Emotional expression in children treated with ADHD medication: development of a new measure.

OBJECTIVE: Although existing instruments contain items addressing the effect of ADHD medications on emotional expression, a review of measures did not yield any instruments that thoroughly evaluated positive and negative aspects of emotional expression. METHOD: The Expression and Emotion Scale for Children (EESC), a parent-report measure, was developed from an analysis of qualitative data from parent focus groups and expert opinion. Data from 179 parents and children treated with stimulants or atomoxetine are used to examine the psychometric properties of the EESC. RESULTS: The EESC demonstrates good internal consistency and test-retest reliability. A factor analysis yields three factors (positive, flat, and emotional lability) that were consistent with the predicted structure of the measure. Small to moderate correlations between the EESC and psychological symptom measures are found, with the strength of the relationships varying by symptom measure. CONCLUSION: The EESC shows appropriate psychometric properties and is appropriate for use in clinical and research settings.

Atomoxetine in the management of children with ADHD: effects on quality of life and school functioning.

The purpose of this study was to examine in a controlled trial the effects of atomoxetine on the management of attention deficit-hyperactivity disorder (ADHD) symptoms and functional impairments at school and at home. Participants were 153 children (age 8 to 12 years) diagnosed with attention-deficit hyperactivity disorder who were randomized to double-blind treatment with either atomoxetine (n = 101) or placebo (n = 52). Findings revealed significant improvements both for parent and teacher ratings of behavior for children receiving atomoxetine therapy. Children also were reported to evidence a trend toward better response to active medication than to placebo for health-related quality of life as rated by parents. No significant effects were revealed for the teacher ratings of academic productivity. Data were interpreted to provide support for the efficacy of atomoxetine on the symptoms associated with ADHD. The effects of atomoxetine on other functional outcomes including academic performance and health-related outcomes are of interest, albeit less compelling for this particular investigation, than for the effects on overt symptom display.

Toward mapping daily challenges of living with ADHD: maternal and child perspectives using electronic diaries.

Attention-deficit/hyperactivity disorder (ADHD) has an impact on the family as well as the affected child. This study developed and tested an electronic diary for mapping the challenges of everyday family life in a sample of children with ADHD being treated with pharmacotherapy. Across 7 days, mothers and children (27 ADHD; 25 non-ADHD) independently reported their moods, behaviors, and social contexts every 30 min during nonschool hours. Symptomatic behaviors and negative moods were elevated in the ADHD group, combined with maternal perceptions of lower parenting effectiveness and quality of life. Differences in the contexts of maternal anger were salient, with mothers in the ADHD group more often angry when with their children and comparison mothers more often angry when not. Although mothers' diaries were more informative, children's diaries also distinguished the two groups, especially during mornings and weekends. The need for family-wide interventions, the utility of child self-reports, and the promise of electronic diaries are discussed.

Atomoxetine treatment in children and adolescents with attention-deficit hyperactivity disorder: what are the long-term health-related quality-of-life outcomes?

OBJECTIVE: Numerous investigations have examined the efficacy of pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD) in children. However, relatively few studies have addressed the impact of treatment on long-term subjective, psychosocial outcomes, such as health-related quality of life (HRQL). This study examines the long-term effects of pharmacological treatment with atomoxetine on HRQL in children and adolescents with ADHD. METHODS: Participants included 6- to 17-year-old children and adolescents (n = 912) with ADHD enrolled in a 24-month, multicenter, open-label trial of atomoxetine. Outcomes included clinician ratings of ADHD, parent ratings of ADHD, and a widely used measure of HRQL (The Child Health Questionnaire (CHQ)). Treatment response rates were calculated based on a CHQ improvement of at least 1 standard error of measurement. RESULTS: Significant improvements in HRQL were found following both acute and long-term treatment for psychosocial but not physical health. Of participants who completed treatment (n = 312 or 34.2% of those enrolled), 81% responded to acute treatment and 78% responded to long-term treatment. Improvements noted after acute treatment were maintained during long-term treatment with the majority of participants (86%) continuing to respond to treatment. CONCLUSIONS: Atomoxetine is associated with improvements in HRQL, and the improvements are generally stable over time.

A comparison of service use and costs among adults with ADHD and adults with other chronic diseases.

OBJECTIVE: This study compared health service use and costs among adults with attention-deficit hyperactivity disorder (ADHD) and adults with depression, diabetes, or seasonal allergic rhinitis (seasonal allergy). METHODS: Pharmacy and medical claims data from January 1, 1999, to December 31, 2001, were obtained from a large U.S. managed care plan. Patients were divided into one of four mutually exclusive cohorts (ADHD, depression, diabetes, or seasonal allergy) on the basis of their diagnosis or prescriptions. Age, gender, comorbid conditions, and type of dominant provider were compared for the four groups. Thereafter, general linear models with post-hoc multiple comparison tests were used to compare health service use and costs by site of service. RESULTS: The study population included 143,561 patients. The four mutually exclusive groups included 58,017 with depression, 45,479 with diabetes, 33,272 with a seasonal allergy, and 6,793 had ADHD. Comorbid mental health conditions occurred with significantly greater frequency among patients with ADHD and among those with depression than among patients in the other groups. Patients with ADHD and those with depression received care from a mental health provider significantly more often than those with diabetes or a seasonal allergy. Patients with ADHD had fewer average outpatient, inpatient, and emergency department visits than patients with depression or diabetes, and office visit frequency for patients with ADHD was significantly different from that of patients with a seasonal allergy. Annual total costs were lowest among patients with a seasonal allergy ($2,743), which were not significantly different than the costs for patients with ADHD ($3,020). CONCLUSIONS: Adult ADHD poses an economic burden that is less than that of depression or diabetes but greater than that of a seasonal allergy.

Improvement in health-related quality of life in children with ADHD: an analysis of placebo controlled studies of atomoxetine.

Despite significant functional impairments associated with attention-deficit hyperactivity disorder (ADHD) and the growing appreciation of the importance of health-related quality of life (HRQL) assessment in children with chronic disorders, relatively few studies have examined the impact of ADHD treatment on HRQL. This investigation examines the effect of atomoxetine, a nonstimulant treatment for ADHD, on HRQL and identifies factors that are predictive of HRQL improvements. The Child Health Questionnaire (CHQ), which is a multidimensional HRQL measure, was collected during three randomized, double-blind, placebo-controlled clinical trials. Children who received atomoxetine had significantly greater improvement in psychosocial functioning compared to the placebo group. No significant differences between once-a-day and twice-a-day dosing were found. Treatment with atomoxetine, lower HRQL baseline score, no history of stimulant use, and absence of oppositional defiant disorder were all associated with improvements in psychosocial functioning. Findings demonstrate the positive impact of atomoxetine on HRQL in children with ADHD.

Stimulant treatment patterns and compliance in children and adults with newly treated attention-deficit/hyperactivity disorder.

OBJECTIVE: To identify newly treated cases of attention-deficit/hyperactivity disorder (ADHD), assess the presence of comorbid psychiatric conditions, identify pharmacological treatment patterns, and examine treatment compliance rates among children and adults with newly diagnosed and pharmacologically treated ADHD in a managed care population. METHODS: Children (aged 18 years or younger) and adults having newly treated ADHD were identified from medical and pharmacy claims in an administrative claims database from 6 health plans. Claims data for services or products provided between April 1, 1997, and September 30, 1999, was analyzed for the managed care population (604,538 children and 1,542,304 adults). Data on compliance, persistence, and pharmacological treatment patterns were collected for the 6 months prior to and the 18 months following each patient.s initial ADHD pharmacological treatment. A medication possession ratio (MPR) was calculated by dividing the number of days supplied in a prescription by the number of days until the next prescription was filled. Compliance was defined as an MPR >0.8 and persistence as an MPR >0.3. RESULTS: The prevalence of diagnosed ADHD in this population was 0.7% (11,962 [2%] of children and 2,636 [0.2%] of adults) and incidence of ADHD was 0.04% (735 [0.1%] of children and 162 [0.01%] of adults). The most common comorbid psychiatric condition for incident cases was depression (31.6% of children and 63% of adults). Few children and adults switched their initial ADHD treatment agent, 11% and 12%, respectively. Dose titration occurred in 67% of children and 54% of adults. On average, changes in treatment (switching, titrating) took place after 2 to 3 months of treatment. Although patients, on average, obtained more than 6 refills for a total 200 days supply, the majority of patients (84% of children and 88% of adults) were compliant for less than 2 months over the period they were refilling prescriptions. CONCLUSION: Although the majority of patients had dosage changes, these changes typically occurred after several months of treatment. Results suggest that, even though patients continued their ADHD medication for several months, they did not consistently take medication for more than 2 months. Given these treatment patterns, pharmacologic treatment in newly treated ADHD patients may be suboptimal and may impact outcomes, including the effectiveness and cost of treatment.

Physician perceptions of the use of medications for attention deficit hyperactivity disorder.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a prevalent mental health condition, occurring in 3% to 5% of school-aged children. Although stimulant medications are a recommended treatment for this disorder, physicians. views of these medications have not been systematically evaluated. OBJECTIVE: This study examined physician-prescriber perceptions of using medications to treat ADHD symptoms in children or adolescents. METHODS: A survey was developed with 4 physicians expert in treating ADHD in children. The survey was pilot-tested with a sample of 10 practicing physicians. A sample of 1,000 physicians, with a history of prescribing stimulant medications to children or adolescents, was randomly selected and mailed a 30-item survey. Items were rated on a 7-point response scale (strongly agree, agree, slightly agree, undecided, slightly disagree, disagree, strongly disagree). RESULTS: A total of 365 physicians responded to the survey, for a 37% response rate. More than 92% of respondents strongly agreed or agreed that ADHD symptoms cause problems in pediatric patients and stimulants are effective in treating ADHD. The stimulant drug side effects of decreased appetite or weight loss, sleep disruption, and exacerbation of anxiety were a concern (strongly agree or agree response) for 32%, 50%, and 22% of physicians, respectively. Diversion of ADHD medication was a concern for 19% of respondents. Physicians reported that controlled medications for children or adolescents with ADHD are a burden for themselves (32% strongly agreed or agreed), for their staff (37% strongly agreed or agreed), and for parents (40% strongly agreed or agreed). Approximately 38% of physicians responded that they would prefer prescribing a nonstimulant medication with a U.S. Food and Drug Administration indication for treating children or adolescents instead of a stimulant medication, and 58% would prefer prescribing a noncontrolled medication that does not have evidence of abuse potential versus one that is controlled and has evidence of abuse potential. CONCLUSION: Although physicians overwhelmingly perceive stimulant medications as being effective for treating ADHD symptoms in children or adolescents, many would prefer a nonstimulant medication. While many physicians consider the side effects of the stimulants easily managed, others are concerned about prescribing stimulants because of their side effects, risk of diversion, and administrative burden. The majority of physicians would prefer to prescribe a noncontrolled medication without abuse potential instead of a controlled medication to treat children or adolescents with ADHD.