In recent years, childhood suicidality has increased, leading many to speculate about how the relationship between 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 association between ADHD pharmacotherapy with externalizing symptoms and suicidality in children.
“ADHD is associated with multiple psychiatric comorbidities, including suicidal ideation, suicide attempt and completed suicide, even after controlling for other comorbid mental 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.”
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 aged 9-11 years.
The mean age of the patient population was 9.9 years old and 8.5% of participants were being treated with ADHD medications, while 8.8% reported previous or current suicidality.
The study exposures at baseline assessment included main and interaction associations of externalizing symptoms – ADHD hyperactivity symptoms, oppositional defiant symptoms, and conduct disorder symptoms – as well as ADHD drug treatment – methylphenidate and amphetamine derivatives, α-2 agonists, and atomoxetine.
The researchers looked for key outcomes of childhood-reported suicidality — past and present at baseline and current for the longitudinal assessment.
The covariates were age, gender, race/ethnicity, parental education, marital status, and concomitant child psychiatric pharmacotherapy, including antidepressants and antipsychotics.
The researchers found that externalizing symptoms were associated with suicidality (for a 1 SD change 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 in patients with more externalizing symptoms (significant symptom-per-drug interaction, B = -0.250; SE = 0.086; P = 0.004). There was also an association between more externalizing symptoms and suicidality in patients not receiving ADHD medication (for a 1 SD change 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 persisted even when the researchers covaried for multiple confounders, including risk and protective factors for suicidality in ABCD. These results were replicated at the 1-year longitudinal follow-up, as well as sensitivity analyzes matching participants with a high number of externalizing symptoms who were or were not taking ADHD medication confirmed the association with less suicidality.
“These findings suggest that treatment with ADHD medications is associated with less suicidality in children with substantial externalizing symptoms and can be used to inform suicide prevention strategies in children,” the authors wrote.
The study, “Evaluation of Attention Deficit/Hyperactivity Disorder Medication, Externalizing Symptoms and Suicidality in Children,” was published online in JAMA Network Open.