Disparities in ADHD assessment, diagnosis, and treatment

Changes in real-world dispensing of ADHD stimulants in youth from 2019 to 2021 in California

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common pediatric neurobehavioral disorders in the U.S. Stimulants, classified as controlled substances, are commonly used for ADHD management. We conducted an analysis of real-world stimulants dispensing data to evaluate the pandemic's impact on young patients (≤ 26 years) in California.

Methods

Annual prevalence of patients on stimulants per capita across various California counties from 2019 and 2021 were analyzed and further compared across different years, sexes, and age groups. New patients initiating simulants therapy were also examined. A case study was conducted to determine the impact of socioeconomic status on patient prevalence within different quintiles in Los Angeles County using patient zip codes. Logistic regression analysis using R Project was employed to determine demographic factors associated with concurrent use of stimulants with other controlled substances.

Results

There was a notable reduction in prevalence of patients ≤26 years old on stimulants during and after the pandemic per 100,000 people (777 in 2019; 743 in 2020; 751 in 2021). These decreases were more evident among the elementary and adolescent age groups. The most prevalent age group on stimulants were adolescents (12-17 years) irrespective of the pandemic. A significant rise in the number of female patients using stimulants was observed, increasing from 107,957 (35.2%) in 2019 to 121,241 (41.1%) in 2021. New patients initiating stimulants rose from 102,754 in 2020 to 106,660 in 2021, with 33.2% being young adults. In Los Angeles County, there was an increasing trend in patient prevalence from Q1 to Q5 income quintiles among patients ≥6 years. Consistently each year, the highest average income quintile exhibited the highest per capita prevalence. Age was associated with higher risk of concurrent use of benzodiazepines (OR, 1.198 [95% CI, 1.195-1.201], p < 0.0001) and opioids (OR, 1.132 [95% CI, 1.130-1.134], p < 0.0001) with stimulants.

Discussion

Our study provides real-world information on dispensing of ADHD stimulants in California youth from 2019 to 2021. The results underscore the importance of optimizing evidence-based ADHD management in pediatric patients and young adults to mitigate disparities in the use of stimulants.

Sociodemographic Disparities in Attention-Deficit/Hyperactivity Disorder Overdiagnosis and Overtreatment During Elementary School

Attention-deficit/hyperactivity disorder (ADHD) overdiagnosis and overtreatment unnecessarily exposes children to potential harm and contributes to provider and community skepticism toward those with moderate or severe symptoms and significant impairments, resulting in less supportive care. Yet, which sociodemographic groups of children are overdiagnosed and overtreated for ADHD is poorly understood. We conducted descriptive and logistic regression analyses of a population-based subsample of 1,070 U.S. elementary schoolchildren who had displayed above-average levels of independently assessed behavioral, academic, or executive functioning the year prior to their initial ADHD diagnoses and who did not have prior diagnostic histories. Among these children, (a) 27% of White children versus 19% of non-White children were later diagnosed with ADHD and (b) 20% of White children versus 14% of non-White children were later using medication. In adjusted analyses, White children are more likely to later be diagnosed (odds ratio [OR] range = 1.70-2.62) and using medication (OR range = 1.70-2.37) among those whose prior behavioral, academic, and executive functioning suggested that they were unlikely to have ADHD.

Associated Factors of Attention-Deficit/Hyperactivity Disorder Diagnosis and Psychostimulant Use: A Nationwide Representative Study

BACKGROUND

Connections between epidemiological findings and children's and adolescents' mental health policies have not been properly made in Brazil, and such nationwide studies are scarce. This epidemiological study (1) estimated the prevalence and predictors of parent-reported attention-deficit/hyperactivity disorder (ADHD) (ADHD-report), (2) estimated the probable diagnosis and risk of ADHD based on Diagnostic and Statistical Manual of Mental Disorders, 5th edition, criteria (ADHD-probable), and (3) estimated current psychostimulant use (ADHD-pst) in a representative nationwide sample of Brazilian school-aged children and adolescents.

METHODS

Data were obtained from 7114 school-aged children (49.9% boys) from 87 cities in 18 Brazilian states. Parents and teachers were interviewed using psychometrically sound questionnaires. Data and codes are available.

RESULTS

The prevalence of ADHD-report, ADHD-probable, and ADHD-pst were 7.1%, 3.9%, and 1.9%, respectively. The agreement was low between ADHD-probable and ADHD-report (22.6%) and between ADHD-report and ADHD-pst (15.6%). Logistic regression revealed that predictors of all three categories were male gender (odds ratio [OR] = 1.71, 2.32, and 1.96, respectively), divorced parents (OR = 1.47, 1.65, and 1.68, respectively), and below-expectation school performance (OR = 3.1, 13.74, and 3.95, respectively). Socioeconomic status was a significant predictor of ADHD-report, and participants from lower classes were less frequently diagnosed with ADHD than their peers from upper classes (OR = 0.57, 95% confidence interval = 0.37-0.88, P = 0.012).

CONCLUSIONS

The present findings provide an accurate description of ADHD in Brazil. We suggest disparities in agreement between report, risk, and psychostimulant use among children and adolescents and discrepancies between socioeconomic classes concerning the prevalence of an ADHD diagnosis.

Guideline adherence in the management of attention deficit hyperactivity disorder in children: An audit of selected medical records in three Australian states

OBJECTIVE

To assess General Practitioner (GP) and pediatrician adherence to clinical practice guidelines (CPGs) for diagnosis, treatment and management of attention deficit hyperactivity disorder (ADHD).

METHOD

Medical records for 306 children aged ≤15 years from 46 GP clinics and 20 pediatric practices in Australia were reviewed against 34 indicators derived from CPG recommendations. At indicator level, adherence was estimated as the percentage of indicators with 'Yes' or 'No' responses for adherence, which were scored 'Yes'. This was done separately for GPs, pediatricians and overall; and weighted to adjust for sampling processes.

RESULTS

Adherence with guidelines was high at 83.6% (95% CI: 77.7-88.5) with pediatricians (90.1%; 95% CI: 73.0-98.1) higher than GPs (68.3%; 95% CI: 46.0-85.8; p = 0.02). Appropriate assessment for children presenting with signs or symptoms of ADHD was undertaken with 95.2% adherence (95% CI: 76.6-99.9), however ongoing reviews for children with ADHD prescribed stimulant medication was markedly lower for both pediatricians (51.1%; 95% CI: 9.6-91.4) and GPs (18.7%; 95% CI: 4.1-45.5).

CONCLUSION

Adherence to CPGs for ADHD by pediatricians was generally high. Adherence by GPs was lower across most domains; timely recognition of medication side effects is a particular area for improvement.

ADHD remission, inclusive special education, and socioeconomic disparities

To understand how institutional environments and socioeconomic backgrounds may influence health outcomes, we examined the relationship among special education environments, socioeconomic status (SES), and likelihood of ADHD remission in children. While the majority of children experience remission by adulthood, the likelihood of remission varies across different SES levels and education environments. We find that for low SES children the likelihood of remission is higher in states that have more inclusive special education regimes. In contrast, for more advantaged children, the odds of remission do not depend on the level of special education inclusivity. Our findings suggest that providing more inclusive education can reduce disparities in behavioral disorders and are particularly important for less advantaged children. In doing so, this study contributes to the fundamental cause and health inequality literature by adding to a growing body of work showing how institutional environments can affect socioeconomic gradients in health treatment and outcomes.

"When the Prescription Pad Is Not Enough": Attention-Deficit Hyperactivity Disorder Management 2.0

Jose is a 13-year-old boy who presents to his primary care provider after struggling in school for many years. When he was in the first grade, he was diagnosed at a tertiary center with attention-deficit hyperactivity disorder. Multiple medication trials have produced few benefits and many side effects including poor sleep, morbid thoughts, lack of motivation, and, according to his parents, "he seemed like a robot."He comes now for his annual physical in April, and the parents tell you that the school is threatening that he be retained in the seventh grade. Parents are very adamant they do not want to try another medication. They have brought you their own and his advisor's Vanderbilt's, which each endorse 7 of 9 inattentive symptoms including trouble organizing, poor attention to detail, and easily distracted and forgetful in daily activities.His birth history and developmental history before beginning formal schooling are unremarkable. His first language was English whereas his parents speak Spanish to each other but not the children. He is healthy and without a history of head trauma, seizures, meningitis, or lead poisoning. An aunt has "learning problems."Jose's family lives in a crowded section of a large urban area. They share an apartment with another family, and both parents are employed full time with his father holding 2 full time jobs working double shifts. Their annual income is at the poverty line. There are 4 children in the family aged between 6 and 13 years.His school has been deemed a "recovery school" because of performing below standard on district-wide achievement tests. His classroom has 27 students, many of whom are English language learners, and he is not on an individualized education plan or 504 accommodations.The family is very concerned about the possibility of retention but have decided that "medicine does not help," and they look to you for other recommendations. Where do you go next?

Parent and Family Processes Related to ADHD Management in Ethnically Diverse Youth

BACKGROUND

Previous research has shown major disparities in attention deficit hyperactivity disorder (ADHD) for diverse youth across America. We do not fully understand, however, how parent and family processes are related to the identification, care-seeking approaches, treatment preferences, and engagement with care systems and services for youth with ADHD.

OBJECTIVES

The present study aimed to explore parent and family processes related to the management of ADHD in racially and ethnically diverse youth.

DESIGN

This integrative review was structured with the methodology proposed by Whittemore and Knafl.

RESULTS

Three major electronic databases yielded a final sample of 32 articles (24 quantitative, 6 qualitative, and 2 mixed methods). Nine themes emerged within three overarching meta-themes.

CONCLUSIONS

Understanding the unique perspectives of families from diverse backgrounds is essential for clinicians, researchers, and policymakers, who are dedicated to understanding racial and ethnic perspectives and developing ecologically appropriate and family-based interventions for youth with ADHD.

Sleep and quality of life in children with traumatic brain injury and ADHD

Objective Attention problems are common in children who sustain a traumatic brain injury (TBI). The differential features of TBI-related Attention Deficit Hyperactivity Disorder (ADHD) and primary ADHD are largely unknown. This study aimed to compare sleep problems and quality of life between children with TBI and ADHD and children with primary ADHD. Methods Twenty children with TBI (mean age = 12.7 ± 3.1 years) who had clinically significant ADHD symptoms according to the structured diagnostic interview and rating scales and a control group with primary ADHD (n = 20) were included. Parents completed Children's Sleep Habits Questionnaire (CSHQ) and Kinder Lebensqualitätsfragebogen: Children's Quality of Life Questionnaire-revised (KINDL-R). Neurology clinic charts were reviewed for TBI-related variables. Results When compared to children with primary ADHD, the Total Score and Sleep Onset Delay, Daytime Sleepiness, Parasomnias, and Sleep Disordered Breathing subscores of CSHQ were found to be higher in children with TBI and ADHD. The Total Score and Emotional Well-Being and Self-Esteem subscores of the KINDL-R were found to be low (poorer) in children with TBI and ADHD. The Total Score and certain subscores of KINDL-R were found to be lower in TBI patients with a CSHQ > 56 (corresponds to significant sleep problems) when compared to those with a CSHQ < 56. CSHQ Total Score was negatively correlated with age. Conclusion Children with TBI and ADHD symptoms were found to have a poorer sleep quality and quality of life than children with primary ADHD. ADHD in TBI may be considered as a highly impairing condition which must be early diagnosed and treated.

Racial and Ethnic Disparities in ADHD Diagnosis and Treatment

OBJECTIVES

We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities were more likely due to underdiagnosis or undertreatment of African-American and Latino children, or overdiagnosis or overtreatment of white children.

METHODS

We used a population-based, multisite sample of 4297 children and parents surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression examined disparities in parent-reported ADHD diagnosis and medication use in the following analyses: (1) using the total sample; (2) limited to children with an ADHD diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms.

RESULTS

Across all waves, African-American and Latino children, compared with white children, had lower odds of having an ADHD diagnosis and of taking ADHD medication, controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental health symptoms. Among children with an ADHD diagnosis or symptoms, African-American children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino children had lower odds at fifth and 10th grades. Among children who had neither ADHD symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted analysis.

CONCLUSIONS

Racial/ethnic disparities in parent-reported medication use for ADHD are robust, persisting from fifth grade to 10th grade. These findings suggest that disparities may be more likely related to underdiagnosis and undertreatment of African-American and Latino children as opposed to overdiagnosis or overtreatment of white children.

The Impact of Chronic Early Administration of Psychostimulants on Brain Expression of BDNF and Other Neuroplasticity-Relevant Proteins

ABSRACT

Frequently, healthy individuals, children, and students are using stimulants to treat attention deficit hyperactivity disorder (ADHD)-like symptoms or to enhance cognitive capacity, attention and concentration. Methylphenidate, the most common treatment for ADHD, similarly to cocaine, blocks the dopamine reuptake, leading to increase in dopamine level in the synaptic cleft. Brain-derived neurotrophic factor (BDNF) and other neuroplasticity-relevant proteins have a major role in cellular plasticity during development and maturation of the brain. Young Sprague Dawley rats (postnatal days (PND) 14) were treated chronically with either cocaine or methylphenidate. The rats were examined behaviorally and biochemically at several time points (PND 35, 56, 70, and 90). We found age-dependent, but stimulant-independent, alterations in the mRNA expression levels of microtubule-associated protein tau, doublecortin, and synaptophysin. The PND 90 rats, treated with methylphenidate at an early age, exhibited increased BDNF protein levels in the prefrontal cortex compared to the saline-treated group. Despite the treatment effects at the biochemical level, cocaine and methylphenidate treatments at an early age had only minor effects on the behavioral parameters measured at older ages. The biochemical alterations may reflect neuroprotective or neuroplastic effects of chronic methylphenidate treatment at an early age.

Caregivers' distress: youth with attention-deficit/hyperactivity disorder and comorbid disorders assessed via telemental health

OBJECTIVE

This article evaluates the additive effects of children's comorbid conditions with attention-deficit/hyperactivity disorder (ADHD) in relation to caregivers' distress, in a clinical trial conducted through telemental health (TMH).

METHODS

The Children's ADHD Telemental Health Treatment Study (CATTS) is examining the effectiveness of treatment delivered via TMH for children with ADHD who are living in underserved communities. The CATTS trial recruited 223 children (μ=9.53±2.06 years) and their caregivers. Diagnoses of ADHD and comorbid oppositional defiant disorder (ODD) and anxiety disorders (ADs) were established with the Child Behavior Checklist and the Computerized Diagnostic Interview Schedule for Children. We took advantage of rich baseline data from the CATTS trial to investigate associations between caregivers' distress and children's comorbid mental health conditions. Caregivers' distress was assessed with the Patient Health Questionnaire-9, Parenting Stress Index, and Caregiver Strain Questionnaire. ANOVAs were used to compare children with ADHD alone with children having one comorbid condition (ODD or ADs) and children having two comorbid conditions (ODD and ADs).

RESULTS

Three quarters (75.3%) of participants met criteria for ODD and/or AD comorbid with ADHD: 24.7% had neither comorbidity; 47.5% had ODD or AD; and 27.8% had both ODD and AD comorbidities. The parents of children with multiple comorbid conditions experienced the highest levels of depression, stress, and burden of care.

CONCLUSIONS

The CATTS sample that was recruited from underserved communities provided evidence of additive effects of child psychiatric comorbidities with caregivers' distress, echoing earlier findings from the Multi-modal Treatment of ADHD (MTA) study that was conducted with a metropolitan sample of youth. Results indicate that caregivers' distress should be addressed in developing treatment models for children with ADHD.

CLINICAL TRIALS REGISTRY

http://clinicaltrials.gov/show/NCT00830700 .

"When the prescription pad is not enough": attention-deficit hyperactivity disorder management 2.0

Jose is a 13-year-old boy who presents to his primary care provider after struggling in school for many years. When he was in the first grade, he was diagnosed at a tertiary center with attention-deficit hyperactivity disorder. Multiple medication trials have produced few benefits and many side effects including poor sleep, morbid thoughts, lack of motivation, and, according to his parents, "he seemed like a robot."He comes now for his annual physical in April, and the parents tell you that the school is threatening that he be retained in the seventh grade. Parents are very adamant they do not want to try another medication. They have brought you their own and his advisor's Vanderbilt's, which each endorse 7 of 9 inattentive symptoms including trouble organizing, poor attention to detail, and easily distracted and forgetful in daily activities. His birth history and developmental history before beginning formal schooling are unremarkable. His first language was English whereas his parents speak Spanish to each other but not the children. He is healthy and without a history of head trauma, seizures, meningitis, or lead poisoning. An aunt has "learning problems."Jose's family lives in a crowded section of a large urban area. They share an apartment with another family, and both parents are employed full time with his father holding 2 full time jobs working double shifts. Their annual income is at the poverty line. There are 4 children in the family aged between 6 and 13 years.His school has been deemed a "recovery school" because of performing below standard on district-wide achievement tests. His classroom has 27 students, many of whom are English language learners, and he is not on an individualized education plan or 504 accommodations.The family is very concerned about the possibility of retention but have decided that "medicine does not help," and they look to you for other recommendations. Where do you go next?