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Kaiser ADHD study

Kaiser ADHD study

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Kaiser ADHD pediatric study
Kaiser ADHD pediatric study

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. . .
O
NLINE
F
IRST
 ARTICLE
Recent Trends in ChildhoodAttention-Deficit/Hyperactivity Disorder
Darios Getahun, MD, PhD; Steven J. Jacobsen, MD, PhD; Michael J. Fassett, MD; Wansu Chen, MS;Kitaw Demissie, MD, PhD; George G. Rhoads, MD, MPH 
Objective
:
To examine trends in attention-deficit/ hyperactivitydisorder(ADHD)byrace/ethnicity,age,sex,and median household income.
Design
:
An ecologic study of trends in the diagnosis of ADHD using the Kaiser Permanente Southern Califor-nia(KPSC)healthplanmedicalrecords.RatesofADHDdiagnosis were derived using Poisson regression analy-ses after adjustments for potential confounders.
Setting
:
Kaiser Permanente Southern California, Pasa-dena.
Participants
:
AllchildrenwhoreceivedcareattheKPSCfrom January 1, 2001, through December 31, 2010(n=842830).
MainExposure
:
Period of ADHD diagnosis (in years).
Main Outcome Measures
:
Incidence of physician-diagnosed ADHD in children aged 5 to 11 years.
Results
:
Rates of ADHD diagnosis were 2.5% in 2001and3.1%in2010,arelativeincreaseof24%.From2001to 2010, the rate increased among whites (4.7%-5.6%;relative risk [RR]=1.3; 95% CI, 1.2-1.4), blacks (2.6%-4.1%; RR=1.7; 95% CI, 1.5-1.9), and Hispanics (1.7%-2.5%; RR=1.6; 95% CI, 1.5-1.7). Rates for Asian/PacificIslanderandotherracialgroupsremainedunchangedovertime.TheincreaseinADHDdiagnosisamongblackswaslargely driven by an increase in females (RR=1.9; 95%CI, 1.5-2.3). Although boys were more likely to be di-agnosed as having ADHD than girls, results suggest thesexgapforblacksmaybeclosingovertime.Childrenliv-inginhigh-incomehouseholdswereatincreasedriskof diagnosis.
Conclusions
:
ThefindingssuggestthattherateofADHDdiagnosisamongchildreninthehealthplannotablyhasincreasedovertime.WeobserveddisproportionatelyhighADHD diagnosis rates among white children and no-table increases among black girls.
 JAMA Pediatr.Published online January 21, 2013.doi:10.1001/2013.jamapediatrics.401
D
URING THE LAST DECADE
,attention-deficit/hyper-activitydisorder(ADHD)diagnosis has reachedepidemic proportions inthe United States.
1
It is one of the mostcommon chronic childhood psychiatricdisorders,affecting4%to12%ofallschool-aged children
1-7
and persisting into ado-lescence and adulthood in approxi-mately 66% to 85% of children.
8-11
The 3major subtypes of ADHD are predomi-nantly inattentive, predominantly hyper-active-impulsive, and combined.
12
Children with ADHD are more likelythan unaffected children to experiencelearning problems, miss school, becomeinjured,experiencetroublesomerelation-shipswithfamilymembersandpeers,
13-16
and exhibit mental and physical condi-tions.
17
Between1995and1999,morethan14 million children in the United Statesaged 5 to 18 years visited physicians fortreatment of ADHD.
18
In 2006 alone,ADHD-related ambulatory care visitsreachedanestimated7million.
19
By2005,inchildrenyoungerthan18years,thean-nual cost attributable to ADHD was esti-matedtobebetween$36billionand$52.4billion.
20
Costsarelikelytocontinuegrow-ing proportional to increasing ADHDprevalence.Although the origin of ADHD is notfullyunderstood,emergingevidencesug-gests that both genetic and environmen-tal factors have important roles.
21-23
Po-tential risk factors include family historyof ADHD,
24
maternal borderline person-alitydisorders,
25
exposuretoenvironmen-tal tobacco smoke,
26-28
exposure to tox-ins and lead,
28,29
maternal use of antidepressant medications during preg-
Aut
DepEval JacoMat(DrMedPerMedDepGyn JohUniDen(Drof EMed Jers(DrsPisc
Author Affiliations:
Departments of Research andEvaluation (Drs Getahun and Jacobsen and Ms Chen) andMaternal-Fetal Medicine(Dr Fassett), West Los AngelesMedical Center, KaiserPermanente Southern CaliforniaMedical Group, Pasadena; andDepartment of Obstetrics andGynecology, Robert Wood Johnson Medical School,University of Medicine andDentistry of New Jersey(Dr Getahun), and Departmentof Epidemiology, University of Medicine and Dentistry of New Jersey–School Public Health(Drs Demissie and Rhoads),Piscataway.
 JAMA PEDIATR PUBLISHED ONLINE JANUARY 21, 2013 WWW.JAMAPEDS.COM
E1
 
. . .
nancy,
30
male sex,
31,32
low birthweight,
33
prematurity,
34
and artificial food additives.
35
Becauseofsmallandnonrepresentativesamples,pre-vious studies have been limited in their applicability tothegeneralpopulation.Furthermore,studies
36-38
havere-lied on parent- and teacher-reported cases, which over-estimate true prevalence. Accurate estimates of diseaseburden in a large study population will provide infor-mation for determining health care resource allocationforADHDpreventionprograms.Inaddition,researchonthe influence of child race/ethnicity on ADHD trends issparse, and identifying potential disparities in ADHDprevalenceisanimportantstepineliminatinghealthin-equalities. The Kaiser Permanente Southern California(KPSC)systemshavedetailedmedicalrecordsandtreat-ment information for a large number of children in thehealth plan. Using these integrated patient medical rec-ords, we investigated recent trends in ADHD diagnosisfrom 2001 to 2010 by child race/ethnicity, age, sex, andmedianhouseholdincome.Specifically,wetestedthefol-lowing hypotheses: (1) that the diagnosis of ADHD hasincreasedmorerapidlyamongchildrenofracesotherthanwhite during the study period, (2) that the diagnosis of ADHD has increased among children of families withhigher socioeconomic status and children across all agegroups from 5 to 11 years, and (3) that the sex gap inADHD diagnosis has narrowed over time.
METHODS
DATA SOURCE AND PATIENT SELECTION
For this analysis, demographic and clinical information from2001 to 2010 was obtained from the KPSC medical records,which include information about membership, inpatient andoutpatientphysicianencounters,andpharmacyuse.TheKPSCmembership records contain information about race/ ethnicity, sex, and date of birth. Information on supplementaldrugbenefits,Medicaidstatus,andchangestomembershipanddemographics are also available.The study cohort is composed of member children aged 5to11yearswhoreceivedcareattheKPSCfromJanuary1,2001,through December 31, 2010, regardless of membership statusatthetimethecarewasgiven.Childreninthisagegroupwereselected to maintain uniformity in diagnostic criteria (
Diag-nostic and Statistical Manual of Mental Disorders [Fourth Edi-tion]
[
DSM-IV 
]). Children with diagnoses of autism spectrumdisorder (n=15400) were excluded from the final study co-hort (n=842830).Potential confounders and mediators included race/ ethnicity (categorized as non-Hispanic white [white], non-Hispanic black [black], Hispanic, Asian/Pacific Islander, andother/multiple [other] racial/ethnic groups), sex (male or fe-male),age(5-7,8-9,and10-11years),andarea-based(USCen-sustract)medianfamilyhouseholdincome(
Ͻ
$29999,$30000-$49000, $50000-$69999, $70000-$89999, and
Ն
$90000).Child race/ethnicity was determined on the basis of maternaland paternal race/ethnicity. The other/multiple (other) race/ ethnicity category includes non-Hispanic children with mul-tiple recorded races.PrimarydiagnosisofADHDwasdeterminedusing
Interna-tional Classification of Diseases, Ninth Revision, Clinical Modi- fication
diagnosis code 314.x from child hospitalization, out-patient office visit, and emergency department visit across allthe KPSC facilities. The outpatient, inpatient, and emergencydepartmentsystemsareintegrated.Duringthechildvisitinanyof these facilities, the practitioner has access to the child’s di-agnosis, but often the diagnosis of ADHD is made in an out-patient setting. The following criteria were used to diagnoseandcodeADHDwithintheKPSC:(1)aChildBehaviorCheck-listmustbefilledoutbyparentsandteacherstodescribechildbehavioral and emotional problems, and (2) a clinical inter-view must be performed by a qualified mental health profes-sional. In a preliminary study conducted for this project, 96%of children with ADHD were found to have had their condi-tions diagnosed by child and adolescent psychiatrists, devel-opmentalandbehavioralpediatricians,childpsychologists,andneurologists.Tofurtherincreasethespecificityofthecasedefi-nition, we used data for receipt of drugs specific to ADHD ex-tractedfrompharmacyrecords.Thesedrugsincludedamphet-amine aspartate, amphetamine sulfate, dextroamphetamineaspartate,dextroamphetaminesulfate,andmethylphenidatehy-drochloride.
STATISTICAL ANALYSIS
First, we compared the distribution of child age, sex, race/ ethnicity,andmedianhouseholdincomebyADHDstatususingthe
2
tests. Second, the annual rates of ADHD per 100 chil-drenwereestimatedusingPoissonregression.Forthis,theyearlycount of ADHD was the outcome variable and year of diagno-sis was the independent variable, adjusting for potential con-founding factors (
Table 1
). Dummy variables were con-structed for the various categories of covariates. The meanpredictedprobabilitieswereestimatedfromtheadjustedmod-els. Third, increases of relative risk (RR) from 2001 to 2010were quantified using regression analysis. The population-
Table 1. Distribution of Child Characteristics Basedon ADHD Status
a
CharacteristicChildren, %With No ADHD(n = 803630)With ADHD(n = 39200)
Child age, y5-7 23.9 16.48-9 17.2 26.610-11 59.0 57.0Child sexFemale 50.2 25.4Male 49.9 74.6Child race/ethnicityNon-Hispanic white 18.3 34.3Non-Hispanic black 8.1 10.2Hispanic 40.8 31.8Asian/Pacific Islander 5.6 2.6Other
b
2.1 2.5Unknown 25.2 18.6Household income, median, $
c
Ͻ
30000 5.7 4.030000-49 999 27.6 22.350000-69 999 29.1 28.170000-89 999 19.8 22.8
Ն
90000 17.5 22.3Abbreviation: ADHD, attention-deficit/hyperactivity disorder.
a
Differences between children with and without ADHD by childcharacteristics were statistically significant at
Ͻ
.001.
b
Other race/ethnicity includes non-Hispanic children with multiplerecorded races/ethnicities.
c
Median household income based on US Census tract information.
 JAMA PEDIATR PUBLISHED ONLINE JANUARY 21, 2013 WWW.JAMAPEDS.COM
E2
 
. . .
basednatureofourstudyandthelowratesofADHDallowoddsratios to be reasonably good approximations of RRs. We further stratified the analyses by child age and sex. Weexamined temporal trends in the diagnosis of ADHD by com-paringratesintheearliest(2001)vsmostrecent(2010)years.ThesignificanceofdifferencesinADHDtrendrateswastestedusing linear regression analysis.InapreviousstudythatusedKPSCmedicalrecords,wefoundthat race/ethnicity data are most commonly missing in chil-dren of races/ethnicities other than white.
39
Similarly, Ray etal
40
and Aratani and Cooper
41
reported that, comparedwith whites, children of other races are less likely to use men-talhealthservices,particularlyAsianAmericanchildren.There-fore,recordswithmissingdataonrace/ethnicityaremorelikelytohavecomefromchildrenofracesotherthanwhite.Weper-formed sensitivity analyses to investigate the effect of missingrace data on our findings. We reran the analyses by assigningmissing race/ethnicity data to every race/ethnicity group oneat a time.AllstatisticalanalyseswereperformedusingSASstatisticalsoftware, version 9.2 (SAS Institute, Inc). The study was ap-proved by the KPSC Institutional Review Board.
RESULTS
Among children in the study who were cared for in theKPSCfromJanuary1,2001,throughDecember31,2010,39200of842830(4.9%)hadadiagnosisofADHD.Dur-ing the same period, the number of children diagnosedashavingADHDincreasedfrom6869(2.5%)in2001to8006 (3.1%) in 2010. Both the race/ethnicity- and sex-specific mean ages at ADHD diagnosis remained rela-tively stable throughout the study period, ranging from8.4 to 9.5 years.Table 1 gives the distributions of child characteris-tics based on ADHD diagnosis. White and black chil-dren were more likely than Hispanics and Asian/PacificIslanderstobediagnosedashavingADHD.Childrenbe-tween 8 and 9 years and those from high-income fami-lies(
Ն
$70000)weremorelikelytobediagnosedashav-ing ADHD, as were boys in general.
Figure1
showsrace/ethnicity-specificadjustedratesof ADHD diagnosis and their relative increases between2001 and 2010. During the study period, we observedmarkedlyhigherratesofADHDdiagnosesamongwhites(4.5%) and a relatively lower rate among Asian/PacificIslanders(1.1%).Between2001and2010,blackshadthehighestrelativeincreaseinADHDdiagnosisrates(69.6%),followedbyHispanics(60.4%)andwhites(29.8%)(
P
forlineartrend
Ͻ
.001).RatesforAsian/PacificIslandersre-mained unchanged over time.
Figure 2
shows biannual median household in-come rates of ADHD diagnosis with adjustment for age,sex, and race/ethnicity. We observed a markedly higherrate of ADHD diagnosis among children living in high-income households (
P
for linear trend
Ͻ
.001).
Table2
and
Table3
give the adjusted ADHD ratesandrelativechangesfromtheearliesttothemostrecentyears. Also included are significance levels for temporaltrends derived using Poisson regression analysis. Aftercontrollingforchildageandhouseholdincome(Table2),we observed increases in ADHD diagnosis rates duringthe study period for white, Hispanic, and black race/ ethnicity and sex categories. Attention-deficit/ hyperactivity disorder increased from 4.7% in 2001 to5.6% in 2010 among whites (RR = 1.3; 95% CI, 1.2-1.4), 2.6% in 2001 to 4.1% in 2010 among blacks(RR = 1.7; 95% CI, 1.5-1.9), and 1.7% in 2001 to 2.5%in 2010 among Hispanics (RR = 1.6; 95% CI, 1.5-1.7).RatesforAsian/PacificIslandersremainedunchangedovertime.Inallracial/ethniccategories,ratesformalesacrossthestudyperiodweresubstantiallyhigherthanthoseforfemales. However, between 2001 and 2010, we noted amarkedincreaseinthediagnosisofADHDamongblackgirls (RR = 1.9; 95% CI, 1.5-2.3). The sex gap remainedstable during the study period among whites, Hispan-ics, and Asian/Pacific Islanders.Table3givestherace/ethnicity-andage-specificADHDdiagnosisrateswithadjustmentforsexandmedianfam-ily household income. During the study period, ADHDdiagnosis rates increased consistently for all race/ ethnicityandagecategories.Althoughwhitechildrenhadsubstantially higher ADHD diagnosis rates than chil-dren of other races in every age group, the increase was
02003 2005 2006 2008 200920072004 201056
    A    d    j   u   s   t   e    d    A    D    H    D     R   a   t   e   s   p   e   r    1    0    0    C    h    i    l    d   r   e   n
Year
432120022001OverallAsian/ Pacific IslanderOther/ MultipleBlack HispanicWhite
Figure 1.
Race/ethnicity-specific adjusted rates ofattention-deficit/hyperactivity disorder (ADHD) diagnosis: Kaiser PermanenteSouthern California (2001-2010). Adjustments were made for child age, sex,and median household income.
030
 
000-49
 
000 50
 
000-69
 
999 70
 
000-89
 
999
 
90
 
0004.04.5
    A    d    j   u   s   t   e    d    A    D    H    D     D    i   a   g   n   o   s    i   s    R   a   t   e   p   e   r    1    0    0    C    h    i    l    d   r   e   n
Median Household Income, $
3.53.02.52.01.51.00.5
<
 
30
 
0002001-2002 2003-2004 2005-2006 2007-2008 2009-2010
Figure 2.
Median household income–specific adjusted rate ofattention-deficit/hyperactivity disorder (ADHD) diagnosis: Kaiser PermanenteSouthern California (2001-2010). Adjustments were made for child age, sex,and race/ethnicity.
 JAMA PEDIATR PUBLISHED ONLINE JANUARY 21, 2013 WWW.JAMAPEDS.COM
E3

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