ADHD treatment should be changed if ineffective

Treatment for attention-deficit/hyperactivity disorder (ADHD) should be changed in the event of complications or lack of effectiveness, according to a recent study.

ADHD has been recorded in 10% of children and 6.5% of adolescents, making it one of the most common neurodevelopmental disorders in youths. Medications and nonpharmacological methods are used to manage ADHD, with stimulants often being the first pharmacological treatments used.

While treatment outcomes depend on factors such as treatment used as well as adherence to treatment, prior studies have observed poor adherence to medications, leading to frequent changes. A recent study found that two-thirds of US children experience a change in ADHD treatment over a 12-month timespan.

Frequent changes and poor adherence can lead to poor academic performances, increased financial burden, and impaired quality of life. To understand the causes of treatment changes, investigators conducted a retrospective panel-based chart review study of children with ADHD.

Participants in the study were children aged 6 to 12 years and teenagers aged 13 to 17 years, and all participants had ADHD. Treating physicians recruited from a panel of M3 Global Research completed online medical chart abstraction from August 27, 2021, to September 16, 2021, in which they provided information on 1 to 3 patients with ADHD.

Information from pediatric patients corresponded to randomly selected treatment which began 1 to 5 years before chart abstraction. Physicians also completed an online survey about their observation of adherence to ADHD treatment in a general population.

Patients were eligible to participate if aged 6 to 17 years during the index date, had been diagnosed with ADHD before index treatment, had at least 1 medical visit in the previous 12 months, and had begun to use ADHD treatment 1 to 5 years before data collection.

Physicians were eligible to participate if they practiced medicine in the United States, had prescribed treatment to at least 1 child or adolescent with ADHD, and had access to medical charts with information on ADHD.

Patient and physician demographic data was collected, along with clinical variables such as severity of ADHD and comorbidities. Information was also collected on index treatment, with changes and modifications being assessed. These changes included treatment discontinuation, add-on, or switch. Reasons for treatment change, duration of treatment, and complications were assessed.

There were 156 physicians and 434 patients participating in the study, with 235 child patients and 199 adolescent patients with ADHD. An average 2.8 charts were extracted per physician. Among physicians, 62.8% were psychiatrists, 20.5% were pediatricians, and 16% were general practitioners. About 75% used a clinical scale to determine ADHD severity.

About 94% of physicians had experience treating children with ADHD, and about 99% for adolescents. Patients in the study were aged an average 11.3 years, and 68.7% were male, 71.4% Caucasian, and 15.9% Black.

Medicaid benefits were available to 21.9% of patients, and 70.3% had commercial insurance. Combined presentation was the most common form of ADHD, followed by inattentive type and hyperactive type. Moderate or severe ADHD was seen in 86.4% of patients.

Anxiety and depression were the most commonly recorded comorbidities, followed by learning disability and emotional impulsivity. Adolescents more often had anxiety and depression than younger children.

Before index treatment, 48.2% of patients had received pharmacological treatment, and 77% non-pharmacological. Stimulants alone were given to 83.2% of patients, followed by non-stimulant alone at 11.3% and combination therapy at 5.1%. These treatments had an average duration of 23.3 months.

Of the 94.9% of patients prescribed to take medication at a regular schedule, 48.3% had an adherence of less than 80%. In cases of discontinuation, treatment lasted an average 13.8 months. Subpar management of symptoms, patient dislike of medication, and ADHD related complications were common reasons for discontinuation, but the most common was contribution to anxiety attacks, emotional impulsivity, and sleep disturbances.

Add-on occurred at an average 9.4 months, most often decided due to subpar management of symptoms, family dislike of medication, and management of ADHD treatment complications. Switching off combination therapy occurred at an average 8.2 months, with family dislike of the medication being the most common reason for switching.

One or more ADHD treatment complication occurred in 42.4% of patients. The most common complication was sleep disturbances at 9.7%, decreased appetite or weight loss at 9.4%, and anorexia at 9.2%. Of patients with complications, 75.5% reported the experience led to adherence to treatment.

Patients remaining on treatment was often because tolerable complications, family preference, other options not being effective, and other options being associated with complications. Results were similar between child and adolescent subgroups.

The complications some patients faced showed the need to change treatment for ADHD. Investigators found a need for more effective and tolerable treatments against ADHD.

Reference

Schein J, Cloutier M, Gauthier-Loiselle M, Bungay R, Guerin A, Childress A. Reasons for treatment changes in children and adolescents with attention-deficit/hyperactivity disorder: achart review study. Adv Ther. 2022;39:5487–5503. doi:10.1007/s12325-022-02329-5