Low Socioeconomic Status Predicts Likelihood of Receiving ADHD Medication

Children and young people of low socioeconomic status are more likely to receive medication for attention-deficit/hyperactivity disorder (ADHD) than their wealthier peers, according to study data published in BJPsych Open.

This cross-sectional study cohort comprised children with a diagnosis of ADHD who were seen at participating secondary care centers in Sheffield, United Kingdom, between January and December 2016. The researchers assessed demographics, comorbid conditions, and medication status with medical record review and measured socioeconomic position with the Index of Multiple Deprivation (IMD). The IMD uses 7 weighted domains of deprivation to stratify neighborhoods into deciles of economic status, with the lowest decile (10%) representing the most deprived.

The researchers also mapped patients’ home postcodes to IMD deciles and performed multivariable logistic regression to calculate the odds ratios (ORs) of medication use by neighborhood deprivation status. Relevant covariates included age, gender, religion, race/ethnicity, and comorbid conditions, and analyses were adjusted for care center site.

The total study cohort comprised 1354 children and young people with ADHD (82.7% boys; mean age, 13.6±3.1 years). Autism spectrum disorder (n=287; 22.4%) and intellectual disabilities (n=134; 10.5%) were somewhat common in the cohort. The median IMD rank was 4.7 (IQR, 1.4-15.7), which corresponded to a median IMD decile of 2 (IQR, 1-5).

Of the 1241 children with available data on medication status, 1135 (91.5%) were prescribed ADHD medication. Children receiving ADHD medication were older (mean age, 13.7 vs 13.0 years; P =.016), had a higher prevalence of ASD (23.2% vs 14.9%; P =.055), and had more comorbid conditions (median, 1.0 vs 0.0; P =.019) than children not receiving medication. Median IMD rank (4.3 vs 8.1; P =.017) and decile (2.0 vs 3.0; P =.021) were significantly lower in children receiving vs children not receiving ADHD medication.

The log odds of receiving ADHD medication had an apparent linear relationship with IMD decile. For each 1-decile increase in IMD, the odds of receiving ADHD medication decreased by 10% (adjusted OR, 0.90; 95% CI, 0.84-0.97), with moderate model discriminative ability. The Hosmer-Lemeshow goodness-of-fit test suggested adequate agreement between predicted and observed probabilities of medication use. In sensitivity analyses accounting for biases in missing values, the association between IMD decile and ADHD medication use persisted.

As study limitations, the investigators cited the cross-sectional design, which could not establish temporality, and they did not ascertain ADHD symptom severity. Furthermore, it may be difficult to extrapolate their findings outside of the United Kingdom, although the results of this study are corroborated by prior studies conducted in Sweden and Denmark.

Children from more deprived backgrounds appear to be more likely to receive ADHD medication. The investigators hypothesized that children with greater neighborhood deprivation may present with greater symptom severity, thus increasing the chances of receiving medication.

“This social gradient presents a challenge not only to clinicians but even more to politicians, public health professionals and social care, and adds further weight to the argument that tackling the social determinants of health should be a priority for public health professionals and policymakers alike,” the study investigators concluded.

Reference

Nunn SPT, Kritsotakis EI, Harpin V, Parker J. Social gradients in the receipt of medication for attention-deficit hyperactivity disorder in children and young people in Sheffield. BJPsych Open. 2020;6(2):e14.