Towards reliable forecasting of healthcare capacity needs: A scoping review and evidence mapping.

BACKGROUND: The COVID-19 pandemic has highlighted the critical importance of robust healthcare capacity planning and preparedness for emerging crises. However, healthcare systems must also adapt to more gradual temporal changes in disease prevalence and demographic composition over time. To support proactive healthcare planning, statistical capacity forecasting models can provide valuable information to healthcare planners. This systematic literature review and evidence mapping aims to identify and describe studies that have used statistical forecasting models to estimate healthcare capacity needs within hospital settings. METHOD: Studies were identified in the databases MEDLINE and Embase and screened for relevance before items were defined and extracted within the following categories: forecast methodology, measure of capacity, forecast horizon, healthcare setting, target diagnosis, validation methods, and implementation. RESULTS: 84 studies were selected, all focusing on various capacity outcomes, including number of hospital beds/ patients, staffing, and length of stay. The selected studies employed different analytical models grouped in six items; discrete event simulation (N = 13, 15 %), generalized linear models (N = 21, 25 %), rate multiplication (N = 15, 18 %), compartmental models (N = 14, 17 %), time series analysis (N = 22, 26 %), and machine learning not otherwise categorizable (N = 12, 14 %). The review further provides insights into disease areas with infectious diseases (N = 24, 29 %) and cancer (N = 12, 14 %) being predominant, though several studies forecasted healthcare capacity needs in general (N = 24, 29 %). Only about half of the models were validated using either temporal validation (N = 39, 46 %), cross-validation (N = 2, 2 %) or/and geographical validation (N = 4, 5 %). CONCLUSION: The forecasting models' applicability can serve as a resource for healthcare stakeholders involved in designing future healthcare capacity estimation. The lack of routine performance validation of the used algorithms is concerning. There is very little information on implementation and follow-up validation of capacity planning models.

Is there evidence of a causal link between childhood maltreatment and attention deficit/hyperactivity disorder? A systematic review of prospective longitudinal studies using the Bradford-Hill criteria.

Background: Studies report an elevated risk of maltreatment in children with attention deficit/hyperactivity disorder (ADHD), and elevated levels of ADHD in people who suffered childhood maltreatment (CM). However, the direction(s) of causality between CM and ADHD remain unclear-does ADHD create a context for CM, does CM cause ADHD, or both? Objective: This study systematically reviews and qualitatively synthesizes the research evidence relating to this question using Bradford-Hill criteria for establishing causality-strength, temporality, dose-response and plausibility. Methods: We conducted a systematic review, following PRISMA guidelines, of prospective longitudinal studies examining both CM and ADHD. We then used Bradford-Hill criteria to assess the quality of evidence for a causal link between CM and ADHD. Results: All 11 included studies demonstrated an association between CM and ADHD. Seven included evidence for temporality: five suggesting that CM precedes ADHD in the lifespan; two suggesting ADHD precedes CM. Four studies demonstrated a dose response relationship in which greater CM exposure was associated with elevated risk of ADHD. Studies presented a range of plausible mechanisms, including CM causing ADHD through biological programming, versus ADHD causing CM through parental stress. Conclusions: The high quality prospective longitudinal studies reviewed confirm the association between ADHD and CM, but present conflicting evidence about the direction of causality and mechanisms underpinning this association. To better understand the complex interplay between CM and ADHD, more studies using new research designs will be required that can partition effects by type of CM and account for bidirectional effects and other complexities.

The effect of the Development and Well-Being Assessment as an adjunct to standard referral letters on referral decisions by child and adolescent mental health services - a randomized feasibility trial.

Background: High rejection rates for referrals to child and adolescent mental health services (CAMHS) are common. The most cited reasons for rejection are that the child does not have a clinical need for assessment and poor quality of the referrals. However, studies of interventions aimed at improving appropriateness of referrals are sparse. Methods: In this randomized feasibility trial, we tested if the Development and Well-Being Assessment (DAWBA) as an adjunct to referral letters could improve accuracy of referral decisions made by CAMHS. The primary outcome of the study was the proportion of "correct" referral decisions. Results: The study included 160 children referred to CAMHS. Almost all (95.6%) participants fulfilled criteria for a mental disorder and 82.1% also reported high impact of symptoms. Compared to the group who did not complete the DAWBA, referral decisions for the DAWBA group showed higher sensitivity (0.63 vs. 0.83), specificity (0.30 vs. 0.42), and negative predictive value (0.14 vs. 0.36) as well as slightly higher positive predictive value (0.81 vs. 0.86). Conclusions: The use of the DAWBA as an adjunct to standard referral letters could lead to more correct referral decisions and reduce the proportion of wrongful rejection referrals to CAMHS.

Medical disorders in a Danish cohort of children with attention-deficit hyperactivity disorder.

Studies have identified a higher prevalence of co-existing psychiatric and medical disorders in children with ADHD. There is a shortage of longitudinal studies providing an overview of potential medical disorders in children with ADHD. The objective of this study was to provide a broad overview of lifetime prevalence and relative risk of medical disorders in a nationwide Danish cohort of children with and without ADHD during the first 12 years of life. A population-based prospective follow-back cohort study used data from Danish national health registries to identify a cohort of all children born in Denmark between 1995 and 2002. The children were followed from birth until 12 years of age in two national registries. Children with ADHD had a significantly higher prevalence of recorded diagnoses across all included chapters of medical disorders in the ICD-10, except for neoplasms, where the association with ADHD was non-significant. The highest relative risk was observed for the chapter concerning diseases of the nervous system, with episodic and paroxysmal disorders being the most frequently registered underlying category. The findings indicate that children with ADHD have an increased risk of a broad range of medical disorders compared to the general population during the first 12 years of life, except for neoplasms.

Help-seeking pathways prior to referral to outpatient child and adolescent mental health services.

AIM: To investigate parental help-seeking patterns prior to referral to outpatient child and adolescent mental health services (CAMHS), and whether type of symptoms or duration of mental health problems prior to referral influence help-seeking. SETTING: Child mental health services in Denmark involve several sectors collaborating based on stepped-care principles. Access to CAMHS is free of charge but requires a formal referral. METHODS: In this cross-sectional observational study, parents of 250 children were interviewed about pathways to outpatient CAMHS using the Children's Services Interview. RESULTS: The median parent-reported duration of mental health problems prior to referral to CAMHS was 6.0 (IQR 3.4-8.5) years for children referred for neurodevelopmental disorders compared to 2.8 (IQR 1.0-6.5) years for children referred for emotional disorders. Educational services were the first help-seeking contact for the majority (57.5%) but referrals to CAMHS were most frequently from healthcare services (56.4%), predominantly general practitioners. Educational services played a greater part in help-seeking pathways for children referred for neurodevelopmental disorders. CONCLUSION: The majority of children referred to CAMHS have mental health problems for years before referral. The delay in time-to-referral was most pronounced for children referred for neurodevelopmental disorders. Help-seeking pathways differ by symptom duration and type of symptoms.

Parent-perceived barriers to accessing services for their child's mental health problems.

BACKGROUND: Many children and adolescents with impairing mental health disorders are not in contact with specialized child and adolescent mental health services (CAMHS). In order to close the service gap, it is important to increase our knowledge of barriers to access. The aim of this study was to investigate parent perceived barriers to accessing services for their child's mental health problems to identify potential areas for improvement of access to CAMHS. METHOD: In this cross-sectional observational study 244 parents of children and adolescents referred to outpatient psychiatric assessment were interviewed using the Children's services interview regarding barriers to accessing child mental health services across healthcare, educational services and social services. Parent reported barriers were analyzed in relation to the child's age, referral reason, symptom duration and impairment of the child. RESULTS: The most commonly reported barriers were lack of information about were to seek help (60.3%), the perception that professionals did not listen (59.8%) and professionals refusing to initiate interventions or provide referral to services (53.7%). Lack of knowledge, stigmatization and unavailability of services were common themes across barriers to help-seeking. Long symptom duration and parent rated impairment was associated with increased risk of reporting several barriers to help-seeking. CONCLUSION: Parents seeking help for their child's mental health encounter numerous barriers that could explain part of the treatment gap and long duration of mental health problems in children prior to referral to CAMHS.

Treatment of ADHD in adults - prevalence of discontinuation and associated factors - results from a cross-sectional analysis of Danish register data.

BACKGROUND: A growing number of adults are receiving pharmacological treatment for ADHD but a sizable proportion also discontinues or have gaps in treatment. The primary aims of this study were to identify how many patients treated for ADHD in adulthood, have at least one event of discontinuation in treatment and to identify possible associated variables. METHODS: Within the Danish population aged 18-60 years on the 1st of January 2013, we identified the number of individuals who had been prescribed ADHD-medication at least once during the 1st of January 2002-31st of December 2013 using Danish register data. Among those who filed more than one prescription, treatment discontinuation was defined as having more than 211 days between two prescriptions. In crude and adjusted logistic regression analysis, we explored potential associations to discontinuation for variables such as gender and age at treatment initiation. RESULTS: In a population, if N = 3,165,844 individuals, n = 42,892 had received at least one prescription for ADHD medication. Among those with more than one prescription (N = 38,289), 29.4% had discontinued their treatment at least once, according to our definition of treatment discontinuation. ADHD treatment discontinuation was associated with being male, unemployment, lower educational attainment, receiving incapacity benefits and younger age at treatment initiation (p < 0.001). CONCLUSIONS: A large proportion of individuals treated for ADHD had at least one discontinuation of treatment according to our definition. Although the present study does not allow for investigating the direction of these effects, nor whether some patients later resumed treatment, having at least one discontinuation was associated with a range of variables relating to e.g. age and gender, and provides an emerging profile for clinicians of patients more likely to discontinue.

Attention-Deficit/Hyperactivity Disorder in Childhood and Adolescence and the Risk of Crime in Young Adulthood in a Danish Nationwide Study.

OBJECTIVE: To determine the risk of long-term conviction and incarceration associated with childhood attention-deficit/hyperactivity disorder (ADHD), and to identify risk and protective factors including associations with active treatment with ADHD medication. METHOD: All participants with ADHD who were 4 to 15 years of age during 1995 to 2005 were matched by year of birth and sex to a random sample of participants without ADHD from the Danish population using nationwide registers. Using Cox proportional hazard models, we estimated the risk of conviction and incarceration associated with ADHD in childhood and estimated associations with active treatment and outcome. RESULTS: The ADHD cohort were followed up at a mean of 22.0 (SD = 5.8) years. Of 4,231 individuals with ADHD, 1,355 (32.0%) had received at least one conviction, compared to 3,059 (15.6%) of the 19,595 participants without ADHD (p < 0.001). ADHD was significantly associated with conviction (hazard ratio [HR] = 2.4, 95% CI = 2.3-2.6) and incarceration (HR = 3.0, 95% CI = 2.8-3.3). Subsequent to adjustment for various risk factors, ADHD exposure was still significantly related to conviction (HR = 1.6, 95% CI = 1.5-1.8) and incarceration (HR = 1.7, 95% CI = 1.5-1.9). Comorbidity with substance use disorder, oppositional-defiant disorder/conduct disorder, low family socioeconomic status, parental incarceration, and parental relationship status all significantly increased the risk of conviction and incarceration. Crime rates increased with the number of associated risks but were reduced during periods of taking ADHD medication. CONCLUSION: In addition to ADHD, a broad range of individual, familial, and social factors increase the risk of antisocial development. The findings imply that ADHD medication may contribute to crime prevention.

What Do Primary and Secondary School Teachers Know About ADHD in Children? Findings From a Systematic Review and a Representative, Nationwide Sample of Danish Teachers.

OBJECTIVE: To identify what primary and secondary school teachers know about ADHD in children and, furthermore, to identify which factors predict their knowledge. METHOD: A 29-item questionnaire about ADHD was distributed to a random, nationwide, and representative sample of Danish primary and secondary school teachers. Data were analyzed descriptively and by hierarchical regression analysis. RESULTS: A total of 528 teachers were included. Most teachers identified the symptoms of ADHD (79%-96%) and effective classroom intervention strategies (75%-98%). However, knowledge about other characteristics, etiology, prognosis, and treatment was inconsistent, for example, only 56% and 17% correctly rejected diet as a cause and effective treatment for ADHD. Among the strongest predictors for correct knowledge was having been provided postgraduate education about ADHD. CONCLUSION: Teachers require knowledge about ADHD to successfully include and manage children with ADHD and, additionally, to ensure positive working environments for teachers and support constructive school-home working collaborations.

Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.

BACKGROUND: The benefits and safety of medications for attention-deficit hyperactivity disorder (ADHD) remain controversial, and guidelines are inconsistent on which medications are preferred across different age groups. We aimed to estimate the comparative efficacy and tolerability of oral medications for ADHD in children, adolescents, and adults. METHODS: We did a literature search for published and unpublished double-blind randomised controlled trials comparing amphetamines (including lisdexamfetamine), atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with each other or placebo. We systematically contacted study authors and drug manufacturers for additional information. Primary outcomes were efficacy (change in severity of ADHD core symptoms based on teachers' and clinicians' ratings) and tolerability (proportion of patients who dropped out of studies because of side-effects) at timepoints closest to 12 weeks, 26 weeks, and 52 weeks. We estimated summary odds ratios (ORs) and standardised mean differences (SMDs) using pairwise and network meta-analysis with random effects. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool and confidence of estimates with the Grading of Recommendations Assessment, Development, and Evaluation approach for network meta-analyses. This study is registered with PROSPERO, number CRD42014008976. FINDINGS: 133 double-blind randomised controlled trials (81 in children and adolescents, 51 in adults, and one in both) were included. The analysis of efficacy closest to 12 weeks was based on 10 068 children and adolescents and 8131 adults; the analysis of tolerability was based on 11 018 children and adolescents and 5362 adults. The confidence of estimates varied from high or moderate (for some comparisons) to low or very low (for most indirect comparisons). For ADHD core symptoms rated by clinicians in children and adolescents closest to 12 weeks, all included drugs were superior to placebo (eg, SMD -1·02, 95% CI -1·19 to -0·85 for amphetamines, -0·78, -0·93 to -0·62 for methylphenidate, -0·56, -0·66 to -0·45 for atomoxetine). By contrast, for available comparisons based on teachers' ratings, only methylphenidate (SMD -0·82, 95% CI -1·16 to -0·48) and modafinil (-0·76, -1·15 to -0·37) were more efficacious than placebo. In adults (clinicians' ratings), amphetamines (SMD -0·79, 95% CI -0·99 to -0·58), methylphenidate (-0·49, -0·64 to -0·35), bupropion (-0·46, -0·85 to -0·07), and atomoxetine (-0·45, -0·58 to -0·32), but not modafinil (0·16, -0·28 to 0·59), were better than placebo. With respect to tolerability, amphetamines were inferior to placebo in both children and adolescents (odds ratio [OR] 2·30, 95% CI 1·36-3·89) and adults (3·26, 1·54-6·92); guanfacine was inferior to placebo in children and adolescents only (2·64, 1·20-5·81); and atomoxetine (2·33, 1·28-4·25), methylphenidate (2·39, 1·40-4·08), and modafinil (4·01, 1·42-11·33) were less well tolerated than placebo in adults only. In head-to-head comparisons, only differences in efficacy (clinicians' ratings) were found, favouring amphetamines over modafinil, atomoxetine, and methylphenidate in both children and adolescents (SMDs -0·46 to -0·24) and adults (-0·94 to -0·29). We did not find sufficient data for the 26-week and 52-week timepoints. INTERPRETATION: Our findings represent the most comprehensive available evidence base to inform patients, families, clinicians, guideline developers, and policymakers on the choice of ADHD medications across age groups. Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD. New research should be funded urgently to assess long-term effects of these drugs. FUNDING: Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the UK National Institute for Health Research Oxford Health Biomedical Research Centre.

The effect of having a child with ADHD or ASD on family separation.

PURPOSE: The primary aim of this study was to estimate the risk of parental separation associated with having a child with ADHD or ASD when controlling for a large range of known risk factors for parental separation using Danish registries. METHODS: The study included all children with ADHD or ASD born between 1990 and 1998 in Denmark and a sex and age matched random sample of children from the background population. We followed these children and their parents from birth until the child's 25th birthday, parental separation or December 31, 2015, whichever came first. Data were analyzed using Cox Proportional Hazard models by estimating hazard ratios (HR) and 95% confidence intervals. Models were adjusted for a range of child, parental, and family variables. RESULTS: The study included the parents of 12,916 children with ADHD, 7496 children with ASD and 18,423 controls. The study found that, even after controlling for a range of potential risk factors, having a child with either ADHD (HR = 1.8, 95% CI 1.6-2.0) or ASD (HR = 1.2, 95% CI 1.1-1.3) significantly increased parents' risk of separating compared with non-affected families. Other factors associated with parental separation were parental imprisonment, parental psychopathology, low parental education level, low household income and living in a larger city. CONCLUSION: Parents of children diagnosed with ADHD or ASD were more likely to separate than control parents. It is important to improve our knowledge about the particular characteristics of families at risk of separating to prevent distress for the families and their child.

Attention Deficit Hyperactivity Disorder in Childhood: Healthcare Use in a Danish Birth Cohort during the First 12 Years of Life.

OBJECTIVES: To compare the mean number of medical and psychiatric hospital-based services in children with and without attention deficit hyperactivity disorder (ADHD) and to assess the effect of ADHD on hospital-based service use, including child-, parental-, and socioeconomic-related risk factors. STUDY DESIGN: A Danish birth cohort was followed through 12 years, and children with ADHD were identified using Danish nationwide registries. Poisson regression analyses were used to assess the association of ADHD with service use and to adjust for a comprehensive set of explanatory variables. RESULTS: Children diagnosed with ADHD used more medical and psychiatric hospital-based healthcare than those without ADHD. In children with ADHD, intellectual disability and parental psychiatric disorder were associated with increased medical and psychiatric service use. Low birth weight and low gestational age were associated with increased medical service use. Psychiatric comorbidity and having a divorced or single parent were associated with increased psychiatric service use. CONCLUSIONS: ADHD independently affected medical and psychiatric hospital-based service use even when adjusting for a comprehensive set of explanatory variables. However, the pattern of medical and psychiatric hospital-based service use is complex and cannot exclusively be explained by the child-, parental-, and socioeconomic-related variables examined in this study.

Comparative efficacy and tolerability of pharmacological interventions for attention-deficit/hyperactivity disorder in children, adolescents and adults: protocol for a systematic review and network meta-analysis.

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is a major public health issue. Pharmacological treatments play an important role in the multimodal treatment of ADHD. Currently, there is a lack of up-to-date and comprehensive evidence on how available ADHD drugs compare and rank in terms of efficacy and tolerability, in children or adolescents as well as in adults. We will conduct a network meta-analysis (NMA), integrating direct and indirect comparisons from randomised controlled trials (RCTs), to rank pharmacological treatments for ADHD according to their efficacy and tolerability profiles. METHODS AND ANALYSIS: We will search a broad range of electronic databases, including PubMed, MEDLINE, EMBASE, PsycINFO, ERIC and Web of Science, with no date or language restrictions. We will also search for unpublished studies using international clinical trial registries and contacting relevant drug companies. We will identify and include available parallel-group, cross-over and cluster randomised trials that compare methylphenidate, dexmethylphenidate, amphetamine derivatives (including lisdexamfetamine), atomoxetine, clonidine, guanfacine, bupropion or modafinil (as oral therapy) either with each other or to placebo, in children, adolescents or adults with ADHD. Primary outcomes will be efficacy (indicated by reduction in severity of ADHD core symptoms measured on a standardised scale) and tolerability (the proportion of patients who left a study early due to side effects). Secondary outcomes will be global functioning, acceptability (proportion of patients who left the study early by any cause) and changes in blood pressure and body weight. NMA will be conducted in STATA within a frequentist framework. The quality of RCTs will be evaluated using the Cochrane risk of bias tool, and the quality of the evidence will be assessed using the GRADE approach. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings. ETHICS AND DISSEMINATION: No ethical issues are foreseen. Results from this study will be published in a peer-reviewed journal and possibly presented at relevant national and international conferences. TRIAL REGISTRATION NUMBER: CRD42014008976.

A meta-analysis and systematic review of the risks associated with childhood attention-deficit hyperactivity disorder on long-term outcome of arrests, convictions, and incarcerations.

The primary aim of this study was to systematically review and estimate the risk of arrests, convictions, and incarcerations associated with childhood Attention Deficit/Hyperactivity Disorder (ADHD) in long-term outcome studies. In addition, all included studies were qualitatively and systematically reviewed for predictors of long-term crimes. The databases Pubmed, PsycINFO and Embase were searched for all controlled studies that included children and adolescents (age 4-15) with ADHD who had been followed longitudinally and reported the frequency of arrests, convictions or incarcerations based on data from official sources. Using random-effects models, the relative risk (RR) with 95% confidence intervals (95% CI) was estimated. A total of 15,442 individuals with childhood ADHD from nine unique samples were included. Childhood ADHD was significantly associated with adolescent and adulthood arrests (RR: 2.2, 95% CI: 1.3-3.5), convictions (RR: 3.3, 95% CI: 2.1-5.2) and incarcerations (RR: 2.9, 95% CI: 1.9-4.3). Individuals with ADHD had a younger age at onset of antisocial involvement and an increased risk of criminal recidivism. The most frequently committed criminal offenses were theft, assault, drug- and weapon-related crimes. Early antisocial behavior problems, childhood maltreatment, sex, and IQ were identified as potentially relevant predictors for antisocial outcomes. The findings support a substantial long-term risk associated with ADHD for later antisocial involvement. Early intensive and specifically targeted multimodal intervention including psychosocial, and pharmacological treatment is warranted to alter these negative long-term developmental trajectories.

Time trends in incidence rates of diagnosed attention-deficit/hyperactivity disorder across 16 years in a nationwide Danish registry study.

OBJECTIVE: To investigate time trends in incidence rates of first-time diagnosed attention-deficit/hyperactivity disorder (ADHD) in a nationwide sample aged 4-65 years across 16 years and identify potential contributing factors to these time trends. METHOD: Incidence rates of first-time diagnosed ADHD based on ICD-10 criteria in Danish psychiatric hospitals per 100,000 person years (PY) were calculated for the total population, the 2 sexes, and 4 age groups using data from the Danish Psychiatric Central Research Registry and annual census data. Time trends and the role of contributing factors were analyzed and identified using joinpoint regression procedures by calculating annual percent changes for the time period 1995-2010. RESULTS: A total of 20,281 patients were diagnosed with ADHD and incidence rates increased from 7.3 to 91.2 per 100,000 PY during the study period. Joinpoint analysis suggested that incidence rates for diagnosed ADHD rapidly increased from 1998 to 2002, peaked from 2002 to 2008, and slowed down from 2008 to 2010. Contributing factors to the observed time trends were a general increase in patients seen in psychiatry for any mental disorder and an increased awareness and recognition of ADHD in females, adolescents, and adults. CONCLUSIONS: These results provide empirical data needed in the public and professional debate often based on theoretical rather than empirical arguments. Results support the notion of increasing incidence rates of diagnosed ADHD and identify that contributing factors are a general increase in the number of patients assessed in psychiatry and an increased recognition of females, adolescents, and adults with ADHD.