Examining the Educational Gap for Children with ADHD and Subthreshold ADHD

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Low Persistence of Inattention Symptoms From Childhood to Adolescence: A Population-Based Study

OBJECTIVE

To investigate the persistence of dimensional measures of inattention in a population-based, gender-balanced sample of adolescents with parent reports of inattention from childhood and self-reports of inattention in adolescence.

METHOD

Adolescents, 16-19 years old, completed the Adult ADHD Self Report Scale. Their parents completed the Swanson, Nolan, and Pelham Rating Scale-4th Edition when they were 7-9 and 11-13 years old.

RESULTS

More severe inattention in boys than girls in childhood shifted to a female predominance in adolescence. The correlation between reports of inattention in childhood and adolescence was weak, with parent reports explaining only ~5% of the variance in the inattention score reported in adolescence.

CONCLUSION

The weak association between inattention in childhood and adolescence is consistent with the emerging challenges associated with being an adolescent, but the impact of shifts in informants, gender and age on symtpom presentations should be investigated in future studies.

How cognitive and behavioural body-functions of children with ADHD are linked to their participation and environmental supports?

BACKGROUND

Children with chronic conditions face participation restrictions and exclusions.

AIMS

To investigate how cognitive and behavioural body-functions are associated with 1) participation patterns and 2) environmental factors among children with attention deficit hyperactivity disorder (ADHD).

METHODS AND PROCEDURES

The study included 83 children with ADHD. Cognitive and behavioural body-functions were assessed with Conners' Parent Rating Scale-Revised Long-Version. The participation patterns of children were assessed with Participation and Environment Measure for Children and Youth (PEM-CY). Multiple regression analyses were used to examine the relationships between cognitive and behavioural body-functions and (1) participation patterns at home, school and community settings, and (2) environmental supports and barriers.

OUTCOME AND RESULTS

In home setting, inattention and ADHD index which determine ADHD children from typically developing peers, were the strongest factors, explaining 24.9 % of variance in activities that mothers wanted to change. In school setting, presence/level of oppositional behaviours had the strongest effect on environmental barriers, with variation of 29.8 %. In community setting, the strongest factor explaining environmental helpfulness was anxious/shy behaviours (16.1 %).

CONCLUSIONS AND IMPLICATIONS

When seeking to improve participation of children with ADHD both the cognitive and behavioural demands of chosen activities should be modified while creating environments that supports these challenges.

Categorical and dimensional approaches to the developmental relationship between ADHD and irritability

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) and irritability commonly co-occur, and follow similar developmental trajectories from childhood to adolescence. Understanding of the developmental relationship between these co-occurrences is limited. This study provides a longitudinal assessment of how ADHD diagnostic status and symptom patterns predict change in irritability.

METHODS

A community sample of 337 participants (45.2% ADHD), recruited for the Childhood Attention Project, completed the Affective Reactivity Index (ARI) to measure irritability at baseline (mean age 10.5 years) and follow-up after 18-months. Latent change score models were used to assess how (a) baseline ADHD vs. control group status, (b) baseline symptom domain (inattention, hyperactivity-impulsivity) and (c) longitudinal change in ADHD symptom severity predicted change in irritability.

RESULTS

Irritability was significantly higher among the ADHD group than controls; however, change in irritability over time did not differ between groups. When assessed across the entire cohort, change in irritability was predicted by higher symptom count in the hyperactive-impulsive domain, but not the inattentive domain. Greater declines in ADHD symptoms over time significantly predicted greater declines in irritability. Baseline ADHD symptom severity was found to significantly predict change in irritability; however, baseline irritability did not significantly predict change in ADHD symptoms.

CONCLUSIONS

ADHD symptoms-particularly hyperactive-impulsive symptoms-predict the degree and trajectory of irritability during childhood and adolescence, even when symptoms are below diagnostic thresholds. The use of longitudinal, dimensional and symptom domain-specific measures provides additional insight into this relationship.

Increased diagnosis of attention-deficit hyperactivity disorder despite stable hyperactive/inattentive behaviours: evidence from two birth cohorts of Australian children

BACKGROUND

Globally, ADHD diagnoses have increased substantially and there is concern that this trend does not necessarily reflect improved detection of cases but that overdiagnosis may be occurring. We directly compared ADHD diagnoses with ADHD-related behaviours and looked for changes across time among Australian children in a large, population-based prospective cohort study.

METHODS

We conducted a secondary analysis of the Longitudinal Study of Australian Children, including 4,699 children born 1999/2000 (cohort 1) and 4,425 children born 2003/2004 (cohort 2), followed from 4 to 13 years of age. We compared pre-diagnosis parent-reported hyperactive/inattentive behaviour scores between newly diagnosed (incident cases) and undiagnosed children and fitted Cox's proportional hazards regression models to examine the relationship between birth cohorts 1 and 2 and the risk of incident ADHD diagnosis.

RESULTS

Cumulative incident ADHD diagnoses increased from 4.6% in cohort 1 (born in 1999/2000) to 5.6% in cohort 2 (born in 2003/2004), while hyperactive/inattentive behaviour scores remained steady. Among ADHD diagnosed children, 26.5% (88/334) recorded pre-diagnosis behaviours in the normal range, 27.6% (n = 92) had borderline scores and 45.8% (n = 153) scored within the clinical range. Children born in 2003/2004 were more likely to be diagnosed with ADHD compared with those born in 1999/2000 (aHR = 1.33, 95% CI = 1.06-1.67, p = .012), regardless of their ADHD behaviour score (p = .972).

CONCLUSIONS

Diagnostic increases were not driven by rises in hyperactive/inattentive behaviours. A quarter of all children with an ADHD diagnosis recorded pre-diagnosis behaviours within the normal range. The increased likelihood of being diagnosed with ADHD for children from the later birth cohort was observed for children across the full range of ADHD-related behaviours.

Association of Attention-Deficit/Hyperactivity Disorder Diagnosis With Adolescent Quality of Life

IMPORTANCE

Appropriate diagnosis of attention-deficit/hyperactivity disorder (ADHD) can improve some short-term outcomes in children and adolescents, but little is known about the association of a diagnosis with their quality of life (QOL).

OBJECTIVE

To compare QOL in adolescents with and without an ADHD diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study followed an emulated target trial design using prospective, observational data from the Longitudinal Study of Australian Children, a representative, population-based prospective cohort study with biennial data collection from 2006 to 2018 with 8 years of follow-up (ages 6-7 to 14-15 years). Propensity score matching was used to ensure children with and without ADHD diagnosis were well matched on a wide range of variables, including hyperactive/inattentive (H/I) behaviors. Eligible children were born in 1999 to 2000 or 2003 to 2004 and did not have a previous ADHD diagnosis. All incident ADHD cases were matched with controls. Data were analyzed from July 2021 to January 2022.

EXPOSURES

Incident parent-reported ADHD diagnosis at age 6 to 7, 8 to 9, 10 to 11, 12 to 13, or 14 to 15.

MAIN OUTCOMES AND MEASURES

Quality of life at age 14 to 15 was measured with Child Health Utility 9D (CHU9D) and 8 other prespecified, self-reported measures mapped to the World Health Organization's QOL domains. Pooled regression models were fitted for each outcome, with 95% CIs and P values calculated using bootstrapping to account for matching and repeat observations.

RESULTS

Of 8643 eligible children, a total of 393 adolescents had an ADHD diagnosis (284 [72.2%] boys; mean [SD] age, 10.03 [0.30] years; mean [SD] H/I Strengths and Difficulties Questionnaire score, 5.05 [2.29]) and were age-, sex-, and H/I score-matched with 393 adolescents without ADHD diagnosis at time zero. Compared with adolescents without diagnosis, those with an ADHD diagnosis reported similar QOL on CHU9D (mean difference, -0.03; 95% CI, -0.07 to 0.01; P = .10), general health (mean difference, 0.11; 95% CI, -0.04 to 0.27; P = .15), happiness (mean difference, -0.18; 95% CI, -0.37 to 0.00; P = .05), and peer trust (mean difference, 0.65; 95% CI, 0.00 to 1.30; P = .05). Diagnosed adolescents had worse psychological sense of school membership (mean difference, -2.58; 95% CI, -1.13 to -4.06; P < .001), academic self-concept (mean difference, -0.14; 95% CI, -0.02 to -0.26; P = .02), and self-efficacy (mean difference, -0.20; 95% CI, -0.05 to -0.33; P = .007); displayed more negative social behaviors (mean difference, 1.56; 95% CI, 0.55 to 2.66; P = .002); and were more likely to harm themselves (odds ratio, 2.53; 95% CI, 1.49 to 4.37; P < .001) than adolescents without diagnosis.

CONCLUSIONS AND RELEVANCE

In this cohort study, ADHD diagnosis was not associated with any self-reported improvements in adolescents' QOL compared with adolescents with similar levels of H/I behaviors but no ADHD diagnosis. ADHD diagnosis was associated with worse scores in some outcomes, including significantly increased risk of self-harm. A large, randomized clinical trial with long-term follow-up is needed.

Cognitive Control Deficits in Children With Subthreshold Attention-Deficit/Hyperactivity Disorder

Subthreshold Attention-Deficit/Hyperactivity Disorder (ADHD) is defined as a neurobiological condition with some core inattentive or hyperactive/impulsive symptoms of ADHD which do not meet the full diagnosis clinically. Although it has been well documented that deficits in cognitive control, a high-level cognitive construct closely related to attention, are frequently found among children with ADHD, whether subthreshold ADHD is also associated with similar deficits remains unclear. In this study, we examined the attention functions and the cognitive control capacity (CCC) in children with ADHD (n = 39), those with subthreshold ADHD (n = 34), and typically developing peers (TD, n = 36). The results showed that the ADHD and subthreshold ADHD groups exhibited similar patterns of the impaired executive function of attention (revealed as an augment in flanker conflict effect) and reduced cognitive control capacity, and no significant difference was found between the two groups. These findings suggest that although children with subthreshold ADHD have not met the full criteria of ADHD, they showed reduced efficiency in cognitive control and attention function, similar to children with ADHD.

The Benefits and Limitations of Stimulants in Treating ADHD

This chapter focusses on the benefits and limitations of stimulant medications in the treatment of ADHD. We highlight the key similarities and differences between the different stimulants used to treat ADHD and briefly discuss mechanisms of action, pharmacokinetics, and pharmacodynamics. We will discuss some of the political, ethical, and moral discussions about the use of stimulants including a consideration of the treatment of subsyndromal ADHD and the use of stimulants as cognitive enhancers. We review the comparative efficacy and effectiveness between stimulants and non-pharmacological treatments for ADHD, between stimulant classes and formulations and between stimulant and non-stimulant medications. We discuss the effects on core symptoms, common associated symptoms, cognition, and more distal outcomes including quality of life and functioning and issues related to tolerance, tolerability and adverse effects. Looking at the clinical implications of these findings, we discuss the importance of measurement-based care in the treatment of ADHD. Finally, we will look at the benefits and limitations of stimulants across several different populations and clinical subgroups.

A Review of Predictors of Psychosocial Service Utilization in Youth with Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood disorders. Professional practice guidelines recommend combined treatment, psychopharmacological and psychosocial, for youth with ADHD. There have been multiple reviews of pharmacological prescription practices and utilization, however, less is known about predictors of ADHD psychosocial service utilization. Given the importance of accessing psychosocial treatment in relation to improving functional impairment, this review synthesizes evidence on predictors of ADHD psychosocial intervention utilization in clinic, community, and school settings. Eighteen studies were identified and included in the review. Findings are summarized across informant profile factors, predisposing characteristics, and barriers and facilitators. The most robust findings were for the impact of symptom severity/impairment, the presence of comorbidities, and age on ADHD psychosocial service utilization. Race/ethnicity, sex, parental knowledge of the disorder and insurance coverage were also identified as key factors. Future avenues of research are provided, and clinical and policy implications targeted at reducing psychosocial treatment disparities in youth with ADHD are discussed.