Racial and Ethnic Disparities in Childhood ADHD Treatment Access and Utilization: Results From a National Study

Systematic Review and Meta-Analysis: Reporting and Representation of Race/Ethnicity in 310 Randomized Controlled Trials of Attention-Deficit/Hyperactivity Disorder Medications

OBJECTIVE

To evaluate the reporting of race/ethnicity data in randomized controlled trials (RCTs) of attention-deficit/hyperactivity disorder (ADHD) medications. Secondary objectives were to estimate temporal trends in the reporting, and to compare the pooled prevalence of racial/ethnic groups in RCTs conducted in the US to national estimates.

METHOD

We drew on, adapted, and updated the search of a network meta-analysis by Cortese et al. (2018) up to March 2022. We calculated the percentage of RCTs reporting data on race/ethnicity of participants in the published article or in related unpublished material. Temporal trends were estimated with logistic regression. The pooled prevalence of each racial/ethnic group across US RCTs was calculated using random-effects model meta-analyses.

RESULTS

We retained 310 RCTs (including 44,447 participants), of which 231 were conducted in children/adolescents, 78 in adults, and 1 in both. Data on race/ethnicity were reported in 59.3% of the RCTs (75% of which were conducted in children/adolescents and 25% in adults) in the published article, and in unpublished material in an additional 8.7% of the RCTs. Reporting improved over time. In the US RCTs, Asian and White individuals were under- and overrepresented, respectively, compared to national estimates in the most recent time period considered.

CONCLUSION

More than 30% of the RCTs of ADHD medications retained in this review did not include data on race/ethnicity in their published or unpublished reports, and more than 40% in their published articles, even though reporting improved over time. Results should inform investigators, authors, editors, regulators, and study participants in relation to efforts to tackle inequalities in ADHD research.

PLAIN LANGUAGE SUMMARY

A systematic review of 310 randomized controlled trials for attention-deficit/hyperactivity disorder (ADHD) medications found that race/ethnicity were reported in only 30% of trials. Compared to national estimates, Asian individuals were underrepresented and non-Hispanic Whites individuals were overrepresented, drawing attention to the inequities in participation in ADHD research.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote sex and gender balance in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

STUDY PREREGISTRATION INFORMATION

Reporting and representation of race/ethnicity in double blind randomised controlled trials of medications for ADHD; https://osf.io/; hfgz8.

Racial-Ethnic Differences in ADHD Diagnosis and Treatment During Adolescence and Early Adulthood

OBJECTIVE

This study examined racial-ethnic differences in attention-deficit hyperactivity disorder (ADHD) diagnosis and treatment during adolescence and early adulthood.

METHODS

A national health care claims database was used to identify a cohort of 4,216,757 commercially insured youths with at least 1 year of coverage during 2014-2019. Racial-ethnic differences in the prevalence of visits with a recorded ADHD diagnosis (identified through ICD-9-CM and ICD-10-CM codes) and of ADHD treatment (identified through medical claims for psychosocial treatments and pharmacy claims for ADHD medications) were examined. Period prevalence rates were determined within five age categories, stratified by race-ethnicity. Poisson regression with a natural log link was used within each age category to estimate prevalence ratios (PRs) comparing prevalence in each racially and ethnically minoritized group with prevalence in the White group.

RESULTS

The overall prevalence of ADHD diagnosis was 9.1% at ages 12-14 and 5.3% at ages 24-25. In each age category, Asian, Black, and Hispanic youths had lower prevalence of ADHD diagnosis than did White youths (PR=0.29-0.77). Among youths with an ADHD diagnosis, relative racial-ethnic differences in treatment were small (PR=0.92-1.03).

CONCLUSIONS

Throughout adolescence and early adulthood, racially and ethnically minoritized youths were less likely than White youths to have health care visits with recorded ADHD diagnoses and, among those with diagnoses, were also slightly less likely to receive treatment. More research is needed to understand the processes underlying these differences and their potential health consequences among racially and ethnically minoritized youths.

Attention-deficit/hyperactivity disorder combined subtype exacerbates opioid use disorder consequences: Mediation by impulsive phenotypes

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is highly prevalent and associated with opioid use disorder (OUD). Yet, little is known about the mechanisms by which ADHD (which is a heterogeneous construct/diagnosis) might alter the trajectory of OUD outcomes in persons who use heroin.

AIM

We examined whether ADHD subtypes are related to heroin-use consequences and the extent to which the effects of ADHD on lifetime heroin-use consequences are mediated by two impulsivity factors that may be partly independent of ADHD: foreshortened time perspective and drug-use impulsivity.

METHODS

Individuals who reported regular heroin use (N=250) were screened using the Assessment of Hyperactivity and Attention (AHA), Impulsive Relapse Questionnaire (IRQ), Stanford Time Perception Inventory (STPI), and a comprehensive assessment of lifetime and current substance use and substance-related consequences. This secondary analysis examined whether ADHD or intermediate phenotypes predicted heroin-use consequences.

RESULTS

Relative to participants whose AHA scores indicated lifetime absence of ADHD (n=88), those with scores indicating persistent ADHD (childhood and adult, n=62) endorsed significantly more total lifetime heroin-use consequences despite comparable heroin-use severity. Likewise, there was a significant indirect effect of the combined ADHD subtype in childhood on lifetime heroin-use consequences. This effect was mediated by STPI scores indicating less future (and more hedonism in the present) temporal orientation and by IRQ scores indicating less capacity for delaying drug use.

CONCLUSION

The combined ADHD subtype is significantly associated with lifetime heroin-use consequences, and this effect is mediated through higher drug-use impulsivity (less capacity for delay) and lower future temporal orientation.

Assessment of centanafadine in adults with attention-deficit/hyperactivity disorder: A matching-adjusted indirect comparison vs lisdexamfetamine dimesylate, atomoxetine hydrochloride, and viloxazine extended-release

BACKGROUND

Head-to-head trials comparing centanafadine, an investigational therapy for adults with attention-deficit/hyperactivity disorder (ADHD), with other treatment options are lacking.

OBJECTIVE

To compare safety and efficacy outcomes of centanafadine sustained-release vs lisdexamfetamine dimesylate (lisdexamfetamine), atomoxetine hydrochloride (atomoxetine), and viloxazine extended-release (viloxazine ER), respectively, using matching-adjusted indirect comparison (MAIC).

METHODS

This MAIC included patient-level data pooled from 2 centanafadine trials (NCT03605680 and NCT03605836) and published aggregate data from comparable trials of 3 comparators-lisdexamfetamine (NCT00334880), atomoxetine (NCT00190736), and viloxazine ER (NCT04016779)-in adult patients with ADHD. Propensity score weighting was used to match characteristics of individual patients from the centanafadine trials to aggregate baseline characteristics from the respective comparator trials. Safety outcomes were rates of adverse events for which information was available in the centanafadine and respective comparator trials. Efficacy outcome was mean change from baseline in the Adult ADHD Investigator Symptom Rating Scale (AISRS) score (ADHD Rating Scale [ADHD-RS] was used as proxy in the comparison with lisdexamfetamine). Anchored indirect comparisons were conducted across matched populations of the centanafadine and respective comparator trials.

RESULTS

After matching, baseline characteristics in the centanafadine trials were the same as those in the respective comparator trials. Compared with lisdexamfetamine, centanafadine was associated with a significantly lower risk of lack of appetite (risk difference [RD] in percentage points: 23.42), dry mouth (19.27), insomnia (15.35), anxiety (5.21), nausea (4.90), feeling jittery (3.70), and diarrhea (3.47) (all P < 0.05) but a smaller reduction in the AISRS/ADHD-RS score (6.58-point difference; P < 0.05). Compared with atomoxetine, centanafadine was associated with a significantly lower risk of nausea (RD in percentage points: 18.64), dry mouth (17.44), fatigue (9.21), erectile dysfunction (6.76), lack of appetite (6.71), and urinary hesitation (5.84) (all P < 0.05) and no statistically significant difference in the change in AISRS score. Compared with viloxazine ER, centanafadine was associated with a significantly lower risk of fatigue (RD in percentage points: 11.07), insomnia (10.67), nausea (7.57), and constipation (4.63) (all P < 0.05) and no statistically significant difference in the change in AISRS score.

CONCLUSIONS

In an anchored MAIC, centanafadine showed a significantly better short-term safety profile than lisdexamfetamine, atomoxetine, and viloxazine ER; efficacy was lower than with lisdexamfetamine and comparable (ie, nondifferent) with atomoxetine and viloxazine ER. This MAIC provides important insights on the relative safety and efficacy of common treatment options to help inform treatment decisions in adults with ADHD. Safety assessment was limited to rates of adverse events reported in both trials of a given comparison.

STUDY REGISTRATION NUMBERS

NCT03605680, NCT03605836, NCT00334880, NCT00190736, and NCT04016779.

Attention-Deficit Hyperactivity Disorder Among American Youth: A Comprehensive 20-Year Analysis of National Center for Health Statistics (NCHS) Data

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that has a significant impact on the lives of children and adolescents. This study conducts a comprehensive 20-year analysis of data from the National Center for Health Statistics (NCHS) to investigate the prevalence of ADHD among American youth, as well as its demographic patterns and socioeconomic determinants.

METHODS

A retrospective analysis of NCHS data spanning from 1997 to 2018 was carried out. The dataset included information on ADHD diagnoses, demographic characteristics (such as age, gender, and race/ethnicity), socioeconomic indicators (including poverty level and health insurance status), and temporal variables. A range of statistical analyses were performed, encompassing temporal trend analysis, demographic assessments, and socioeconomic examinations.

RESULTS

It was consistently observed that boys had a higher prevalence of ADHD (12.93% compared to 5.61%), aligning with established trends. Among adolescents aged 10-17, the prevalence was the highest at 11.09%, while for the 5-9 age group, it stood at 6.57%. In terms of racial and ethnic groups, individuals identifying as two or more races exhibited the highest prevalence at 12.36%, followed by white (9.83%), black or African American (10.09%), Hispanic or Latino (5.36%), and non-Hispanic or Latino (10.64%). Socioeconomic disparities were evident, with a prevalence of 11.41% among those living below the poverty line, compared to 10.6% (100%-199% of the poverty line), 8.6% (200%-399%), and 8.39% (400% or more). Medicaid beneficiaries had the highest prevalence at 12.57%, followed by those with private insurance (9.65%), insured (8.11%), and uninsured (5.83%).

CONCLUSION

These findings underscore the intricate relationship between ADHD prevalence and demographic and socioeconomic factors. It is imperative to address these disparities to ensure equitable assessment and intervention for ADHD, taking into account cultural influences, determinants of health tied to socioeconomic status, and access to healthcare for all children. This analysis by the NCHS provides essential insights into ADHD among American youth, emphasizing the necessity for tailored interventions, equitable healthcare access, and further research to comprehensively address this complex neurodevelopmental disorder.

Joint polygenic and environmental risks for childhood attention-deficit/hyperactivity disorder (ADHD) and ADHD symptom dimensions

Background

attention-deficit/hyperactivity disorder (ADHD) is associated with both polygenic liability and environmental exposures, both intrinsic to the family, such as family conflict, and extrinsic, such as air pollution. However, much less is known about the interplay between environmental and genetic risks relevant to ADHD-a better understanding of which could inform both mechanistic models and clinical prediction algorithms.

Methods

Two independent data sets, the population-based Adolescent Brain Cognitive Development Study (ABCD) (N = 11,876) and the case-control Oregon-ADHD-1000 (N = 1449), were used to examine additive (G + E) and interactive (GxE) effects of selected polygenic risk scores (PRS) and environmental factors in a cross-sectional design. Genetic risk was measured using PRS for nine mental health disorders/traits. Exposures included family income, family conflict/negative sentiment, and geocoded measures of area deprivation, lead exposure risk, and air pollution exposure (nitrogen dioxide and fine particulate matter).

Results

ADHD PRS and family conflict jointly predicted concurrent ADHD symptoms in both cohorts. Additive-effects models, including both genetic and environmental factors, explained significantly more variation in symptoms than any individual factor alone (joint R 2 = .091 for total symptoms in ABCD; joint R 2 = .173 in Oregon-ADHD-1000; all delta-R 2 p-values <2e-7). Significant effect size heterogeneity across ancestry groups was observed for genetic and environmental factors (e.g., Q = 9.01, p = .011 for major depressive disorder PRS; Q = 13.34, p = .001 for area deprivation). GxE interactions observed in the full ABCD cohort suggested stronger environmental effects when genetic risk is low, though they did not replicate.

Conclusions

Reproducible additive effects of PRS and family environment on ADHD symptoms were found, but GxE interaction effects were not replicated and appeared confounded by ancestry. Results highlight the potential value of combining exposures and PRS in clinical prediction algorithms. The observed differences in risks across ancestry groups warrant further study to avoid health care disparities.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.