English: Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2007 (Photo credit: Wikipedia)
Before this post.......Im just a family doctor and also epidemiologyst.......can any explain me why the percentage of diagnosis of ADHD is so different between Maine or Cunneticut against California or Nex Mexico ? Marketing or epidemiology ?
May 4, 2013 — A recent study by
pediatricians from the Cohen Children's Medical Center of New York
examined to what extent pediatric physicians adhere to American Academy
of Pediatrics (AAP) clinical guidelines regarding pharmacotherapy in
treating young patients with Attention Deficit Hyperactivity Disorder
(ADHD). The results showed that more than 90 percent of medical
specialists who diagnose and manage ADHD in preschoolers do not follow
treatment guidelines recently published by the AAP.
"It is unclear why so many physicians who specialize in the
management of ADHD -- child neurologists, psychiatrists and
developmental pediatricians -- fail to comply with recently published
treatment guidelines," said Andrew Adesman, MD, senior investigator and
chief of developmental and behavioral pediatrics at Cohen Children's
Medical Center in New Hyde Park. "With the AAP now extending its
diagnosis and treatment guidelines down to preschoolers, it is likely
that more young children will be diagnosed with ADHD even before
entering kindergarten. Primary care physicians and pediatric specialists
should recommend behavior therapy as the first line treatment." Current clinical guidelines for pediatricians and child psychiatrists
associated with the American Academy of Child & Adolescent
Psychiatry (AACAP) recommend that behavior therapy be the initial
treatment approach for preschoolers with ADHD, and that treatment with
medication should only be pursued when counseling in behavior management
is not successful. The study also found that more than one-in-five specialists who
diagnose and manage ADHD in preschoolers recommend pharmacotherapy as a
first-line treatment alone or in conjunction with behavior therapy.
Although the AAP recommends that pediatricians prescribe methylphenidate
when medication is indicated, more than one-third of specialists who
prescribe medication for preschool ADHD said they 'often' or 'very
often' choose a medication other than methylphenidate initially (19.4
percent amphetamines; 18.9 percent non-stimulants). "Although the AAP's new ADHD guidelines were developed for primary
care pediatricians, it is clear that many medical subspecialists who
care for young children with ADHD fail to follow recently published
guidelines," said Jaeah Chung, MD, the study's principal investigator
who also practices at Cohen Children's. "At a time when there are public
and professional concerns about over-medication of young children with
ADHD, it seems that many medical specialists are recommending medication
as part of their initial treatment plan for these children."
The following PRODIGY topics have been updated to include new evidence and recommendations published by the National Institute of Health and Clinical Excellence (NICE), the Medicines and Healthcare products Regulatory Agency (MHRA), the Faculty of Sexual and Reproductive Health (FSRH), the Quality and outcomes framework guidance for GMS contract 2011/12 and manufacturers’ summary of product characteristics (SPC).
Attention deficit hyperactivity disorder has been updated to include new safety information from the MHRA about the importance of regularly monitoring people on atomoxetine.
Bipolar disorder and Schizophrenia have been updated to include information about the rare association of quetiapine with diabetic ketoacidosis from the manufacturer’s SPC.
Contraception – assessment has been amended to clarify the UK medical eligibility criteria for the use of progestogen-only pills in women with a past history (5 years or more) of migraine with aura, at any age.
The new recommendation from the FSRH Emergency Contraceptionguidance (updated January 2012) that all eligible women presenting between 0 and 120 hours of unprotected sexual intercourse or within 5 days of expected ovulation should be offered a copper intrauterine device, because of the low documented failure rate.
New advice on dosing, adverse effects, and drug interactions from new safety data regarding the association of domperidone with an increased risk of serious ventricular arrhythmias or sudden cardiac death published by McNeil Products Ltd and the MHRA.
Epilepsy has been updated to reflect the relevant changes from the update NICE epilepsy guideline The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (2012).
Los temas PRODIGY siguientes se han actualizado para incluir nuevas pruebas y las recomendaciones publicadas por el Instituto Nacional de Salud y Excelencia Clínica (NICE), los medicamentos y productos de Salud Agencia Reguladora (MHRA), la Facultad de Salud Sexual y Reproductiva (FSRH), la Calidad y orientación marco de resultados para el contrato de GMS 2011/12 y el resumen de los fabricantes de las características del producto (SPC).
Por déficit de atención e hiperactividad ha sido u pdated para incluir nueva información de seguridad de la MHRA sobre la importancia del control periódico de las personas sobre la atomoxetina.
El trastorno bipolar y la esquizofrenia se han actualizado para incluir información sobre la rara asociación de quetiapina con cetoacidosis diabética de SPC por el fabricante.
Anticoncepción - evaluación ha sido enmendada para aclarar los criterios de elegibilidad médica del Reino Unido para el uso de píldoras con sólo progestágeno en mujeres con una historia pasada (5 años o más) de la migraña con aura, a cualquier edad.
La nueva recomendación de la guía de anticoncepción de emergencia FSRH (actualizado en enero de 2012) que todas las mujeres elegibles que presentan entre 0 y 120 horas de relaciones sexuales sin protección o dentro de los 5 días de la ovulación espera que se les debe ofrecer un dispositivo intrauterino de cobre, debido a la baja tasa de fallos documentados .
Un nuevo informe sobre la dosificación, efectos adversos e interacciones medicamentosas de nuevos datos de seguridad con respecto a la asociación de domperidona con un mayor riesgo de arritmias ventriculares graves o la muerte súbita de origen cardíaco publicado por McNeil Products Ltd y de la MHRA.
La epilepsia se ha actualizado para reflejar los cambios relevantes de la directriz de la epilepsia actualización NICE Las epilepsias: el diagnóstico y tratamiento de las epilepsias en adultos y niños en la atención primaria y secundaria (2012).
La información de referencia para un ataque isquémico transitorio en el accidente cerebrovascular y AIT tema ha sido modificado en consonancia con la calidad y la orientación marco de resultados para el contrato de GMS 2011/12.
By Nancy Walsh, Staff Writer, MedPage Today Published: September 29, 2011
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Image via WikipediaThe use of stimulant medications among children with attention deficit hyperactivity disorder (ADHD) continues to rise, particularly among adolescents, a nationally representative survey showed.
In 2008, these medications were used by 3.5% (95% CI 3.0 to 4.1) of children ages 18 and younger compared with 2.4% (95% CI 1.8 to 2.9) in 1996, according to Samuel H. Zuvekas, PhD, of the Agency for Healthcare Research and Quality in Rockville, Md., and Benedetto Vitiello, MD, of the National Institute of Mental Health in Bethesda, Md.
But among those ages 13 to 18, the rate of use increased by 6.5% annually, rising from 2.3% (95% CI 1.5 to 3.1) in 1996 and reaching 5% (95% CI 3.9 to 6.1) by 2008 (P<0.001), the researchers reported online in the American Journal of Psychiatry.
Explain that the use of stimulant medications among children with attention deficit hyperactivity disorder (ADHD) continues to rise, particularly among adolescents.
Note that consistent with the gender predominance of ADHD, three times as many boys as girls were treated with stimulants.
Some 9% of children ages 6 to 17 at some time have been diagnosed as having ADHD. Prescribing of stimulant medications rose sharply in the 1990s, and in the subsequent decade numerous new formulations were developed.
"As the market for ADHD medications has expanded, concerns have been raised about the possible misuse and abuse of stimulants, especially because the increase in ADHD diagnoses has been most marked in adolescents," the researchers wrote.
To examine the patterns of use of drugs such as methylphenidate and amphetamines among young people, Zuvekas and Vitiello analyzed data from the Medical Expenditure Panel Survey, an ongoing report that follows trends in the treatment of psychiatric disorders.
They found that approximately 2.8 million children were using stimulants in 2008, a number that had risen by 3.4% each year since 1996.
The rate of use was highest among children ages 6 to 12, and that rate has held fairly steady over time -- 4.2% (95% CI 3.2 to 5.2) were treated with stimulant medications in 1996, while 5.1% (95% CI 4.1 to 6.1) were on the drugs in 2008.
Children younger than 6 were the least common recipients of stimulant medications. Before 2004, yearly estimates for this age group were 0.3% to 0.4%, but thereafter fell to and remained at 0.1%, which was a significant decrease (t=3.71, P<0.001), according to the researchers.
Although a clinical trial in 2006 demonstrated efficacy for methylphenidate among preschool-age children, it also identified a higher incidence of adverse effects, and the current data showed that, in fact, ADHD medications are little used in the youngest children, Zuvekas and Vitiello pointed out.
Reflecting the gender predominance of ADHD, three times as many boys as girls were treated with stimulants (5.3% versus 1.6%).
Use was highest in whites, being 4.4% in 2008, compared with 3% of African Americans and 2.1% of Hispanics.
And although use was lower in minorities, it had risen notably from 1.9% and 0.7% in 1996 among African Americans and Hispanics, respectively.
This reflects a growing recognition of ADHD among groups that have often been underserved in mental health resources, while also suggesting that cultural barriers remain, according to the researchers.
Rates were low (1.3%) among children lacking health insurance, and those with public insurance were more likely to be on the medications than those with private insurance (OR 1.36, t=2.14, P=0.016).
Geography also influenced use, with 4.6% of children in the Northeast taking stimulants in 2008 compared with 1.6% of those living in the West.
The survey suggested that the majority of children with ADHD actually do not receive stimulant medications.
"This may not be unexpected, since about half of those diagnosed present with only mild symptoms and since other treatments, including psychosocial interventions and nonstimulant medications, are available," the researchers explained.
Among other medications taken by small numbers of children were clonidine, guanfacine, and atomoxetine (Strattera).
The findings of this study should be interpreted in light of certain limitations, they noted, such as possible recall bias and underestimation of medication use, as well as a lack of validation for diagnoses in the survey.
Thanks to an increasing reliance on stimulants among parents and schools to combat attention deficit disorders among kids, more meds have been prescribed in recent years. But what does that usage look like exactly? Well, ADHD pills were used by 3.5 percent of children 18 years old and younger in 2008, up from 2.4 percent in 1996, according to a new study in the American Journal of Psychiatry.
However, usage was most pronounced among teenagers: the rate increased 6.5 percent annually. In 1996, 2.3 percent of those between 13 and 18 years old were taking ADHD pills, rising to 5 percent by 2008. This increased use occurred as the meds became more popular and new formulations appeared. As MedPage Today notes, 9 percent of kids ages 6 to 17 have been diagnosed with ADHD at some point, raising concerns that misuse occurred.
“As the market for ADHD medications has expanded, concerns have been raised about the possible misuse and abuse of stimulants, especially because the increase in ADHD diagnoses has been most marked in adolescents,” wrote the researchers, Samuel Zuvekas of the Agency for Healthcare Research and Quality and Benedetto Vitiello of the National Institute of Mental Health.
To gauge patterns, they analyzed data from the Medical Expenditure Panel Survey and found that approximately 2.8 million children were using stimulants in 2008, which amounted to annual increase of 3.4 percent since 1996. And while the usage rate was highest among children ages 6 to 12, this has remained steady – 4.2 percent using the pills in 1996, compared with 5.1 percent in 2008.
Not surprisingly, perhaps, three times as many boys as girls were given ADHD pills – 5.3 percent compared with 1.6 percent. As for the youngest kids, usage among those under 6 years old was estimated at 0.3 percent to 0.4 percent before 2004, but fell to 0.1 percent thereafter and remained at that level. Among whites, usage was 4.4 percent compared with 3 percent among African Americans and 2.1 percent among Hispanics; rates for minories, by the way, rose since 1996 (here is the abstract).
SAN DIEGO – Significant increases in adiposity and insulin resistance quickly became apparent in a 12-week study of low-dose antipsychotics to treat mainly nonpsychotic disorders in 144 children.
Newer, “atypical” antipsychotics increasingly are being used to treat mood and disruptive behavior disorders in children, Dr. John W. Newcomer said at the annual meeting of the American Diabetes Association.
“It’s a topic of increasing concern in a number of state Medicaid” systems, he said. Concerns have been generated in part by data showing premature mortality in people with mental disorders that’s related primarily to cardiovascular disease but also to cardiometabolic risk.
Children in the open-label study were randomized to flexibly dosed treatment with risperidone, olanzapine, or aripiprazole. It was their first use of antipsychotics.
Dr. John W. Newcomer
These were “very low doses,” he emphasized. “These are not doses that would be used to treat a psychotic disorder,” said Dr. Newcomer, who led the study while at Washington University, St. Louis. He now is a professor of psychiatry and behavioral sciences at the University of Miami.
The 5-year Metabolic Effects of Antipsychotics in Children (MEAC) study targeted symptoms of aggression and irritability in patients aged 6-18 years. “Typically, they had been suspended from school,” he said.
The main primary diagnosis was treatment-refractory attention deficit hyperactivity disorder (ADHD) in 57% of patients. “This is what clinicians are using these drugs for in this type of public-sector population – kids who fail two or three courses of stimulants who then are looking for some other treatment.”
Other main diagnoses included oppositional defiant disorder in 22%, pervasive developmental disorder in 6%, bipolar disorder in 4%, and major depression in 3%. Smaller proportions of patients were diagnosed with other mood disorders, Asperger’s syndrome, autism, obsessive-compulsive disorder, or Tourette’s syndrome.
Mean doses were 1 mg/day in the 49 patients on risperidone, 6.3 mg/day in the 46 patients on olanzapine, and 6 mg/day in the 49 patients on aripiprazole. Approximately half of patients also were on stable doses of stimulants for ADHD.
Total body percentage of adiposity increased 2.4% after 12 weeks on antipsychotics – slightly less than a standard deviation, and a highly significant change, Dr. Newcomer and his associates reported. Mean total fat increased 2.3 kg, they added.
The percentage body fat increased the most in the youngest children. Greater changes were seen with olanzapine than with risperidone or aripiprazole. About a fourth of patients on risperidone or aripiprazole showed little change in body fat, but three-quarters on those drugs and nearly all patients on olanzapine showed increases.
Whole-body insulin sensitivity decreased approximately from 8 mg/kg per minute to 7 mg/kg per minute, a significant reduction. Olanzapine produced the greatest reduction in whole-body insulin sensitivity.
Importantly, scores for irritability and aggression improved in all groups, he added.
“I’m not a child psychiatrist. I was not terribly sympathetic to this at the beginning” of clinicians’ use of antipsychotics for these indications, said Dr. Newcomer, who chaired the Drug Utilization Review Board for Missouri Medicaid for 14 years. “But I was educated by the psychiatric outcome. There was really profound psychiatric symptom improvement, with kids going back to school and [behaving differently],” he said. The psychiatric response was similar among treatment groups in the study.
As early as 6 weeks after starting therapy, significant changes could be seen on adiposity. Children with the biggest changes in body fat showed effects within the first month of treatment.
Height, weight, waist circumference, body mass index, and BMI percentile were measured at all visits. At baseline and at 12 weeks, investigators performed dual-energy x-ray absorptiometry (DEXA) scans and MRI to assess changes in adiposity, hyperinsulinemic euglycemic clamp with isotopomers to assess changes in insulin sensitivity, plasma sampling (such as oral glucose tolerance test or measuring fasting glucose and lipids), ECG, and psychiatric ratings. At the 6-week follow-up, patients underwent DEXA, oral glucose tolerance testing, and lab measures of fasting status.
A previous nonrandomized study of 272 antipsychotic-naive children and adolescents reported weight gains of 4-8 kg and increases in BMI percentile for patients taking any of four atypical antipsychotics for a median of 11 weeks, compared with a control group (JAMA 2009;302:1811-2).
The study’s design raised concern that the effects could be larger than reported, however, because overweight or obese children were assigned to drugs considered to have the lowest risk for weight gain, Dr. Newcomer said.
In a post-hoc analysis, Dr. Newcomer showed that at the start of the current study, the children had similar rates of overweight or obesity as did children in the general population, but rates were higher in the cohort by the end of the study. The rate of overweight or obese children in the cohort increased from about 33% to 48%.
“I’m personally skeptical about the idea that it’s the psychiatric disorders themselves that are the metabolic challenge, rather than the treatment being the primary effect,” he said.
Medicaid data suggest that 43% of prescriptions for atypical antipsychotics are for indications that are not backed by evidence justifying use, he said. Visits to U.S. physicians that included prescriptions for antipsychotics to patients aged 20 years or younger more than doubled between 1997 and 2002, to a rate greater than 1,400 per 100,000 visits, a separate study reported (Arch Gen. Psych. 2006;63-681).
The National Institutes of Health funded the study. Dr. Newcomer has been a consultant for or received grants from Janssen Pharmaceuticals Inc., Pfizer Inc. , AstraZeneca, Bristol-Myers Squibb, Otsuka Pharmaceutical Co. Ltd., Schering/Merck, Vivus Inc., Obecure Ltd., Biovail Corp., Lundbeck A/S, Sanofi, and Dainippon Sumitomo Pharma Co. Ltd./Sepracor Inc.
Use Judiciously, Monitor Carefully
We know from a variety of studies in adults using atypical antipsychotics that there is a range of potential weight gain seen with this class of agents. With these agents also being used in children for major mental health concerns, it’s important to have information from studies like Dr. Newcomer’s on the metabolic effects in that age group.
The challenge is finding the balance between selecting the agent that works best for the child and monitoring very carefully for things like rapid weight gain, higher blood glucose values, and issues that may be associated with these metabolic disturbances such as high levels of triglycerides or increases in appetite.
Dr. David M. Kendall
Weight gain is part and parcel of our environment, and in many cases is attributed to the availability of calorie-dense foods and decreased physical activity. If we have medications that add to that, in this case the atypical antipsychotics, we have to be judicious about using these medications. Clinicians need to be very attentive, both the in specialty setting and the primary care setting, to watch for changes such as rapid weight gain, and then offer alternative therapies if they are available.
As we’ve learned with adults, anyone who is considering prescribing this class of medications should carefully monitor body weight, plasma glucose (an obvious measure of changing glucose tolerance), and other associated risk factors like blood pressure and blood lipids, which can change as adiposity changes. I think it would be critical to monitor all of those in a situation like this.
Dr. David M. Kendall is chief scientific and medical officer for the American Diabetes Association, Alexandria, Va. He said he has no relevant conflicts of interest.
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