Profiles of service utilization and the resultant economic impact in preschoolers with attention deficit/hyperactivity disorder

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.

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.

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.

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.

Practitioner Review: Assessment and treatment of preschool children with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) often emerges during the preschool years and remains impairing throughout the life span. Early identification and intervention may yield lasting benefits that alter the often-adverse trajectory of the disorder.

METHODS

This Practitioner Review provides up-to-date information regarding the evaluation and treatment of ADHD in preschool children. The clinical presentation of ADHD in preschool children, its persistence into later childhood, the applicability of DSM-5 criteria for preschoolers with ADHD, and early predictors of long-term trajectories are addressed, as well as current findings from randomized controlled trials of both nonpharmacological and pharmacological interventions.

RESULTS

Symptoms of hyperactivity/impulsivity extend down to age 3, but several inattention symptoms, as defined by DSM-V, less accurately differentiate preschoolers with and without ADHD. Most preschool youth with ADHD symptoms continue to manifest symptoms and impairment into school-age and adolescence. However, few predictors of persistence beyond early severity have been identified. Behavioral interventions constitute a first-line treatment for preschool ADHD symptoms, with telepsychiatry increasing in prominence to help to mitigate financial, geographic, and/or logistical barriers to care. Pharmacological interventions, particularly psychostimulants, also confer demonstrable benefits, yet efficacy and safety profiles are less desirable relative to findings in school-age youth.

CONCLUSIONS

Acute treatments have demonstrable efficacy, but do not appear to fundamentally alter underlying mechanisms or long-term trajectories.

Normative ADHD-RS-Preschool Data in a Community Sample in Spain

OBJECTIVE

The objective was to obtain normalized data from the ADHD Rating Scale-IV-Preschool Version (ADHD-RS-IV-P) in a Spanish sample.

METHOD

We translated and adapted the ADHD-RS-IV to our culture to obtain normalized data from a random representative sample of 1,426 Spanish preschool children (3 to <7 years old; 49.7% males). To analyze differences between evaluators, we used MANOVA. Internal consistency was assessed via Cronbach's alpha.

RESULTS

The mean age was 4.7 years old. There was a significant sex effect. The questionnaire had an internal consistency between .86 and .96 according to subscale and evaluator.

CONCLUSION

To evaluate ADHD in preschool children, it is necessary to use scores standardized by sex. Using a validated scale in schools and primary care centers may be useful for early detection of ADHD.

Outpatient rehabilitation resources and medical expenditure in children with attention-deficit hyperactivity disorder in Taiwan

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder in children. This study investigated the use of rehabilitation treatment in Taiwan. We selected children aged 3-12 years from the National Health Insurance Research Database from 2008 to 2012 and included them in the analysis. The children who received a diagnosis according to the International Classification of Diseases, Ninth Revision, Clinical Modification were divided into two groups: ADHD and non-ADHD. We used the chi-squared test, independent sample t test, and multiple regression analysis to conduct the analysis. The utilisation of rehabilitation resources was higher in the ADHD group than in the non-ADHD group. The number of school-aged children with ADHD was higher than the number of preschool-aged children (p < 0.001). The highest utilisation of rehabilitation resources was observed in clinics (p < 0.001). In terms of region, Taipei exhibited the highest utilisation of rehabilitation resources, and the East exhibited the lowest resource utilisation (p < 0.001). Prediction of the use of rehabilitation resources, average cost, average frequency of visits, and total annual cost was affected by factors such as the average frequency of rehabilitation use, demographic characteristics, and the hospital characteristics and location (p < 0.001). The number of children with ADHD and rehabilitation use are increasing yearly; however, limitations in payment restrict the growth of rehabilitation resource use in hospitals. Supplementation of rehabilitation resources at clinics accounts for more than 60%, however, the total annual cost is less than what is observed for hospitals (p < 0.001). Policies should be established to aid in the early detection and treatment of children with ADHD to improve treatment outcomes and reduce the family burden and treatment expenditure in the future.

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent-child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study's limitations, and future directions for research are further discussed.

Health Care Costs Associated With Parent-Reported ADHD: A Longitudinal Australian Population-Based Study

OBJECTIVE

To examine the health care costs associated with ADHD within a nationally representative sample of children.

METHOD

Data were from Waves 1 to 3 (4-9 years) of the Longitudinal Study of Australian Children ( N = 4,983). ADHD was defined by previous diagnosis and a measure of ADHD symptoms (Strengths and Difficulties Questionnaire [SDQ]). Participant data were linked to administrative data on health care costs. Analyses controlled for demographic factors and internalizing and externalizing comorbidities.

RESULTS

Costs associated with health care attendances and medications were higher for children with parent-reported ADHD at each age. Cost differences were highest at 8 to 9 years for both health care attendances and medications. Persistent symptoms were associated with higher costs ( p < .001). Excess population health care costs amounted to Aus$25 to Aus$30 million over 6 years, from 4 to 9 years of age.

CONCLUSION

ADHD is associated with significant health care costs from early in life. Understanding the costs associated with ADHD is an important first step in helping to plan for service-system changes.

Preschool Predictors of ADHD Symptoms and Impairment During Childhood and Adolescence

PURPOSE OF REVIEW

This paper summarizes key, recently published research examining longitudinal outcomes for preschoolers with high levels of inattention and/or hyperactivity/impulsivity.

RECENT FINDINGS

Symptom trajectories show that hyperactivity/impulsivity declines across childhood. At the group level, the course of inattention appears more variable. However, identification of subgroups of children showing stable, rising, and falling inattention over time is promising. Early ADHD-like symptoms portend risk for academic and social difficulties, as well as comorbid emotional and behavioral problems in childhood and adolescence. Several early risk factors appear to moderate these relations, including comorbid symptoms, parental psychopathology, socioeconomic disadvantage, and perhaps neuropsychological dysfunction. Furthermore, high levels of inattention and/or hyperactivity/impulsivity during the preschool period appear to compromise development of regulatory and neuropsychological functions, which in turn increases risk for negative outcomes later in childhood. Identified risk factors are targets for novel interventions, which ideally would be delivered early to at-risk children.

Psychomotor development and learning difficulties in preschool children with probable attention deficit hyperactivity disorder: An epidemiological study in Navarre and La Rioja

INTRODUCTION

ADHD symptoms begin to appear at preschool age. ADHD may have a significant negative impact on academic performance. In Spain, there are no standardized tools for detecting ADHD at preschool age, nor is there data about the incidence of this disorder.

OBJECTIVE

To evaluate developmental factors and learning difficulties associated with probable ADHD and to assess the impact of ADHD in school performance.

METHODS

We conducted a population-based study with a stratified multistage proportional cluster sample design.

RESULTS

We found significant differences between probable ADHD and parents' perception of difficulties in expressive language, comprehension, and fine motor skills, as well as in emotions, concentration, behaviour, and relationships. Around 34% of preschool children with probable ADHD showed global learning difficulties, mainly in patients with the inattentive type. According to the multivariate analysis, learning difficulties were significantly associated with both delayed psychomotor development during the first 3 years of life (OR: 5.57) as assessed by parents, and probable ADHD (OR: 2.34) CONCLUSIONS: There is a connection between probable ADHD in preschool children and parents' perception of difficulties in several dimensions of development and learning. Early detection of ADHD at preschool ages is necessary to start prompt and effective clinical and educational interventions.

Behavioral and Academic Progress of Children Displaying Substantive ADHD Behaviors in Special Education: A 1-Year Follow-up

OBJECTIVE

Exploring differences in behavioral and academic progress between children displaying substantive ADHD behaviors (M age of 9.4 years) in special schools (n = 38) and in inclusive education (n = 26). The contribution of pedagogical strategies to positive outcomes was also examined.

METHOD

Measurements used were the Teachers' Report Form, the Social Emotional Questionnaire, assessments of academic achievement, and the Pedagogical Methods Questionnaire. Mixed-model ANOVAs and Pearson's correlations were used to analyze the data.

RESULTS

Significant progress was found regarding disorder-specific problem behavior and in all academic areas, but no interaction effect was found between time and setting. Correlations indicated that positive behavior reinforcement and emotional support are the pedagogical strategies that contributed most to behavioral adaptation.

CONCLUSION

Children displaying substantive ADHD behaviors in both groups develop equally well in the areas of behavioral and academic functioning where significant progress was found.

Preschool hyperactivity is associated with long-term economic burden: evidence from a longitudinal health economic analysis of costs incurred across childhood, adolescence and young adulthood

BACKGROUND

Preschool hyperactivity is an early risk factor for adult mental health problems and criminality. Little is known about; (a) the patterns of long-term service costs associated with this behavioural marker in the general population and (b) the specific factors predicting hyperactivity-related costs. We undertook a prospective study investigating associations between preschool hyperactivity and average individual annual service costs up to late adolescent and young adulthood.

METHODS

One-hundred and seventy individuals rated as hyperactive by their parents and 88 nonhyperactive controls were identified from a community sample of 4,215 three years olds. Baseline information about behaviour/emotional problems and background characteristics were collected. At follow-up (when individuals were aged between 14 and 25 years) information was obtained on service use, and associated costs since the age of three. Based on this information we calculated the average cost per annum incurred by each individual.

RESULTS

Compared to controls, preschoolers with hyperactivity had 17.6 times higher average costs per annum across domains (apart from nonmental health costs). These were £562 for each hyperactive individual compared with £30 for controls. Average annual costs decreased as a function of age, with higher costs incurred at younger ages. The effects of hyperactivity remained significant when other baseline factors were added to the model. Effects were fully mediated by later psychiatric morbidity. When the hyperactive group were examined separately, costs were consistently predicted by male gender and, for some cost codes, by conduct problems.

CONCLUSIONS

Preventative approaches targeting early hyperactivity may be of value. Services should be targeted towards high-risk individuals with careful consideration given to the cost-to-benefit trade-off of early intervention strategies.

Impact of occupational, physical, and speech and language therapy in preschoolers with hyperactive/inattentive symptoms: A naturalistic 2-year follow-up study

OBJECTIVE

Impact of speech and language therapy (ST) and occupational/physical therapy (OT/PT) on language and motor skills was examined in hyperactive/inattentive children.

METHODS

Preschoolers were divided into those receiving and not receiving ST or OT/PT.

RESULTS

Children receiving ST showed no gains in language functioning relative to those not receiving ST. OT/PT yielded similar results for motor functions. Hours of a service did not predict improvement. However, children who received ST showed improvement in social skills.

DISCUSSION

The apparent lack of benefit suggests the need for further investigation into efficacy of these treatments in hyperactive/inattentive preschool children.

Diagnosing attention-deficit hyperactivity disorder (ADHD) in children involved with child protection services: are current diagnostic guidelines acceptable for vulnerable populations?

Children involved with child protection services (CPS) are diagnosed and treated for attention-deficit hyperactivity disorder (ADHD) at higher rates than the general population. Children with maltreatment histories are much more likely to have other factors contributing to behavioural and attentional regulation difficulties that may overlap with or mimic ADHD-like symptoms, including language and learning problems, post-traumatic stress disorder, attachment difficulties, mood disorders and anxiety disorders. A higher number of children in the child welfare system are diagnosed with ADHD and provided with psychotropic medications under a group care setting compared with family-based, foster care and kinship care settings. However, children's behavioural trajectories change over time while in care. A reassessment in the approach to ADHD-like symptoms in children exposed to confirmed (or suspected) maltreatment (e.g. neglect, abuse) is required. Diagnosis should be conducted within a multidisciplinary team and practice guidelines regarding ADHD diagnostic and management practices for children in CPS care are warranted both in the USA and in Canada. Increased education for caregivers, teachers and child welfare staff on the effects of maltreatment and often perplexing relationship with ADHD-like symptoms and co-morbid disorders is also necessary. Increased partnerships are needed to ensure the mental well-being of children with child protection involvement.

Annual research review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders

BACKGROUND

Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses.

SCOPE AND METHODS

The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012.

FINDINGS

Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8).

CONCLUSION

Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.

Neuropsychological functioning and severity of ADHD in early childhood: a four-year cross-lagged study

Children with attention deficit/hyperactivity disorder (ADHD) have poorer neuropsychological functioning relative to their typically developing peers. However, it is unclear whether early neuropsychological functioning predicts later ADHD severity and/or the latter is longitudinally associated with subsequent neuropsychological functioning; and whether these relations are different in children with and without early symptoms of ADHD. This study aimed to examine the longitudinal associations between ADHD severity and neuropsychological functioning among children at high and low risk of developing ADHD. Hyperactive/Inattentive (H/I; n = 140) and Typically developing (TD; n = 76) preschoolers (age 3-4 years) were recruited (BL) and followed annually for 3 years (F1, F2, and F3). Teachers rated the children's ADHD severity and impairment using the Behavior Assessment System for Children-2 and the Children's Problem Checklist, respectively. Parent reports of children's ADHD severity were obtained using the Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and Lifetime version. Neuropsychological functioning was assessed using the NEPSY. In the full sample, there were bidirectional longitudinal associations between neuropsychological functioning and ADHD severity between F1 and F3. Among H/I children, neuropsychological functioning at F1 and F2 predicted ADHD severity at F2 and F3, respectively. In contrast, among TD children the only significant relationship observed was that elevated ADHD symptoms at F2 were associated with poorer neuropsychological functioning at F3. Improved neuropsychological functioning may attenuate ADHD symptoms and associated impairment among H/I children during the early school years. Interventions designed to improve neuropsychological functioning among young H/I children may be beneficial in reducing their ADHD severity.

ADHS im Vorschulalter

Aktivitäts- und Aufmerksamkeitsstörungen (ADHS) im Vorschulalter sind der ADHS im Grundschulalter bezüglich Erscheinungsbild und Komorbiditäten teils ähnlich und teils unähnlich. Zudem ergeben sich besondere Herausforderungen hinsichtlich der Diagnostik und Behandlung u. a. aufgrund altersabhängiger Diagnosekriterien, einer schwierigen Unterscheidung von altersadäquatem und abweichendem Verhalten und erhöhten Nebenwirkungen bei der medikamentösen Behandlung. Daher werden in diesem Übersichtsartikel Subtypen und Komorbiditäten von ADHS, für den klinischen Gebrauch geeignete Diagnostikinstrumente sowie gezielte Behandlungsansätze, insbesondere Elterntrainings und Medikation, genauer betrachtet.

Association between variation in neuropsychological development and trajectory of ADHD severity in early childhood

OBJECTIVE

This longitudinal study examined if changes in neuropsychological functioning were associated with the trajectory of symptoms related to attention deficit hyperactivity disorder (ADHD) and impairment between preschool and school age.

METHOD

The sample consisted of 3- and 4-year-old children (N=138) who were identified as being at risk for ADHD based on parent and teacher reports. Neuropsychological functioning was measured annually using the NEPSY at four time points (mean ages, 4.19, 5.36, 6.35, and 7.35 years). ADHD symptoms and impairment were assessed with semiannual parent and teacher reports using the ADHD Rating Scale-IV and the Children's Problems Checklist at 10 time points (mean ages at baseline and final assessment, 4.19 and 8.81 years, respectively). Hierarchical linear modeling was used to assess the trajectories of change in neuropsychological functioning and ADHD severity as well as the association of change in neuropsychological functioning with change in ADHD severity over time.

RESULTS

Baseline neuropsychological functioning was not significantly associated with the slope of change in ADHD severity. However, the magnitude of change in neuropsychological functioning was linearly associated with the trajectory of ADHD symptom severity and impairment, such that individuals with greater neuropsychological growth over time had a greater diminution of ADHD severity and impairment. Family socioeconomic status at baseline was significantly associated with initial ADHD severity and impairment, but not with change over time.

CONCLUSIONS

Interventions that enhance neuropsychological functioning at an early age may be beneficial in attenuating long-term ADHD severity and impairment.

Social and emotional difficulties in children with ADHD and the impact on school attendance and healthcare utilization

BACKGROUND

The objective of this study was to examine the impact of co-occurring social and emotional difficulties on missed school days and healthcare utilization among children with attention deficit/hyperactivity disorder (ADHD).

METHODS

Data were from the 2007 U.S. National Health Interview Survey (NHIS) and were based on parental proxy responses to questions in the Sample Child Core, which includes questions on demographics, health, healthcare treatment, and social and emotional status as measured by questions about depression, anxiety, and phobias, as well as items from the brief version of the Strength and Difficulties Questionnaire (SDQ). Logistic regression was used to assess the association between co-occurring social and emotional difficulties with missed school days and healthcare utilization, adjusting for demographics.

RESULTS

Of the 5896 children aged 6-17 years in the 2007 NHIS, 432 (7.3%) had ADHD, based on parental report. Children with ADHD and comorbid depression, anxiety, or phobias had significantly greater odds of experiencing > 2 weeks of missed school days, ≥ 6 visits to a healthcare provider (HCP), and ≥ 2 visits to the ER, compared with ADHD children without those comorbidities (OR range: 2.1 to 10.4). Significantly greater odds of missed school days, HCP visits, and ER visits were also experienced by children with ADHD who were worried, unhappy/depressed, or having emotional difficulties as assessed by the SDQ, compared with ADHD children without those difficulties (OR range: 2.2 to 4.4).

CONCLUSIONS

In children with ADHD, the presence of social and emotional problems resulted in greater odds of missed school days and healthcare utilization. These findings should be viewed in light of the limited nature of the parent-report measures used to assess social and emotional problems.

Economic impact of childhood and adult attention-deficit/hyperactivity disorder in the United States

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent mental disorders in children in the United States and often persists into adulthood with associated symptomatology and impairments. This article comprehensively reviews studies reporting ADHD-related incremental (excess) costs for children/adolescents and adults and presents estimates of annual national incremental costs of ADHD.

METHOD

A systematic search for primary United States-based studies published from January 1, 1990 through June 30, 2011 on costs of children/adolescents and adults with ADHD and their family members was conducted. Only studies in which mean annual incremental costs per individual with ADHD above non-ADHD controls were reported or could be derived were included. Per-person incremental costs were adjusted to 2010 U.S. dollars and converted to annual national incremental costs of ADHD based on 2010 U.S. Census population estimates, ADHD prevalence rates, number of household members, and employment rates by age group.

RESULTS

Nineteen studies met the inclusion criteria. Overall national annual incremental costs of ADHD ranged from $143 to $266 billion (B). Most of these costs were incurred by adults ($105 B-$194 B) compared with children/adolescents ($38 B-$72 B). For adults, the largest cost category was productivity and income losses ($87 B-$138 B). For children, the largest cost categories were health care ($21 B-$44 B) and education ($15 B-$25 B). Spillover costs borne by the family members of individuals with ADHD were also substantial ($33 B-$43 B).

CONCLUSION

Despite a wide range in the magnitude of the cost estimates, this study indicates that ADHD has a substantial economic impact in the United States. Implications of these findings and future directions for research are discussed.

A systematic review of global publication trends regarding long-term outcomes of ADHD

There is increased global recognition of attention deficit hyperactivity disorder (ADHD) as a serious medical condition with long-term consequences. Although originally conceived of as a childhood disorder, ADHD is being increasingly recognized in adults. Individual geographic regions may have specific interests and objectives for the study of ADHD. A systematic review of long-term outcomes (LTOs) in ADHD was conducted to evaluate research on ADHD LTOs on a global scale. Studies that were at least 2 years in duration were examined. A total of 351 studies were identified in the final analysis. We identified nine outcomes of interest and classified studies by specific geographical regions, age groups studied and study design by region and over time. Published studies of LTOs in ADHD have increased in all geographical regions over the past three decades, with a peak number of 42 publications in 2008. This rise in publications on ADHD LTOs may reflect a rise in global interest and recognition of consequences and impairment associated with ADHD. Although many world regions have published on ADHD LTOs, the majority of studies have emerged from the US and Canada, followed by Europe. While investigators in the US and Canada were predominantly interested in drug addiction as a LTO, European researchers were more interested in antisocial behavior, and Eastern Asian investigators focused on both of these LTOs as well as self-esteem. Geographical differences in the focus of ADHD LTO studies may reflect regional variations in cultural values. Proportionally fewer prospective longitudinal studies and proportionally more retrospective and cross-sectional studies have been published in more recent decades. Finally, more studies focusing on ADHD in adolescents and adults have been conducted in recent years, and particularly adolescents in Eastern Asia. These changes in basic study design may reflect an increase in the recognition that ADHD is a lifetime chronic disorder. This systematic review analysis of publication trends in ADHD LTOs reflects geographically based interests that change over time.

ADHD in children and adults: diagnosis and prognosis

Attention-deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders with childhood onset, having a chronic course associated with high dysfunction and morbidity throughout life. Despite significant advances in our understanding of the neurobiological underpinnings of the disorder, diagnosis of ADHD remains strictly clinical and is based on behavioral symptoms of inattention, impulsivity, and hyperactivity. In this chapter, we review the diagnostic process and current controversies in the diagnosis of ADHD, discuss the clinical presentation of the disorder across the lifespan, and examine the patterns of comorbidity and the longitudinal predictors of outcomes. We conclude by pointing out some of the challenges that need to be addressed in future classifications systems to improve the characterization and validity of the diagnosis of ADHD.

Behavioral vaccines and evidence-based kernels: nonpharmaceutical approaches for the prevention of mental, emotional, and behavioral disorders

In the United States the rates for some mental, emotional, and behavioral problems (MEBs) have objectively increased over the past 20 to 50 years. The attributes of a public health approach to the treatment of MEBs are defined in this article. Multiple examples of how public health approaches might reduce or prevent MEBs using low-cost evidence-based kernels, which are fundamental units of behavior, are discussed. Such kernels can be used repeatedly, which then act as "behavioral vaccines" to reduce morbidity or mortality and/or improve human wellbeing. The author calls for 6 key policy actions to improve MEBs in young people.

Developmental psychopathology: Attention Deficit Hyperactivity Disorder (ADHD)

BACKGROUND

Attention Deficit/Hyperactivity Disorder (ADHD), formerly regarded as a typical childhood disorder, is now known as a developmental disorder persisting over the lifespan. Starting in preschool-age, symptoms vary depending on the age group affected.

METHOD

According to the variability of ADHD-symptoms and the heterogeneity of comorbid psychiatric disorders, a broad review of recent studies was performed. These findings were summarized in a developmental psychopathological model, documenting relevant facts on a timeline.

RESULTS

Based on a genetic disposition and a neuropsychological deregulation, there is evidence for factors which persist across the lifespan, change age-dependently, or show validity in a specific developmental phase. Qualitative changes can be found for children in preschool-age and adults.

CONCLUSION

These differences have implications for clinical practice as they can be used for prevention, diagnostic proceedings, and therapeutic intervention as well as for planning future studies. The present article is a translated and modified version of the German article "Entwicklungspsychopathologie der ADHS", published in Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 56, 2008, S. 265-274.