Differences in ADHD medication usage patterns in children and adolescents from different cultural backgrounds in the Netherlands

Prevalence, diagnosis and treatment of ADHD in Arab and Jewish children in Israel, where are the gaps?

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder affecting children and causing significant impairment. It is not clear to what extent ADHD differs between population groups. This study aims to assess prevalence, diagnosis and treatment of ADHD among Arab and Jewish children of primary school age in Israel.

METHODS

Cross-sectional survey, including 517 parents of children ages 7-10 (225 Jewish and 292 Arab) and 60 homeroom teachers of the corresponding children. Both parents and homeroom teachers completed the ADHD Rating Scale-V-RV. ADHD was defined according to DSM-5 ADHD criteria by both parents and teachers, or clinical diagnosis. In addition, parents reported ADHD medication and adherence to medication.

RESULTS

Prevalence of ADHD was similar for both groups. Yet, seeking diagnosis was lower among Arab Muslim children (9.2%) compared to Jewish children (17.8%). Arab Muslim children received significantly less medication compared to Jewish children. Parental decision to seek diagnosis was associated with education (OR = 6.14, CI 1.74-21.71), not ethnicity. Ethnicity predicted parents' decisions to pharmacologically treat their children with ADHD (OR = 7.61, CI 1.14-50.86) and adherence to medication (OR = 10.19, CI 1.18-88.01).

CONCLUSION

Education is critical in the help-seeking process, affecting the rate of ADHD diagnosis. Pharmacological treatment and adherence are correlated with ethnicity. Parents with limited education and minorities should be targeted for interventions to increase awareness regarding ADHD and treatment.

Time of onset and/or diagnosis of ADHD in European children: a systematic review

BACKGROUND

Attention-Deficit/ Hyperactivity Disorder (ADHD) is one of the most common childhood neurobehavioral conditions. Symptoms related to this disorder cause a significant impairment in school tasks and in the activities of children's daily lives; an early diagnosis and appropriate treatment could almost certainly help improve their outcomes. The current study, part of the Models Of Child Health Appraised (MOCHA) project, aims to explore the age at which children experience the onset or diagnosis of ADHD in European countries.

METHODS

A systematic review was done examining the studies reporting the age of onset/diagnosis (AO/AD) of ADHD in European countries (28 European Member States plus 2 European Economic Area countries), published between January 1, 2010 and December 31, 2019. Of the 2276 identified studies, 44 met all the predefined criteria and were included in the review.

RESULTS

The lowest mean AO in the children diagnosed with ADHD alone was 2.25 years and the highest was 7.5 years. It was 15.3 years in the children with ADHD and disruptive behaviour disorder. The mean AD ranges between 6.2 and 18.1 years.

CONCLUSIONS

Our findings indicate that there is a wide variability in both the AO and AD of ADHD, and a too large distance between AO and AD. Since studies in the literature suggest that an early identification of ADHD symptoms may facilitate early referral and treatment, it would be important to understand the underlying reasons behind the wide variability found.

TRIAL REGISTRATION

PROSPERO registration: CRD42017070631 .

Maternal Sociodemographic Factors Are Associated with Methylphenidate Initiation in Children in the Netherlands: A Population-Based Study

Multiple factors may contribute to the decision to initiate methylphenidate treatment in children such as maternal sociodemographic factors of which relatively little is known. The objective was to investigate the association between these factors and methylphenidate initiation. The study population included 4243 children from the Generation R Study in the Netherlands. Maternal sociodemographic characteristics were tested as determinants of methylphenidate initiation through a time-dependent Cox regression analysis. Subsequently, we stratified by mother-reported ADHD symptoms (present in 4.2% of the study population). When ADHD symptoms were absent, we found that girls (adjusted HR 0.25, 95%CI 0.16-0.39) and children born to a mother with a non-western ethnicity (compared to Dutch-Caucasian) (adjusted HR 0.42, 95%CI 015-0.68) were less likely to receive methylphenidate. They were more likely to receive methylphenidate when their mother completed a low (adjusted HR 2.29, 95%CI 1.10-4.77) or secondary (adjusted HR 1.71, 95%CI 1.16-2.54) education. In conclusion, boys and children born to a mother of Dutch-Caucasian ethnicity were more likely to receive methylphenidate, irrespective of the presence of ADHD symptoms.

Autism Spectrum and Other Neurodevelopmental Disorders in Children of Immigrants: A Brief Review of Current Evidence and Implications for Clinical Practice

Children of immigrants may have higher neurodevelopmental risks than those of non-immigrant populations. Yet, some evidence suggests that this group may receive late diagnosis, and therefore miss beneficial early interventions. Clinicians may misattribute symptoms of disorders to other social, behavioral or language problems. Likewise, there might be cultural differences in parents' likelihood of perceiving or reporting first developmental concerns to clinicians. Population-based standardized screening may play an important role in addressing ethnic inequalities in the age at diagnosis, although further research focusing on cross-cultural use is necessary. Once children are diagnosed, clinicians may rely on culturally sensitive procedures (translation services, cultural mediators) to increase the accessibility of interventions and improve adherence among immigrant families. In this brief review, we provide an overview about what is currently known about the epidemiology and risk factors of neurodevelopmental disorders, paying special attention to autism spectrum disorder (ASD), in children of immigrants and suggest the necessity of population-based screening and culturally sensitive care.

Challenges in ADHD care for ethnic minority children: A review of the current literature

While attention deficit hyperactivity disorder (ADHD) has been extensively studied in the past decades, the role of social and cultural practices in its assessment, diagnosis, and treatment has been often overlooked. This selective review provides an overview of research that explores social and cultural influences on help-seeking behavior in ethnic minority children with ADHD. Studies were selected that address cultural diversity in three areas of ADHD help-seeking: problem recognition, access to mental health services, and treatment. Special attention was given to studies of treatment selection and adherence in minority groups. Findings suggested that cultural disparities in ADHD care among ethnic minority children occur in the early stages of problem recognition, through service selection, and in the quality of treatment. Ethnic minority children were less likely than their nonminority counterparts to be diagnosed with ADHD and its comorbid conditions and less likely to be prescribed and adhere to stimulant drug treatment. These differences reflect cultural diversity in norms and attitudes towards mental health issues (e.g., fear of social stigma) as well as limited access to qualified health care. Paradoxically, cultural, racial, and language bias may also lead to the overidentification of ethnic minority children as disabled and to higher ratings of ADHD symptoms. This review highlights the importance of sociocultural factors in understanding developmental psychopathology and help-seeking behavior. In addition, it further supports calls for increasing cultural competence in communications during clinical assessment, diagnosis, and treatment in minority communities. Clinical, theoretical, and methodological considerations for future research are discussed.

Barriers and predictors of medication use for childhood ADHD: findings from a UK population-representative cohort

PURPOSE

Little is known about sociodemographic and clinical factors that predict and act as barriers to ADHD medication independently of symptom severity. We examined the proportion of children using medication for ADHD, age of initiation of medication, and predictors of medication use in a population-representative cohort.

METHODS

Data from the Millennium Cohort Study on child ADHD, medication use for ADHD at age 14 (in 2014-2015) and child, parent and sociodemographic variables were collated. Logistic regression models were used to identify factors that predict medication use for ADHD (the main outcome measure), adjusting for symptom severity at age seven.

RESULTS

The weighted prevalence of ADHD was 3.97% (N = 11,708). 45.57% of children with ADHD (N = 305) were taking medication. The median age at initiation was 9 years (range 3-14). Male gender (AOR 3.66, 95% CI 1.75, 7.66) and conduct problems at age seven (AOR 1.24 95% CI 1.04, 1.47) and 14 predicted medication use at age 14 after adjusting for symptom severity.

CONCLUSIONS

Our study is the first to assess predictors of medication whist adjusting for ADHD symptom severity. Girls with ADHD were less likely to be prescribed medication, even when they displayed similar ADHD symptom levels to boys. Conduct problems also predicted medication independently of ADHD symptoms. ADHD may be more often medicated in boys because clinicians may think a prototypical ADHD child is male, and perhaps conduct problems make boys more disruptive in the classroom, leading to boys being more often treated.

Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012

Over the last two decades, the use of ADHD medication in US youth has markedly increased. However, less is known about ADHD medication use among European children and adolescents. A repeated cross-sectional design was applied to national or regional data extracts from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The prevalence of ADHD medication use was assessed, stratified by age and sex. Furthermore, the most commonly prescribed ADHD medications were assessed. ADHD medication use prevalence increased from 1.8% to 3.9% in the Netherlands cohort (relative increase: +111.9%), from 3.3% to 3.7% in the US cohort (+10.7%), from 1.3% to 2.2% in the German cohort (+62.4%), from 0.4% to 1.5% in the Danish cohort (+302.7%), and from 0.3% to 0.5% in the UK cohort (+56.6%). ADHD medication use was highest in 10-14-year olds, peaking in the Netherlands (7.1%) and the US (8.8%). Methylphenidate use predominated in Europe, whereas in the US amphetamines were nearly as common as methylphenidate. Although there was a substantially greater use of ADHD medications in the US cohort, there was a relatively greater increase in ADHD medication use in youth in the four European countries. ADHD medication use patterns in the US differed markedly from those in western European countries.

Dispensing of psychotropic medication among 400,000 immigrants in The Netherlands

PURPOSE

Previously, a high prevalence of certain psychiatric disorders was shown among non-Western immigrants. This study explores whether this results in more prescriptions for psychotropic medication.

METHODS

Data on dispensing of medication among adults living in the four largest Dutch cities in 2013 were linked to demographic data from Statistics Netherlands. Incident (i.e., following no dispensing in 2010-2012) and prevalent dispensing among immigrants was compared to that among native Dutch (N = 1,043,732) and analyzed using multivariable Poisson and logistic regression.

RESULTS

High adjusted Odds Ratios (OR_adj) of prevalent and high Incidence Rate Ratios (IRR_adj) of incident dispensing of antipsychotics were found among Moroccan (N = 115,455) and Turkish individuals (N = 105,460), especially among young Moroccan males (OR_adj = 3.22 [2.99-3.47]). Among Surinamese (N = 147,123) and Antillean individuals (N = 41,430), slightly higher rates of dispensed antipsychotics were found and the estimates decreased after adjustment. The estimates for antipsychotic dispensing among the Moroccan and Turkish increased, following adjustment for household composition. Rates for antidepressant dispensing among Turkish and Moroccan subjects were high (Moroccans: OR_adj = 1.74 [1.70-1.78]). Among Surinamese and Antillean subjects, the rates for antidepressant dispensing were low and the OR_adj lagged behind the IRR_adj (Surinamese: 0.69 [0.67-0.71] vs. 1.06 [1.00-1.13]). Similar results were found for anxiolytics. For ADHD medication, lower dispensing rates were found among all migrant groups.

CONCLUSIONS

The findings agree with earlier reports of more mental health problems among Moroccan and Turkish individuals. Surinamese/Antillean individuals did not use psychotropic drugs at excess and discontinued antidepressants and anxiolytics earlier. The data strongly suggest under-treatment for ADHD in all ethnic minority groups.

Problematic Peer Functioning in Girls with ADHD: A Systematic Literature Review

Objective

Children with attention deficit hyperactivity disorder (ADHD) experience many peer interaction problems and are at risk of peer rejection and victimisation. Although many studies have investigated problematic peer functioning in children with ADHD, this research has predominantly focused on boys and studies investigating girls are scant. Those studies that did examine girls, often used a male comparison sample, disregarding the inherent gender differences between girls and boys. Previous studies have highlighted this limitation and recommended the need for comparisons between ADHD females and typical females, in order to elucidate the picture of female ADHD with regards to problematic peer functioning. The aim of this literature review was to gain insight into peer functioning difficulties in school-aged girls with ADHD.

Methods

PsychINFO, PubMed, and Web of Knowledge were searched for relevant literature comparing school-aged girls with ADHD to typically developing girls (TDs) in relation to peer functioning. The peer relationship domains were grouped into ‘friendship’, ‘peer status’, ‘social skills/competence’, and ‘peer victimisation and bullying’. In total, thirteen studies were included in the review.

Results

All of the thirteen studies included reported that girls with ADHD, compared to TD girls, demonstrated increased difficulties in the domains of friendship, peer interaction, social skills and functioning, peer victimization and externalising behaviour. Studies consistently showed small to medium effects for lower rates of friendship participation and stability in girls with ADHD relative to TD girls. Higher levels of peer rejection with small to large effect sizes were reported in all studies, which were predicted by girls’ conduct problems. Peer rejection in turn predicted poor social adjustment and a host of problem behaviours. Very high levels of peer victimisation were present in girls with ADHD with large effect sizes. Further, very high levels of social impairment and social skills deficits, with large effect sizes, were found across all studies. Levels of pro-social behaviour varied across studies, but were mostly lower in girls with ADHD, with small to large effect sizes. Overall, social disability was significantly higher among girls with ADHD than among TD girls.

Conclusion

Congruous evidence was found for peer functioning difficulties in the peer relationship domains of friendship, peer status, social skills/competence, and peer victimisation and bullying in girls with ADHD.