Evidence of Low Adherence to Stimulant Medication Among Children and Youths With ADHD: An Electronic Health Records Study

Two single arm trials of AKL-T01, a digital therapeutic for adolescents and adults with ADHD

Inattention symptoms represent a key driver of functional impairment in ADHD and often persist into adolescence and adulthood, underscoring a need for novel treatments targeting attentional control. We evaluated AKL-T01-a digital therapeutic that is FDA-cleared for children 8-12 y with ADHD-in adolescents and adults with ADHD in two independent single-arm trials: STARS-ADHD-Adolescent, a 4-week trial in adolescents 13-17 y (n = 162 enrolled), and STARS-ADHD-Adult, a 6-week trial in adults 18 and older (n = 221 enrolled). AKL-T01 was linked with improvements on the Test of Variables of Attention (TOVA®) Attention Comparison Score (ACS) of 2.6 (95% CI: 2.02, 3.26; p < 0.0001) in adolescents and 6.5 in adults (95% CI: 5.35, 7.57; p < 0.0001), along with improvements in secondary endpoints. 15 participants reported adverse device effects, all mild or moderate. Though limited by a single-arm design, results provide preliminary support for the safety and efficacy of AKL-T01 for adolescents and adults with ADHD.

Short- and Long-Term Outcomes of Suboptimal Medication Adherence in Adolescents with Attention-Deficit/Hyperactivity Disorder: A Systematic Literature Review

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition with severe and life-long consequences. Adolescents and young adults represent a particularly vulnerable subgroup because of the unique demands of their developmental stage. Despite the well-known efficacy of medication treatment for ADHD, there remains a notable concern regarding poor medication adherence in this population. Objectives: This systematic literature review aimed to synthesize the existing empirical evidence on the outcomes and consequences of medication nonadherence among adolescents and young adults with ADHD. Methods: An extensive database search was conducted on September 26, 2022, with no time limits applied. The databases included Scopus, PubMed, CINAHL, Cochrane, and PsycINFO. Results: Six studies met the inclusion criteria. Each study revealed that medication nonadherence was associated with a range of adverse outcomes, including decreased academic performance, heightened familial, and psychological stress, and an increased likelihood of substance use, pregnancy, obesity, and injury. Conversely, adherence led to improvements in at least one ADHD-related outcome. Conclusions: Research exploring the consequences of suboptimal medication adherence in adolescents and young adults with ADHD is currently limited, and effective strategies to address this issue remain scarce. A thorough understanding of such consequences is critical for developing interventions aimed at improving medication adherence and mitigating the risk of adverse outcomes, especially considering the susceptibility of this population.

Change in Adolescents' Perceived ADHD Symptoms Across 17 Days of Ecological Momentary Assessment

OBJECTIVE

To test whether adolescents' perceived ADHD symptoms may improve while monitoring them throughout the day.

METHOD

In a sample of 90 adolescents (Mage = 14.7; 66% boys, 34% girls; 76.7% White, 13.3% Black or African American, 8.9% more than one race, 1.1% "other") treated for ADHD by their pediatricians, this study examined: (1) whether self-rated ADHD symptoms decreased across 17 days of 4 times daily ecological momentary assessment (EMA) of symptoms and (2) whether completing versus missing an EMA survey was associated with lower self-rated ADHD symptoms in the subsequent hours.

RESULTS

Multilevel regression analyses showed that, on average, adolescents' perceived ADHD symptoms (inattention, hyperactivity, impulsivity, and total across domains) decreased across 17 days of EMA. Within person, symptoms were lower following completed versus missed EMA surveys. Significant moderating effects showed that the effect of completing the prior EMA survey weakened across the day and over the course of the 17 days.

CONCLUSIONS

This study is the first to document acute improvements in self-rated ADHD symptoms using EMA in adolescents' naturalistic environments. Symptom monitoring throughout the day may help adolescents improve their day-to-day ADHD, at least acutely, and holds promise as one component of mobile-health ADHD interventions.

One year follow-up of participants in a randomised controlled trial of a CBT-based group therapy programme for adolescents diagnosed with ADHD

BACKGROUND

Adolescents with ADHD often struggle on many areas of their lives and have a high risk of adverse outcomes and negative life trajectories. Multimodal treatment including psychosocial interventions is recommended but evidence regarding effect of such interventions is still limited.

MATERIALS AND METHODS

This study was a follow-up study of adolescents participating in a randomised controlled trial (RCT) of a group intervention based on cognitive behavioural therapy (CBT). Participants were adolescents diagnosed with ADHD and still impaired by their symptoms after standard treatment including psychoeducation and medication. All participants were interviewed by telephone one year after inclusion, and outcome measures included both quantitative and qualitative measures.

RESULTS

There were 100 adolescents included in the study. We found no significant differences between treatment and control group on measures of ADHD-symptoms, self-efficacy, overall problems, global psychosocial functioning, or symptom severity at one-year follow-up. Still, participants in the intervention group reported on positive gains and that they learned a lot about ADHD and themselves.

CONCLUSIONS

The intervention delivered in this trial failed to show a treatment effect on symptom level when added to standard care. Participants did however report on positive gains and felt they learned a lot. More research is needed to explore how the programme and delivery of treatment might be improved, and which patients might benefit the most from this type of interventions.

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.

Treatment Adherence and Related Factors Among Children with Attention-Deficit/Hyperactivity Disorder in Saudi Arabia

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood psychiatric disorder. It frequently persists into adulthood and is a risk factor for other mental disorders and adverse outcomes, mainly if not managed optimally. This study aimed to assess ADHD treatment adherence and explore the underlying causes of non-adherence in ADHD children in Saudi Arabia.

Methods

A cross-sectional study of a convenience sample of 221 participants. The survey included demographic characteristics of the child and parents, the child's medical history, quality of services evaluation, as well as medication adherence assessment by Medication Adherence Report Scale (MARS), the general beliefs about medicines questionnaire (General-BMQ), in addition to assessing the parents' beliefs about ADHD and provided/recommended treatment.

Results

The sample was primarily 6 to 8-year-old children (32.81%) and males (78.52%). Most subjects were prescribed extended-release agents (45.7%), and overall, high-quality services were provided to the patients. The adherence rate of ADHD patients to their medication was 89.77%. The mother's education correlated significantly with patient adherence (p=0.029), and the mother's age correlated significantly with their beliefs (p=0.021), in addition to the family income (0.033). Children on Methylphenidate Immediate Release had good compliance with the medication (p=0.008). Moreover, Methylphenidate Extended Release has shown continuity results, increasing the adherence rates (p=0.035).

Conclusion

ADHD medication adherence was high and associated with older age, educational status, and type of medication used. Physicians should consider these factors to improve adherence in their patients.

ADHD medication discontinuation and persistence across the lifespan: a retrospective observational study using population-based databases

BACKGROUND

Although often intended for long-term treatment, discontinuation of medication for ADHD is common. However, cross-national estimates of discontinuation are missing due to the absence of standardised measures. The aim of this study was to determine the rate of ADHD treatment discontinuation across the lifespan and to describe similarities and differences across countries to guide clinical practice.

METHODS

We did a retrospective, observational study using population-based databases from eight countries and one Special Administrative Region (Australia, Denmark, Hong Kong, Iceland, the Netherlands, Norway, Sweden, the UK, and the USA). We used a common analytical protocol approach and extracted prescription data to identify new users of ADHD medication. Eligible individuals were aged 3 years or older who had initiated ADHD medication between 2010 and 2020. We estimated treatment discontinuation and persistence in the 5 years after treatment initiation, stratified by age at initiation (children [age 4-11 years], adolescents [age 12-17 years], young adults [age 18-24 years], and adults [age ≥25 years]) and sex. Ethnicity data were not available.

FINDINGS

1 229 972 individuals (735 503 [60%] males, 494 469 females [40%]; median age 8-21 years) were included in the study. Across countries, treatment discontinuation 1-5 years after initiation was lowest in children, and highest in young adults and adolescents. Within 1 year of initiation, 65% (95% CI 60-70) of children, 47% (43-51) of adolescents, 39% (36-42) of young adults, and 48% (44-52) of adults remained on treatment. The proportion of patients discontinuing was highest between age 18 and 19 years. Treatment persistence for up to 5 years was higher across countries when accounting for reinitiation of medication; at 5 years of follow-up, 50-60% of children and 30-40% of adolescents and adults were covered by treatment in most countries. Patterns were similar across sex.

INTERPRETATION

Early medication discontinuation is prevalent in ADHD treatment, particularly among young adults. Although reinitiation of medication is common, treatment persistence in adolescents and young adults is lower than expected based on previous estimates of ADHD symptom persistence in these age groups. This study highlights the scope of medication treatment discontinuation and persistence in ADHD across the lifespan and provides new knowledge about long-term ADHD medication use.

FUNDING

European Union Horizon 2020 Research and Innovation Programme.

Memory performance on the ChAMP in autism spectrum disorder with and without attention-deficit/hyperactivity disorder

Memory difficulties have been identified in youth with neurodevelopmental conditions including autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). The Child and Adolescent Memory Profile (ChAMP) is a newer memory measure with a burgeoning research base. This study seeks to explore memory performance on the Lists and Objects subtests of the ChAMP in a clinical sample of those with ASD with/without co-occurring ADHD. Participants were 146 youth referred for a neuropsychological evaluation (M age = 11.8 years; 76.03% male) diagnosed with ASD (N = 92 with ADHD, N = 54 without). Logistic regression (p = .393) indicated ChAMP performance is not predictive of whether the ASD group had co-occurring ADHD indicating there is no additive effect on memory. Compared to the ChAMP examiner's manual ASD sample, this study sample performed significantly better (p <.001) on all ChAMP measures. While the ChAMP is sensitive to memory difficulties in neurodevelopmental disorders, as indicated by the performance of the manual sample, the ASD sample of the manual may differ from other ASD samples. There were no differences between verbal and visual memory performance across the present study's sample.

A novel intervention for treating adults with ADHD using peripheral visual stimulation

Objective

Stimulation of the peripheral visual field has been previously reported as beneficial for cognitive performance in ADHD. This study assesses the safety and efficacy of a novel intervention involving peripheral visual stimuli in managing attention deficit hyperactivity disorder (ADHD).

Methods

One hundred and eight adults, 18-40 years old, with ADHD, were enrolled in a two-month open-label study. The intervention (i.e., Neuro-glasses) consisted of standard eyeglasses with personalized peripheral visual stimuli embedded on the lenses. Participants were assessed at baseline and at the end of the study with self-report measures of ADHD symptoms (the Adult ADHD Self-Report Scale; ASRS), and executive functions (The Behavior Rating Inventory of Executive Function Adult Version; BRIEF-A). A computerized test of continuous performance (The Conners' Continuous Performance Test-3; CPT-3) was tested at baseline with standard eyeglasses and at the end of study using Neuro-glasses. The Clinical Global Impression-Improvement scale (CGI-I) was assessed at the intervention endpoint. Safety was monitored by documentation of adverse events.

Results

The efficacy analysis included 97 participants. Significant improvements were demonstrated in self-reported measures of inattentive symptoms (ASRS inattentive index; p = 0.037) and metacognitive functions concerning self-management and performance monitoring (BRIEF-A; p = 0.029). A continuous-performance test (CPT-3) indicated significant improvement in detectability (d'; p = 0.027) and reduced commission errors (p = 0.004), suggesting that the Neuro-glasses have positive effects on response inhibition. Sixty-two percent of the participants met the response criteria assessed by a clinician (CGI-I). No major adverse events were reported.

Conclusion

Neuro-glasses may offer a safe and effective approach to managing adult ADHD. Results encourage future controlled efficacy studies to confirm current findings in adults and possibly children with ADHD.Clinical trial registration: https://www.clinicaltrials.gov/, Identifier NCT05777785.

Efficacy of non-pharmacological interventions on executive functions in children and adolescents with ADHD: A systematic review and meta-analysis

OBJECTIVE

Although front-line doctors recommend medications, this kind of treatment has limited efficacy in improving executive functions (EFs) in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). This study explored the effects of non-pharmacological intervention on EFs in children and adolescents with ADHD.

METHODS

In accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines, we searched seven electronic databases: APA PsycINFO, CINAHL Complete, EMBASE, ERIC, Medline, Pubmed, and Web of Science, from inception to March 2022. Two authors independently screened studies for eligibility, extracted data, and assessed bias risk using the Physiotherapy Evidence Database scale. Our analyses included randomized controlled trials and non-randomized comparison studies of non-pharmacological interventions and assessed EFs through neurocognitive tasks in children and adolescents between 5 and 18 years.

RESULTS

Sixty-seven studies with 3147 participants met the inclusion criteria. The final meta-analysis included 74 independent interventions categorized into six categories: cognitive training, EF-specific curriculum, game-based training, mindfulness practice, neurofeedback training, and physical exercise. Overall, non-pharmacological interventions (combined) produced significant moderate to large effects on overall EFs in children and adolescents with ADHD (g=0.673). Physical exercise had a large positive effect on domain-specific EFs, including inhibitory control (g=0.900) and cognitive flexibility (g=1.377). Cognitive training had a large training effect on working memory (g=0.907), and an EF-specific curriculum had a small to moderate beneficial effect on planning performance (g=0.532).

CONCLUSION

Non-pharmacological interventions, particularly physical exercise, cognitive training, and an EF-specific curriculum, appear to have beneficial effects on EFs in children and adolescents with ADHD.

Social difficulties in adolescent attention deficit hyperactivity disorder: Social motivation, social anxiety and symptom severity as contributing factors

BACKGROUND

Many interventions have been developed to address the social difficulties commonly experienced by adolescents with attention-deficit/hyperactivity disorder (ADHD), yet they are largely ineffective.

OBJECTIVE

This study examined social impairment among adolescents with and without ADHD, determining whether gender, social anxiety, age, and ADHD symptom type (inattention and hyperactivity/impulsivity) and severity are associated with social impairment.

METHOD

Parents and primary caregivers of adolescents (aged 13-17) with (n = 76) and without ADHD (n = 36) completed the Strengths and Weaknesses of ADHD and Normal Behavior, Social Responsiveness Scale 2nd Edition, and Spence Children's Anxiety Scale.

RESULTS

Adolescents with ADHD scored significantly higher than TD adolescents across social impairment domains. ADHD symptoms were associated with severity of impairment in all domains excluding Social Motivation. Hyperactivity/impulsivity and social anxiety predicted social impairment, whereas gender did not.

CONCLUSION

Adolescents with ADHD are more likely to experience social impairment than TD adolescents, and interventions targeting symptom reduction and social anxiety may improve these social impairments.

Development of an electronic medical record provider evaluation template for children with attention deficit hyperactivity disorder

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral condition in children. Current guidelines recommend that Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) criteria be met before diagnosing ADHD. However, 14-49% of providers are not documenting the use of DSM-V criteria in screening and diagnosis. The use of a standardized electronic health record (EHR) ADHD template is a potential option to assist providers with documenting the DSM-V criteria. The aim for this project was to provide a 1-hour educational in-service on the use of the DSM-V criteria, Vanderbilt rating scale, and a revised EHR ADHD template, and to assess provider use pre and post intervention. Results showed that few providers (n = 1; 2%) document using DSM-V criteria preintervention and post intervention with only a modest increase in template use (n = 3; 5%). However, there were statistical differences between provider type with advanced practice registered nurses and physician assistants screening more frequently using the EHR DSM-V ADHD template compared with physicians (p = .009). Future studies are needed to evaluate barriers to use, including practice preference, openness to change, and other factors that may affect provider workflow.

Open assessment of the therapeutic and rate-dependent effects of brain balance center® and interactive metronome® exercises on children with attention deficit hyperactivity disorder

The aim of this open study was to delineate domains of benefit and effect size measures to design an appropriately powered randomized control trial to assess the efficacy of Brain Balance^@ exercises and Interactive Metronome^@ training (BB/IM) on ADHD symptoms in children. Participants underwent an extensive 15-week, 5 time per week, at-home training program. Results were assessed in 16 youths with ADHD (14M/2F, 10.8±1.7 years) who completed the program and compared to 8 typically developing controls (4M/F4, 11.0±1.8 years). BB/IM was associated with a significant reduction of 8.3 and 8.2 points on the Conner's Parent Rating Scale - Revised and the ADHD Rating Scale - IV. BB/IM was not associated with improvement on the Quotient ADHD System but with rate-dependent effects on hyperactivity and attention that were similar to previously reported effects of low dose methylphenidate. Both therapeutic and rate-dependent effects were observed on the Tower of London. The study provides information that could be used to design a randomized control trial, which is required for proof of efficacy. A key limitation is that 59% of the 39 enrolled participants with ADHD dropped out of the study and a new study should include multiple ratings during the course of treatment.

Making Evidence-Based Knowledge Accessible to Parents to Promote Child Mental Health Care

Parenting is often described as one of the most complicated life challenges, and the complexity increases in the presence of child developmental and/or mental health conditions. In the field of child psychiatry, parental psychoeducation-including guidance, support, and skill building-is an integral part of treatment that improves both the child patient's wellbeing and the quality of life of the family. Parents are the primary agent of care delivery for the child patient, which means that parental beliefs, attitudes, and knowledge about mental health care fundamentally influence service use and treatment adherence. Parents' and caregivers' access to accurate and up-to-date information regarding child development and mental health conditions can be critical in helping families optimize their use of mental health services, feel more confident in managing their child's symptoms, and make informed decisions about treatment strategies, which ultimately improve mental health outcomes in children.1.

Treatment patterns among children and adolescents with attention-deficit/hyperactivity disorder in the United States - a retrospective claims analysis

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder affecting approximately 10.0% of children and 6.5% of adolescents in the United States (US). A comprehensive assessment of the current treatment landscape is warranted to highlight potential unmet needs of children and adolescents with ADHD. Therefore, this study described treatment patterns and healthcare costs among commercially insured children and adolescents with ADHD in the US.

METHODS

Children and adolescents with ADHD initiating pharmacological treatment indicated for ADHD were identified from IBM MarketScan Commercial Database (2014-2018). A treatment sequence algorithm was used to examine treatment patterns, including discontinuation (≥ 180 days following the last day of supply of any ADHD treatment), switch, add-on, and drop (discontinuation of an agent in combination therapy), during the 12-month study period following the index date (i.e., first observed ADHD treatment). Total adjusted annual healthcare costs were compared between patients with and without treatment changes.

RESULTS

Among 49,756 children and 29,093 adolescents included, mean age was 9 and 15 years, respectively, and 31% and 38% were female. As the first treatment regimen observed, 92% of both children and adolescents initiated a stimulant and 11% initiated combination therapy. Over half of the population had a treatment change over 12 months-59% of children and 68% of adolescents. Treatment discontinuation over 12 months was common in both populations-21% of children and 36% of adolescents discontinued treatment. Healthcare costs increased with the number of treatment changes observed; children and adolescents with treatment changes (i.e., 1, 2, or ≥ 3) incurred an incremental annual cost of up to $1,443 and $2,705, respectively, compared to those without a treatment change (p < 0.001). Costs were largely driven by outpatient visits.

CONCLUSIONS

Over a 12-month period, treatment changes were commonly observed and were associated with excess costs, highlighting the unmet treatment needs of children and adolescents with ADHD in the US.

Cognitive behavioural group therapy for adolescents with ADHD: a study of satisfaction and feasibility

BACKGROUND

Adolescents with ADHD are at increased risk of adverse outcomes and a negative life trajectory into adulthood. Evidence regarding treatment specifically tailored for the needs of this age group are still limited. High dropout rates, discontinuation of medication and treatment resistance are common issues in this population, and the patient perspective on new treatment options is therefore important. In this study, we aimed to investigate treatment satisfaction and feasibility of a group CBT program for adolescents with ADHD. We further aimed to identify any baseline characteristics predicting satisfaction.

MATERIALS AND METHODS

This study was part of a larger RCT of group CBT as add-on treatment for adolescents aged 14-18 years (Mean age 15.9 years, SD 1.3) with ADHD in Norway. Satisfaction and feasibility in the treatment group (n = 48) were measured by completion of an evaluation questionnaire, attendance of group sessions and a group-leaders checklist. Predictors of satisfaction were analysed using linear regression.

RESULTS

Overall satisfaction was very high with a significant age effect, the eldest participants being most satisfied. Attendance rate was high with few dropouts and medical adherence during the treatment period was good. Group-leaders generally self-evaluated adherence to treatment manual positively but addressing resistance towards homework as challenging.

CONCLUSIONS

The participants were very satisfied with the group CBT treatment. Treatment options that are accepted and well-liked by the targeted population have the potential of reducing resistance towards treatment, improving future health and adherence to medication. The program is considered suitable for a clinical setting and may represent a feasible treatment supplement for adolescent ADHD.

Predictors of Treatment Engagement and Outcome Among Adolescents With Attention-Deficit/Hyperactivity Disorder: An Integrative Data Analysis

OBJECTIVE

To identify patient- and treatment-level factors that predict intervention engagement and outcome for adolescents with attention-deficit/hyperactivity disorder (ADHD), guiding efforts to enhance care.

METHOD

Integrative data analysis was used to pool data from 4 randomized controlled trials of adolescent ADHD treatment with participants (N = 854) receiving various evidence-based behavioral therapy packages in 5 treatment arms (standard [STANDARD], comprehensive [COMP], engagement-focused [ENGAGE]), community-based usual care (UC), or no treatment (NOTX). Participants also displayed varying medication use patterns (negligible, inconsistent, consistent) during the trial. Regression and latent growth curve analyses examined treatment- and patient-level predictors of engagement and outcome.

RESULTS

Compared with COMP, ENGAGE was associated with higher parent engagement in behavioral therapy (d = 1.35-1.73) when delivered in university, but not community, clinics. Under some conditions, ENGAGE also predicted youth engagement in behavioral therapy (d = 1.21) and lower likelihood of negligible medication use (odds ratio = 0.49 compared with NOTX). UC was associated with poorer parent engagement compared with COMP (d = -0.59) and negligible medication use (odds ratio = 2.29) compared with NOTX. Compared with COMP, ENGAGE (in university settings) was consistently associated with larger ADHD symptom improvements (d = 0.41-0.83) at 6-month follow-up and sometimes associated with larger grade point average (d = 0.68) and parent-teen conflict (d = 0.41) improvements. Consistent medication use during behavioral therapy was associated with larger improvements in ADHD symptoms (d = 0.28) and parent-teen conflict (d = 0.25-0.36). An ADHD+internalizing clinical profile predicted larger improvements in grade point average (d = 0.45). Family adversity predicted poorer parent and youth engagement (rate ratio = 0.90-0.95), negligible medication use (odds ratio = 1.22), and smaller improvements in grade point average (d = -0.23). African American race predicted smaller improvements in parent-teen conflict (d = -0.49).

CONCLUSION

Engagement-focused behavioral therapy and consistent medication use most frequently predicted stronger clinical engagement and outcomes for adolescents with ADHD. Youths who are African American or who experience family adversity may demonstrate treatment-related disparities for certain outcomes; youths with ADHD+internalizing symptoms may demonstrate excellent academic outcomes following behavioral therapy.

DATA SHARING

The full ADHD TIDAL dataset is publicly available through the National Data Archive (https://nda.nih.gov), including a data dictionary. The study protocol is also publicly available: https://doi.org/10.1186/s12888-020-02734-6.

Economic burden of attention-deficit/hyperactivity disorder among children and adolescents in the United States: a societal perspective

OBJECTIVE

To provide a comprehensive evaluation of the economic burden associated with attention-deficit/hyperactivity disorder (ADHD) among children and adolescents from a US societal perspective.

MATERIALS AND METHODS

Direct healthcare costs of children (5-11 years) and adolescents (12-17 years) with ADHD were obtained using claims data from the IBM MarketScan Research Databases (01/01/2017-12/31/2018). Direct non-healthcare and indirect costs were estimated based on literature and government publications. Each cost component was estimated using a prevalence-based approach, with per-patient costs extrapolated to the national level.

RESULTS

The total annual societal excess costs associated with ADHD were estimated at $19.4 billion among children ($6,799 per child) and $13.8 billion among adolescents ($8,349 per adolescent). Education costs contributed to approximately half of the total excess costs in both populations ($11.6 billion [59.9%] in children; $6.7 billion [48.8%] in adolescents). Other major contributors to the overall burden were direct healthcare costs ($5.0 billion [25.9%] in children; $4.0 billion [29.0%] in adolescents) and caregiving costs ($2.7 billion [14.1%] in children; $1.6 billion [11.5%] in adolescents).

LIMITATIONS

Cost estimates were calculated based on available literature and/or governmental publications due to the absence of a single data source for all costs associated with ADHD. Thus, the quality of cost estimates is limited by the accuracy of available data as well as the study populations and methodologies used by different studies.

CONCLUSION

ADHD in children and adolescents is associated with a substantial economic burden that is largely driven by education costs, followed by direct healthcare costs and caregiver costs. Improved intervention strategies and policies may reduce the clinical and economic burden of ADHD in these populations.

Attention-Deficit/Hyperactivity Disorder Medication Adherence in the Transition to Adulthood: Associated Adverse Outcomes for Females and Other Disparities

PURPOSE

The purpose of this study was to assess the association between attention-deficit/hyperactivity disorder (ADHD) medication adherence and adverse health outcomes in older adolescents transitioning to adulthood.

METHODS

In a cohort of 17-year-old adolescents with ADHD at Kaiser Permanente Northern California, we assessed medication adherence (medication possession ratio ≥70%) and any medication use and associations with adverse outcomes at 18 and 19 years of age. We conducted bivariate tests of association and multivariable logistic regression models.

RESULTS

Adherence declined from 17 to 19 years of age (36.7%-19.1%, p < .001). Non-white race/ethnicity, lower estimated income, and male sex were associated with nonadherence. Model results show nonadherent females experienced several adverse outcomes: Adherence at 18 years of age (referent: nonadherence) was associated with lower odds of pregnancy (adjusted odds ratio [AOR]: .13, 95% confidence interval [CI]: .03-.54). Any use (referent: nonuse) at 18 years of age was associated with lower odds of sexually transmitted infections among females (AOR: .39, 95% CI: .19-.83), pregnancies (AOR: .26, 95% CI: .13-.50), emergency department visits (AOR: .69, 95% CI: .55-.85), and greater odds of injuries (AOR: 1.16, 95% CI: 1.02-1.32). Adherence at 19 years of age was associated with lower odds of pregnancy (AOR: .13, 95% CI: .02-.95). Any use at 19 years of age was associated with lower odds of injury in females (AOR: .77, 95% CI: .60-.99) pregnancy (AOR: .35, 95% CI: .16-.78), and, in both sexes, substance use (AOR: .71, 95% CI: .55-.92).

CONCLUSIONS

Late adolescence is associated with decline in ADHD medication use and adherence. ADHD medication adherence and any ADHD medication use is associated with fewer adverse health outcomes, particularly in females.

Exploring the Efficacy of a Mindfulness Program for Boys With Attention-Deficit Hyperactivity Disorder and Oppositional Defiant Disorder

Objective: This study was the first attempt to explore the efficacy of a mindfulness protocol for children with attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and their parents. Method: Fifty male children with ADHD and ODD diagnosis, aged 8 to 12, were randomly assigned to the mindfulness intervention (n = 25) or the wait-list (n = 25) group. Outcome measures included children, parents', and teachers' reports and objective measures of attention. Results: Children from the intervention group had a greater reduction in hyperactive behaviors in the school context (effect size [ES] = 0.59) and a greater improvement in visual sustained attention (ES = 0.77) and in Avoidance and Fusion Questionnaire scores (ES = 0.43) than those in the wait-list control group. No significant effect of the intervention on aggressive behaviors was revealed. Conclusion: A mindfulness intervention for children and their parents showed partial beneficial effects in children with ADHD + ODD.

Genetic, Clinical, and Sociodemographic Factors Associated With Stimulant Treatment Outcomes in ADHD

OBJECTIVE

Stimulant medications are effective for treating attention deficit hyperactivity disorder (ADHD), yet discontinuation and switch to nonstimulant ADHD medications are common. This study aimed to identify genetic, clinical, and sociodemographic factors influencing stimulant treatment initiation, discontinuation, and switch to nonstimulants in individuals with ADHD.

METHODS

The authors obtained genetic and national register data for 9,133 individuals with ADHD from the Danish iPSYCH2012 sample and defined stimulant treatment initiation, discontinuation, and switch from prescriptions. For each stimulant treatment outcome, they examined associations with polygenic risk scores (PRSs) for psychiatric disorders and clinical and sociodemographic factors using survival analyses, and conducted genome-wide association studies (GWASs) and estimated single-nucleotide polymorphism heritability (h2SNP).

RESULTS

Eighty-one percent of the sample initiated stimulant treatment. Within 2 years, 45% discontinued stimulants and 15% switched to nonstimulants. Bipolar disorder PRS (hazard ratio=1.05, 95% CI=1.02, 1.09) and schizophrenia PRS (hazard ratio=1.07, 95% CI=1.03, 1.11) were associated with discontinuation. Depression, bipolar disorder, and schizophrenia PRSs were marginally but not significantly associated with switch (hazard ratio range, 1.05-1.07). No associations were observed for ADHD and autism PRSs. Individuals diagnosed with ADHD at age 13 or older had higher rates of stimulant initiation, discontinuation, and switch (hazard ratio range, 1.27-2.01). Psychiatric comorbidities generally reduced rates of initiation (hazard ratio range, 0.84-0.88) and increased rates of discontinuation (hazard ratio range, 1.19-1.45) and switch (hazard ratio range, 1.40-2.08). h2SNP estimates were not significantly different from zero. No GWAS hits were identified for stimulant initiation or discontinuation. A locus on chromosome 16q23.3 reached genome-wide significance for switch.

CONCLUSIONS

The study findings suggest that individuals with ADHD with higher polygenic liability for mood and/or psychotic disorders, delayed ADHD diagnosis, and psychiatric comorbidities have a higher risk for stimulant treatment discontinuation and switch to nonstimulants. Despite the study's limited sample size, one putative GWAS hit for switch was identified, illustrating the potential of utilizing genomics linked to prescription databases to advance ADHD pharmacogenomics.

Transcutaneous vagus nerve stimulation in patients with attention-deficit/hyperactivity disorder: A viable option?

Individuals with attention-deficit/hyperactivity disorder (ADHD) suffer from a range of cognitive and behavioral problems that severely impair their educational and occupational attainment. ADHD symptoms have been linked to structural and functional changes within and between different brain regions, particularly the prefrontal cortex. At the system level, reduced availability of the neurotransmitters dopamine (DA) and norepinephrine (NE) but also γ-aminobutyric acid (GABA) have been repeatedly demonstrated. Recently, non-invasive brain stimulation (NIBS) techniques have been explored as treatment alternatives to alter dysfunctional activation patterns in specified brain areas or networks. In the current paper, we introduce transcutaneous vagus nerve stimulation (tVNS) as a systemic approach to directly affect NE and GABA neurotransmission. TVNS is a non-drug intervention with low risk and proven efficacy in improving cognitive particularly executive functions. It is easy to apply and therefore well-suited to provide home-based or mobile treatment options allowing a significant increase in treatment intensity and providing easier access to medical care for individuals who are unable to regularly visit a clinician. We describe in detail the underlying mechanisms of tVNS and current fields of application and discuss its potential as an adjuvant treatment for ADHD.

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.

A Phase 3, Placebo-Controlled Trial of Once-Daily Viloxazine Extended-Release Capsules in Adolescents With Attention-Deficit/Hyperactivity Disorder

PURPOSE

This phase 3 clinical trial evaluated the efficacy and safety of viloxazine extended-release capsules (VLX-ER) as a monotherapy for attention-deficit/hyperactivity disorder (ADHD) in adolescents (12-17 years).

METHODS

Eligible subjects (n = 310) were randomized to receive once-daily 200 and 400 mg VLX-ER, or placebo for 6 weeks. The primary efficacy end point was change from baseline (CFB) at the end of study (EOS) in ADHD Rating Scale-5 Total score. Key secondary end points were Clinical Global Impression-Improvement score at EOS, CFB at EOS in Conners 3-Parent Short Form Composite T-score, and CFB at EOS in Weiss Functional Impairment Rating Scale-Parent Total average score.

RESULTS

In the 200-mg/d and 400-mg/d VLX-ER treatment groups, a significant improvement was found in the CFB at EOS in ADHD Rating Scale-5 Total (P = 0.0232, P = 0.0091) and Inattention (P = 0.0424, P = 0.0390) and Hyperactivity/Impulsivity (P = 0.0069, P = 0.0005) subscale scores versus placebo. The Clinical Global Impression-Improvement score was significantly improved at EOS in the 200-mg/d and 400-mg/d VLX-ER groups versus placebo (P = 0.0042, P = 0.0003). The Conners 3-Parent Short Form composite T-score and Weiss Functional Impairment Rating Scale-Parent Total average score exhibited improvement in both VLX-ER groups; however, the difference versus placebo was not statistically significant. The most common treatment-related adverse events were somnolence, headache, decreased appetite, nausea, and fatigue. The adverse event-related discontinuation rates were <5% in all groups.

CONCLUSIONS

Viloxazine extended-release demonstrated statistically significant and clinically meaningful improvement in ADHD symptoms in adolescents and was generally well tolerated.

A novel digital health intervention to improve patient engagement to stimulants in adult ADHD in the primary care setting: Preliminary findings from an open label study

AIMS

We piloted the effectiveness and acceptability of a novel text messaging-based (SMS) digital health intervention aimed at addressing the previously documented poor rate of patient engagement in stimulant treatment in the primary care setting.

METHODS

117 adults ages 18-55 from primary care and psychiatric practices who were prescribed a stimulant medication for ADHD treatment received the SMS intervention. Comparators were age-, race-, and sex-matched patients from the same health care organization's electronic medical record who had been prescribed stimulant medications over a similar time period. Using documented prescription records, we determined whether patients had timely prescription refills.

RESULTS

Ninety-six percent (N = 112) of participants completed our a priori metric of patient engagement consisting of 37 days of the SMS program. Eighty-one percent of participants refilled their index prescriptions in a timely manner compared to only 36% of patients receiving treatment as usual (OR=7.54, 95% CI: 4.46, 12.77; p<0.001). We found no significant interaction between prescribing source (non-psychiatry vs. psychiatry) and intervention group (SMS vs. treatment as usual).

CONCLUSIONS

These data suggest that an ADHD-centric, digital health intervention using text messaging significantly improves patient engagement in stimulant treatment in adults with ADHD.

An innovative SMS intervention to improve adherence to stimulants in children with ADHD: Preliminary findings

BACKGROUND

Although large datasets document that stimulants decrease the risk for many adverse ADHD-associated outcomes, compliance with stimulants remains poor.

AIMS

This study examined the effectiveness of a novel ADHD-centric text messaging-based intervention aimed to improve adherence to stimulant medications in children with ADHD.

METHODS

Subjects were 87 children aged 6-12, who were prescribed a stimulant medication for ADHD treatment. Prescribers gave permission to contact their patients for participation in the study. Subjects were primarily from the primary care setting with a subsample of psychiatrically referred subjects for comparison. Age- and sex-matched comparators were identified (3:1) from the same pool of prescriber-approved subjects that did not participate. Timely prescription refills (within 37 days) were determined from prescription dates documented in patients' electronic medical record.

RESULTS

Eighty-five percent of SMS intervention patients refilled their prescriptions in a timely manner compared with 62% of patients receiving treatment as usual (OR = 3.46, 95% CI: 1.82, 6.58; p < 0.001). The number needed to treat statistic was computed as five, meaning for every five patients who receive the SMS intervention, we can keep one adherent to their stimulant treatment.

CONCLUSIONS

These preliminary findings support the potential utility of a readily accessible technology to improve the poor rate of adherence to stimulant treatment in children with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for children with ADHD. These results support the need for further examination of this technology through more definitive randomized clinical trials.

Editorial: A Spoonful of Injury Prevention Makes the ADHD Medicine Go Down

Unintentional injuries are the leading cause of disability and mortality in youths across the United States¹ and globally.² Attention-deficit/hyperactivity disorder (ADHD) has been associated with an increased rate of unintentional injuries in multiple countries, as reviewed in a recent meta-analysis of studies in youths.³ The study by Ghirardi et al.⁴ in this issue of the Journal adds to this literature by examining this issue within stratifications of injury and of characteristics of youths with ADHD.⁴ The authors accessed a very large sample (nearly 2 million youths) drawn from the Truven Health MarketScan Commercial Claims and Encounters databases. They identified all youths in the databases with a diagnosis of ADHD or receiving an ADHD medication prescription from January 1, 2005, to December 31, 2014, who presented to an emergency department with unintentional injuries. To determine the differential rate of unintentional injuries, they used a case-control methodology to compare youths with a diagnosis of ADHD or an ADHD medication with a control group of youths without an ADHD diagnosis or treatment matched on a variety of characteristics. Results of the population comparison not only supported the overall association, but also demonstrated an increased rate of unintentional injuries for both boys and girls and that youths with ADHD had higher rates of traumatic brain injury compared with matched control youths without ADHD.⁴.