Receipt of Medication and Behavioral Therapy Among a National Sample of School-Age Children Diagnosed With Attention-Deficit/Hyperactivity Disorder

doi:10.1016/j.acap.2017.10.003

Academic Pediatrics

Volume 18, Issue 3, April 2018, Pages 256-265

https://doi.org/10.1016/j.acap.2017.10.003 Get rights and content

Abstract

Objective

In 2011, the American Academy of Pediatrics published practice guidelines for attention-deficit/hyperactivity disorder (ADHD), recommending both medication and behavioral therapy for school-age children. The current study examines associations between child/family characteristics and ADHD medication, behavioral, and combined therapy.

Methods

This study used data from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette syndrome, a nationally representative follow-up survey to the 2011–2012 National Survey of Children's Health. Descriptive statistics were used to estimate frequencies of ADHD treatments and multivariable logistic regression to examine child/family characteristics associated with parent-reported medication use, classroom management, and parent training for children aged 8 to 17 diagnosed with ADHD (n = 2401).

Results

Black and Hispanic children were less likely than white children to have ever received ADHD medication. Hispanic children were less likely than white children to be currently receiving medications (adjusted odds ratio, 0.49; 95% confidence interval, 0.30–0.80). No differences were found in current medication use for black children compared to white children. Thirty-percent of parents reported that their child was currently receiving classroom management, and 31% reported having ever received parent training for ADHD. Children whose ADHD medication was managed by a primary care physician were less likely to receive combined medication and behavioral therapy compared to children managed by specialty physicians (adjusted odds ratio, 2.58; 95% confidence interval, 1.75–3.79).

Conclusions

Most school-age children reported receiving medication for ADHD; however, medication disparities persist. Parent-reported use of behavioral therapies are low. Future research should examine reasons for observed variation in treatment and interventions to optimize ADHD care.

Section snippets

Study Design

We conducted a secondary analysis of the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome (NS-DATA) data set.

Data Source

The 2014 NS-DATA was a follow-up survey to the 2011–2012 National Survey of Children's Health (NSCH), including all 2- to 17-year-old children with a reported diagnosis of ADHD.²⁰ Specifically, the NSCH was a nationally representative, random-digit dial survey of the emotional and physical health of children from birth

Description of Sample

The final sample included 2401 children between the ages of 8 and 17 with a current diagnosis of ADHD. Consistent with the epidemiology of ADHD,² the majority of the sample comprised boys (Table 1). The mean age at ADHD diagnosis was 7 years, which is similar to previously documented average age at diagnosis.² Sixty-three percent of the sample was classified as non-Hispanic white.

ADHD Management

Seventy-three percent of parents reported that their child was receiving medication for ADHD at the time of the

Discussion

In this nationally representative sample of children diagnosed with ADHD, we found that most children with ADHD had received medication since their diagnosis; however, receipt of recommended behavioral therapies was low. Impoverished children, Hispanic children, and older children had significantly lower odds of currently receiving medications for ADHD compared to higher-income children, white children, and younger children, respectively. Children whose ADHD medication was managed by a

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To describe changes in blood pressure (BP) and body mass index (BMI) associated with stimulant medication fills in children.
Observational, retrospective matched cohort study of children 6–17.9 years initiating stimulant medication between 7/1/2010–6/30/2017 matched 1:3 by age, race, ethnicity, and sex to children with no stimulant use during this period. All BPs and BMIs recorded during ambulatory visits were identified. Generalized linear models were used to estimate differences in change in systolic BP (SBP), diastolic BP (DBP), and BMI over time.
The 686 children with stimulant prescription fills and 2048 matched controls did not differ by baseline SBP or BMI. The matched control group (30.5% female, mean age 11.2 ± 3.4 years 79.7% white) was more likely to be publicly insured (35% vs. 21%, P < .01). After adjusting for baseline values, over a mean follow-up of 144 days change in SBP or DBP did not differ significantly between patients with stimulant medication fills and matched controls. Stimulant use was associated with a 4.7 percentile decrease in BMI percentile compared to matched controls (95% CI: 3.69, 5.71; P < .01).
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Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.
Assessing undertreatment and overtreatment/misuse of ADHD medications in children and adolescents across continents: A systematic review and meta-analysis
2021, Neuroscience and Biobehavioral Reviews
A controversy exists on whether there is an over or underuse of medications for Attention-Deficit/Hyperactivity Disorder (ADHD). We conducted the first meta-analysis to estimate the rate of ADHD pharmacological treatment in both diagnosed and undiagnosed individuals. Based on a pre-registered protocol (CRD42018085233), we searched a broad set of electronic databases and grey literature. After screening 25,676 abstracts, we retained 36 studies including 104,305 subjects, from which 18 studies met our main analysis criteria. The pooled pharmacological treatment rates were 19.1 % and 0.9 % in school-age children/adolescents with and without ADHD, respectively. We estimated that for each individual using medication without a formal ADHD diagnosis, there are three patients with a formal diagnosis who might benefit from medication but do not receive it in the US. Our results indicate both overtreatment/misuse of medication in individuals without ADHD and pharmacological undertreatment in youths with the disorder. Our findings reinforce the need for public health policies improving education on ADHD and discussions on the benefits and limitations of ADHD medications.
Variation in Rate of Attention-Deficit/Hyperactivity Disorder Management by Primary Care Providers
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To describe variation in rates of attention-deficit/hyperactivity disorder (ADHD) management by pediatrics primary care providers (PCPs) and to assess influence of clinician characteristics on variation.
Retrospective cohort study of electronic health records from all office visits of patients aged 4 to 17 years seen at least twice between 2015 and 2017 by 73 clinicians in 9 pediatrics practices of a community-based primary health care network in California. Outcomes per clinician: 1) percent patients seen for ADHD management; (2) percent ADHD patients with diagnosed comorbid conditions. Logistic random-effects regression models examined practice- and clinician-level variation.
Of 40,323 patients in the cohort, 2039 (5.1%) carried an ADHD diagnosis, of which 1142 (56%) received ADHD medication. Percent of patients seen for ADHD management varied by clinician from 0.0% to 8.3% (median 3.0%). After accounting for practice-level variation and patient characteristics (ie, sex, age, insurance), clinician characteristics explained 28% of clinician variation in ADHD management. ADHD management rate was associated with high-percent full-time equivalent (odds ratio 1.17; 95% confidence interval 1.07–1.27). Percent of ADHD patients with diagnoses of comorbidities varied by clinician from 0.0% to 100% (median 35%). Association between ADHD management rate and comorbidity diagnosis was minimal (R = 0.10).
Objective electronic health records measures showed that PCPs in this network varied widely in their involvement in ADHD management. For most PCPs, percent of patients with ADHD and diagnosis of comorbidities was lower than estimated prevalence rates. Exploration of modifiable factors associated with PCP variation is needed to inform strategies for implementation of evidence-based practices.
Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings
2019, Journal of Pediatrics
Citation Excerpt :
Children from neighborhoods with higher household medical expenditures were more likely to receive ADHD prescriptions. Prior studies—with varied findings—have examined socioeconomic status as a predictor of ADHD medication use: some found that higher income predicts increased medication use,1,2,7,8,13,22,25,40 and others linked higher income to decreased prescriptions.10,15,24 Our study did not find an association between household income and ADHD medication prescription, possibly because we used a referred sample.
To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training).
A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations.
Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription.
We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.
Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid
2019, Journal of Pediatrics
Citation Excerpt :
Our findings are consistent with those recently published for school-age children with ADHD.11 Specific similarities include higher rates of stimulant prescribing for children reported as white compared with black and Hispanic children, less use of behavioral therapy for children treated by primary care physicians compared with those treated by psychiatrist and neurologists, and low rates of behavioral health interventions.11 In young children, especially those living in poverty, a number of factors may be associated with attention and behavioral problems, such as exposure to adverse childhood events,12 sleep problems,13 and chaotic home environments.14
To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care.
Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016.
More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016.
Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

View all citing articles on Scopus

: The authors have no conflicts of interest to disclose.

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Receipt of Medication and Behavioral Therapy Among a National Sample of School-Age Children Diagnosed With Attention-Deficit/Hyperactivity Disorder

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Study Design

Data Source

Description of Sample

ADHD Management

Discussion

Acad Pediatr

J Adolesc Health

J Adolesc Health

Attention deficit–hyperactivity disorder in children and adolescents

N Engl J Med

Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011

J Am Acad Child Adolesc Psychiatry

ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents

Pediatrics

Clinical and social factors associated with attention-deficit hyperactivity disorder medication use: population-based longitudinal study

Br J Psychiatry

The effects of classroom interventions on off-task and disruptive classroom behavior in children with symptoms of attention-deficit/hyperactivity disorder: a meta-analytic review

PLoS One

Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers

J Dev Behav Pediatr

Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder

Pediatrics

Practice patterns and guideline adherence in the management of attention deficit/hyperactivity disorder

Clin Pediatr (Phila)

Race/ethnicity and insurance status as factors associated with ADHD treatment patterns

J Child Adolesc Psychopharmacol

Racial and ethnic disparities in ADHD diagnosis from kindergarten to eighth grade

Pediatrics

Treatment of attention-deficit/hyperactivity disorder in adolescents: a systematic review

JAMA

Outpatient visits and medication prescribing for US children with mental health conditions

Pediatrics

Parent medication concerns predict underutilization of mental health services for minority children with ADHD

Clin Pediatr (Phila)

Latina mothers' stances on stimulant medication: complexity, conflict, and compromise

J Dev Behav Pediatr