December 7, 2021
A team of German researchers explored five million member records from a database that tracks more than sixty nationwide statutory health insurance programs. The database closely tracks the characteristics of the overall German population.
This was a longitudinal cohort study, tracking individuals first diagnosed with adult ADHD between 2013 and 2017. Anyone who was not continuously insured during this period was excluded, as were those who died, plus anyone older than 55 to prevent bias from high morbidity in the top age brackets.
The study team used the database to add up direct healthcare costs, including inpatient care, outpatient care, psychotherapy, medical aids and remedies, medication, and sickness benefits. In Germany, sickness benefits kick in after more than six weeks of continuous inability to work.
The study tracked data within a window extending both four years back and four years forward from the initial adult ADHD diagnosis.
The resulting study cohort consisted of 2,380 persons between 18 and 55, initially diagnosed with ADHD at an average age of 35. Sixty percent were male.
One-third were prescribed ADHD medication upon diagnosis. Four years later, only one-eighth were still on medication.
Almost two-thirds received psychotherapy, dropping to under a third in succeeding years.
During the year following diagnosis, average healthcare costs totaled about €4,000 per individual. For those who initiated ADHD medication, the average cost was just over €5,400, and for those who did not it was almost €3,500.
The authors concluded, "An important finding of the present investigation is that in the year of initial diagnosis, less than one-third of individuals received any prescription of ADHD-specific medication, and only a fourth got at least two prescriptions. At the same time, almost two-thirds of individuals received psychotherapy in the year of ADHD[adult ADHD] diagnosis. In about one-third of individuals, psychotherapy had been initiated already before a diagnosis of ADHD, presumably for treatment of comorbid disorders. ... In current German guidelines, ADHD-specific medication is recommended as the first choice ... Apparently, despite the vast body of evidence for the beneficial effects of ADHD-specific medication, at least in the short-term, and in contrast to the recommendations of previous and current guidelines, stimulant medication is only reluctantly prescribed in newly identified adults with ADHD. ... Overall, our findings suggest that significant deficiencies may currently exist concerning the reality of healthcare for ADHD in Germany, and that guideline recommendations are not yet comprehensively implemented in everyday routine care."
Berit Libutzki, Benno Neukirch, Melanie May, Markus Gleitz, Michael Karus, Catharina A. Hartman, and Andreas Reif, "Diseaseburden and direct medical costs of incident adult ADHD: A retrospective longitudinal analysis based on German statutory health insurance claims data," EuropeanPsychiatry (2020),63(1), e86, 1-9, https://doi.org/10.1192/j.eurpsy.2020.84.
Given the persistence of ADHD and its adverse effects on children and adolescents, one might expect caregivers to face greater parenting challenges, with potential effects on their own mental health.
To what extent do parenting stress, depression, and – at the extreme – even suicidal ideation manifest themselves among caregivers of ADHD patients as opposed to caregivers of children and adolescents without ADHD?
A pair of Korean researchers made use of their country’s single-payer health insurance system, which maintains records on virtually the entire population, to perform a nationwide population study. They used data from the Korean National Health and Nutrition Examination Surveys (KNHANES) covering the decade from 2011 to 2020. KNHANES is an annual survey using a sophisticated sampling design conducted by the Korean Ministry of Health and Welfare to represent the entire population of South Korea.
The analysis included 14,428 individuals who had children younger than 19 at the time of participation. All were asked whether their child had ever been diagnosed with ADHD by a physician. The mental health problems of the parents were assessed in terms of perceived stress, depressive symptoms, and suicidality.
Of the 14,428 participants, 8,298 (57.5 %) were mothers and 6,130 (42.5 %) were fathers. Of the mothers, 116 (1.4 %) had a child with ADHD, and of the fathers, 86 (1.4 %) had a child with ADHD.
The researchers adjusted for the following confounders: age of caregiver, education level, household income, area of residence, employment status, alcohol consumption, smoking status, cohabitation status, number of children, and child’s age.
After adjustment, mothers of ADHD patients fared significantly worse than mothers of typically developing children on all three categories of mental health problems. They were 67% more likely to report higher stress, three times as likely to report symptoms of depression, and 2.5 times more likely to report suicidal ideation.
Yet that pattern did not carry over to fathers, where there was no significant difference in mental health indicators between fathers of children with ADHD and fathers of children without ADHD.
The authors concluded, “Parents of children with ADHD, especially mothers, need community support and public health attention to help alleviate their mental health problems.”
Background:
ADHD is commonly accompanied by psychiatric comorbidities that complicate its diagnosis and treatment. Roughly two out of three affected children and adolescents have one or more comorbid psychiatric disorder.
Because the peak age of ADHD onset is typically a decade or more earlier than those for schizophrenia, depressive disorder, or bipolar disorder, it is essential to explore these comorbidities over an extended period. Populations studies help researchers identify broader patterns and trends within an entire population and includes adults as well as children. This type of study provides unique insights into the population at large, rather than a sample group.
In earlier studies the maximum follow-up period was twelve years, insufficient in view of the roughly ten years between onset of ADHD and onset of major psychiatric disorders. Also, previous nationwide population studies have included less than 150,000 participants.
This study, relying on data from South Korea’s universal single-payer health insurance system, included over one and a half million individuals. Persons previously diagnosed with depression, bipolar disorder, tic disorder, or schizophrenia were excluded.
382,434 individuals had been diagnosed with ADHD, while 1,169,279 were without an ADHD diagnosis.
Propensity score matching ensured that potential confounders, both sociodemographic and clinical, were equalized for the ADHD and control groups. After matching, there were 353,898 individuals in each group.
After these adjustments, individuals in the ADHD group were at least an order of magnitude more likely to subsequently be diagnosed with psychiatric disorders than their peers without an ADHD diagnosis:
Conclusion:
The Korean study team concluded, “Overall, our findings suggest that upon prolonged examination, the risk of subsequent diagnoses of other psychiatric disorders in individuals with ADHD appears to be higher than that reported previously. … Therefore, patients with ADHD should be carefully screened for the presence of other psychiatric symptoms on a regular basis from an earlier age … It is advisable to have a follow-up period extending beyond 10 years to sufficiently identify the occurrence of comorbid disorders in patients with ADHD.”
Children with ADHD often face challenges in social interactions, leading to long-term consequences if not properly addressed. While various interventions exist, many fail to consider the broader social context in which these children interact. A recent study conducted in Bergen, Norway, explored how primary school teachers perceive their role in supporting children with ADHD who struggle socially and the strategies they use to assist them.
Researchers conducted semi-structured interviews with five focus groups of primary school teachers. Using reflexive thematic analysis, they identified two major themes:
Rather than relying on standardized interventions, teachers tailored their strategies to foster an inclusive and supportive social environment. Their methods included both active participation in social situations and behind-the-scenes efforts to encourage peer inclusion and understanding.
This study underscores the need to move beyond labels and recognize children with ADHD as individuals with distinct social needs. Teachers play a crucial role in shaping these children’s experiences, using flexible and personalized approaches to promote positive social interactions. By integrating social context and individualized support, educators can help children with ADHD build meaningful connections and navigate their social world more effectively.
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