6.1%, 3.5 million children). A parent-reported history of ADHD increased by 42% from 2003 to 2011. Prevalence of a history of ADHD, current ADHD, medicated ADHD, and moderate/severe ADHD increased significantly from 2007 estimates. Prevalence of medicated ADHD increased by 28% from 2007 to 2011.

CONCLUSIONS

Approximately 2 million more U.S. children/adolescents aged 4 to 17 years had been diagnosed with ADHD in 2011, compared to 2003. More than two-thirds of those with current ADHD were taking medication for treatment in 2011. This suggests an increasing burden of ADHD on the U.S. health care system. Efforts to further understand ADHD diagnostic and treatment patterns are warranted.

The impact of attention deficit hyperactivity disorder on recovery from mild traumatic brain injury

OBJECT

Attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) are significant independent public health concerns in the pediatric population. This study explores the impact of a premorbid diagnosis of ADHD on outcome following mild TBI.

METHODS

The charts of all patients with a diagnosis of mild closed head injury (CHI) and ADHD who were admitted to Children's Hospital of Pittsburgh between January 2003 and December 2010 were retrospectively reviewed after institutional review board approval was granted. Patient demographics, initial Glasgow Coma Scale (GCS) score, hospital course, and King's Outcome Scale for Childhood Head Injury (KOSCHI) score were recorded. The results were compared with a sample of age-matched controls admitted with a diagnosis of CHI without ADHD.

RESULTS

Forty-eight patients with mild CHI and ADHD, and 45 patients with mild CHI without ADHD were included in the statistical analysis. Mild TBI due to CHI was defined as an initial GCS score of 13-15. The ADHD group had a mean age of 12.2 years (range 6-17 years), and the control group had a mean age of 11.14 years (range 5-16 years). For patients with mild TBI who had ADHD, 25% were moderately disabled (KOSCHI Score 4b), and 56% had completely recovered (KOSCHI Score 5b) at follow-up. For patients with mild TBI without ADHD, 2% were moderately disabled and 84% had completely recovered at follow-up (p < 0.01). Patients with ADHD were statistically significantly more disabled after mild TBI than were control patients without ADHD, even when controlling for age, sex, initial GCS score, hospital length of stay, length of follow-up, mechanism of injury, and presence of other (extracranial) injury.

CONCLUSIONS

Patients who sustain mild TBIs in the setting of a premorbid diagnosis of ADHD are more likely to be moderately disabled by the injury than are patients without ADHD.

Attention-deficit/hyperactivity disorder increased the risk of injury: a population-based follow-up study

AIM

To explore the frequency and risk for injury among children with Attention-deficit/hyperactivity Disorder (ADHD) in Taiwan through a population-based study.

METHODS

A total of 3616 subjects aged between four and twelve years diagnosed with ADHD were selected along with a comparison cohort comprising 18 080 subjects. Each subject was individually traced for a three-year period from their index date to identify those subjects who subsequently received a diagnosis of injury. We used stratified Cox proportional hazards regressions to examine the three-year injury-free survival rates between the two cohorts.

RESULTS

Of the subjects, the incidence rate of injury during the three-year follow-up period was 7.97 (95% CI = 7.45-8.51) and 5.36 (95% CI = 5.17-5.56) for the study and comparison cohort, respectively. After adjusting for geographic region, the hazard ratio (HR) of injury for subjects with ADHD was 1.64 (95% CI = 1.50-1.79) that of comparison subjects. In addition, we found children with ADHD aged between four and 6 years to demonstrate a greater HR (1.98, 95% CI = 1.72-2.28) than those aged between seven and twelve (HR = 1.46, 95% CI = 1.31-1.63).

CONCLUSIONS

Children with ADHD appear to be at a higher risk for injury than children that are not diagnosed with ADHD.

In utero exposure to ischemic-hypoxic conditions and attention-deficit/hyperactivity disorder

OBJECTIVE

To examine the association between ischemic-hypoxic conditions (IHCs) and attention-deficit/hyperactivity disorder (ADHD) by gestational age and race/ethnicity.

METHODS

Nested case-control study using the Kaiser Permanente Southern California (KPSC) medical records. The study cohort included children aged 5 to 11 years who were delivered and cared for in the KPSC between 1995 and 2010 (N = 308,634). Case children had a diagnosis of ADHD and received ≥ 2 prescriptions specific to ADHD during the follow-up period. For each case, 5 control children were matched by age at diagnosis. Exposures were defined by using International Classification of Diseases, Ninth Revision codes. A conditional regression model was used to estimate adjusted odds ratios (ORs).

RESULTS

Among eligible children, 13,613 (4.3%) had a diagnosis of ADHD. Compared with control children, case children were more likely to be male and of white or African American race/ethnicity. Case children were more likely to be exposed to IHCs (OR = 1.16, 95% confidence interval [CI] 1.11-1.21). When stratified by gestational age, cases born at 28 to 33, 34 to 36, and 37 to 42 weeks of gestation, were more likely to be exposed to IHCs (ORs, 1.6 [95% CI 1.2-2.1], 1.2 [95% CI 1.1-1.3], and 1.1 [95% CI 1.0-1.2], respectively) compared with controls. IHC was associated with increased odds of ADHD across all race/ethnicity groups.

CONCLUSIONS

These findings suggest that IHCs, especially birth asphyxia, respiratory distress syndrome, and preeclampsia, are independently associated with ADHD. This association was strongest in preterm births.

The relationship between childhood behaviour disorders and unintentional injury events

OBJECTIVE

To examine the controversy regarding the existence of a relationship between behavioural disorders and unintentional injuries in children.

DESIGN

A retrospective cohort analysis of children between six and 19 years of age, who were diagnosed with attention deficit hyperactivity disorder (ADHD) only (n=955), ADHD plus conduct problems (CP) (n=160), or CP only (n=234), were compared with a nondisorder group of children (n=21,308) for unintentional injury events resulting in a physician office or emergency room visit, or hospitalization.

RESULTS

The risk of an injury event was greater among children with a behaviour disorder diagnosis and severity of injury varied among the behaviour disorder groups. Children with ADHD were the only disorder group at increased risk for all three injury outcomes. Children with a comorbid diagnosis were at a greater risk for both minor and more serious emergency injury visits, and children with CP only were at greatest risk for the most serious injuries (hospital admission).

CONCLUSIONS

These findings provide further support that children with ADHD are at an increased risk for not only hospitalized injury events but also minor injury events. In addition, these findings provide evidence that serious injuries are more likely to be experienced by children with CP.

Treating attention-deficit/hyperactivity disorder beyond symptom control alone in children and adolescents: a review of the potential benefits of long-acting stimulants

Attention-deficit/hyperactivity disorder (ADHD), one of the most common neuropsychiatric conditions of childhood, often has a chronic course and persists into adulthood in many individuals. ADHD may have a clinically important impact on health-related quality of life in children, a significant impact on parents' emotional health and interfere with family activities/cohesion. To date, the main targets of ADHD treatment have focused on reducing the severity of symptoms during the school day and improving academic performance. However, the treatment of ADHD should reach beyond symptom control to address the issues of social competencies and improvement of health-related quality of life from the perspectives of individuals with ADHD and their families, to support them in reaching their full developmental potential. Methylphenidate (MPH) is recognised as the first-line choice of pharmacotherapy for ADHD in children and adolescents. This paper focuses on the importance and benefits to child development of ADHD symptom control beyond the school day only, i.e. extending into late afternoon and evening and uses the example of an extended-release MPH formulation (OROS((R)) MPH) to demonstrate the potential benefits of active full day coverage (12 h) with a single daily dose. Concerns of long-term stimulant treatment are also discussed.

Injury risk in young psychiatric outpatients: an 11-year follow-up of 302 adolescents

BACKGROUND

Studies investigating the association between injuries and mental health have mainly focused on mental health sequelae of injuries. The aim of this prospective cohort study was to assess the incidence and risk factors of physical injury hospitalisation and poisoning hospitalisation among adolescent psychiatric outpatients.

SUBJECTS AND METHODS

Data on 302 consecutively referred Finnish psychiatric outpatients aged 12-22 years (mean 16) were collected at treatment entry. The end-point of the average 11-year follow-up was death or end of follow-up on 31 December 2005. The main outcome variables were physical injury hospitalisation and poisoning hospitalisation.

RESULTS

Altogether 111 physical injury hospitalisations occurred in 65 (22% of all) persons during follow-up, incidence being 27.9 (95% CI: 22.7-33.1) per 1,000 person-years. Poisoning hospitalisation occurred in 22 (7.3%) persons, altogether 50 times, incidence being 12.6 (95% CI: 9.1-16.0). Seven injury-related deaths occurred, incidence being 1.8 (95% CI: 0.5-3.1) per 1,000 person-years. The most common physical injury types were fractures (40%), followed by distortions (10%) and wounds (10%), while poisoning for drugs accounted for 72% of the poisonings. Previous inpatient care, psychotropic medication, suicidality, and major depression were associated with poisoning hospitalisation during the follow-up while only gender was associated with physical injury hospitalisation.

CONCLUSION

Injuries cause significant morbidity among psychiatric outpatients, but only poisonings seem to be related with suicidality in Finnish adolescent psychiatric outpatients. The high frequency of injuries seems to justify clinicians' attention to these aspects when assessing the need for care among young people.

Is NICE infallible? A qualitative study of its assessment of treatments for attention-deficit/hyperactivity disorder (ADHD)

BACKGROUND

Conclusions of the recent NICE technology appraisal of treatments for attention-deficit/hyperactivity disorder (ADHD) differ from recommendations by other Health Technology Assessment (HTA) agencies, such as the Scottish Medicines Consortium (CMS) and the Australian Pharmaceutical Benefits Advisory Committee (PBAC). NICE did not identify differences on grounds of clinical effectiveness between treatment options studied and issued technology guidance based on clinical profiles of compounds and on drug acquisition costs. The aim of the present study was to explore the robustness of NICE assessment methods when addressing a complex clinical problem such as the evaluation of ADHD treatment strategies. This robustness will be of interest to international policy-makers, given the widespread perception of NICE as a role model for the implementation of HTAs including economic evaluation.

METHODS

A qualitative case study was performed to critically appraise the technology assessment report (AR) underlying NICE conclusions, including a systematic search for and analysis of relevant literature.

RESULTS

The AR produced on behalf of NICE was found to exhibit a range of anomalies. Search criteria were not applied consistently, and the available clinical evidence was not used optimally; selection of clinical endpoints and clinical trials for analysis were idiosyncratic. The primary cost-effectiveness model relied on six short-term studies only, and secondary extensions combined heterogeneous study designs and different clinical endpoints. Neither the distinction between efficacy and effectiveness nor the role of treatment compliance in ADHD was addressed adequately. Long-term extensions of the model were impaired by use of inappropriate discount rates and absence of consideration of long-term sequelae associated with ADHD.

CONCLUSION

A review of the literature strongly suggests that the NICE assessment of ADHD treatment strategies was incomplete and likely prone to bias. It is concluded that NICE did not adequately accommodate a complex clinical decision problem. Although the present qualitative case study of one assessment cannot, and was not designed to, invalidate the NICE approach to economic evaluation of healthcare programs, this observation may have potentially far-reaching implications for the generalizability of NICE-like approaches.

Trauma and Adult Attention Deficit Hyperactivity Disorder

This study investigated the relationship between adult attention deficit hyperactivity disorder (ADHD) and trauma. Fifty-eight adults admitted to hospital with musculoskeletal trauma were evaluated using scales that determine the presence of ADHD in childhood and adulthood. Each patient was also interviewed by an adult psychiatrist and a child and adolescent psychiatrist. The control group consisted of 30 adult patients with complaints other than trauma who did not have a history of repetitive traumas. There were 36 (62.2%) cases of ADHD in the patient group compared with four (13.3%) in the control group; this difference was statistically significant. When the level of trauma was evaluated, ADHD was identified in 23 of the 26 (88.5%) patients with high energy traumas compared with 14 of the 32 (43.8%) patients with low energy traumas; this difference was also statistically significant. This study shows that patients with adult ADHD are more prone to injuries, particularly high energy traumas such as motor vehicle accidents. Patients who have repeated high energy traumas should be evaluated by a psychiatrist for ADHD.

ADHD service use patterns in youth

OBJECTIVE

To review what is currently known about service use by youth with attention-deficit/hyperactivity disorder (ADHD) and discuss research and policy implications.

METHODS

Literature review.

RESULTS

The primary care, mental health, and educational service system sectors all play an essential role in caring for youth with ADHD. Recent studies also suggest increasing use of stimulants and other psychoactive medication for youth with ADHD, decreasing mental health visits for ADHD unassociated with medication use, increased use of other psychotropic medications, and a number of barriers to care coordination across primary care, mental health, and schools.

CONCLUSIONS

Four important services, research, and policy areas that need to be addressed over the next decade include: 1) delving deeper into current service use, 2) paying attention to the context in which service use occurs, 3) operationalizing evidence-based care for real-world settings, and 4) learning what changes clinician and educator behavior.

NICE accountability for reasonableness: a qualitative study of its appraisal of treatments for attention-deficit/hyperactivity disorder (ADHD)

OBJECTIVE

The UK National Institute for Health and Clinical Excellence (NICE) is widely regarded a role model for the implementation of Health Technology Assessments including cost-effectiveness evaluation. The aim of the present study was to explore the real-life robustness of the NICE technology appraisal process when addressing complex clinical problems, using the Accountability for Reasonableness (A4R) framework proposed by Daniels and Sabin as a reference.

METHOD

A qualitative case study of NICE Technology Appraisal No. 98, 'Treatments for Attention-Deficit/Hyperactivity Disorder (ADHD)', analyzing each step of the appraisal process.

RESULTS

Scoping was narrower than that for corresponding clinical guidelines. Economic evaluation for assessment was primarily based on six short-term studies, was unable to differentiate compounds on grounds of effectiveness, and cost-effectiveness modeling suggested a clear recommendation driven by acquisition costs. After appraisal, all treatment options assessed were recommended within their licensed indications. With estimated costs per quality-adjusted life years (QALYs) compared to no treatment generally falling below 7000 pounds, NICE guidance specified that choice of drug should be primarily based on clinical considerations, followed by cost.

CONCLUSION

The appraisal process adhered to predefined timelines, which were sensibly adapted by NICE to changes in the environment. A4R criteria most pertinent to the case study were 'publicity' and 'relevance'. The 'publicity' condition was greatly fulfilled, except for commercial-in-confidence data and economic model. 'Relevance' requires appraisals to reflect concerns for fairness and to be evidence-based; in that respect, principles and realization of the assessment deserve further scrutiny. Questions also remain regarding the 'appeal' and 'enforcement' conditions under A4R.

Identified attention-deficit/hyperactivity disorder and medically attended, nonfatal injuries: US school-age children, 1997-2002

OBJECTIVE

To determine the medically attended, nonfatal injury rate among children 6-17 years of age ever and never identified with attention-deficit/hyperactivity disorder (ADHD).

METHODS

An analysis was performed of parentally reported injury episodes during the past 3 months and current demographic characteristics of 3,741 sample children ever identified with ADHD and 48,243 never identified with ADHD in the 1997-2002 National Health Interview Surveys.

RESULTS

The annualized rate of injury was 204 episodes per 1,000 among children with ADHD compared with 115 episodes per 1,000 among children without ADHD. Injury episode rates were higher for children with ADHD regardless of age, sex, or health insurance. Logistic regression, which controlled for confounding risk factors, showed a robust association between ADHD and injury. The adjusted odds ratio (OR) for ADHD (OR(adj) = 1.83) was similar to the ORs for other important predictors of injury, such as male sex (OR(adj) = 1.45), older age (OR(adj) = 1.50), and private health insurance (OR(adj) = 1.44). Children with other health conditions had an increased odds for injury (OR(adj) = 1.51 for children with other developmental disorders and OR(adj) = 1.53 for children with physical disorders). Characteristics of injury episodes were generally similar for children with and without ADHD.

CONCLUSIONS

Results from a large, nationally representative sample indicate that children ever identified with ADHD were more likely to have a medically attended, nonfatal injury than children never identified with ADHD. The increased odds of injury among children with ADHD could not be attributed to other confounding risk factors. Children with ADHD may benefit from targeted injury prevention efforts.

Adolescents with attention deficit and hyperactivity disorder/learning disability and their proneness to accidents

OBJECTIVE

The aim of the study was to determine if attention deficit and hyperactivity disorder (ADHD)/ learning disability (LD) adolescents are more prone to accidents and to investigate the parental mode of coping with that risk.

METHODS

One hundred and eight high school pupils diagnosed with ADHD/LD and studying in an institute of "special education" were examined and interviewed on the subject of accidents. Eighty-seven pupils, studying in a nearby academic high school, served as a control group.

RESULTS

The results showed that pupils in the study group had been involved in 0.57 +/- 1.6 accidents (until the present study) in comparison to 0.23 +/- 0.4 accidents in the control group (p=0.001). The accidents in the ADHD/LD study group had occurred at the mean age of 11.1 +/- 3.4 yr. Eight decimal three percent of these pupils had been involved in recurrent accidents. Circumstances and locations where the accidents occurred were: falls while running or participating in sports activities (38.5%), home environment (23%), school environment (19.2%) and road accidents (11.5%).

CONCLUSION

The study shows that there is a real risk for ADHD/LD adolescents to be involved in all kinds of accidents. Parents should be counting on the help of professional advisors to decrease that risk. Physicians should caution these adolescents and their parents about that risk and advise them on ways and means of accident prevention.