Exploring Factors Influencing Medication Adherence From Initiation to Discontinuation in Parents and Adolescents With Attention Deficit Hyperactivity Disorder.

Clin Pediatr (Phila). 2020 03;59(3):285-296

Authors: Khan MU, Aslani P

Abstract
This study explored factors influencing parents' and adolescents' decisions to initiate, continue, and discontinue medication for attention deficit hyperactivity disorder (ADHD). Three focus groups were conducted with parents (n = 23) of children with ADHD, and 2 with adolescents diagnosed with ADHD (n = 11). Parents and adolescents independently discussed the complexities surrounding their decisions to adhere to ADHD medication. Parents' negative beliefs about medication (fear of side effects) discouraged them from initiating therapy. Once initiated, parents struggled in balancing the need to medicate (improvements in learning and behavior) and concerns (weight loss, perceived delayed development) about the medication. Parents who had more concerns about the medication were more in favor of discontinuation. For adolescents, the desire for self-expression without being medicated was the primary factor determining nonadherence and/or discontinuation of the medication. Adolescents' medication-related concerns were relatively different from the parents. Phase- and group-specific interventions are required to improve medication adherence in people with ADHD.

PMID: 31976758 [PubMed - indexed for MEDLINE]

ADHD Diagnosis and Treatment Guidelines: A Historical Perspective.

Pediatrics. 2019 10;144(4):

Authors: Wolraich ML, Chan E, Froehlich T, Lynch RL, Bax A, Redwine ST, Ihyembe D, Hagan JF

Abstract
Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (∼76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication can improve monitoring of ADHD symptoms and functional performance. The American Academy of Pediatrics ADHD guidelines were initially developed to help primary care clinicians address the needs of their patients with ADHD and were further refined with the second revision in 2019.

PMID: 31570649 [PubMed - indexed for MEDLINE]

Healthcare provider perspectives on diagnosing and treating adults with attention-deficit/hyperactivity disorder.

Postgrad Med. 2019 Sep;131(7):461-472

Authors: Adler LA, Farahbakhshian S, Romero B, Flood E, Doll H

Abstract
Objective: This study examined adult attention-deficit/hyperactivity disorder (ADHD) screening and management patterns among healthcare provider (HCP) subgroups. Methods: An online survey of US-based HCPs (neurologists, n = 200; nurse practitioners [NPs], n = 100; psychiatrists, n = 201; primary care physicians [PCPs], n = 201) was conducted from May to June 2017. The survey assessed issues relating to adult ADHD screening and management and HCP perceptions of factors influencing patient choice of pharmacotherapy. Participants were required to be experienced in diagnosing and/or treating ADHD in adults (≥5 patients/month for neurologists and NPs; ≥10 patients/month for psychiatrists and PCPs). Results: Significantly greater percentages of psychiatrists than non-psychiatrists were confident in diagnosing ADHD (P < 0.001) and screened/evaluated for ADHD in patients with depression/anxiety disorders (P < 0.001). Significantly greater percentages of psychiatrists versus non-psychiatrists prescribed once-daily long-acting (LA) stimulants (71.6% vs 62.2%; P = 0.023) or short-acting (SA) stimulants more than once daily (40.3% vs 29.7%; P = 0.009) as first-line therapy. In contrast, a significantly greater percentage of non-psychiatrists than psychiatrists prescribed once-daily SA stimulants (32.9% vs 17.4%; P < 0.001). Psychiatrist and non-psychiatrist HCPs viewed insurance coverage/treatment costs (79.9%), perceived duration of effect (72.2%), and side effects (66.5%) as important factors to patients when choosing treatment. HCPs reported that the greatest mean ± SD percentages of patients changed their treatment regimen in the past 6 months because of perceptions of insufficient duration of effect (35.4% ± 22.1%) and lack of efficacy (30.3% ± 21.0%). Conclusion: Compared with psychiatrists, non-psychiatrists exhibited less confidence in diagnosing adult ADHD and experienced greater difficulty determining optimal treatment regimens.

PMID: 31340712 [PubMed - indexed for MEDLINE]

Clinical Pharmacogenetics Implementation Consortium Guideline for Cytochrome P450 (CYP)2D6 Genotype and Atomoxetine Therapy.

Clin Pharmacol Ther. 2019 07;106(1):94-102

Authors: Brown JT, Bishop JR, Sangkuhl K, Nurmi EL, Mueller DJ, Dinh JC, Gaedigk A, Klein TE, Caudle KE, McCracken JT, de Leon J, Leeder JS

Abstract
Atomoxetine is a nonstimulant medication used to treat attention-deficit/hyperactivity disorder (ADHD). Cytochrome P450 (CYP)2D6 polymorphisms influence the metabolism of atomoxetine thereby affecting drug efficacy and safety. We summarize evidence from the published literature supporting these associations and provide therapeutic recommendations for atomoxetine based on CYP2D6 genotype (updates at www.cpicpgx.org).

PMID: 30801677 [PubMed - indexed for MEDLINE]

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid.

J Pediatr. 2019 04;207:185-191.e1

Authors: Davis DW, Feygin Y, Creel L, Williams PG, Lohr WD, Jones VF, Le J, Pasquenza N, Ghosal S, Jawad K, Yan X, Liu G, McKinley S

Abstract
OBJECTIVES: 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.
STUDY DESIGN: 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.
RESULTS: 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.
CONCLUSIONS: Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

PMID: 30545564 [PubMed - indexed for MEDLINE]

Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review.

Pediatrics. 2018 06;141(6):

Authors: Goode AP, Coeytaux RR, Maslow GR, Davis N, Hill S, Namdari B, LaPointe NMA, Befus D, Lallinger KR, Bowen SE, Kosinski A, McBroom AJ, Sanders GD, Kemper AR

Abstract
CONTEXT: Nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD) encompass a range of care approaches from structured behavioral interventions to complementary medicines.
OBJECTIVES: To assess the comparative effectiveness of nonpharmacologic treatments for ADHD among individuals 17 years of age and younger.
DATA SOURCES: PubMed, Embase, PsycINFO, and Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2009 through November 7, 2016.
STUDY SELECTION: We included studies that compared any ADHD nonpharmacologic treatment strategy with placebo, pharmacologic, or another nonpharmacologic treatment.
DATA EXTRACTION: Study design, patient characteristics, intervention approaches, follow-up times, and outcomes were abstracted. For comparisons with at least 3 similar studies, random-effects meta-analysis was used to generate pooled estimates.
RESULTS: We identified 54 studies of nonpharmacologic treatments, including neurofeedback, cognitive training, cognitive behavioral therapy, child or parent training, dietary omega fatty acid supplementation, and herbal and/or dietary approaches. No new guidance was identified regarding the comparative effectiveness of nonpharmacologic treatments. Pooled results for omega fatty acids found no significant effects for parent rating of ADHD total symptoms (n = 411; standardized mean difference -0.32; 95% confidence interval -0.80 to 0.15; I2 = 52.4%; P = .10) or teacher-rated total ADHD symptoms (n = 287; standardized mean difference -0.08; 95% confidence interval -0.47 to 0.32; I2 = 0.0%; P = .56).
LIMITATIONS: Studies often did not reflect the primary care setting and had short follow-up periods, small sample sizes, variations in outcomes, and inconsistent reporting of comparative statistical analyses.
CONCLUSIONS: Despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.

PMID: 29848556 [PubMed - indexed for MEDLINE]

Association of Mental Health Conditions and Treatments With Long-term Opioid Analgesic Receipt Among Adolescents.

JAMA Pediatr. 2018 05 01;172(5):423-430

Authors: Quinn PD, Hur K, Chang Z, Scott EL, Krebs EE, Bair MJ, Rickert ME, Gibbons RD, Kroenke K, D'Onofrio BM

Abstract
Importance: Adults with mental health conditions are more likely than those without to receive long-term opioid therapy. Less is known about opioid therapy among adolescents, especially those with mental health conditions.
Objective: To examine associations between preexisting mental health conditions and treatments and initiation of any opioid and long-term opioid therapy among adolescents.
Design, Setting, and Participants: A cohort of 1 224 520 incident opioid recipients without cancer diagnoses aged 14 to 18 years at first receipt was extracted from nationwide commercial health care claims data from January 1, 2003, to December 31, 2014. Analysis was conducted from August 19, 2016, to November 16, 2017. Associations between preexisting mental health conditions and treatments and any opioid receipt were examined by comparing recipients with nonrecipients matched on sex, calendar year and years of age of first enrollment, and months of enrollment (prior to the index month for recipients, ever for nonrecipients). Associations between preexisting mental health conditions and treatments and subsequent long-term opioid therapy were examined among recipients with at least 6 months' follow-up using Cox proportional hazards regressions adjusted for demographics.
Exposures: Mental health condition diagnoses and treatments recorded in inpatient, outpatient, and filled-prescription claims prior to opioid receipt.
Main Outcomes and Measures: Opioid receipt, defined as any opioid analgesic prescription claim, and long-term opioid therapy, defined as more than 90 days' supply within a 6-month window having no gaps in supply of more than 32 days.
Results: Of the 1 224 520 new opioid recipients included, the median age at first receipt was 17 years (interquartile range, 16-18 years), and 51.1% were female. Median follow-up after first receipt was 625 days (interquartile range, 255-1268 days). Adolescents with anxiety, mood, neurodevelopmental, sleep, and nonopioid substance use disorders and most mental health treatments were significantly more likely to receive any opioid (odds ratios from 1.13 [95% CI, 1.10-1.16] for nonopioid substance use disorders to 1.69 [95% CI, 1.58-1.81] for nonbenzodiazepine hypnotics). Among the 1 000 453 opioid recipients (81.7%) who had at least 6 months' follow-up, the cumulative incidence of long-term opioid therapy was 3.0 (95% CI, 2.8-3.1) per 1000 recipients within 3 years after first opioid receipt. All preexisting mental health conditions and treatments were strongly associated with higher rates of long-term opioid therapy (adjusted hazard ratios from 1.73 [95% CI 1.54-1.95] for attention-deficit/hyperactivity disorder to 8.90 [95% CI, 5.85-13.54] for opioid use disorder).
Conclusions and Relevance: Commercially insured adolescents with many types of preexisting mental health conditions and treatments were modestly more likely to receive any opioid and were substantially more likely to subsequently transition to long-term opioid therapy relative to those without, although overall rates of long-term opioid therapy were low.

PMID: 29532067 [PubMed - indexed for MEDLINE]

Variation in the 12-Month Treatment Trajectories of Children and Adolescents After a Diagnosis of Depression.

JAMA Pediatr. 2018 01 01;172(1):49-56

Authors: Joyce NR, Schuler MS, Hadland SE, Hatfield LA

Abstract
Importance: Depression during childhood and adolescence is heterogeneous. Treatment patterns are often examined in aggregate, yet there is substantial variability across individual treatment trajectories. Understanding this variability can help identify treatment gaps among youths with depression.
Objective: To characterize heterogeneity in 12-month trajectories of psychotherapy and antidepressant treatment in youths with depression.
Design, Setting, and Participants: This is a longitudinal-cohort study of youths 18 years or younger with a new diagnosis of depression and at least 12 months of follow-up following diagnosis, as determined from commercial insurance claims filed from 2007 to 2014. Latent class models were fit to summary measures of psychotherapy and antidepressant use in the 12 months following the index diagnosis. We examined variation in baseline health, health care utilization, and health outcomes across classes with similar patterns of psychotherapy and antidepressant use. Data analysis took place between June 2016 and March 2017.
Main Outcomes and Measures: Psychotherapy and antidepressant use.
Results: The cohort included 84 909 individuals with a mean (SD) age at index diagnosis of 15.0 (2.6) years, of whom 49 995 (59%) were female. Attention-deficit/hyperactivity disorder (n = 14 625; 17%) and anxiety (n = 12 358; 15%) were the most common comorbid diagnoses. During the assessment period, 59 023 individuals (70%) received psychotherapy at any point, and 33 997 individuals (40%) were dispensed antidepressants at any point. Eight classes with distinct treatment trajectories were identified, which we classified into 4 broad groups: 3 classes that received dual therapy (n = 18 710; 22%), 2 classes that received antidepressant monotherapy (n = 15 287; 18%), 2 classes that received psychotherapy monotherapy (n = 40 313; 48%) and 1 class that received no treatment (n = 10 599; 13%). The most common class received psychotherapy monotherapy (n = 35 243; 42%) and had the lowest incidence of attempted suicide (0.8 per 100 person-years [PY]) and inpatient hospitalization (3.5 per 100 PY) during the assessment period and postassessment period (0.5 per 100 PY and 1.3 per 100 PY, respectively). The group receiving dual therapy had the highest incidence of attempted suicide during the assessment period (4.7-7.1 per 100 PY, depending on the class) and postassessment period (1.5-1.7 per 100 PY).
Conclusions and Relevance: In our sample, 13% of youths received no treatment, and 18% received antidepressants without concomitant psychotherapy. Summary measures of treatment can mask informative patterns of psychotherapy and antidepressant use. Latent class analysis can be used to identify subgroups of individuals with similar treatment trajectories and help identify treatment gaps under current practice patterns.

PMID: 29159404 [PubMed - indexed for MEDLINE]