Preschool ADHD Diagnoses Stabilize After Guideline (Source: Medscape, 15.11.2016)
The increasing rate of attention-deficit/hyperactivity disorder (ADHD) diagnoses in preschool-aged children stabilized after release of the American Academy of Pediatrics’ practice guideline in 2011, a new study shows. Meanwhile, the overall rate of stimulant prescriptions, which had declined before the guideline release, remained the same.
“These are reassuring results given that a standardized approach to diagnosis was recommended and stimulant treatment is not recommended as first-line therapy for this age group.
The American Academy of Pediatrics released the practice guideline on October 1, 2011; therefore, the study periods of interest were January 1, 2008, to September 30, 2011 (preguideline) and October 1, 2011, to June 30, 2014 (postguideline). The preguideline period included 118,957 visits among 87,067 children, and the postguideline period included 92,601 visits among 56,814 children.
In the preguideline period, children had an ADHD diagnosis at 0.7% of visits compared with 0.9% in the postguideline period.
“These rates of preschool ADHD are lower than those found in the epidemiologic surveys of community samples that report between 2% and 4% of preschool children affected but, as expected, higher than rates found among 2- to 5-year-olds using claim data (0.5%–0.6%),” the authors report.
Although the mechanism behind the observed pattern would require a detailed chart review of the diagnostic processes used by individual clinicians, “our findings indicate that the standardization provided by the guideline did not trigger increases in diagnosis.”
The rate of stimulant prescribing in the current study was stable across periods, at 0.4%, the authors report. “An examination of these rates is particularly important because behavior therapy, not stimulant medication treatment, is first-line management for ADHD in this age group, and previous investigations have found that nearly 80% of preschool children with ADHD received medication, compared with only slightly more than half receiving behavior therapy,” they write.
Of note, the likelihood of receiving medication given a diagnosis of ADHD significantly decreased before the release of the 2011 guideline, but stabilized after. “This pattern of decreasing medication use given a diagnosis of ADHD over time may have been driven by the Preschool ADHD Treatment Study, published in 2006, which found that the effect size of stimulant treatment in preschool-aged children is lower than in school-aged children.”
It is also possible that, as the proportion of all preschoolers diagnosed with ADHD increased, the severity of the condition across the population decreased, resulting in decreased stimulant prescribing, the authors hypothesize.
The researchers also observed significant variation across practice sites in the proportion of visits with an ADHD diagnosis or stimulant prescription from before to after guideline release. Specifically, the rates of diagnoses and stimulant prescribing, respectively, increased in 41% and 22% of practices, remained stable in 19% and 21% of practices, and decreased in 24% and 41% of practices.
“Because guidelines standardize care, we expected to see decreased variation across sites after guideline release. However, we found varying responses of sites to the guideline, and the interquartile range across practices for both diagnosis and stimulant prescribing did not narrow,” the authors write. “These findings indicate that although the overall results of our study are reassuring, practices may be responding differently to the guideline both for diagnosis and prescribing, and standardization of ADHD practice may be difficult to achieve.”
Further research is warranted “to understand whether these patterns reflect local changes in the population under care, varying demand for evaluation of preschool ADHD, or known differences in how clinicians respond to guidelines,” the authors stress.
The current study is also notable because it demonstrates the feasibility of using multisite EHR data to measure practice change associated with the publication of clinical practice guidelines, the authors write. The systematic measurement of practice change in this way “could provide an opportunity to assess in what circumstances and contexts guidelines demonstrate the greatest impact, where there might be unintended consequences, and when additional practice supports are needed to better achieve guideline-based care.
Policy and technology improvements are needed to facilitate better communication across stakeholders, Dr. Wolraich explains. Such improvements could include enhanced communication through patient and community portals and the electronic availability of behavior-rating scales, which “can be completed and reviewed by the providers and families on an ongoing basis. There needs to be greater standardization of assessment and treatment modalities so that we can better examine the outcomes of changes in treatment.
ADHD Symptoms from Childhood May Lead to Greater Challenges for Adults
(Source: Psychiatric News: American Psychiatric Association, 08.09.2016.)
The outcomes of adults, who were diagnosed with attention-deficit/hyperactivity disorder (ADHD) as children generally tend to report greater social and emotional challenges than those who were not diagnosed with ADHD, vary widely. A study in the Journal of the American Academy of Child and Adolescent Psychiatry now suggests that persisting ADHD symptoms in adulthood are associated with greater functional impairments.
The study also underscores the importance of treating people with ADHD to remission and not just improvement because symptom remission appears to be somewhat protective against anxiety, depression, and substance use disorder, according to the authors.
As part of the Multimodal Treatment Study of Children with ADHD (MTA), researchers’ tracked 579 children aged 7 to 9 with ADHD and 258 age- and sex-matched classmates without ADHD through childhood and adolescence and into adulthood (when participants were aged 19 to 28).
At age 18 and after, participants and their parents completed Conners’ Adult ADHD Rating Scale (CAARS) and the Diagnostic Interview Schedule for Children–Parent version (DISC-P) and Young Adult version (DISC-YA). From these assessments, researchers obtained information on educational, occupational, emotional outcomes, and more.
Overall, participants with persistent symptoms of ADHD tended to fare worse with regard to educational and occupational outcomes (including post-secondary education and income), followed by those whose ADHD symptoms were in remission, and controls. Participants in the symptom-persistent ADHD subgroup also scored worse on impulsivity/emotional lability (self- and parent-report) and neuroticism, and endorsed higher rates of mood (7.8% versus 1.8%) and anxiety disorders (14.2% vs. 5.0%) than the symptom-desistent subgroup, which exhibited outcomes similar to the controls.
“These findings suggest that functional outcomes in adults who were diagnosed with ADHD in childhood are not uniform but differ across domains, giving rise to different patterns of outcomes,” Lily Hechtman, M.D., and colleagues wrote, “Both ADHD symptoms and functioning need to be targets of appropriate, innovative, and ongoing intervention in this chronic condition.”
Meds May Curb Risky Behaviors for Kids with ADHD
(Source: HealthDay News; 17.08.2016)
A new research suggests that stimulants used to treat attention-deficit/hyperactivity disorder (ADHD) are linked with less risky behaviors in teens, despite concerns that it might raise the risk of drug abuse. Anna Chorniy, a postdoctoral associate at Princeton University in New Jersey, stated that ADHD medications are “effective in reducing the probability of these events”. Young people with ADHD tend to have problems with self-control and discount the future more heavily than their healthy peers, Chornly said. This makes them more injury-prone and more likely to engage in risky behaviors, such as dangerous driving and substance abuse. The study results showed that children with ADHD who took medication were 7 percent less likely to have a substance abuse disorder and nearly 4 percent less likely to contract a sexually transmitted disease, compared to those who did not receive medication. They were also 2 percent less likely to be injured. Treatment was also linked to a reduction in injuries for the teens, by more than 6,000 cases a year.
As of 2011, about 11 percent of American kids aged 4 to 17 have been diagnosed with ADHD, according to the U.S. Centers for Disease Control and Prevention. Patients are typically hyperactive, have trouble paying attention and act impulsively. Young people with ADHD tend to have problems with self-control and discount the future more heavily than their healthy peers. The disorder can be managed with behavioral therapy and stimulants. The prescriber needs to carefully assess the individual child, because of the controlled substances that have potential for abuse or dependence and educate the child as well as the family on securing the medication and making certain it is administered as directed.
Risk for Substance Abuse in ADHD Relatives Due to Genetics
Source: Liam Davenport October 29, 2014
Previous research indicates that Attention-deficit hyperactivity disorder (ADHD) is highly associated with Substance Use Disorders (SUD). These studies however, have failed to clarify the nature of the overlap. The main aim was to explore if the overlap between ADHD and SUD could be explained by shared genetic and environmental factors or by harmful effects of ADHD medication.
Matched cohort design across different levels of family relatedness recorded from 1973 to 2009. By linking longitudinal Swedish national registers, 62,015 ADHD probands and their first and second degree relatives were identified and matched 1:10 with non-ADHD controls and their corresponding relatives. Any record of SUD defined by discharge diagnoses of the International Classification of Diseases and/or a purchase of any drug used in the treatment of SUD.
First degree relatives of ADHD probands were at elevated risk for SUD compared to relatives of controls. The corresponding relative risk in second degree relatives was substantially lower. The familial aggregation patterns remain similar for first degree and second degree relatives after excluding individuals with coexisting disorders such as schizophrenia, bipolar disorder, depression and conduct disorder.
Findings suggest that the co-occurrence of ADHD and SUD are due to genetic factors shared between the two disorders, rather than to a general propensity for psychiatric disorders or harmful effects of ADHD medication.
ADHD Diagnosis, Treatment Differ Across the Globe
(Source: American Psychiatric Association May 2011)
Attention-deficit hyperactivity disorder (ADHD) has received wide international recognition as a chronic neurodevelopmental disorder leading to high levels of impairment and requiring effective service delivery. Concerns have been raised about cross-national variation in the prevalence of ADHD, under the assumption that cultural differences are likely to underlie disparities between countries. However, a meta-regression analysis by Polanczyk and colleagues showed that despite international variation in prevalence estimates for ADHD (around an overall mean of slightly more than 5%), most of the cross-country variation was attributable to methodological differences—such as diverging definitions of the disorder or different algorithms for combining assessment information—rather than to cultural or national-level factors.
These are just a few of the insights that came out of a meeting of 18 international leaders in developmental psychopathology research who met in Berkeley, Calif., in March 2010. The members represented nine countries—Australia, Brazil, Canada, China, Germany, Israel, the Netherlands, the United Kingdom, and the United States—all specifically selected because they were known to have either low or high rates of diagnosis and treatment of youth with ADHD. Economic, historical, and political forces and cultural values affect the implementation of treatment for ADHD worldwide. The ways in which school settings perceive and react to ADHD symptoms of children differ widely between countries. Survey respondents from Israel commented on the tolerance for high activity levels in the nation’s classrooms, whereas respondents from China noted that children are expected to remain still and on task for long hours in large, structured, quiet classrooms. Comments from Brazil indicated that the country retains a highly psychoanalytic perspective on ADHD, which results in low rates of referral from schools. Indeed, some State Councils on Psychology in Brazil have officially campaigned against ADHD (and dyslexia) as “true” disorders. Because of strong regional variation in the United States, there are divergent norms for deviant classroom behavior.
It was concluded that there was a significant gap between prevalence and the availability of trained professionals to provide services. Across-state variability in use of medication has been documented (Mitchell PB, Levy F, Hadzi-Pavlovic D, et al., unpublished manuscript, 2011), driven by service availability, professional leadership, and rates of public funding.
The guidelines recommend that medication should not be used as a first-line treatment for preschool children with ADHD; when stimulants are tried, they should be used in a low dose, in short-acting forms only, and in close conjunction with appropriate behavioral intervention. For school-aged children, treatment of severe ADHD with stimulants is considered a first-line treatment if it is in line with child and parent or caregiver preferences. Parallel recommendations are in place for adults, as long as medication does not cause unacceptable side effects.
In Brazil, light physical punishment is considered by a large number of teachers to be “therapeutic,” and physical exercise is considered a viable alternative to medication for children with ADHD. Psychoanalysis is still the predominant theoretical perspective in the clinical professions in Brazil, as well as in print media and television. The education system is largely under the influence of “constructivisim,” meaning that behavioral problems are not viewed as related to clinical manifestations of syndromes or disorders. Light physical punishment is conceived as “therapeutic” by a large number of teachers. Also, many respondents to a large poll cited “physical exercise” as a viable alternative to medication. In short, acceptance of ADHD as a biomedical condition and of medications as a primary treatment has been slow. Intriguingly, ADHD has been recently noted in indigenous children from the Brazilian Amazon who were presenting with behavioral problems.
In Canada, health professionals view ADHD as an impairing, often lifelong disorder that requires careful assessment and multimodal intervention. Substantial evidence exists that Canadian health professionals view ADHD as an impairing, often life-long disorder that requires careful assessment and multimodal intervention. Canadian experts in ADHD developed an “ADHD Toolkit” to facilitate provision of standardized treatment by primary care practitioners as well as specialists, with particular focus on the treatment of adults. Family doctors and pediatricians have the option to refer patients with complex treatment needs to ADHD centers of excellence. The geography of the country requires the provision of care over long distances, through the use of e-health, telehealth, and outreach and by transporting patients by air when necessary.
The nationalized health care system makes both medication treatment and a wide range of psychosocial interventions accessible to the general population. Nevertheless, there is no distinct designation of ADHD within the education system. A child with ADHD will usually receive an individual education plan; however, the school does not receive additional funds as it does for autism. Although treatment of adults with ADHD is increasing rapidly, there are no dedicated hospital clinics for this population, leading to a situation in which adults with ADHD continue with pediatric providers.
In China, ADHD is greatly underdiagnosed and undertreated. Because of the cultural acceptance of herbal treatments, they are used as much as, if not more than, stimulant medications. Recently, one-child policies, economic development, and education have all been prioritized. As a result, children have been under strong pressure to achieve at high levels in all subject areas, and problems with attention and deportment have become quite salient in classroom settings. Attention and behavior problems may be exacerbated by strong cultural expectations for achievement, the predominant practice of passive student learning in lecture-style classrooms, and stressful parent-child interactions related to high achievement expectations. Because the prevailing culture assumes that the child must conform to the school, provision of individualized education plans is not culturally acceptable.
Also salient in China are high levels of stigma related to mental illness, a lack of training in the treatment of ADHD among medical and mental health professionals, and strong controls on potentially addictive medications such as stimulants. Indeed, the Shanghai Health Bureau and relevant insurance regulations enforce a policy of a maximum of two weeks for any methylphenidate prescriptions, meaning that follow-up every two weeks is necessary.
In Germany there is a trend toward increasing awareness and detection of ADHD among children and adolescents. The treated prevalence of patients with ADHD medications more than doubled between 2003 and 2008, raising concerns and debate about the quality of clinical diagnoses as well as possible overtreatment. Immediate-release formulations have been largely replaced by extended-release medications. It is noteworthy that direct medical costs for patients with ADHD, from the perspective of statutory health insurance, exceed those of matched control patients without ADHD by a factor of more than 2.5.
The main population-based prevalence studies were conducted with DSM-III and DSM-III-R criteria, and no large-scale epidemiological studies have used the DSM-IV subtypes. Treatment has moved from essentially no pharmacological intervention in the 1980s to a mixed-modality model (medication and psychosocial intervention). Biases concerning pharmacological intervention remain, although no-stimulant medication has proved clinically useful in this respect.
A key area of poor coordination of services is the transition of adolescents with ADHD to adult psychiatric services. This fragmentation is being addressed by professional education but not as yet with formal mechanisms of transfer to adult care.
The number of children and adolescents in Norway who receive an ADHD diagnosis has increased substantially in recent years, as has the prescription of medication to such youths. A ten-year governmental effort (1998–2008) focused on mental health has resulted in increased awareness and acceptance of ADHD but has also spurred debate about quality of diagnosis and potential overtreatment, both among clinicians and in the general public. Even though governmental consensus recommendations are delivered to all relevant clinical settings, there are large geographical differences in estimated prevalence rates, which vary between counties from four to 68 per 1,000 inhabitants under age 19. Expenditures related to treatment of ADHD have not yet been a major issue in Norway.
Recognition and diagnosis in actual clinical practice were extremely low more than 20 years ago but increased rapidly during the 1990s. Approximately .3% of the child population is currently treated. Recognition was initially kept low by a disinclination to prescribe stimulants and by a tendency to diagnose conduct problems instead; it increased with epidemiological evidence and pressure from service user groups. NICE has provided detailed guidelines for treatment of children, adolescents, and adults. Indeed, treatment of adults is rising rapidly. Referral to specialized services usually comes from primary health care and is largely dependent on parents’ knowledge of ADHD and the pressure they place on primary care providers. The education system does not provide resources on the basis of ADHD per se; such resources follow instead from educational assessment.
Stephen Hinshaw, Ph.D., said that the most surprising finding from the study was the wide range of ADHD service-delivery systems internationally—from highly sophisticated to almost nonexistent.
“With our limited resources for this initial look at the issue, we concentrated on high versus low,” Hinshaw told Psychiatric News. “Ideally, larger investigations can further examine the whole range of rates of diagnosis and treatment. We were attempting a first-pass, qualitative, and quantitative analysis; we knew our results would be suggestive, not definitive.” It was found out that although the prevalence of ADHD varies across nations, largely due to disparate diagnostic practices and algorithms, far larger international variability exists with respect to treated prevalence and treatment procedures.
“The most surprising finding from this collaboration is the incredible range of ADHD service-delivery systems internationally, from highly organized and integrated on the one hand to barely acknowledging the existence and importance of ADHD on the other,” said Hinshaw.
Even as all nations have witnessed large increases in use of medication for ADHD, and even as evidence-based psychosocial treatments have gained credence, there is still a major struggle to provide care, said the group.