Economic Burden of Attention-Deficit/Hyperactivity Disorder among Pediatric Patients in the United States

Settling a distracted globe: An overview of psychosocial and psychotherapeutic treatment of attention-deficit/hyperactivity disorder

While the currently prevailing theory of ADHD postulates a neurobiological background and core deficits of behavioural inhibition and executive functioning as the basis of ADHD symptoms, our current conceptualisation also acknowledges the essential contributory role of psychosocial, ecological, and cognitive factors. Considering the multifactorial background of ADHD, its treatment equally needs to be multifactorial involving, besides pharmacotherapy, skill development and psychotherapy as well, especially if we postulate the increasing contribution of social factors in the background of the increasing burden of ADHD. Pharmacotherapies, including stimulants and non-stimulant ADHD medications applied as first-line treatments have a positive effect on core behavioural symptoms, however, they often do not sufficiently remediate several other symptoms and comorbid disorders, which are consequences of ADHD, especially considering that ADHD persists into adulthood and is present over the whole life span. Furthermore, pharmacological treatment is not sufficient to substitute for the skills needed to manage symptoms and adapt well to the environment. As part of a multimodal treatment approach, psychological therapies for ADHD target, besides core ADHD symptoms, other associated features including emotional dysregulation, personality development, neurocognitive dysfunction, depression, anxiety, and sleep problems. Insufficiently treated ADHD may contribute to psychological and personality developmental problems in children, as well as increased health costs and decreased productivity warranting multimodal treatment to address the areas not sufficiently targeted by ADHD-specific pharmacotherapy.

Economic Burden and Service Utilization of Children With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children. This study aims to systematically synthesize the literature on service utilization and costs for children with ADHD.

METHODS

The search included 9 databases for peer-reviewed primary studies in English from 2007 to 2023. Two independent reviewers conducted title/abstract and full-text screenings and quality assessment. Meta-analysis was conducted on direct medical costs.

RESULTS

Thirty-two studies were included. Children with ADHD have used more pharmaceuticals, mental health, and special education services than children without ADHD (counterparts). Nevertheless, one study found that children with ADHD were twice as likely to have unmet health needs than their counterparts. Annual health system costs per patient were highly varied and higher in children with ADHD ($722-$11 555) than their counterparts ($179-$3646). From a societal perspective, children with ADHD were associated with higher costs ($162-$18 340) than their counterparts ($0-2540). The overall weighted mean direct medical cost was $5319 for children with ADHD compared with $1152 for their counterparts when all studies with different sample sizes were considered together, with the difference being $4167. Limited literature on productivity losses associated with ADHD reported them as a substantial cost. ADHD in children had a "large" effect on the increment of direct medical costs.

CONCLUSIONS

ADHD was associated with increased service utilization and costs. However, unmet health needs or underuse among children with ADHD was also evident. Governments should endeavor to improve access to effective services for children with ADHD to mitigate the impact of ADHD.

Barriers and Enablers of Service Access and Utilization for Children and Adolescents With Attention Deficit Hyperactivity Disorder: A Systematic Review

OBJECTIVE

To update a systematic review of the literature on the barriers and enablers of service access and utilization for children and adolescents with a diagnosis, or symptoms of attention deficit/hyperactivity disorder (ADHD), from the perspective of caregivers, clinicians, and teachers.

METHODS

Five databases were searched for peer-reviewed literature published from May 2012 to March 2023. Two independent reviewers completed a two-stage screening process and quality assessment.

RESULTS

Of 4,523 search results, 30 studies were included. Five main themes were generated: 1) Awareness of ADHD, 2) Stigma, 3) Parental choice and partnerships, 4) Education services as an integral component, 5) Referrals, waiting times, and logistics. More than half of the studies reported poor acknowledgement, expertise of ADHD, and stigma.

CONCLUSION

Findings highlight the need for ongoing ADHD education for all involved and policy changes to service delivery systems to increase the availability of health providers with specialist ADHD expertise.

Alerting network, cognitive flexibility in children with attention deficit hyperactivity disorder and the moderating effect of neuroticism

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder, and cognitive flexibility is a sub-component of executive functioning. Studies have shown impairments in cognitive flexibility in ADHD, which is affected by attentional processes. Personality, as a long-standing trait, has a profound effect on ADHD. However, previous studies have not assessed the relationship between attentional function, personality traits, and cognitive flexibility in children with ADHD. This study explored the association between attention networks, personality, and cognitive flexibility in ADHD, filling a gap in the related field. We expect our findings will provide insights into and clues for the prevention and interventional treatment of ADHD. This study primarily aimed to analyze differences in cognitive flexibility between individuals with ADHD and those without and further examine associations between attention networks, personality, and cognitive flexibility in children with ADHD. Overall, 55 children aged 7 to 11 years diagnosed with ADHD and 40 children without ADHD participated in this study. Cognitive flexibility, personality traits, and attentional networks were assessed using the Wisconsin Card Sorting Test, Eysenck Personality Questionnaire, and Attention Network Test, respectively. Additionally, the association between personality traits and strong attentional functioning and cognitive flexibility was investigated using multiple regression analysis. Children with ADHD had significant deficits in cognitive flexibility. A multiple regression analysis revealed that the alerting effect was highly associated with cognitive flexibility at high levels of neuroticism. This association was not salient in individuals with low levels of neuroticism. This study demonstrated that the ADHD group experienced lower cognitive flexibility than the control group. In addition, we showed the effect of neuroticism and alerting networks on cognitive flexibility. These findings may help psychiatrists provide intervention strategies to mitigate the impairment of social functioning in ADHD with cognitive spirituality deficits.

Medical Expenditures Associated with Attention-Deficit/Hyperactivity Disorder Among Adults in the United States by Age, 2015-2019

BACKGROUND

Attention-deficit hyperactivity disorder is a common disorder that affects both children and adults. However, for adults, little is known about ADHD-attributable medical expenditures.

OBJECTIVE

To estimate the medical expenditures associated with ADHD, stratified by age, in the US adult population.

DESIGN

Using a two-part model, we analyzed data from Medical Expenditure Panel Survey for 2015 to 2019. The first part of the model predicts the probability that individuals incurred any medical costs during the calendar year using a logit model. The second part of the model estimates the medical expenditures for individuals who incurred any medical expenses in the calendar year using a generalized linear model. Covariates included age, sex, race/ethnicity, geographic region, Charlson comorbidity index, insurance, asthma, anxiety, and mood disorders.

PARTICIPANTS

Adults (18 +) who participated in the Medical Expenditure Panel Survey from 2015 to 2019 (N = 83,776).

MAIN MEASURES

Overall and service specific direct ADHD-attributable medical expenditures.

KEY RESULTS

A total of 1206 participants (1.44%) were classified as having ADHD. The estimated incremental costs of ADHD in adults were $2591.06 per person, amounting to $8.29 billion nationally. Significant adjusted incremental costs were prescription medication ($1347.06; 95% CI: $990.69-$1625.93), which accounted for the largest portion of total costs, and office-based visits ($724.86; 95% CI: $177.75-$1528.62). The adjusted incremental costs for outpatient visits, inpatient visits, emergency room visits, and home health visits were not significantly different. Among older adults (31 +), the incremental cost of ADHD was $2623.48, while in young adults (18-30), the incremental cost was $1856.66.

CONCLUSIONS

The average medical expenditures for adults with ADHD in the US were substantially higher than those without ADHD and the incremental costs were higher in older adults (31 +) than younger adults (18-30). Future research is needed to understand the increasing trend in ADHD attributable cost.

For Which Children with ADHD is TBR Neurofeedback Effective? Comorbidity as a Moderator

We examined psychiatric comorbidities moderation of a 2-site double-blind randomized clinical trial of theta/beta-ratio (TBR) neurofeedback (NF) for attention deficit hyperactivity disorder (ADHD). Seven-to-ten-year-olds with ADHD received either NF (n = 84) or Control (n = 58) for 38 treatments. Outcome was change in parent-/teacher-rated inattention from baseline to end-of-treatment (acute effect), and 13-month-follow-up. Seventy percent had at least one comorbidity: oppositional defiant disorder (ODD) (50%), specific phobias (27%), generalized anxiety (23%), separation anxiety (16%). Comorbidities were grouped into anxiety alone (20%), ODD alone (23%), neither (30%), or both (27%). Comorbidity (p = 0.043) moderated acute effect; those with anxiety-alone responded better to Control than to TBR NF (d = - 0.79, CI - 1.55- - 0.04), and the other groups showed a slightly better response to TBR NF than to Control (d = 0.22 ~ 0.31, CI - 0.3-0.98). At 13-months, ODD-alone group responded better to NF than Control (d = 0.74, CI 0.05-1.43). TBR NF is not indicated for ADHD with comorbid anxiety but may benefit ADHD with ODD.Clinical Trials Identifier: NCT02251743, date of registration: 09/17/2014.

Differential costs for the non-adult ADHD population in Catalonia

Attention-Deficit/Hyperactivity Disorder (ADHD) is young children's most common mental health disorder. We aim to provide causal estimates of the differential costs for the non-adult population with ADHD. We used longitudinal administrative data covering the non-adult population over five years and different healthcare providers (general practitioners, hospitalisations and emergency departments, visits to mental healthcare centres-day-care or hospitals) of 1,101,215 individuals in Catalonia (Spain). We also include the consumption of pharmaceuticals and cognitive therapies. We instrumented ADHD diagnosis by the probability of being diagnosed by the most visited healthcare provider based on individual monthly visits to the provider in which this visit was related to ADHD and the density of professionals in the different mental health providers. After using matching procedures to include a proper control group, we estimated two-part and finite mixture models. Our results indicate that ADHD children and adolescents displayed 610€ higher annual health direct costs compared to not diagnosed counterparts. We provide average costs disentangling the sample by age boundaries, gender, and comorbidities to offer values for cost-effective analyses and incremental costs after diagnosis, which is around 400€. A significant differential annual direct health cost for the non-adult population with ADHD is determined, which will be helpful for cost-effectiveness analysis and complete cost-of-illness studies.

Predictors of mental health service utilization as adolescents with attention deficit hyperactivity disorder transition into adulthood

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) symptoms may persist into adulthood and are likely to cause great problems in young adults. To date, few studies have explored the characteristics of patients diagnosed with ADHD that might influence the utilization of adult mental health services (AMHS). We aimed to examine and identify predictive symptoms of AMHS.

METHODS

We analysed data from 114 participants diagnosed with ADHD from a cohort of adolescents recruited at the age of 12-17 years, who, at the time of data analysis, were over 18 years old.

RESULTS

Among AMHS users, hyperactivity/impulsivity measures were significantly more severe (t = 2.668, df = 112, p < .001), ADHD combined subtype diagnosis (χ²  = 4.66, df = 1, p = .031) was more frequent and dysregulation profile in the SDQ-P was also significantly higher (t = -2.497, df = 109, p = .014). However, the dysregulation profile did not remain statistically significant after controlling for type of AMHS contact.

CONCLUSIONS

Our findings suggest that adolescents with ADHD are more likely continue their care under AMHS if they present more severe symptoms of hyperactivity/impulsivity and emotional dysregulation. The better characterization of the patient profile will help clinicians to early identify groups at-risk and to tailor interventions and prevention strategies.

Gestational organophosphate ester exposure and preschool attention-deficit/hyperactivity disorder in the Norwegian Mother, Father, and Child cohort study

BACKGROUND

Attention-deficit/hyperactivity-disorder (ADHD) is a leading neurodevelopmental disorder in children worldwide; however, few modifiable risk factors have been identified. Organophosphate esters (OPEs) are ubiquitous chemical compounds that are increasingly prevalent as a replacement for other regulated chemicals. Current research has linked OPEs to neurodevelopmental deficits. The purpose of this study was to assess gestational OPE exposure on clinically-assessed ADHD in children at age 3 years.

METHODS

In this nested case-control study within the Norwegian Mother, Father, and Child Cohort study, we evaluated the impact of OPE exposure at 17 weeks' gestation on preschool-age ADHD. Between 2007 and 2011, 260 ADHD cases were identified using the Preschool Age Psychiatric Assessment and compared to a birth-year-stratified control group of 549 children. We categorized bis(2-butoxyethyl) phosphate (BBOEP) and bis(1,3-dichloro-2-propyl) phosphate (BDCIPP) as values < limit of detection (LOD) (BBOEP N = 386, BDCIPP N = 632), ≥LOD but < limit of quantification (LOQ) (BBOEP N = 413; BDCIPP N = 75), or above LOQ (BBOEP N = 70; BDCIPP N = 102). Diphenyl phosphate (DPhP) and di-n-butyl phosphate (DnBP) were categorized as quartiles and also modeled with a log10 linear term. We estimated multivariable adjusted odds ratios (ORs) using logistic regression and examined modification by sex using an augmented product term approach.

RESULTS

Mothers in the 3rd DnBP quartile had 1.71 times the odds of having a child with ADHD compared to the 1st quartile (95%CI: 1.13, 2.58); a similar trend was observed for log10 DnBP and ADHD. Mothers with BDCIPP ≥ LOD but < LOQ had 1.39 times the odds of having a child with ADHD compared to those with BDCIPP < LOD (95%CI: 0.83, 2.31). Girls had lower odds of ADHD with increasing BBOEP exposure (log10 OR: 0.55 (95%CI: 0.37, 0.93), however boys had a weakly increased odds (log10 OR: 1.25 (95%CI: 0.74, 2.11) p-interaction = 0.01].

CONCLUSIONS

We found modest increased odds of preschool ADHD with higher DnBP and BDCIPP exposure.

Partnering with Family Advocates to Understand the Impact on Families Caring for a Child with a Serious Mental Health Challenge

Family-driven care is a key principle of the system of care framework, but little research has documented the impact caring for a child with a serious mental health challenge has on families. In partnership with family advocates, this prospective, descriptive study was conducted to understand the impact a child's mental health challenge has on families' time, finances, life events, and caregiver employment. Study results showed the average family spent over $250 a week in unreimbursed costs, even though 84% of the children in the study received Medicaid. Caregivers spent approximately 10 h per week attending to the child's mental health needs, not including direct care for the child. Caregivers also reported a substantial impact on their employment. The results of this study have implications for the system of care supports for families. Perhaps most importantly, systems must utilize two-generation strategies in systems of care to minimize the impact on caregiver employment.

Direct medical and indirect absenteeism costs among working adult ADHD patients in the United States

OBJECTIVE

This study investigated the direct medical and indirect (i.e. absenteeism) costs among working adults diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) in the United States.

METHODS

This study utilized 2017-2018 Medical Expenditure Panel Survey data. Attribution and regression-based incremental cost approaches were utilized to estimate direct medical costs, i.e. prescription drug costs and total costs. The regression-based approach was utilized to estimate absenteeism cost.

RESULTS

The study sample consisted of 32,222 observations (weighted: 187,207,896). Of these, 459 (weighted: 3,175,033) had ADHD. The mean annual per person ADHD-attributable prescription drug cost was 2018 US $1,248 (standard error (SE): 97) and the ADHD-attributable total cost was $2,031 (SE: 371). This contributed to a mean overall annual spending of $3.96 (SE: 0.42) billion on ADHD-attributable prescription drugs and $6.45 (SE: 1.26) billion on ADHD-attributable total direct medical costs among adult ADHD patients. Based on the regression-based approach, the mean annual incremental cost for ADHD was $1,641 (SE: 164) and $4,328 (SE: 862) per person for prescription medication costs and total costs, respectively. The mean indirect cost of ADHD was estimated at $512 (SE: 91) per year, per person among working adults with ADHD in the United States.

CONCLUSIONS

There is a significant direct and indirect economic burden on working adults with ADHD.

EXPERT OPINION

There is a significant economic burden of ADHD in terms of direct medical (including out-of-pocket) cost as well as indirect absenteeism cost. The per person annual costs estimated using a regression approach were approximately twice as much as the costs using the sum disease-specific approach, suggesting a potential role for 'spillover' costs among working adults with ADHD. Prescription drug costs were top-ranked contributors to the direct medical costs. As a group, working adults with ADHD are relatively understudied and more research is needed to better understand the burden of ADHD in this group.

The relationship between persistent organic pollutants and Attention Deficit Hyperactivity Disorder phenotypes: Evidence from task-based neural activity in an observational study of a community sample of Canadian mother-child dyads

BACKGROUND

Prenatal exposure to persistent organic pollutants (POPs), widespread in North America, is associated with increased Attention Deficit/Hyperactivity Disorder (ADHD) symptoms and may be a modifiable risk for ADHD phenotypes. However, the effects of moderate exposure to POPs on task-based inhibitory control performance, related brain function, and ADHD-related symptoms remain unknown, limiting our ability to develop interventions targeting the neural impact of common levels of exposure.

OBJECTIVES

The goal of this study was to examine the association between prenatal POP exposure and inhibitory control performance, neural correlates of inhibitory control and ADHD-related symptoms.

METHODS

Prospective data was gathered in an observational study of Canadian mother-child dyads, with moderate exposure to POPs, including polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs), as part of the GESTation and the Environment (GESTE) cohort in Sherbrooke, Quebec, Canada. The sample included 87 eligible children, 46 with maternal plasma samples, functional magnetic resonance imaging (fMRI) data of Simon task performance at 9-11 years, and parental report of clinical symptoms via the Behavioral Assessment System for Children 3 (BASC-3). Simon task performance was probed via drift diffusion modeling, and parameter estimates were related to POP exposure. Simon task-based fMRI data was modeled to examine the difference in incongruent vs congruent trials in regions of interest (ROIs) identified by meta analysis.

RESULTS

Of the 46 participants with complete data, 29 were male, and mean age was 10.42 ± 0.55 years. Increased POP exposure was associated with reduced accuracy (e.g. PCB molar sum rate ratio = 0.95; 95% CI [0.90, 0.99]), drift rate (e.g. for PCB molar sum β = -0.42; 95% CI [-0.77, -0.07]), and task-related brain activity (e.g. in inferior frontal cortex for PCB molar sum β = -0.35; 95% CI [-0.69, -0.02]), and increased ADHD symptoms (e.g. hyperactivity PCB molar sum β = 2.35; 95%CI [0.17, 4.53]), supporting the possibility that prenatal exposure to POPs is a modifiable risk for ADHD phenotypes.

DISCUSSION

We showed that exposure to POPs is related to task-based changes in neural activity in brain regions important for inhibitory control, suggesting a biological mechanism underlying previously documented associations between POPs and neurobehavioral deficits found in ADHD phenotypes.

Predictive scores failing at identifying psychiatric disabilities following childhood bacterial meningitis calls for revision of current follow-up guidelines

BACKGROUNDS

Psychiatric disabilities affect one in three survivors of bacterial meningitis. Since current guidelines do not recommend psychiatric follow-up in all children, disabilities are often detected late. Identifying children with elevated risk of psychiatric disabilities using predictive scores could be one strategy for detecting psychiatric disabilities without having to conduct psychiatric evaluations in all children. Therefore, we searched for existing predictive scores and later tested five predictive scores' ability to predict psychiatric disabilities following childhood bacterial meningitis.

METHODS

From an existing dataset, we selected 73 children with bacterial meningitis of whom 22 later developed psychiatric disease and 15 experienced concentration or learning difficulties. Using these, we tested each predictive score's sensitivity at their cut-off level for predicting psychiatric disease and concentration or learning difficulties using a chi-square test. Furthermore, we performed a receiver operating characteristic curve (ROC) analysis to assert the area under the curve (AUC) as a measure of overall predictive performance.

RESULTS

The sensitivity of each predictive score' ranged from 6 to 38% for psychiatric disease and from 8 to 57% for concentration or learning difficulties. In the ROC-analysis, the AUC was 0.59-0.73 and 0.53-0.72, respectively.

CONCLUSIONS

All predictive score failed at identifying children later developing psychiatric disabilities, excluding this as a feasible strategy for detecting psychiatric disabilities. Hence, current guidelines for bacterial meningitis need to be revised to recommend psychiatric evaluations in all children.KEY NOTESCurrent guidelines not recommending psychiatric evaluations in all children following bacterial meningitis may result in late detection of psychiatric disabilities.We tested predictive scores' ability to identify children later developing psychiatric disabilities following bacterial meningitis.All predictive score failed at identifying children later developing psychiatric disabilities, excluding this as a feasible strategy. Hence, current guidelines for bacterial meningitis need to be revised to recommend psychiatric evaluations in all children.

Dietary phytochemical index and attention-deficit/hyperactivity disorder in Iranian children: a case control study

OBJECTIVE

Attention Deficit/Hyperactivity Disorder (ADHD) is a common behavioral disorder among children. Based on literature, it has been hypothesized that the higher intake of rich sources of phytochemicals may be inversely related to the risk of ADHD. We investigated the association of dietary phytochemical index (DPI) with odds of ADHD.

METHODS

This case-control study was conducted on 360 children and adolescents 7-13 years old in Yazd, Iran. Subjects were categorized into the case (n = 120) and control groups (n = 240) based on matching age and sex. To diagnose ADHD, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSMIV-TR) was used. Food frequency questionnaire was used to measure food intake. DPI was calculated by percent of daily energy intake from phytochemical-rich foods. The association of DPI with the odds ratio of ADHD was examined by logistic regression.

RESULTS

Subjects in the highest quartile of DPI have higher intake of macronutrient, eicosatetraenoic acid, docosahexaenoic acid, calcium, zinc, iron, vitamins B12, B6, and folic acid compared to lowest quartile. After adjusting for potential confounders, subjects in the highest quartile of DPI compared with subjects in the lowest quartile showed a lower risk of ADHD (OR: 0.44; 95% CI: 0.18-0.90). There was a significant decreasing trend in the odds of ADHD across increasing quartile of DPI (P for trend: 0.02).

CONCLUSION

We found that higher DPI score is associated with lower risk of ADHD in children. Cohort and clinical studies are necessary to approve our results.

Patterns of Medication Prescription among Children and Adolescents with Attention-Deficit/Hyperactivity Disorder in the United States

The objectives of this study are to: (1) quantify the difference in the annual number of prescription medications (total and unique) between children and adolescents with ADHD and those without ADHD; and (2) identify the most prescribed medication classes and unique medications among children and adolescents with ADHD. A retrospective cross-sectional study design was employed using data from the 2015 and 2017 Medical Expenditure Panel Survey. The study sample comprised children and adolescents (5–17 years). In the 5–12-year age group, those with ADHD were 2.4%, 17%, and 15% significantly more likely to have one, 2–4, and ≥5 prescription medications, respectively. Similarly, those in the 13–17-year age group were more likely to have one prescription medication (3%), 2–4 prescription medications (15%), and ≥5 prescription medications (12%) than those without ADHD. The most prescribed medications among children and adolescents with ADHD were methylphenidate and amphetamine-dextroamphetamine. ADHD was associated with both higher annual total and unique prescription medications. Additionally, concurrent use of prescription medications was more prevalent among children and adolescents with ADHD. High-quality randomized clinical trials on the safety and efficacy of combinations of multiple psychotherapeutics and stimulants’ agents are required to guide the evidence-based practices.

Childhood ADHD, Going Beyond the Brain: A Meta-Analysis on Peripheral Physiological Markers of the Heart and the Gut

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurodevelopmental disorder diagnosed in children. Questions regarding its increased diagnostic rates and pharmacological treatments in developing children have led to a more holistic review of the multi-system pathophysiology observed in ADHD. The dopaminergic neurotransmitter system, known for its influence on reward-motivated behaviors and motor control, and the frontostriatal systems, that mediate motor, cognition, and behavior, are associated with ADHD's development. However, studies have shown that these neural systems do not wholly account for ADHD's multilayered and heterogeneous symptom presentation. For instance, the literature suggests that emotional dysregulation, the inability to regulate one's emotional responses to provoking stimuli, is associated with increased risk for social impairment in ADHD. A broader examination of physiological systems in children with ADHD has found potential markers in the heart-brain and gut-brain axes that correspond with certain behaviors associated with emotional dysregulation in recent studies. Hence, the purpose of this meta-analysis is to aggregate ten applicable published case studies and analyze task-related heart rate reactivity (HRR; n = 5 studies) and gut microbiota (n = 5 studies) data in children with and without ADHD. Data from a total of 531 youth with ADHD and 603 youth without ADHD revealed significant small and medium effect sizes for higher Chao1 levels and Actinobacteria levels in the ADHD group, respectively, but no evidence of altered task-related HRR. Thus, further research into multi-system psychophysiological measures of emotional dysregulation and ADHD is warranted. The clinical, empirical, and educational implications of these findings are discussed.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42021236819).

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.

Long-Term Treatment With Extended-Release Methylphenidate Treatment in Children Aged 4 to <6 Years

OBJECTIVE

To investigate long-term (12-month) safety and symptom control of extended-release methylphenidate (MPH-MLR) in children aged 4 to <6 years after treatment optimization.

METHOD

A total of 90 children aged 4 to <6 years with attention-deficit/hyperactivity disorder (ADHD) were enrolled from 2 MPH-MLR studies. Treatment-emergent adverse events (TEAEs) and ADHD symptom control were assessed in the safety population (n = 89) and modeled with mixed model analyses.

RESULTS

Most TEAEs (89.9%) were rated by investigators as of mild or moderate severity. One serious AE was reported (unrelated to study drug). Ten children discontinued because of TEAEs. Two discontinued because of weight loss; no significant increase in the rate of underweight children from baseline to endpoint was observed. Overall, 18% lost weight and 18% reported decreased appetite. Weight and height z scores and obesity rates decreased significantly from baseline to endpoint. Insomnia was reported (9%); none of these children discontinued. Sleep quality did not change significantly. Hypertension was reported (6.7%); none of these children dropped out. Diastolic, but not systolic, blood pressure increased significantly during the follow-up. Control of ADHD symptoms was maintained throughout follow-up.

CONCLUSION

These data contribute to the understanding of the long-term safety of an extended-release stimulant in children 4 to <6 years of age. The observed risk of a TEAE-related discontinuation was ∼11%. TEAEs were not dose related, and most were of mild to moderate severity. Symptom control was maintained through the year-long study.

CLINICAL TRIAL REGISTRATION INFORMATION

A 12-Month Open Label Safety Study of Aptensio XR® in Children Ages 4-5 Years Diagnosed With ADHD (EF004); https://clinicaltrials.gov; NCT02677519.

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

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is associated with substantial clinical burden as individuals transition to adulthood, including higher rates of comorbidities, mortality, incarceration, and psychiatric hospitalizations than in individuals without ADHD. These higher rates likely contribute to substantial economic burden as well. OBJECTIVE: To provide a comprehensive evaluation of the economic burden associated with ADHD in the US adult population. METHODS: Direct health care costs were obtained by using claims data from the IBM MarketScan Research Databases (January 1, 2017, through December 31, 2018). Direct non-health care costs and indirect costs were estimated on the basis of the literature and government publications. Excess costs incurred by adults with ADHD during 2018 were evaluated from a societal perspective; per-patient costs were extrapolated to the national level. RESULTS: An estimated 8.7 million adults live with ADHD in the United States, resulting in a total societal excess cost attributable to ADHD of $122.8 billion ($14,092 per adult). Excess costs of unemployment ($66.8 billion; 54.4%) comprised the largest proportion of the total, followed by productivity loss ($28.8 billion; 23.4%) and health care services ($14.3 billion; 11.6%). CONCLUSIONS: ADHD in adults is associated with substantial economic burden. DISCLOSURES: This study was funded by Otsuka Pharmaceutical Development & Commercialization, Inc. (Otsuka). The study sponsor contributed to and approved the study design, participated in the interpretation of data, and reviewed and approved the manuscript. Schein is an employee of Otsuka. Gagnon-Sanschagrin, Davidson, Kinkead, Cloutier, Guérin, and Lefebvre are employees of Analysis Group, Inc., a consulting company that provided paid consulting services to Otsuka to develop and conduct this study and write the manuscript. Adler has received research support from Shire/Takeda, Sunovion, and Otsuka; consulting fees from Bracket, Shire/Takeda, Sunovion, Otsuka, the State University of New York (SUNY), the National Football League (NFL), and Major League Baseball (MLB); and royalty payments (as inventor) from New York University (NYU) for license of adult ADHD scales and training materials. Childress has received research support from Allergan, Takeda/Shire, Emalex, Akili, Ironshore, Arbor, Aevi Genomic Medicine, Neos Therapeutics, Otsuka, Pfizer, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, and the US Food and Drug Administration; was on the advisory board of Takeda/Shire, Akili, Arbor, Cingulate, Ironshore, Neos Therapeutics, Otsuka, Pfizer, Purdue, Adlon, Rhodes, Sunovion, Tris, Supernus, and Corium; received consulting fees from Arbor, Ironshore, Neos Therapeutics, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, Corium, Jazz, and Tulex Pharma; received speaker fees from Takeda/Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Tris, and Supernus; and received writing support from Takeda/Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Purdue, Rhodes, Sunovion, and Tris. Part of the material in this study was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2021 Virtual Meeting; May 17-20, 2021.

U.S. national, regional, and state-specific socioeconomic factors correlate with child and adolescent ADHD diagnoses pre-COVID-19 pandemic

Attention-deficit/hyperactivity disorder (ADHD), the most diagnosed emerging neurodevelopmental disorder in children, is a growing health crisis in the United States. Due to the potential increase in ADHD severity during and post the COVID-19 pandemic, we analyzed recent national and two state-specific ADHD data distribution among U.S. children and adolescents by investigating a broad range of socioeconomic status (SES) factors. Child and adolescent ADHD diagnosis and treatment data were parent-reported via National Survey of Children's Health (NSCH). The nationwide childhood prevalence of ADHD is 8.7%, and 62.1% of diagnosed children are taking medication. Louisiana (15.7%) has the highest percentage of children diagnosed with ADHD and California (5.6%) has the lowest, followed by Nevada (5.9%). Multiple correspondence analysis (MCA, n = 51,939) examining 30 factors highlights four areas of interest at the national and state level: race/ethnicity, financial status, family structure, and neighborhood characteristics. Positive correlations between ADHD diagnosis and unsafe school, unsafe neighborhood, and economic hardship are evident nationally and statewide, while the association between a lack of ADHD diagnosis and higher urban neighborhood amenities are evident nationally, but not in two opposing outlier states-Louisiana or Nevada. National and state-specific hierarchical analyses demonstrate significant correlations between the various SES factors and ADHD outcomes. Since the national analysis does not account for the demographic heterogeneity within regions or individual states, the U.S. should rely on comprehensive, county-specific, near real-time data reporting to effectively model and mitigate the ADHD epidemic and similar national health crises.

Elevated risk of attention deficit hyperactivity disorder (ADHD) in Japanese children with higher genetic susceptibility to ADHD with a birth weight under 2000 g

BACKGROUND

Both genetic and pre- and perinatal factors, including birth weight, have been implicated in the onset of attention deficit hyperactivity disorder (ADHD) traits among children. This study aimed to elucidate to what extent the genetic risk of ADHD moderates the association between birth weight and ADHD traits among Japanese children.

METHODS

We conducted a longitudinal birth cohort study (Hamamatsu Birth Cohort for Mother and Children Study) to investigate the association of genetic risk for ADHD and low birth weight with ADHD traits among Japanese children. Out of 1258 children, we included 796 who completed follow-ups at 8 to 9 years of age. Birth weight was categorized as <2000 g, 2000-2499 g, and ≥2500 g. Polygenic risk score for ADHD was generated using the summary data of a large-scale genome-wide association study. The Rating Scale IV (ADHD-RS) assessed ADHD traits (inattention and hyperactivity/impulsivity) based on parental reports. Following previous studies, sex, birth order of the child, gestational age at birth, mother's age at delivery, educational attainment, pre-pregnancy body mass index, pre-pregnancy or during pregnancy smoking status, alcohol consumption during pregnancy, father's age, education, and annual family income were considered as covariates. Multivariable negative binomial regression was applied to evaluate the association between birth weight and ADHD traits, while adjusting for potential covariates. The interaction term between birth weight categories and binary polygenic risk was added to the model.

RESULTS

Birth weight of 2000-2499 g was not associated with ADHD traits. Birth weight under 2000 g was significantly associated with both inattention and hyperactivity. When accounting for higher and lower genetic risk for ADHD, only those with higher genetic risk and birth weight < 2000 g were associated with inattention (rate ratio [RR] 1.56, 95% CI 1.07-2.27) and hyperactivity (RR 1.87, 95% CI 1.14-3.06).

CONCLUSIONS

Birth weight under 2000 g, together with the genetic risk of ADHD, contributes to higher levels of ADHD traits among Japanese children aged 8 to 9 years. The suggested association between low birth weight and ADHD is confined to children with a genetic susceptibility to ADHD, indicating the relevance of genetic-environmental interactions in the etiology.

Relationship Between Treatment Duration and Efficacy of Pharmacological Treatment for ADHD: A Meta-Analysis and Meta-Regression of 87 Randomized Controlled Clinical Trials

Objective: To determine the relationship between treatment duration and the efficacy of pharmacological treatment for reducing ADHD symptoms. Method: We conducted a systematic review of randomized, double-blind, placebo-controlled clinical trials investigating the efficacy of pharmacological interventions in patients with ADHD. The last bibliographic search was performed in April 15, 2019. The effect of treatment duration on efficacy was studied using meta-regression. Results: A total of 87 studies lasting from 3 to 28 weeks were included. Pharmacological treatment improved ADHD symptom severity by -7.35 points. Treatment duration did not moderate the efficacy of pharmacological treatment. Consistent results were found for psychostimulant drugs, methylphenidate, amphetamine derivatives, atomoxetine, and α2-agonists. A negative correlation was found between baseline ADHD severity efficacy (Coefficient = -.250, p = .013). Conclusion: The efficacy of pharmacological treatment for ADHD remains stable over time. A greater efficacy in more severe patients is suggested.

Association between perinatal depression and risk of attention deficit hyperactivity disorder among children: a retrospective cohort study

PURPOSE

Perinatal depression has previously been identified as a risk factor for attention deficit hyperactivity disorder (ADHD) in the offspring. Population-based studies utilizing diagnosis data are needed to better understand the relationship between these two variables. The objective of this study was to examine the association between perinatal depression and the risk of ADHD among children born during a 5 or-more-year follow-up period.

METHODS

The sample was drawn from a population-based cohort of privately insured mother-child pairs within the state of Iowa. Hazard ratios for risk of ADHD by exposure to perinatal depression were estimated using adjusted Cox proportional-hazard models.

RESULTS

Among the 5,635 mother-child pairs, 484 mothers were diagnosed with depression during the perinatal period, and 269 children were diagnosed with ADHD. After adjustment for confounders, children born to mothers with perinatal depression were over three times more likely to be diagnosed with ADHD (HR 3.16 (95% CI 2.35, 4.23)).

CONCLUSIONS

Children born to mothers with perinatal depression were found to be at increased risk of ADHD. This finding suggests that ADHD and its adverse sequelae could be mitigated by increasing maternal depression intervention efforts as well as ADHD screening and treatment efforts targeted to this vulnerable population.

Cortisol response to acute psychosocial stress in ADHD compared to conduct disorder and major depressive disorder: A systematic review

BERNHARD, A., J. S. Mayer, N. Fann, and C. M. Freitag. Cortisol response to acute psychosocial stress in ADHD compared to Conduct Disorder and Major Depressive Disorder: A systematic review. NEUROSCI BIOBEHAV REV XX(X) XXX-XXX, 2020. - Heterogeneous alterations of the cortisol stress response in Attention-deficit/hyperactivity Disorder (ADHD) were recently reported by a systematic literature review. To investigate the moderating effect of frequent psychiatric comorbidities, we systematically searched for studies on cortisol stress response to psychosocial stress in ADHD compared to Conduct Disorder (CD) and Major Depressive Disorder (MDD) following PRISMA guidelines. EBSCOhost and PubMed databases were searched in July 2020, employing relevant keywords. Nineteen studies met inclusion criteria. While blunted cortisol stress response was consistently reported in individuals with CD and/or Oppositional Defiant Disorder (ODD), alterations of cortisol stress response were less pronounced in ADHD. Consistently blunted cortisol stress response in ADHD was only found in children with comorbid CD/ODD. Results on cortisol stress response in children and adolescents with MDD were mixed, and no indication for influence of comorbid MDD on cortisol stress response in ADHD was found. Taken together, altered cortisol stress response in ADHD is driven by comorbidity with disruptive behavior disorders. Limitations of previous research and suggestions for future studies are discussed.

Prevalence of ADHD and Its Comorbidities in a Population-Based Sample

Objective: We aimed to investigate the prevalence of ADHD and its comorbidities and some associated demographic factors in a large sample population-based study. Method: As part of a population-based survey among 30,532 children and adolescents between 6 and 18 years, we used K-SADS-PL to screen and detect ADHD and its comorbidities. Results: The prevalence of ADHD was 4%, with more prevalence among boys (5.2% vs. 2.7%), younger participants, urban residents, and offspring of mothers who had a history of psychiatric hospitalization. Anxiety disorders (37.9%) and behavioral disorders (31%) are the most prevalent group of comorbidities, and oppositional defiant disorder (ODD) is the most prevalent comorbid disorder (26.1%). Mood disorders and anxiety disorders are more common among girls, but conduct disorder has a higher rate among boys. Conclusion: ADHD is a common neurodevelopmental disorder which is accompanied by several comorbid conditions. The high rate of comorbidities makes it complicated and difficult to manage.

Vitamin D levels in children with attention deficit hyperactivity disorder: Association with seasonal and geographical variation, supplementation, inattention severity, and theta:beta ratio

We examined seasonal and geographic effects on vitamin D [25(OH)D] levels, association with attention-deficit/hyperactivity disorder (ADHD) symptom severity, and effects of supplementation in 222 children age 7-10 with rigorously diagnosed ADHD. 25(OH)D insufficiency rates were 47.2 % in Ohio and 28.5 % 400 miles south in North Carolina. Nadir of 25(OH)D levels was reached by November in Ohio, not until January in NC. Thirty-eight children with insufficiency/deficiency took vitamin D (1000-2000 IU/day for a month); levels rose 52 %. Although inattention did not correlate with 25(OH)D at screen nor improve significantly with supplementation, inattention improvement after supplementation correlated with 25(OH)D increase (rho = 0.41, p = 0.012). A clinically significant proportion of children with ADHD have insufficient 25(OH)D even at summer's end, more so in the winter and north of the 37th parallel. The significant correlation of inattention improvement with 25(OH)D increase suggests further research on 25(OH)D as ADHD treatment.

Global Economic Burden of Attention-Deficit/Hyperactivity Disorder: A Systematic Review

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children and adults. Previous systematic reviews have provided estimates of ADHD-associated costs but were limited to the USA and Europe.

OBJECTIVES

This study aimed to systematically summarise all global evidence on the economic burden of ADHD.

METHODS

A systematic search for published studies on costs of ADHD was conducted in EconLit, EMBASE, PubMed, ERIC, and PsycINFO. Additional literature was identified by searching the reference lists of eligible studies. The quality of the studies was assessed using the Larg and Moss checklist.

RESULTS

This review included 44 studies. All studies were conducted in high-income countries and were limited to North America and Europe except for four studies: two in Asia and two in Australia. Most studies were retrospective and undertook a prevalence-based study design. Analysis revealed a substantial economic impact associated with ADHD. Estimates based on total costs ranged from $US831.38 to 20,538 for per person estimates and from $US356 million to 20.27 billion for national estimates. Estimates based on marginal costs ranged from $US244.15 to 18,751.00 for per person estimates and from $US12.18 million to 141.33 billion for national estimates. Studies that calculated economic burden across multiple domains of direct, indirect, and education and justice system costs for both children and adults with ADHD reported higher costs and translated gross domestic product than did studies that captured only a single domain or age group.

CONCLUSIONS

Despite the wide variation in methodologies in studies reviewed, the literature suggests that ADHD imposes a substantial economic burden on society. There is a dire need for cost-of-illness research in low- and middle-income countries to better inform the treatment and management of ADHD in these countries. In addition, guidelines on the conduct and reporting of economic burden studies are needed as they may improve standardisation of cost-of-illness studies.

Effectiveness of a digital therapeutic as adjunct to treatment with medication in pediatric ADHD

STARS-Adjunct was a multicenter, open-label effectiveness study of AKL-T01, an app and video-game-based treatment for inattention, as an adjunct to pharmacotherapy in 8-14-year-old children with attention-deficit/hyperactivity disorder (ADHD) on stimulant medication (n = 130) or not on any ADHD medication (n = 76). Children used AKL-T01 for 4 weeks, followed by a 4-week pause and another 4-week treatment. The primary outcome was change in ADHD-related impairment (Impairment Rating Scale (IRS)) after 4 weeks. Secondary outcomes included changes in IRS, ADHD Rating Scale (ADHD-RS). and Clinical Global Impressions Scale-Improvement (CGI-I) on days 28, 56, and 84. IRS significantly improved in both cohorts (On Stimulants: -0.7, p < 0.001; No Stimulants: -0.5, p < 0.001) after 4 weeks. IRS, ADHD-RS, and CGI-I remained stable during the pause and improved with a second treatment period. The treatment was well-tolerated with no serious adverse events. STARS-Adjunct extends AKL-T01's body of evidence to a medication-treated pediatric ADHD population, and suggests additional treatment benefit.

Psychiatric Disabilities and Other Long-term Consequences of Childhood Bacterial Meningitis

BACKGROUND

Bacterial meningitis is known to cause hearing impairments and neurologic deficits; however, less is known regarding psychiatric disabilities. In this study, we assessed psychiatric disabilities and other long-term consequences of childhood bacterial meningitis.

METHODS

From a previously validated dataset, we selected children having had bacterial meningitis. We then reviewed medical records and child health records from discharge onwards to identify disabilities. We calculated the occurrence of disabilities with a 95% confidence interval (CI), and we used a χ test to assess possible individual risk factors associated with occurrence of disabilities.

RESULTS

Of the 80 children included in this study, permanent disabilities not attributed to preexisting diseases were noted in 56% (CI: 45-67) during the mean observation period of 19 years and 2 months. Psychiatric disease was diagnosed in 30% (CI: 21-41), and another 5% (CI: 2-13) were under ongoing investigations for symptoms of psychiatric disease. Hearing impairments affected at least 30% (CI: 20-40), and neurologic deficits affected at least 23% (CI: 15-34). While other disabilities were often detected within the first year, psychiatric disabilities were detected after a mean time period of 14 years (CI: 11:1-16:11). Although some associations were noted, no individual risk factor was able to predict the occurrence of disabilities.

CONCLUSIONS

Psychiatric disabilities affect more than one-third of survivors and are among the most common long-term consequence of childhood bacterial meningitis. Late discovery and predictive difficulties call for a revision of current guidelines to include a specific long-term strategy for detecting psychiatric disabilities.

Medical Costs and Productivity Loss Due to Mild, Moderate, and Severe Asthma in the United States

Background

Little is known about economic and productivity loss by severity of asthma. We investigate health-care utilization, direct medical costs, and indirect costs due to productivity loss from asthma by severity.

Methods

We conducted a cross-sectional analysis of the Medical Expenditure Panel Survey database (2010–2017) of patients with asthma aged ≥12 years and categorized them into mild, moderate, and severe asthma groups based on symptom control medications. Study outcomes included health-care utilization, direct medical costs, and indirect costs of asthma-related absenteeism. We used zero-inflated Poisson regression models to estimate incremental health-care utilization and generalized linear models to estimate incremental annual direct medical costs compared to patients without asthma.

Results

An estimated 139 million persons had an asthma diagnosis. Of patients with asthma, 77.1%, 22.2%, and 0.7% had mild, moderate, and severe asthma, respectively. Compared to patients without asthma, patients with asthma had incremental mean differences of 4.16 outpatient visits, 0.18 emergency department visits, and 0.07 hospitalizations per year. Annual direct medical costs were significantly associated with asthma severity ($3305 in mild, $7250 in moderate, and $9175 in severe asthma) (P < 0.05). Patients with mild, moderate, and severe asthma reported 0.76, 2.31, and 7.19 missed work or school days, resulting in $106, $321, and $1000 indirect costs per person per year, respectively.

Conclusion

Asthma-related direct and indirect costs are significantly associated with asthma severity, with severe asthma medical costs being about three times higher than mild. Controlling asthma symptoms is important to reduce the economic and social burden of asthma.

Family Burden of Raising a Child with ADHD

The purpose of the study was to estimate the burden to families of raising a child with attention-deficit/hyperactivity disorder (ADHD). Data were drawn from a longitudinal sample recruited in western Pennsylvania. When participants were between 14 and 17 years old, parents completed a questionnaire assessing economic burden over the course of raising their children. Domains of economic burden to families included direct costs related to child's behaviors (excluding treatment expenses) and indirect costs related to caregiver strain. On average, participants with ADHD incurred a total economic burden over the course of child development that was more than five times greater compared to youths without ADHD (ADHD = $15,036 per child, Control = $2,848 per child), and this difference remained significant after controlling for intellectual functioning, oppositional defiant symptoms, or conduct problems. Parents of participants with ADHD were more likely to have changed their job responsibilities or been fired and reported lower work efficiency. The current evaluation of economic burden to individual families extends previous estimates of annual societal cost of illness (COI) of ADHD. Our rough annual estimate of COI for ADHD in children and adolescents is $124.5 billion (2017 US Dollars). Findings underscore the need for interventions to reduce the costly dysfunctional outcomes in families of children with ADHD.

Prenatal alcohol exposure and risk of attention deficit hyperactivity disorder in offspring: A retrospective analysis of the millennium cohort study

OBJECTIVE

To investigate the relationship between prenatal maternal alcohol consumption and the risk of attention deficit hyperactivity disorder (ADHD), the strengths and difficulties questionnaire (SDQ) score and abnormal hyperactivity score in seven-year-old children.

METHODS

This study is a retrospective analysis of the Millennium Cohort Study (MCS). Questionnaires were used to gather data on gestational alcohol consumption when children were 9 months old and neurodevelopmental outcomes in offspring at 7 years of age (N = 13,004). Alcohol consumption was classified into never, light, moderate and heavy. Crude and adjusted logistic regression models were used for data analysis.

RESULTS

The total number of women who reported drinking alcohol in pregnancy (the light, moderate and heavy drinking group) was 3916 (30.1%). No significant association was found between light, moderate or heavy gestational alcohol consumption and ADHD (adjusted odds ratio [aOR] for light = 0.80, 95% confidence interval [CI] = [0.53,1.22], aOR for moderate = 0.83, [0.40, 1.74]; aOR for heavy = 1.27, [0.54, 2.98]); for abnormal SDQ score (aOR for light = 0.94, [0.78,1.13], aOR for moderate = 0.70, [0.49,1.00]; aOR for heavy = 1.08, [0.70, 1.66]); for abnormal Hyperactivity score (aOR for light = 1.02, [0.89,1.17]; aOR for moderate = 1.05, [0.82, 1.34]; aOR for heavy = 0.90, [0.62, 1.32]), in offspring.

CONCLUSION

Light, moderate or heavy antenatal alcohol consumption was not associated with an increased susceptibility to ADHD or behavioural outcomes in this study. However, due to the limited number of cases we cannot rule out an increased risk of ADHD in relation to heavy alcohol consumption.

Economic Burden and Disability-Adjusted Life Years (DALYs) of Attention Deficit/Hyperactivity Disorder

Objective: We investigated the economic burden and disability-adjusted life years (DALYs) for attention deficit/hyperactivity disorder (ADHD) in the Republic of Korea. Method: Using the National Health Insurance Service claims data for the population aged 19 years or younger, a prevalence-based approach was used to calculate the DALYs of ADHD. Direct medical costs, direct nonmedical costs, and indirect costs resulting from ADHD were estimated to calculate the economic burden of ADHD. Results: A total of 69,353 people in Korea were diagnosed with ADHD in 2012. The burden of ADHD as measured by the prevalence-based approach was 32,605 DALYs. The total economic burden of ADHD was US$47.55 million, which accounted for approximately 0.004% of Korean GDP (gross domestic product) in 2012. Conclusion: Our findings shed light on the considerable burden of ADHD, emphasizing the need for policies that can encourage ADHD treatment and enhance compliance.

Association Between Maternal Exposure to Magnetic Field Nonionizing Radiation During Pregnancy and Risk of Attention-Deficit/Hyperactivity Disorder in Offspring in a Longitudinal Birth Cohort

IMPORTANCE

An association between maternal exposure to magnetic field (MF) nonionizing radiation during pregnancy and the risk of attention-deficit/hyperactivity disorder (ADHD) has been reported in both animal and human studies.

OBJECTIVES

To determine whether maternal exposure to high levels of MF nonionizing radiation is associated with an increased risk of ADHD in offspring by using more accurate measurements of MF nonionizing radiation levels and physician-diagnosed ADHD, rather than self-reports, and to determine whether the association differs for the subtypes of ADHD with or without immune-related comorbidities.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal birth cohort study was conducted at Kaiser Permanente Northern California among 1482 mother-child pairs whose mothers were participants of an existing birth cohort and whose level of exposure to MF nonionizing radiation was captured during pregnancy in 2 studies conducted from October 1, 1996, to October 31, 1998, and from May 1, 2006, to February 29, 2012. The offspring were followed up from May 1, 1997, to December 31, 2017.

EXPOSURE

All participating women wore a monitoring meter for 24 hours during pregnancy to capture the level of exposure to MF nonionizing radiation from any sources.

MAIN OUTCOMES AND MEASURES

Physician-diagnosed ADHD and immune-related comorbidities of asthma or atopic dermatitis up to 20 years of age in offspring captured in the Kaiser Permanente Northern California electronic medical record from May 1, 1997, to December 31, 2017. Confounders were ascertained during in-person interviews during pregnancy.

RESULTS

Among the 1454 mother-child pairs (548 white [37.7%], 110 African American [7.6%], 325 Hispanic [22.4%], 376 Asian or Pacific Islander [25.9%], and 95 other or unknown [6.5%]; mean [SD] maternal age, 31.4 [5.4] years]), 61 children (4.2%) had physician-diagnosed ADHD. Using Cox proportional hazards regression to account for follow-up time and confounders, compared with children whose mothers had a low level of exposure to MF nonionizing radiation during pregnancy, children whose mothers were exposed to higher levels of MF nonionizing radiation had more than twice the risk of ADHD (adjusted hazard ratio [aHR], 2.01; 95% CI, 1.06-3.81). The association was stronger for ADHD that persisted into adolescence (≥12 years of age), with an aHR of 3.38 (95% CI, 1.43-8.02). When the subtypes of ADHD were examined, the association existed primarily for ADHD with immune-related comorbidities (asthma or atopic dermatitis), with an aHR of 4.57 (95% CI, 1.61-12.99) for all ADHD cases and an aHR of 8.27 (95% CI, 1.96-34.79) for persistent cases of ADHD.

CONCLUSIONS AND RELEVANCE

Consistent with the emerging literature, this study suggests that in utero exposure to high levels of MF nonionizing radiation was associated with an increased risk of ADHD, especially ADHD with immune-related comorbidity. The findings should spur more research to examine the biological association of in utero MF exposure with risk of ADHD in offspring, given that almost everyone is exposed to it.

Towards a fuller assessment of the economic benefits of reducing air pollution from fossil fuel combustion: Per-case monetary estimates for children's health outcomes

BACKGROUND

Impacts on children's health are under-represented in benefits assessments of policies related to ambient air quality and climate change. To complement our previous compilation of concentration-response (C-R) functions for a number of children's health outcomes associated with air pollution, we provide per-case monetary estimates of the same health outcomes.

OBJECTIVES

Our goal was to establish per-case monetary estimates for a suite of prevalent children's health outcomes (preterm birth, low birth weight, asthma, autism spectrum disorder, attention-deficit/hyperactivity disorder, and IQ reduction) that can be incorporated into benefits assessments of air pollution regulations and climate change mitigation policies.

METHODS

We conducted a systematic review of the literature published between January 1, 2000 and June 30, 2018 to identify relevant economic costs for these six adverse health outcomes in children. We restricted our literature search to studies published in the U.S., with a supplemental consideration of studies from the U.K. and prioritized literature reviews with summary cost estimates and papers that provided lifetime cost of illness estimates.

RESULTS

Our literature search and evaluation process reviewed 1065 papers and identified 12 most relevant papers on per-case monetary estimates for preterm birth, low birth weight, asthma, autism spectrum disorder, and attention-deficit/hyperactivity disorder. Details are presented in full. We separately identified estimates of the lost lifetime earnings associated with the loss of a single IQ point. The final per-case cost estimates for each outcome were selected based on the most robust evidence. These estimates range from $23,573 for childhood asthma not persisting into adulthood to $3,109,096 for a case of autism with a concurrent intellectual disability.

CONCLUSION

To our knowledge, this is the first time that the child-specific health outcomes of preterm birth, low birth weight, asthma, autism spectrum disorder, attention-deficit/hyperactivity disorder, and IQ reduction have been systematically valued and presented in one place. This is an important addition to the body of health-related valuation literature as these outcomes have substantial economic costs that are not considered in most assessments of the benefits of air pollution and climate mitigation policies. In general, however, the available per-case estimates presented here did not incorporate the broad societal and long-term costs and are likely underestimates. Although our context has been air pollution and climate policies, the per-case monetary estimates presented here can be applied to other environmental exposures. Fuller assessments of health benefits to children and their corresponding economic gains will improve decision-making on environmental policy.

A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is a common paediatric neurodevelopmental disorder with substantial effect on families and society. Alternatives to traditional care, including novel digital therapeutics, have shown promise to remediate cognitive deficits associated with this disorder and may address barriers to standard therapies, such as pharmacological interventions and behavioural therapy. AKL-T01 is an investigational digital therapeutic designed to target attention and cognitive control delivered through a video game-like interface via at-home play for 25 min per day, 5 days per week for 4 weeks. This study aimed to assess whether AKL-T01 improved attentional performance in paediatric patients with ADHD.

METHODS

The Software Treatment for Actively Reducing Severity of ADHD (STARS-ADHD) was a randomised, double-blind, parallel-group, controlled trial of paediatric patients (aged 8-12 years, without disorder-related medications) with confirmed ADHD and Test of Variables of Attention (TOVA) Attention Performance Index (API) scores of -1·8 and below done by 20 research institutions in the USA. Patients were randomly assigned 1:1 to AKL-T01 or a digital control intervention. The primary outcome was mean change in TOVA API from pre-intervention to post-intervention. Safety, tolerability, and compliance were also assessed. Analyses were done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02674633 and is completed.

FINDINGS

Between July 15, 2016, and Nov 30, 2017, 857 patients were evaluated and 348 were randomly assigned to receive AKL-T01 or control. Among patients who received AKL-T01 (n=180 [52%]; mean [SD] age, 9·7 [1·3] years) or control (n=168 [48%]; mean [SD] age, 9·6 [1·3] years), the non-parametric estimate of the population median change from baseline TOVA API was 0·88 (95% CI 0·24-1·49; p=0·0060). The mean (SD) change from baseline on the TOVA API was 0·93 (3·15) in the AKL-T01 group and 0·03 (3·16) in the control group. There were no serious adverse events or discontinuations. Treatment-related adverse events were mild and included frustration (5 [3%] of 180) and headache (3 [2%] of 180). Patient compliance was a mean of 83 (83%) of 100 expected sessions played (SD, 29·2 sessions).

INTERPRETATION

Although future research is needed for this digital intervention, this study provides evidence that AKL-T01 might be used to improve objectively measured inattention in paediatric patients with ADHD, while presenting minimal adverse events.

FUNDING

Sponsored by Akili Interactive Labs.

Non-pharmacologic management of attention-deficit/hyperactivity disorder in children and adolescents: a review

Attention-deficit/hyperactivity disorder (ADHD) is a very common neurobehavioral disorder that affects children and adolescents with impact that persists beyond adolescence into adulthood. Medication and non-pharmacological treatments are evidence-based interventions for ADHD in various age groups, and this article will elaborate on the psychosocial, physical and integrative medicine interventions that have been studied in ADHD.

ADHD symptoms induced by prenatal methamphetamine exposure

Methamphetamine is commonly used psychostimulant in the Czech Republic and is often abused by pregnant women. Methamphetamine may cause abnormalities in placenta and umbilical cord that results in hypoxia and malnutrition. ADHD is a mental disorder with a heterogeneous origin. The number of patients suffering from ADHD is growing. The pathophysiological mechanisms causing ADHD have not yet been clarified. There are very few rat models for ADHD and include genetic models, chemically induced models (ethanol, nicotine, PCBs, 6-hydroxydopamine lesion) or environmentally induced models (anoxia). The aim of the present study was to test prenatal methamphetamine exposure (5 mg/kg) as a potential novel animal model for ADHD. We found that adult male offspring prenatally exposed to methamphetamine presented hyperactivity while exploring novel environments. Together with cognition changes found in our previous studies, these might represent symptoms similar to those seen in ADHD. More experiments are planned to investigate our hypothesis.

Prenatal pet keeping and caregiver-reported attention deficit hyperactivity disorder through preadolescence in a United States birth cohort

BACKGROUND

While the keeping of pets has been shown to protect against childhood allergic disease and obesity, less is known regarding potential associations of prenatal pet keeping and attention deficit hyperactivity disorder (ADHD). We sought to examine the associations between prenatal dog or cat keeping with caregiver-reported ADHD in preadolescents in the Wayne County Health, Environment, Allergy and Asthma Longitudinal Study (WHEALS) birth cohort (N = 1258).

METHODS

At an interview with the caregiver at child age 10-12 years, caregivers reported if the WHEALS child had ever been diagnosed with ADHD. Similarly, during an interview with the mother prenatally, pet keeping (defined as dog or cat kept inside ≥1 h/day) was ascertained. Logistic regression models were fit to examine the association of prenatal pet keeping (dog keeping and cat keeping, separately) with ADHD.

RESULTS

A subset of 627 children were included in the analyses: 93 who had ADHD and 534 with neurotypical development. After accounting for confounders and loss to follow-up, maternal prenatal dog exposure was associated with 2.23 times (95% CI: 1.15, 4.31; p = 0.017) greater odds of ADHD among boys. Prenatal dog keeping was not statistically significantly associated with ADHD in girls (odds ratio = 0.27, 95% CI: 0.06, 1.12; p = 0.070). Prenatal cat keeping was not associated with ADHD.

CONCLUSIONS

In boys, but not girls, maternal prenatal dog keeping was positively associated with ADHD. Further study to confirm these findings and to identify potential mechanisms of this association (e.g., modification of the gut microbiome, exposure to environmental toxicants or pet-related medications) is needed.

A Virtual Resiliency Intervention Promoting Resiliency for Parents of Children with Learning and Attentional Disabilities: A Randomized Pilot Trial

OBJECTIVES

One in five children have a learning and attentional disability (LAD). Parents of children with LAD are vulnerable to distress, but an evidence-based treatment has not been developed.

METHODS

From June 2016 to November 2017, we conducted a mixed methods study to adapt and assess the virtual delivery of a mind-body group resiliency program, the Stress Management and Resiliency Training-Relaxation Response Resiliency Program (SMART-3RP), to meet the needs of parents of children with LAD; this is an 8-session weekly group intervention. In the first phase, we conducted 4 parent focus group interviews, 2 professional focus group interviews, and 5 professional individual interviews, and 1 pilot group to adapt the SMART-3RP to target the needs of parents of children with LAD. In the second phase, we conducted a pilot wait-list controlled study to assess the feasibility, acceptability, and preliminary efficacy of a videoconferencing delivery of the adapted program. Parents were randomized to an immediate intervention group (IG) or wait-list control group (WC). Surveys were administered at baseline (time 1), end of intervention for the IG or 3 months post-baseline for the WC (time 2), and 3 months post treatment for the IG or end of intervention for the WC (time 3).

RESULTS

Qualitative findings illustrated high levels of parental stress, with primary stressors including navigating the educational system, interactions with other parents, familial concerns, and financial and professional sacrifices. We adapted the manual to target these stressors and modified session logistics and delivery. Fifty-three parents (mean age = 46.8; 90.6% female) participated nationally in the pilot trial. 62.5% of participants completed ≥ 6/8 sessions; 81.8% reported continued daily/weekly relaxation response exercise practice. T1-T2 comparisons found that IG versus WC participants showed significant improvements in distress [VAS], ∆M = - 1.95; d = .83 and resilience [CES], ∆M = 6.38; d = .83, as well as stress coping [MOCS-A] ∆M = 8.69; d = 1.39; depression and anxiety [PHQ-4], ∆M = - 1.79; d = .71; social support [MOS-SSS], ∆M = 5.47; d = .71; and empathy [IRI], ∆M = 3.17; d = .77; improvements were sustained at the 3 month post intervention follow-up.

CONCLUSION

Pilot wait-list randomized trial findings showed promising feasibility, acceptability, and preliminary efficacy for the SMART-3RP intervention adapted for parents of children with LAD. This virtually-delivered resiliency intervention improved parents' distress, resiliency, and stress coping, which were sustained.

CLINICAL TRIALS ID

NCT02772432.

Measurement Invariance of the ADHD Rating Scale-IV Home and School Versions Across Age, Gender, Clinical Status, and Informant

The present study aimed to investigate the measurement invariance across age, gender, clinical status, and informant of the Attention-Deficit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS-IV) Home and School versions. The participants were 1,106 Romanian children and adolescents (mean age = 12.74 years, standard deviation = 2.84, age range 6-18 years). Both parents and teachers assessed ADHD symptoms. The factorial structure of the scale was assessed using confirmatory factor analysis, and measurement invariance was assessed using multigroup confirmatory factor analysis. The results supported the reliability of the ADHD-RS-IV, with high internal consistency coefficients for both versions. Confirmatory factor analysis validated a two-factor model. Multigroup confirmatory factor analysis confirmed the measurement invariance of ADHD-RS-IV across age, gender, clinical status, and informant. ADHD-RS-IV had good psychometric properties in a sample of Romanian children and adolescents. It is a reliable instrument given its strong invariance. Implications for evidence-based assessment of ADHD are discussed.

Predictors of Burden of Care Among Caregivers of Drug-Naive Children and Adolescents With ADHD: A Cross-Sectional Correlative Study From Muscat, Oman

OBJECTIVE

the study assessed the prevalence of burden of care among caregivers of children with ADHD in Oman. A related aim is to explore the predictors of the burden of care, subtypes of ADHD, and socio-demographic factors.

METHOD

Arabic version of the Zarit Burden Interview (ZBI) was administered to 117 caregivers of drug-naive children with ADHD. Sociodemographic background and clinical data were gathered from medical records and from the attending caregivers themselves. The ADHD symptoms were grouped under three categories : hyperactive, inattentive, or mixed.

RESULTS

the prevalence of the burden of care was estimated to be 34%. Income levels and the child's ADHD diagnosis being of "mixed" type have significant impact on the burden of care.

CONCLUSION

the results of this study indicate that the prevalence of the burden of care among the caregivers of ADHD children in Oman is comparable with that in the other regions of the world.

Direct medical costs of ADHD and its comorbid conditions on basis of a claims data analysis

Background:

ADHD is a highly prevalent disease in childhood which often persists into adulthood, then co-occurring with common adult conditions. Especially for adult ADHD, little is known about the costs of ADHD and the additional costs of comorbid conditions.

Aims:

To determine medical costs of ADHD and costs of comorbidities (mood, anxiety and substance use disorders, obesity), including their co-occurrence rates, stratified by age and gender.

Method:

Claims data from a German Statutory Health Insurance database with approximately four million member-records per year were analysed. A total of 25,300 prevalent ADHD patients were identified by means of an ICD-10 GM diagnosis of ADHD. A 1:1 age and gender adjusted reference group without ADHD diagnosis was randomly selected. Total health claims and health care costs related to ADHD were analysed, in addition to more targeted analyses of the occurrence and costs of pre-defined common comorbidities of, in particular, adult ADHD (SUD, mood and anxiety disorders, obesity). Outcomes were mean costs per patient and occurrence rates of comorbid conditions. Surplus costs of a comorbid condition in persons with ADHD relative to costs of this condition in persons without ADHD were calculated. Subgroup analyses were conducted based on age (0–12 years, 13–17 years, 18–30years, 30+ years) and gender.

Results:

Patients with ADHD were €1500 more expensive annually than individuals without ADHD (p < 0.001). Main cost drivers were inpatient care, psychiatrists and psychotherapists. Mood, anxiety, substance use disorders and obesity were significantly more frequent in ADHD patients and additional costs resulting from the comorbid conditions amounted up to €2800. Costs were slightly higher in women than men and increased with age for both genders. In young adults (18–30 years) health care costs dropped notably, especially costs for the medical treatment of ADHD with stimulants and costs for psychiatrists, before rising again in the group of patients over 30 years who had higher comorbidity rates.

Conclusions:

Medical costs for ADHD are substantial, in part through frequently occurring comorbid conditions, and particularly in adulthood, and are likely to further accelerate in the coming years. A gap of care was found, starting with the transition age group of patients over 17 years, as indicated by reduced costs per person during young adulthood, as well as an overall strong drop in administrative prevalence. In the future, approaches to improve the situation of care and reduce costs at the same time, i.e. through managed care programmes, should be implemented and benefit from detailed knowledge on age and gender-specific cost-drivers.

Treatment Patterns and Costs Among Children Aged 2 to 17 Years With ADHD in New York State Medicaid in 2013

Objective: To identify children with ADHD enrolled in New York State (NYS) Medicaid and characterize ADHD-associated costs by treatment category. Method: In 2013, 1.4 million children aged 2 to 17 years were enrolled in NYS Medicaid. Medicaid claims and encounters were used to identify children with ADHD, classify them by type of treatment received, and estimate associated costs. Results: The ADHD cohort comprised 5.4% of all Medicaid-enrolled children, with 35.0% receiving medication only, 16.2% receiving psychological services only, 42.2% receiving both, and 6.6% receiving neither. The total costs for the ADHD cohort (US$729.3 million) accounted for 18.1% of the total costs for children enrolled in NYS Medicaid. Conclusion: This study underscores the importance of achieving a better understanding of children with ADHD enrolled in NYS Medicaid. A framework to categorize children with ADHD based on their treatment categories may help to target interventions to improve the quality of care and reduce costs.

Healthcare utilization and costs of children with attention deficit/hyperactivity disorder initiating atomoxetine versus extended-release guanfacine

OBJECTIVES

To compare 1-year direct healthcare costs and utilization among children and adolescents initiating non-stimulant medications atomoxetine (ATX) or extended-release guanfacine (GXR).

METHODS

In this retrospective, observational cohort study, children and adolescents aged 6-17 years with attention deficit/hyperactivity disorder (ADHD) who had ≥1 prescription claim for ATX or GXR between December 31, 2009 and January 1, 2011 were identified in the MarketScan Commercial or Multi-State Medicaid claims databases. The first claim was set as the index. Patients with no claims for other ADHD medications that overlapped with the days' supply for the index therapy during the post-period were classified as initiating monotherapy. All-cause and ADHD-related utilization and costs (2011 US$) and treatment patterns (adherence and persistence) were evaluated during the 12 months following index. Propensity score adjustment accounted for differences in patient characteristics, and bootstrapping was used for comparisons.

RESULTS

A total of 13,239 children and adolescents with ADHD met the study criteria (4,411 ATX initiators and 8,828 GXR initiators). There were 2,699 ATX monotherapy patients. In propensity-score-adjusted analyses, mean all-cause total costs were significantly less for monotherapy ATX initiators than for GXR initiators ($7,553 vs $10,639; difference = -$3,086, p < .0001), as were mean ADHD-related total costs ($3,213 vs $4,544; difference = -$1,330, p < .0001). Monotherapy ATX initiators had significantly fewer all-cause and ADHD-related total medical visits and ∼22 days shorter persistence to index therapy (p < .0001). Results were similar for secondary analyses comparing all ATX with all GXR initiators, regardless of monotherapy or combination regimen, and comparing only monotherapy initiators.

CONCLUSIONS

Children and adolescents with ADHD who initiated ATX monotherapy incurred lower all-cause and ADHD-related total healthcare costs than patients who initiated GXR. This was due in part to less healthcare resource utilization and slightly shorter persistence for ATX patients. These findings may aid decision-making and inform future studies, but must be tempered due to inherent observational research limitations.

Smoking Cessation Is Associated With Lower Indirect Costs

Objective:

This study quantified differences in indirect costs due to decreased work productivity between current and former smokers. Former smokers were further categorized by number of years since quitting to assess corresponding differences.

Methods:

Data on employed individuals were obtained from the 2013 US National Health and Wellness Survey (NHWS; N = 75,000). Indirect costs were calculated for current smokers and former smokers from weekly wages based on age and sex.

Results:

The annual total indirect costs for current smokers were $1327.53, $1560.18, and $1839.87 higher than for those who quit 0 to 4 years, 5 to 10 years, and more than or equal to 11 years prior, respectively. There were no significant differences in mean total indirect costs between the former smoker groups.

Conclusions:

Current smokers showed significantly higher total annual indirect costs compared with former smokers, independently of the number of years since quitting smoking.