Factors associated with medium-term response to psychostimulant medication

OBJECTIVE: To determine, in a sample of children first prescribed psychostimulants for attention deficit hyperactivity disorder (ADHD) between 1992 and 1994, which child and family factors, components of assessment, and aspects of management, were associated with a favourable treatment response, and with parental satisfaction with management. METHODOLOGY: Data were obtained by mail survey in March 1995. Factors considered potentially significant to treatment response and parental satisfaction were entered in a three-step hierarchical multiple regression equation. RESULTS: Responses were received from 788 (59.7%) of a possible 1319 parents. Items making a significant individual contribution to both improvement and parental satisfaction were: younger age of the child; amount of information provided by the clinician; shorter interval between review appointments; continued use of medication; and fewer treatment side effects. items contributing only to treatment response were: longer time taken over establishing the diagnosis; and the use of parent and teacher checklists in assessment. CONCLUSIONS: These data support early intervention for ADHD. A considered approach to assessment which includes the use of parent and teacher checklists is recommended. Providing adequate information to parents and children is essential. Review intervals of less than 6 months appear to foster better outcomes.     

Management of attention deficit hyperactivity disorder: a parental perspective

OBJECTIVES: There are few studies exploring parental perceptions of the diagnosis and overall treatment of their children with attention deficit hyperactivity disorder (ADHD). This community-based study was conducted to consider this important aspect of care. METHODS: A total of 7 226 (65%) parents responded to a community survey of 11 184 children aged 10-12 years living in northern Sydney in 2000, out of which 278 children with ADHD were identified. Their parents completed an anonymous questionnaire covering their perceptions relating to diagnosis, treatment and overall management. RESULTS: Only 66% of parents recalled the use of questionnaires or rating scales. There were 82% of children who had trialed medication and 66% of these were still taking it. Behavioural intervention had occurred in 42% of the children. Non-conventional treatments, most commonly elimination diet and/or fatty acid supplementation, had been used in 71% of the children. These were considered helpful in one-third of cases. A total of 55% of parents reported being either satisfied or very satisfied with their child's care. Parents were more likely to report satisfaction when their children were on medication and when reviews were held at least 6 monthly. Lack of educational support and teachers' understanding of ADHD were identified as ongoing issues. CONCLUSION: Parental responses suggested that adherence to recommended diagnostic guidelines was inadequate. Behavioural intervention was underutilized despite its documented positive role. Non-conventional therapies were widely used and considered helpful in one-third of the children who used them. Use of stimulant medication and frequent reviews were more likely to be associated with overall management satisfaction.     

Racial differences in parental reports of attention-deficit/hyperactivity disorder behaviors

OBJECTIVE: Accurate assessment of racial disparities in attention-deficit/hyperactivity disorder (ADHD) depends on measurement that is equally valid for all groups. This study examines differences among African American and white children in ADHD measurement with a widely used parental report instrument, the Diagnostic Interview Schedule for Children (DISC). METHODS: Data come from 1070 children in the Fast Track Project, a longitudinal study of predominantly low-income children at risk of emotional and/or behavioral problems. Item Response Theory (IRT) methodology is used to determine whether ADHD screening items provide comparable information for African American and white children or whether differential item function (DIF) exists. IRT scores and race/ethnicity are entered in logistic regression models predicting use of ADHD medication. RESULTS: Seven of 39 DISC items performed differently among African Americans and whites. In most cases, parents of white children were more likely to endorse these items than were parents of African American children at comparable underlying levels of children's hyperactivity. When items exhibiting differential functioning were deleted, race disparities predicting underlying need as indicated by ADHD medication use decreased and were no longer statistically significant. CONCLUSIONS: Perceptions of ADHD-related symptoms among parents of African American children appear to differ in important ways from those of parents of white children, and screening instruments relying on parent report may yield different results for African American and white children with similar underlying treatment needs. Gathering information from additional sources including teachers and school counselors can provide a more complete picture of the behavioral functioning and therapeutic needs of children in all race/ethnic groups.     

Educators' knowledge and attitudes regarding stimulants in the treatment of attention deficit hyperactivity disorder.

Educators often are asked to provide information regarding students' responses to medication used for the treatment of attention deficit hyperactivity disorder (ADHD). We designed a questionnaire to determine the knowledge and attitudes of educators regarding stimulants. Two hundred ninety-one regular classroom and special education teachers in two Ohio school systems received the questionnaire; the overall response rate was 65%. Our findings suggest that educators generally believe stimulants are useful for students with ADHD and that they frequently recommend them to parents. However, educators indicated their knowledge of the effects of stimulants was limited and that they had received little education about stimulants. Physicians requesting input from educators regarding students taking stimulants should be aware of the limitations of educators' knowledge and participate in the development of programs to improve that knowledge.     

Response to methylphenidate in boys with attention-deficit hyperactivity disorder

The response to methylphenidate was examined in 36 boys, aged 7-11 y, with attention-deficit hyperactivity disorder (ADHD) in a double-blind, placebo-controlled, crossover design. Hyperactivity and conduct problems were significantly reduced during methylphenidate treatment. Stimulant medication was associated with improvements on tests of sustained attention, working memory and motor steadiness. When individual changes were studied, it was found that 83% showed a significant improvement in their hyperactivity at home or at school, and for 60% their levels of hyperactive behaviour were within the normal range. High levels of hyperactivity at school and relatively low age were significant predictors of normalization of hyperactivity in at least one setting. However, these predictors could only classify correctly 71% of the children. In clinical practice a trial with stimulants is indicated in ADHD children who show symptoms that are sufficiently severe to cause impairment at home and at school.     

Attention deficit hyperactivity disorder: comorbidity and medication use

Children evaluated for attention deficit hyperactivity disorder (ADHD) may have other disorders resembling ADHD leading to inappropriate stimulant medication use. This study was completed to identify relationships between referral complaints of ADHD, behavior problems or learning problems and age, gender, final diagnosis, and medication use. One hundred eighty-nine children ages 2 to 15 years referred for evaluation of ADHD, behavior or learning problems were evaluated by an interdisciplinary team. Diagnoses of ADHD, specific learning disability (SLD), mental retardation (MR), developmental language disorders (LANG), and other behavior disorders (DIS) were established. Medication use pre- and post-evaluation was reviewed. Forty-three percent of all subjects had a final diagnosis of ADHD. Forty percent referred specifically for presumed ADHD did not have it. More children older than 5 years were diagnosed as having ADHD than those 5 years old or younger (p < 0.0001). More subjects 5 years old or younger were diagnosed as having LANG than those older than 5 years (p < 0.0001). Fewer subjects with a chief complaint of ADHD were diagnosed with MR than those with behavior or learning problems (p = 0.001). In subjects 5 years old or younger, 35% were diagnosed with MR and 49% with other DIS. In children older than 5 years, 41% were diagnosed with SLD. Ten percent of subjects without ADHD were using stimulants. Only 48% of subjects with confirmed ADHD took stimulants. Children presenting with behavior problems or those 5 years old or younger are at higher risk for MR, LANG, and DIS and less likely to have ADHD. Children presenting with learning problems or those older than 5 years are more likely to have SLD or ADHD. Multiple diagnoses were common for all ages and presentations. Ten percent of children without confirmed ADHD used stimulants before evaluation.     

Barriers to the identification of children with attention deficit/hyperactivity disorder

BACKGROUND: In most countries, the majority of children with attention deficit/hyperactivity disorder (ADHD) are undiagnosed. In the United Kingdom, a major barrier to accessing specialist services is the limited recognition of disorders by general practitioners. However, it is unclear whether there are also barriers at other stages of the help-seeking process. For children with ADHD, this study aims to examine the correlates of the different stages of help-seeking. METHOD: Children with ADHD (n = 232) were identified from the 1999 British Child and Adolescent Mental Health Survey. Rates and correlates of parental recognition of child mental health problems and contact with services for these problems were examined. Children who had used particular types of services were compared with those who had not. RESULTS: Most (80%) parents of children with ADHD recognise that their child has a problem although few (35%) construe this in terms of hyperactivity. The impact of the symptoms on key adults, rather than child factors, best predicted parental recognition of problems. Most parents had been in contact with education-based professionals but few had consulted primary care for these problems or had sought help from relevant specialist health services. Parental recognition of problems and perceived burden, rather than child factors, were the main correlates of contact with services. Parental views that their child has hyperactivity were associated with greater severity of symptoms. CONCLUSIONS: The main barrier to care for ADHD is the limited presentation of these problems to primary care. The majority of parents discuss their concerns with professionals based in education services. There is a need for parental education about ADHD and for health service input to support education professionals in their contact with concerned parents.     

Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder

Treatment of attention deficit hyperactivity disorder (ADHD), one of the most common behavioral disorders in children in the United States, remains controversial because of concern about stimulant medication use. Extending a previous study of pediatricians, the present study surveyed a random national sample of family practitioners and then directly screened 457 patients of 10 pediatricians and family practitioners in two small midwestern cities. Responses to the national survey indicated that stimulant medication remains the main treatment prescribed by primary care physicians for children with ADHD. In the direct patient screening, the prevalence of ADHD diagnoses was 5.3% (pediatricians) and 4.2% (family practitioners) of all elementary-school-aged children screened. Eighty-eight percent of these children were treated with methylphenidate. Although medication was considered an effective treatment by the parents of 85% of the children given the medication, efficacy was unrelated to the accuracy of diagnosis. When explicit DSM-III-R criteria were used, only 72% of those assigned a diagnosis of ADHD by the physicians would have received that diagnosis based on a structured psychiatric interview with the parents and only 53% received that diagnosis based on teacher report of symptoms, even when the child was not receiving medication. Although the majority of physicians (in both the surveys and the direct screenings) reported using at least some behavioral treatments with their patients, parents reported infrequent use of nonpharmacologic forms of therapy, such as behavior modification. These data thus indicate a relatively modest rate of stimulant medication use for ADHD, but a serious underuse of systematic behavioral treatments in primary care.(ABSTRACT TRUNCATED AT 250 WORDS)     

Investigating ADHD treatment trajectories: listening to families' stories about medication use

OBJECTIVE: Policymakers, federal agencies, and researchers have called for more in-depth investigation of contextual mechanisms that may explain differences in medication use among youths with attention-deficit/hyperactivity disorder (ADHD). METHOD: We conducted qualitative interviews with 28 families from varied socioeconomic and racial/ethnic and linguistic backgrounds regarding diagnostic and treatment trajectories for their children with symptoms consistent with ADHD, with a particular focus on whether and how medication use became a part of the trajectory. RESULTS: Four longitudinal patterns of help-seeking trajectories emerged: (1) a pattern characterized by delay to diagnosis, common among youths with complicated clinical and/or environmental pictures or primarily inattentive ADHD symptoms; (2) an initial nonmedication treatment pattern in which parents at first chose to use other modalities of treatment; (3) a reluctant receipt of an ADHD diagnosis and/or treatment pattern, mainly seen among the low-income, Spanish-speaking families; and (4) a rapid engagement in medication use pattern, characterized by directed movement to and maintenance of medication use. These patterns resulted from a dynamic interplay of explanatory models regarding the cause, course, and cure of a child's problems; the influence of extended social networks; and factors previously examined in medical utilization models. Additional themes included (1) parents' need for more information about ADHD, (2) families' desire for additional mental health and school services making medications less necessary, and (3) the importance of cultural sensitivity and a longitudinal relationship between the caregiver and clinician to enhance communication between families and clinicians. CONCLUSIONS: These findings deserve further study in a larger, more diverse sample.     

Enhancing behavioral and social skill functioning in children newly diagnosed with attention-deficit hyperactivity disorder in a pediatric setting

The objective of this study was to evaluate the effectiveness of an 8-week behavioral and social skill (BSS) class for children newly diagnosed with attention-deficit hyperactivity disorder (ADHD) and their parents, initiating stimulant treatment in primary care. The subjects were 100 children, aged 5 to 12 years, recently diagnosed with ADHD and treated with stimulant medication, and their parents or guardians. Eligible families were randomly assigned to an intervention group (IG: n = 59) or control group (CG: n = 41). The BSS function of each child was assessed using DuPaul's ADHD Parent Rating Scale (18-item) and Child Attention Profile (12-item) during blinded baseline and follow-up interviews. Parent discipline practice was assessed using a five-item inventory based on Likert-scale ratings during identical periods. Computerized pharmacy records were used to track psychostimulant use over time. IG children exhibited significantly lower parent-rated ADHD symptoms, whereas IG parents reported significantly better and more consistent discipline practices compared with CG parents across time. No significant differences were found between groups in Child Attention Profile scores across time. Psychostimulant use did not significantly differ between groups across time. BSS training was well accepted and seemed to significantly improve BSS functioning among IG children in the home setting only.     

Psychotherapeutic medication patterns for youths with attention-deficit/hyperactivity disorder

OBJECTIVES: (1) To describe temporal patterns of office visits for attention-deficit/hyperactivity disorder (ADHD) and stimulant treatment for 5- to 14-year-old US youths; (2) to compare youth visits for ADHD with and without melication according to patient demographics, physician specialty, reimbursement source, and comorbid diagnoses; and (3) to compare office visits for youths with ADHD in relation to common medication patterns (stimulants alone, stimulants with other psychotherapeutic medication, and nonstimulant psychotherapeutic medications alone). DESIGN: Survey based on a national probability sample of office-based physicians in the United States. SETTING: Physician offices. PARTICIPANTS: A systematically sampled group of office-based physicians. MAIN OUTCOME MEASURES: National estimates of office visits for ADHD and psychotherapeutic drug visits for ADHD for each year and for a combined 8-year period. RESULTS: Youth visits for ADHD as a percentage of total physician visits had a 90% increase, from 1.9% in 1989 to 3.6% in 1996. Stimulant therapy within ADHD youth visits rose from 62.6% in 1989 to 76.6% in 1996. While the majority of non-ADHD youth visits were conducted by primary care physicians, one third of ADHD youth visits were managed by psychiatry and neurology specialists. Health maintenance organization insurance was the reimbursement source for 17.9% of non-ADHD youth visits but only 11.7% of ADHD youth visits. Complex medication therapy was more likely to be prescribed by psychiatrists and less likely to be related to visits with health maintenance organization reimbursement. CONCLUSIONS: National survey estimates in the 1990s confirm the substantial increase in visits for youths diagnosed as having ADHD, with more than three quarters of these visits associated with psychotherapeutic medication treatment. Physician specialty and reimbursement source variables identify distinct patient populations with a gradient in psychotherapeutic medication patterns from single-drug standard (stimulant) therapy to complex multidrug treatment regimens for which evidence-based scientific information is lacking.     

Stimulant Diversion Risk Among College Students Treated for ADHD: Primary Care Provider Prevention Training

ObjectiveTo address increasing rates of stimulant misuse in college students, this study developed an evidence-based, brief clinical practice intervention for primary care providers (PCPs) to reduce stimulant medication diversion among young adults with attention-deficit/hyperactivity disorder (ADHD).MethodsCollege students (N-114; 18–25 years; 68% attending universities; 24% attending community college) treated for ADHD with a stimulant and their PCPs across six practices participated in this initial, uncontrolled study of pre- to post-intervention change. An educational workshop providing strategies aimed at reducing stimulant diversion was developed and delivered to providers and staff across all practices (50% pediatric; 50% family medicine). Patients and providers completed baseline and post intervention surveys.ResultsDiversion was relatively infrequent, 16.7% at baseline and 14.9% post-intervention, respectively. Statistically significant decreases from baseline to post-intervention were found for three diversion risk factors: (1) number of times approached to divert, (2) intent to share, sell, or trade stimulants, and (3) disclosure of stimulant use. Providers and staff reported mostly high satisfaction with the training.ConclusionsThis study provides initial evidence for a PCP-delivered intervention to reduce stimulant diversion. Research is needed on the efficacy of targeting college students directly, working with pharmacies and student health centers, and preventing misuse among teenagers.     

Impact of low birth weight on attention-deficit hyperactivity disorder

The objective of the study was to evaluate an association between low birth weight (LBW) and attention-deficit hyperactivity disorder (ADHD) attending to potential family-genetic and environmental confounders. We examined 252 ADHD cases (boys and girls) and 231 non-ADHD controls and their parents. All subjects were extensively assessed with structured diagnostic interviews, cognitive assessments, and structured interviews of prenatal, infancy, and delivery complications. ADHD cases were three times more likely to have been born LBW than were non-ADHD controls, after attending to potential confounders such as prenatal exposure to alcohol and cigarettes, parental ADHD, social class, and comorbid disruptive behavior disorders in parents and offspring. If this association was causal, 13.8% of all ADHD cases could be attributed to LBW. These results converge with prior studies documenting similar associations and indicate that LBW is an independent risk factor for ADHD. Children with LBW, however, make up a relatively small proportion of children with ADHD.     

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

OBJECTIVE. Disparities in attention deficit hyperactivity disorder (ADHD) treatment are recognized with minority children using services less than nonminority children. The authors examine minority parents' knowledge and perceptions of ADHD as they relate to service utilization. METHODS. Using a longitudinal cohort design, parents of children with untreated ADHD were surveyed regarding their knowledge and perceptions of ADHD and then followed for 3 to 6 months to determine whether they used services. RESULTS. Seventy parents of 5- to 18-year-old children with untreated ADHD were enrolled. Of the 70 children, 33 (47.1%) had not attended any mental health appointments and 51 (72.9%) had not used any treatments by 3- to 6-month follow-up. Logistic regression indicated that increasing age and medication concerns were associated with less follow-up at mental health appointments (P < .05) and less utilization of treatments (P < .05). CONCLUSIONS. The results of this study highlight the importance of addressing medication concerns, when referring minority children to mental health services or offering treatments.     

Complementary and alternative therapies in childhood attention and hyperactivity problems

To determine the prevalence and factors associated with complementary and alternative medicine (CAM) use for childhood attention and hyperactivity problems, we surveyed parents of children referred for evaluation of attention-deficit hyperactivity disorder (ADHD). Parents indicated whether they had used CAM therapies (e.g., acupuncture, nutritional supplements) in the past year and rated how important different reasons were in making their therapy decisions. Overall, 62 of 114 (54%) parents reported using CAM, most commonly expressive therapies, vitamins, and dietary manipulation, to treat their child's attention problems. Parents who used CAM rated a "natural therapy" and "having more control over treatments" significantly more important in their choice of therapy than parents who did not use CAM. Only 11% of parents discussed using CAM with their child's physician. Because parents often use CAM to treat their child's attention and hyperactivity problems without their pediatrician's knowledge, pediatricians need to initiate discussions of CAM use with patients and families.     

Update on attention-deficit/hyperactivity disorder

PURPOSE OF REVIEW: Attention-deficit/hyperactivity disorder (ADHD) is present in 3% to 10% of children in the United States. Children with ADHD can have academic impairments, social dysfunction, and poor self-esteem. There is also a higher risk of both cigarette smoking and substance abuse. Given this, the importance of treatment for ADHD needs to be underscored. This article will briefly review the diagnosis, etiology, and treatment of ADHD, with particular focus on nonstimulant medication and alternative treatment modalities. RECENT FINDINGS: Recent evidence suggests that the overall rate of medication treatment for ADHD has been increasing, with over 2 million children being treated with stimulants in 1997. With this increase, controversy has arisen over the possible association of stimulants with growth suppression. In addition, estimates indicate that as many as 30% of children with ADHD either do not respond to stimulant treatment or cannot tolerate the treatment secondary to side effects. This has lead to the consideration of treatment with both nonstimulant medications as well as alternative therapies, including diet, iron supplementation, herbal medications, and neurofeedback. Considering the various treatment options now available for ADHD, along with the complexity of the condition, clinical practice guidelines are emerging for the treatment of ADHD and will be discussed. SUMMARY: ADHD continues to be a serious health problem. Adequate treatment is needed to avoid academic impairments, social dysfunction, and poor self-esteem. This treatment includes consideration of stimulant medication, nonstimulant medication, as well as alternative therapies. The child with ADHD is likely better served with a mutimodal treatment plan, including medication, parent/school counseling, and behavioral therapy. Implementing an evidenced based algorithm for the treatment of ADHD may prove to be most effective.     

Treatment experiences of children and adolescents with attention-deficit/hyperactivity disorder

Aim: To gain insight into the treatment experiences of children and adolescents diagnosed with attention‐deficit/hyperactivity disorder (ADHD). Methods: Convenience sampling was used to recruit eligible parents and carers at paediatric clinics of the Children's, Youth and Women's Health Service to participate in an interview to discuss experiences, using a semi‐structured questionnaire. Results: Thirty‐five interviews were conducted. Twenty‐five subjects had trialled an average of 1.5 interventions prior to receiving an ADHD diagnosis, namely, dietary modifications (46%), behavioural therapy (24%), learning assistance (8%) and natural remedies (8%). Following an ADHD diagnosis, 25 subjects tried an average of 2.8 interventions, most commonly behavioural therapies (48%), expressive therapies (48%) and fish oil (36%). All subjects started psychostimulant medication after receiving an ADHD diagnosis. Despite 52% of parents expressing initial reluctance towards psychostimulants, 97% reported positive experiences with use in terms of schooling, social interaction and family life. Of those being treated with psychostimulants, 22 (73%) were concurrently using other treatments at the time of interview. Conclusions: Few patients use psychostimulant medication in isolation, with the majority of parents using multiple approaches to manage their child's behaviour. Parents tried a variety of therapies before commencing psychostimulant medication, often because of fears regarding psychostimulant safety. Parents were generally happy with the results gained; however adolescents interviewed were less convinced of the benefits of psychostimulants.     

Treatment of attention-deficit/hyperactivity disorder: overview of the evidence

The American Academy of Pediatrics' Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, reviewed and analyzed the current literature for the purpose of developing an evidence-based clinical practice guideline for the treatment of the school-aged child with attention-deficit/hyperactivity disorder (ADHD). This review included several key reports, including an evidence review from the McMaster Evidence-Based Practice Center (supported by the Agency for Healthcare Research and Quality), a report from the Canadian Coordinating Office for Health Technology Assessment, the Multimodal Treatment for ADHD comparative clinical trial (supported by the National Institute of Mental Health), and supplemental reviews conducted by the subcommittee. These reviews provided substantial information about different treatments for ADHD and their efficacy in improving certain characteristics or outcomes for children with ADHD as well as adverse effects and benefits of multiple modes of treatment compared with single modes (eg, medication or behavior therapies alone). The reviews also compared the effects of different medications. Other evidence documents the long-term nature of ADHD in children and its classification as a chronic condition, meriting the application of general concepts of chronic-condition management, including an individual treatment plan with a focus on ongoing parent and child education, management, and monitoring. The evidence strongly supports the use of stimulant medications for treating the core symptoms of children with ADHD and, to a lesser degree, for improving functioning. Behavior therapy alone has only limited effect on symptoms or functioning of children with ADHD, although combining behavior therapy with medication seems to improve functioning and may decrease the amount of (stimulant) medication needed. Comparison among stimulants (mainly methylphenidate and amphetamines) did not indicate that 1 class outperformed the other.