Exploring parental country of birth differences in the use of psychostimulant medications for ADHD: a whole-population linked data study

Geographic variation and sociodemographic correlates of prescription psychotropic drug use among children and youth in Ontario, Canada: a population-based study

BACKGROUND

Population-based research examining geographic variability in psychotropic medication dispensing to children and youth and the sociodemographic correlates of such variation is lacking. Variation in psychotropic use could reflect disparities in access to non-pharmacologic interventions and identify potentially concerning use patterns.

METHODS

We conducted a population-based study of all Ontario residents aged 0 to 24 years who were dispensed a benzodiazepine, stimulant, antipsychotic or antidepressant between January 1, 2018, and December 31, 2018. We conducted small-area variation analyses and identified determinants of dispensing using negative binomial generalized estimating equation models.

RESULTS

The age- and sex-standardized rate of psychotropic dispensing to children and youth was 76.8 (range 41.7 to 144.4) prescriptions per 1000 population, with large variation in psychotropic dispensing across Ontario's census divisions. Males had higher antipsychotic [rate ratio (RR) 1.40; 95% confidence interval (CI) 1.36 to 1.44) and stimulant (RR 1.75; 95% CI 1.70 to 1.80) dispensing rates relative to females, with less use of benzodiazepines (RR 0.85; 95% CI 0.83 to 0.88) and antidepressants (RR 0.81; 95% CI 0.80 to 0.82). Lower antipsychotic dispensing was observed in the highest income neighbourhoods (RR 0.72; 95% CI 0.70 to 0.75) relative to the lowest. Benzodiazepine (RR 1.12; 95% CI 1.01 to 1.24) and stimulant (RR 1.11; 95% CI 1.01 to 1.23) dispensing increased with the density of mental health services in census divisions, whereas antipsychotic use decreased (RR 0.82; 95% CI 0.73 to 0.91). The regional density of child and adolescent psychiatrists and developmental pediatricians (RR 1.00; 95% CI 0.99 to 1.01) was not associated with psychotropic dispensing.

CONCLUSION

We found significant variation in psychotropic dispensing among young Ontarians. Targeted investment in regions with long wait times for publicly-funded non-pharmacological interventions and novel collaborative service models may minimize variability and promote best practices in using psychotropics among children and youth.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm

PURPOSE

Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments.

METHODS

A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS.

RESULTS

Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85).

CONCLUSION

Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.

Attention deficit hyperactivity disorder in first- and second-generation immigrant children and adolescents: A nationwide cohort study in Sweden

BACKGROUND

Studies on the incidence of Attention Deficit Hyperactivity Disorder (ADHD) among immigrant children and adolescents is limited and results are mixed. The aim of this study was to compare the ADHD risk between first- and second-generation immigrants aged 4-16 years and their native peers in Sweden.

METHODS

This was an open nationwide retrospective cohort study. We included 1,902,526 native and 805,450 children and adolescents with an immigrant background, born 1987-2010, and aged 4-16 years at baseline. We identified participants using national population data and participants were observed until they received an ADHD diagnosis in the National Patient Register, turned 18 years, migrated, died, or until the end of the study, whichever came first. ADHD risks were adjusted for birth year and age and maternal income at baseline.

RESULTS

For both males and females, the ADHD risk was lower among most immigrant groups. However, the combination of a Swedish-born mother and foreign-born father was associated with an increased risk of ADHD. The ADHD risk varied substantially between immigrants from different regions of the world. For example, immigrants from other Scandinavian countries, North America, and Latin America and the Caribbean had higher rates of ADHD compared with natives.

CONCLUSIONS

Future research should examine the underlying factors behind the differences in ADHD risks between certain immigrant subgroups and natives, such as family structure, cultural and language barriers and potential differences in health care utilization among immigrant families.

Clinical correlates of socioeconomic status in adolescent bipolar disorder

BACKGROUND

Lower socioeconomic status (SES) is associated with symptomatic severity, comorbidity, and functional impairment in adults with bipolar disorder (BD). Little is known about clinical correlates of SES in adolescents with BD.

METHODS

Participants included 195 adolescents, 13-20 years old, with BD type I, II or not otherwise specified (NOS). Diagnoses were determined by standardized semi-structured interviews. Based on the Hollingshead scale, participants were divided into "low" (SES 1-3) and the "high" (SES 4-5) SES groups. Demographic and clinical correlates of SES were evaluated in univariate analyses; significant variables were evaluated in a logistic regression model.

RESULTS

Compared to participants in the high SES group (n = 150), participants in the low SES group (n = 45) were significantly younger, less likely to be of Caucasian race and living with natural parents. In the logistic regression model, controlling for age and race, the low SES group had higher risk of police contact or arrest (OR = 2.41, 95% CI:1.14-5.11, p = 0.022), less treatment with stimulants(OR = 0.20 95% CI: 0.06-0.67, p = 0.009), and more post-traumatic stress disorder (PTSD) (OR = 4.08, 95% CI:1.33-12.46, p = 0.014) compared to the high SES group. In sensitivity analyses that further controlled for intact family, the finding of higher rates of police contact or arrest was no longer significant.

LIMITATIONS

Cross-sectional design; higher-skewed SES sample.

CONCLUSIONS

Lower SES in adolescent BD is associated with higher legal risk, increased PTSD, and under-treatment of attention-deficit/hyperactivity disorder (ADHD). Future studies are needed to evaluate the inter-relationships of these correlates, using prospective designs that can evaluate the direction of these associations. Further studies incorporating neurobiological markers are also needed to explore mechanisms underlying SES-related differences in BD.

Neighborhood Socioeconomic Characteristics and Utilization of ADHD Medication in Schoolchildren: A Population Multilevel Study in Stockholm County

Objective: To examine the effects of neighborhood socioeconomic disadvantage and ethnic composition on the utilization of ADHD medication in schoolchildren after accounting for individual- and family-level characteristics. Method: A cohort of all schoolchildren living in Stockholm County was prospectively followed for new prescriptions of ADHD medication (N = 276,955). Three-level logistic regression models were used with individual/family characteristics (e.g., immigrant background) at the first level and small area market statistics (SAMS) and municipality characteristics (i.e., socioeconomic disadvantage and ethnic composition) at the second and third level. Results: SAMS socioeconomic disadvantage was associated with increased utilization of ADHD medication. The utilization of ADHD medication was lower among immigrant children as compared with natives, and their odds of not utilizing medication increased as the degree of concentration of foreign-born increased. Conclusion: These results suggest that interventions at the neighborhood level may offer an additional route for the prevention of the disorder and/or alleviation of its consequences.

ADHD medication in offspring of immigrants - does the income level of the country of parental origin matter?

BACKGROUND

Child psychiatric treatment facilities vary greatly worldwide and are virtually non-existent in many low-income countries. One of the most common psychiatric disorders in childhood is ADHD, with an estimated prevalence of 3-5% in Sweden. Previous studies have shown a similar prevalence of ADHD in minority and majority children in Sweden and the UK. However, clinical studies demonstrated that children from immigrant families living in Sweden received less psychiatric care than those of native-born parents. We tested the hypothesis that the consumption of child psychiatric care in immigrant families would be determined by the availability of such treatment in the parents' country of origin. Patterns of medication for attention-deficit hyperactivity disorder (ADHD) were studied as a proxy for child psychiatric care.

METHODS

This was a register study of dispensed stimulant medication during 2013-2014 in Swedish national birth cohorts from 1995-2009. The study population, consisting of nearly 1.4 million children, was divided by national income of the parental country of origin and whether the parents were native Swedes, European immigrants, non-European immigrants or a mixture. Logistic regression was used to calculate the odds ratios of having been dispensed at least one ADHD drug during 2013, with adjustments for gender, family status indicating whether the child is living with both parents, household income and area of residence.

RESULTS

Having parents born in low-income (OR [95% confidence interval] 0.27 [0.24-0.29]) or middle-income (European: OR 0.23 [0.20-0.26], non-European: OR 0.39 [0.34-0.41]) countries was associated with lower ADHD treatment levels than having parents born in high-income countries (European: OR 0.60 [0.54-0.66], non-European: OR 0.68 [0.59-0.79]), when compared to children of parents born in Sweden. In families with a background in low or middle income countries, there was no significant association between household income and ADHD medication, while in children with Swedish and mixed backgrounds high level of disposable income was associated with lower levels of ADHD medication.

CONCLUSION

The use of child psychiatric care by immigrant families in Sweden was largely associated with the income level of the country of origin.

How evolutionary thinking can help us to understand ADHD

We argue that current debates about attention-deficit hyperactivity disorder (ADHD) can be considered afresh using an evolutionary lens. We show how the symptoms of ADHD can often be considered adaptive to their specific environment. We suggest that, from an evolutionary point of view, ADHD symptoms might be understood to result from an ‘evolutionary mismatch’, in which current environmental demands do not fit with what evolution has prepared us to cope with. For example, in our ancestral environment of evolutionary adaptedness (EEA), children were not expected to sit still and concentrate on academic tasks for many hours a day. Understanding ADHD in terms of such a ‘mismatch’ raises significant issues regarding the management of childhood ADHD, including ethical ones. An approach based on the concept of mismatch could provide an alternative to current debates on whether ADHD results from nature or nurture and whether it is under- or over-diagnosed. It would allow clinicians and policy makers to take both the child and the environment into account and consider what might be desirable and feasible, both in society and for specific children, to lessen the mismatch.

LEARNING OBJECTIVES

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Identifying cross-cultural variations in psychostimulant use for attention deficit hyperactivity disorder using linked data

BACKGROUND

To validate the association between country-of-birth and disparities in the stimulant use for ADHD among individuals in Western Australia.

METHODS

Using linked data, a population-based retrospective cohort of individuals admitted to hospital before age 25 years was followed through to identify having stimulants for ADHD in 2003-2007. Multivariate logistic and linear regressions were used to characterise associations between stimulants and country-of-birth, geographical remoteness and socioeconomic status.

RESULTS

Of 679,645 individuals, 14,122 (2.1%) had a record of having stimulants for ADHD. Of these, 205 (1.5%) were born in Africa, Asia, Middle-East or South America, while 13,664 (96.8%) were born in Australia/New Zealand, Europe or North America. Individuals with traditionally non-Anglophonic backgrounds were around one-half as likely to have stimulants as individuals with Anglophonic backgrounds (OR = 0.53, 95% CI 0.46-0.61, p < 0.001). Non-Anglophones were an average of 2.7 years older than Anglophones at onset of having stimulants. Individuals from remote and disadvantaged backgrounds had stimulants at younger ages than individuals living in metropolitan areas and with least disadvantage.

CONCLUSIONS

The results highlight the importance of identifying factors underlying cultural differences in stimulant treatment for ADHD. Improving awareness of cultural variations may foster trust and rapport between patients and clinicians, and so better facilitate the appropriate and effective treatment of ADHD for each patient.

Use of prescription stimulant for Attention Deficit Hyperactivity Disorder in Aboriginal children and adolescents: a linked data cohort study

BACKGROUND

Increasing recognition of Attention Deficit Hyperactivity Disorder (ADHD) among Aboriginal children, adolescents and young adults is a public health challenge. We investigated the pattern of prescription stimulants for ADHD among Aboriginal individuals in Western Australia (WA).

METHODS

Using a whole-population-based linked data we followed a cohort of individuals born in WA from 1980-2005, and their parents were born in Australia, to identify stimulant prescription for ADHD derived from statutory WA stimulant prescription dispensing between 2003 and 2007. Parental link was ascertained through WA Family Connections Genealogical Linkage System. Cox proportional hazards regression (HR) models were performed to determine the association between stimulant use and Aboriginal and non-Aboriginal status.

RESULTS

Of the total cohort of 186,468, around 2% (n = 3677) had prescription stimulants for ADHD. Individuals with both Aboriginal parents were two-thirds (HR 0.33, 95 % CI 0.26-0.42), and with only Aboriginal mother were one-third (HR 0.69, 95% CI 0.53-0.90) less likely to have stimulants, compared to individuals with non-Aboriginal parents. HR in Aboriginals was 62% lower (HR 0.35, 95% CI 0.25-0.49) in metropolitan areas, and 72% lower (HR 0.28, 95% CI 0.20-0.38) in non-metropolitan areas, than non-Aboriginals. The risk for simulant use was four times higher among Aboriginal boys than Aboriginal girls (HR 4.08, 95% CI, 2.92-5.69).

CONCLUSION

Aboriginal cultural understanding of ADHD and attitude towards stimulant medication serve as a determinant of their access to health services. Any ADHD intervention and policy framework must take into account a holistic approach to Aboriginal culture, beliefs and individual experience to provide optimal care they need.

What's more general than a whole population?

Statistical inference is commonly said to be inapplicable to complete population studies, such as censuses, due to the absence of sampling variability. Nevertheless, in recent years, studies of whole populations, e.g., all cases of a certain cancer in a given country, have become more common, and often report p values and confidence intervals regardless of such concerns. With reference to the social science literature, the current paper explores the circumstances under which statistical inference can be meaningful for such studies. It concludes that its use implicitly requires a target population which is wider than the whole population studied - for example future cases, or a supranational geographic region - and that the validity of such statistical analysis depends on the generalizability of the whole to the target population.