ADHD Treatment Reduces Suicidality in Pediatric Patients

Externalizing ADHD symptoms was linked to suicidality.

In recent years childhood suicidality rates have increased, leading many to speculate how the relationship between attention-deficit/hyperactivity disorder (ADHD), a known risk factor, pharmacotherapy and childhood suicidality is a factor.

A team, led by Gal Shoval, MD, Geha Mental Health Center and Sackler School of Medicine, Tel Aviv University, examined the link between ADHD pharmacotherapy with externalizing symptoms and childhood suicidality.

“ADHD is associated with multiple psychiatric comorbidities, including suicidal ideation, suicide attempts, and completed suicide, even after controlling for other comorbid mental health disorders,” The authors wrote. “Large-scale population-based studies from Sweden, Taiwan, and the US indicated that psychostimulants, particularly methylphenidate, may be associated with less suicidal behavior in patients with ADHD.”

The Cohort

In the cohort study, the researchers used data collected between 2016-2019 from the Adolescent Brain Cognitive Development (ABCD) study to examine cross-sectional and one-year-longitudinal associations of 11,878 pediatric patients. THE ABCD study is a large, diverse US sample of pediatric patients between 9-11 years old.

The mean age of the patient population was 9.9 years old and 8.5% of the participants were treated with ADHD medication, while 8.8% reported past or current suicidality.

The study’s exposures at the baseline assessment included main and interaction associations of externalizing symptoms—hyperactivity ADHD symptoms, oppositional defiant, and conduct disorder symptoms—as well as ADHD medication treatment—methylphenidate and amphetamine derivatives, α-2-agonists, and atomoxetine.

The researchers sought main outcomes of child-reported suicidality—past and present at baseline and current for the longitudinal assessment.

The covariates were age, sex, race/ethnicity, parents’ education, marital status, and concomitant child psychiatric pharmacotherapy, including antidepressants and antipsychotics.

The Link

The researchers found externalizing symptoms was linked to suicidality (for a change of 1 SD in symptoms, OR, 1.34; 95% CI, 1.26-1.42; P <0 .001). This was also true for ADHD medication (OR, 1.32; 95% CI, 1.06-1.64; P = 0.01).

However, ADHD treatment was associated with less suicidality for patients with more externalizing symptoms (significant symptom-by-medication interaction, B = −0.250; SE = 0.086; P = 0 .004). There was also an association between more externalizing symptoms and suicidality for patients not receiving ADHD medications (for a change of 1 SD in symptoms, OR, 1.42; 95% CI, 1.33-1.52; P <0 .001).

On the other hand, there was no association between externalizing symptoms and suicidality in participants not receiving ADHD medication (OR, 1.15; 95% CI, 0.97-1.35; P = 0 .10).

The association with medication remained even when the investigators covaryed for multiple confounders, including risk and protective factors for suicidality in ABCD. These results were replicated in the 1-year longitudinal follow-up as did sensitivity analyses matching participants with high numbers of externalizing symptoms taking and not taking ADHD medication treatment confirmed its association with less suicidality.

“These findings suggest that ADHD medication treatment is associated with less suicidality in children with substantial externalizing symptoms and may be used to inform childhood suicide prevention strategies,” the authors wrote.

The study, “Evaluation of Attention-Deficit/Hyperactivity Disorder Medications, Externalizing Symptoms, and Suicidality in Children,” was published online in JAMA Network Open.