Prevalence of medically treated children with ADHD and type 1 diabetes in Germany - Analysis of two representative databases

The impacts associated with having ADHD: an umbrella review

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) affects up to 5% of the population and is characterised by symptoms of impulsivity, hyperactivity and inattention. These symptoms are significantly impairing and carry additional risks for children and adults with ADHD, including negative mental health (e.g. depression), physical health (e.g. obesity) and societal outcomes (e.g. imprisonment, divorce). Very few studies have attempted to synthesise these risks in one publication due to the breadth of evidence published on the adverse outcomes of ADHD.

Methods

An umbrella review was performed to identify reviews (systematic, meta-analysis and narrative) that investigate the risks arising from having ADHD. We conducted a narrative synthesis of the findings and conducted a quality review of the included publications.

Results

Upon searching five databases, 16,675 records were identified. Of these, 125 reviews met the criteria for inclusion. A narrative synthesis of these findings highlighted three key domains of risks associated with ADHD: mental health, physical health, social and lifestyle. Most reviews were of good and moderate quality.

Discussion

This review highlights the many risks associated with having ADHD, beyond its three key symptom domains and the impact of the condition on daily functioning.

Registration

International Prospective Register of Systematic Reviews (PROSPERO CRD42023404073).

Researching Eyesight Trends IN ADHD (RETINA)

BACKGROUND

There has been limited exploration of the relationship between ADHD and vision impairment, especially in relation to ADHD medication regimens and age. This study aims to examine trends in visual disorders in young patients with ADHD.

METHODS

We analyzed deidentified patient records from TriNetX database. Patients under 22 years old were divided into cohorts based on ADHD status and medication regimen. We compared prevalence of vision disorders between cohorts.

RESULTS

We studied over 1 million patients. The ADHD cohort had higher rates of all visual disorders than their non-ADHD peers. Medication usage was found to have a slight impact, with non-stimulants associating with higher rates for all outcomes.

DISCUSSION

Our findings suggest that the higher occurrence of visual disorders in ADHD is not primarily due to misdiagnosis or medication effects. There is a need for regular eye care in ADHD patients and further investigation into the role of ADHD medications in eye health.

Do sex differences in paediatric type 1 diabetes care exist? A systematic review

AIMS/HYPOTHESIS

Sex differences are present in cardiovascular care and in outcomes among adults with type 1 diabetes mellitus, which typically commences in childhood. Whether sex influences care and outcomes in childhood is not known. This systematic review provides an overview of sex differences in children with type 1 diabetes, focusing on patient and disease characteristics, treatment, comorbidities and complications.

METHODS

Literature in MEDLINE up to 15 June 2021 was searched, using the terms diabetes mellitus, sex characteristics, sex distribution, children and/or adolescents. All primary outcome studies on children with type 1 diabetes that mentioned a sex difference in outcome were included, with the exception of qualitative studies, case reports or case series. Studies not pertaining to the regular clinical care process and on incidence or prevalence only were excluded. Articles reporting sex differences were identified and assessed on quality and risk of bias using Joanna Briggs Institute critical appraisal tools. Narrative synthesis and an adapted Harvest plot were used to summarise evidence by category.

RESULTS

A total of 8640 articles were identified, rendering 90 studies for review (n=643,217 individuals). Studies were of observational design and comprised cohort, cross-sectional and case-control studies. Most of the included studies showed a higher HbA_1c in young female children both at diagnosis (seven studies, n=22,089) and during treatment (20 out of 21 studies, n=144,613), as well as a steeper HbA_1c increase over time. Many studies observed a higher BMI (all ages, ten studies, n=89,700; adolescence, seven studies, n=33,153), a higher prevalence of being overweight or obese, and a higher prevalence of dyslipidaemia among the female sex. Hypoglycaemia and partial remission occurred more often in male participants, and ketoacidosis (at diagnosis, eight studies, n=3561) and hospitalisation was more often seen in female participants. Most of the findings showed that female participants used pump therapy more frequently (six studies, n=211,324) and needed higher insulin doses than male participants. Several comorbidities, such as thyroid disease and coeliac disease, appeared to be more common in female participants. All studies reported lower quality of life in female participants (15 studies, n=8722). Because the aim of this study was to identify sex differences, studies with neutral outcomes or minor differences may have been under-targeted. The observational designs of the included studies also limit conclusions on the causality between sex and clinical outcomes.

CONCLUSIONS/INTERPRETATION

Sex disparities were observed throughout diabetes care in children with type 1 diabetes. Several outcomes appear worse in young female children, especially during adolescence. Focus on the cause and treatment of these differences may provide opportunities for better outcomes.

REGISTRATION

This systematic review is registered in PROSPERO (CRD42020213640).

Association between type 1 diabetes and neurodevelopmental disorders in children and adolescents: A systematic review and meta-analysis

Type 1 diabetes and neurodevelopmental disorders are common chronic conditions in childhood and adolescence, and having one may lead to an increased chance of developing the other. Type 1 diabetes mellitus is mainly manifested by elevated blood glucose, while neurodevelopmental diseases are composed of a variety of diseases, which are relatively complex. The purpose of this meta-analysis was to find out the prevalence of type 1 diabetes-related neurodevelopmental disorders in children and adolescents and to explore the potential association between neurodevelopmental disorders and type 1 diabetes. PubMed, Embase and Web of science databases were searched from the inception to May 22, 2022 to identify relevant studies, Finally, 24 original studies were included in the meta-analysis. Prevalence estimates for neurodevelopmental disorders in the type 1 diabetes adolescent and their 95% confidence intervals were pooled using random effects models. The pooled estimates for autism spectrum disorders (ASD) and attention deficit hyperactivity disorder (ADHD) in the type 1 diabetes population were 1.2 and 5.3%, respectively, both of which are higher than the 2019 global prevalence of ASD and ADHD in the general population. The results of the subgroup analysis showed that the prevalence of ASD and ADHD in the T1DM population tended to increase with age. In conclusion, there may be a potential link between the occurrence of type 1 diabetes mellitus and the development of neurodevelopmental disorders in children and adolescents, but more relevant studies are needed to understand the link between the underlying pathogenesis of type 1 diabetes and neurodevelopmental disorders.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CDR42022333443].

The relationship between diabetes mellitus and attention deficit hyperactivity disorder: A systematic review and meta-analysis

Background

This study aims to investigate the prevalence estimate of diabetes mellitus (DM) among people with attention deficit hyperactivity disorder (ADHD) as well as the prevalence of ADHD among those with DM. In addition, the impact of ADHD on glycemic control in patients with DM was also assessed using a systematic review and meta-analysis of currently available published data.

Materials and methods

The PubMed, Embase, Web of Science, and PsycInfo databases were searched for potential studies. Two reviewers independently selected studies according to the inclusion and exclusion criteria. All pooled analyses were conducted using the random-effects models on Review Manager 5.3.

Results

Seventeen observational studies were included. The pooled results showed an increase in the prevalence of DM among patients with ADHD versus those without ADHD [type 1 DM OR: 1.37 (95% CI: 1.17-1.61); type 2 DM OR: 2.05 (95% CI: 1.37-3.07)]. There was an overall 35% increase in the prevalence of ADHD among patients with type 1 DM [OR: 1.35 (95% CI: 1.08-1.73)]. Children with type 1 DM and ADHD had higher levels of hemoglobin A1c [standardized mean of differences: 0.67 (95% CI: 0.48-0.86)], and prevalence of hypoglycemic and ketoacidosis index compared with those without ADHD.

Conclusion

Our study revealed the bidirectional associations between ADHD and DM. Patients with ADHD and type 1 DM comorbidities were more likely to have poorer diabetes control. More studies are needed to confirm this association and elucidate the underlying mechanism.

Sweet but sour: Impaired attention functioning in children with type 1 diabetes mellitus

Children diagnosed with type 1 diabetes mellitus (T1DM) are at risk for neurocognitive sequelae, including impaired attention functioning. The specific nature of the cognitive deficit varies; current literature underscores early age of diabetes diagnosis and increased disease duration as primary risk factors for this neurocognitive decline. Forty-three children with T1DM were evaluated for Attention Deficit/Hyperactivity Disorder (ADHD) symptomatology using the MOXO continuous performance test (MOXO-CPT) performed during a routine outpatient evaluation. The study cohort demonstrated a significant decline in all four domains of attention functioning. The effect was most pronounced with early age at T1DM diagnosis, a longer disease duration and with poorer glycemic control (represented by higher HbA1c values). With increased disease duration (of 5 plus years), acute hyperglycemia was associated with inattention in the real-time setting. These findings highlight the need for routine screening of neurocognitive function in children with T1DM so that early intervention can be employed during this crucial period of cognitive development.

Glycemic Control and Diabetes Related Complications in Adults with Type 1 Diabetes Mellitus and ADHD

OBJECTIVE

To assess the correlation of co-morbid ADHD and diabetes-related complications in patients with type-1-diabetes-mellitus (T1DM).

METHODS

A retrospective cross-sectional study was conducted during 2018 using the Leumit-Health-Services(LHS) database. Diabetes-related complications were assessed in patients with T1DM and ADHD (T1DM-ADHD+) and compared with patients with T1DM alone (T1DM-ADHD-).

RESULTS

Out of 789 adult-patients with T1DM, 75 (9.5%) were T1DM-ADHD+, matched to 225 T1DM-ADHD-. HbA₁C levels were higher in T1DM-ADHD+ patients (8.1% ± 1.6 vs. 7.4% ± 1.2, p < .01), as well as diabetes-related complications: neuropathy (22.7% vs. 5.8%, p < .01), ulcers (8% vs. 0.9%, p < .05), limb amputation (5.3% vs. 0.9%, p < .05), albuminuria (15.5% vs. 2.8%, p < .01), chronic renal failure (10.6% vs. 2.5%, p = .01), and emergency room admissions rate (26.7% vs. 15.1%, p < .05). In sub-analysis, lower average HbA₁C levels and diabetic ulcer rates were found among ADHD patients treated with stimulants, all p < .05.

CONCLUSION

Co-morbidity of ADHD and T1DM is associated with poor glycemic control and higher complication rates.

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder

BACKGROUND

Misconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base.

METHODS

We reviewed studies with more than 2000 participants or meta-analyses from five or more studies or 2000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder.

RESULTS

We generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 80 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 366 people who have read this document and agree with its contents.

CONCLUSIONS

Many findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.

Possible Associations of Disturbed Neurometals and Ammonia with Glycaemic Control in Type 1 Diabetic Children with Attention Deficit Hyperactivity Disorder

The chronicity of type 1 diabetes mellitus (T1DM) is reported to be associated with various psychological disorders. The current study aimed to evaluate the levels of serum ammonia and various neurometals (zinc, copper, and magnesium) in patients with T1DM with and without ADHD and to correlate their levels with glycaemic status. A prospective case-control study was conducted with 60 diabetic children with T1DM (allocated into a group of 20 patients with a diagnosis of ADHD and a group of 40 patients without ADHD) who were comparable to 60 matched controls. Assays of glucose, glycated haemoglobin (HbA1c), ammonia, zinc, copper, and magnesium were performed. Overall, ammonia and copper levels were significantly higher in the diabetic patients especially those with ADHD than in the control group (p ˂ 0.05 for all). The calculated copper/zinc ratio was significantly higher in the diabetic patient group than in the control group and higher in diabetic children with ADHD than in diabetic children without ADHD (p ˂ 0.05 for all). Diabetic children had significantly lower magnesium levels than the controls (p ˂ 0.05), but no significant difference between the diabetic subgroups was detected. A positive correlation between glycaemic control (HbA1c %) and ammonia level was found in the diabetic group and subgroups, and a positive correlation was found between HbA1c % and the Cu/Zn ratio in diabetic children with ADHD (p ˂ 0.05 for all). The current study confirms an association of elevated ammonia and copper/zinc ratio with poor glycaemic control and ADHD development among children with T1DM.

The association of maternal diabetes with attention deficit and hyperactivity disorder in offspring: a meta-analysis

OBJECTIVE

Recent controversial evidence suggests that maternal diabetes may increase the risk of attention deficit and hyperactivity disorder (ADHD) in offspring. To examine this potential association, a systematic literature search and meta-analysis was performed.

METHODS

OR or risk ratio (RR) from each study was obtained and combined for evaluating the risk. Six cohort studies and three case-control studies were included in the present study.

RESULTS

The meta-analysis of the highly heterogeneous case-control studies did not find significant association between maternal diabetes and ADHD risk (OR: 1.20, 95% CI: 0.96-1.49). The combining of the cohort studies demonstrated that offspring of diabetic mothers were at higher risk of ADHD (RR: 1.40, 95% CI: 1.27-1.54); however, publication bias was identified. When exposure was specified as gestational diabetes mellitus (GDM), GDM exposure increased the risk of ADHD for children by 164% (95% CI: 1.25-5.56) in a Caucasian population. Neither heterogeneity nor publication bias was detected.

CONCLUSION

Maternal diabetes, especially GDM, is probably a risk factor for ADHD in the Caucasian population. More studies based on large sample size and different ethnicities are needed to confirm this association.

Assessment of Attention Deficits in Adolescent Offspring Exposed to Maternal Type 1 Diabetes

OBJECTIVE

The aim of this study was to examine the potential association between intrauterine exposure to maternal diabetes and attention deficits in the offspring.

RESEARCH DESIGN AND METHODS

Adolescent offspring of a prospectively followed cohort of women with type 1 diabetes (n = 269) and a control group from the background population (n = 293) participated in a follow-up assessment in 2012-2013. We used scores from Conners Continuous Performance Test II to assess attention and based on a principal component analysis we evaluated scores on five different attention factors: focused attention, vigilance, hyperactivity/impulsivity, sustained attention and response style.

RESULTS

A higher frequency of the exposed offspring had a parent/self-reported use of Attention Deficit Hyperactivity Disorder (ADHD) medication compared to the control group (2.2% vs. 0.0%, p = 0.01). Clinical significant differences between adolescents exposed to maternal diabetes and unexposed controls were not found in either single scores on Conners Continuous Performance Test or on any of the five attention factors identified.

CONCLUSIONS

Exposure to maternal type 1 diabetes did not seem to increase the risk of attention deficits in the adolescent offspring. However, a higher self-reported use of ADHD medication in the exposed group could suggest a difference in attention not revealed by the applied test.