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Challenges in ADHD Treatment :

May 22, 2017

In a recently released issue of Pediatrics, Dr. Janet Cummings and colleagues examine racial and ethnic differences in ADHD treatment among 172,322 children ages 6-12 years in 9 states who initiated medication for ADHD.

In a recently released issue of Pediatrics (10.1542/peds.2016-2444), Dr. Janet Cummings and colleagues examine racial and ethnic differences in ADHD treatment among 172,322 children ages 6-12 years in 9 states who initiated medication for ADHD. Their thought-provoking analyses give food for thought for primary care physicians, psychiatrists and researchers. While racial and ethnic differences were identified in medication and psychotherapy discontinuation, and in overall treatment disengagement, results were not straightforward, and minority youth were less likely to have received treatment in some analyses, but certainly not in all.  The main study findings that impressed me, though, were related to sample characteristics and medication discontinuation rates across the sample.

Fully 1/3 (33.2%) of the youths studied were characterized as having an “other mental health disorder” and 1 of 5 (21.7%) had been diagnosed with oppositional defiant disorder or conduct disorder, while 6.7% were depressed and 8.2% were characterized as bipolar. A similar study which also examined ADHD treatment among Medicaid enrollees ages 3-17 years from 2001 to 2010 in 20 states reported that 43.3% of children in 2010 had a secondary mental health diagnosis.1 These comparable and large Medicaid-enrolled groups of children carry a profoundly heavy mental health burden, which threatens to dwarf any examination of treatment of ADHD. The fact that 38.2% of children in the current study of Cummings et al actually did have any psychotherapy visit (with a mean of 9.5 visits per child) could reflect treatment for these other conditions as much as it reflects specific treatment for ADHD. This is not a nuance that one could expect to extract from a Medicaid claims database, but bears consideration since not all psychotherapy may have been intended or prescribed as an ADHD treatment modality.

Cummings et al examined the rates of medication treatment and discontinuation in their sample. The HEDIS (Health Effectiveness Data and Information Set) definition of “continuous medication treatment” is having an ADHD prescription filled for at least 210 of the 300 days that span the initiation, and continuation and management phases of ADHD treatment.  They found that the overall rate of medication discontinuation (among those who started medication and remained Medicaid eligible) was 60.4%, so most children who initiated medication did not achieve even this relatively low bar for adherence (continuation). The rate of discontinuation was even higher (70.3%) among those who had no psychotherapy visit.  The adjusted rate of medication discontinuation was 22.4 percentage points higher among Black than White youths and 16.7 percentage points higher among Hispanic than White youth, reflecting one of the disparities the authors note. The “elephant in the room” question, though, is why do so few children who begin ADHD medication continue or adhere?

This adherence issue was well demonstrated in the MTA trial (Multimodal Treatment Study of children with ADHD), the only randomized controlled trial of medication for ADHD with long term follow up.  In this study, salivary drug testing was performed, and it was revealed that only 136 (53.5%) of parents gave medication at every time point, and that 24.8% were non-adherent on 50% or more of saliva samples – this means that nearly half of children in the trial experienced some degree of non-adherence.2   A recent systematic review that examined adherence, persistence and discontinuation included 91 original studies and concluded that despite lack of consistency in measurement techniques, “drug adherence and persistence are generally poor among patients with ADHD.” The most frequent reasons for discontinuing ADHD medications were medication side effects and inadequate symptom control. 3 Meanwhile, the MTA trial followed subjects to adulthood, and in a summary article the investigators muse: “The key paradox is that whereas ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive.”4 Is it possible that high rates of ADHD medication discontinuation reveal a truth that youths and parents recognize, but that providers have not yet fully identified or addressed?  Please add your comments and thoughts!


  1. Hoagwood KE, Kelleher K, Zima BT, Perrin JM, Bilder S, Crystal S.Ten-Year Trends In Treatment Services For Children With Attention Deficit Hyperactivity Disorder Enrolled In Medicaid. Health Aff (Millwood). 2016 Jul 1;35(7):1266-70. doi: 10.1377/hlthaff.2015.1423.
  2. Pappadopulos E, Jensen PS, Chait AR, Arnold LE, Swanson JM, Greenhill LL, Hechtman L, Chuang S, Wells KC, Pelham W, Cooper T, Elliott G, Newcorn JH. Medication adherence in the MTA: saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioral treatment.J Am Acad Child Adolesc Psychiatry. 2009 May;48(5):501-10. doi: 10.1097/CHI.0b013e31819c23ed.
  3. Gajria K, Lu M, Sikirica V, et al. Adherence, persistence, and medication discontinuation in patients with attention-deficit/hyperactivity disorder – a systematic literature review. Neuropsychiatric Disease and Treatment. 2014;10:1543-1569. doi:10.2147/NDT.S65721.
  4. Hinshaw SP, Arnold LE. MTA Cooperative Group.Attention-deficit hyperactivity disorder, multimodal treatment, and longitudinal outcome: evidence, paradox, and challenge. Wiley Interdiscip Rev Cogn Sci. 2015 Jan-Feb;6:39-52. doi: 10.1002/wcs.1324. Epub 2014 Nov 3.
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