Factors associated with stimulant persistence among children with ADHD: a retrospective cohort study.

Importance: Optimizing ADHD stimulant therapy in children is difficult due to individual variability and lack of reliable response predictors, forcing a trial-and-error approach that burdens both patients and families. Objective: To identify factors associated with treatment success based on real-world patterns of ADHD stimulant use. Design: Setting and participants: In this retrospective cohort study we used the comprehensive electronic health records of Maccabi Healthcare Services. We included children aged 6-18 years diagnosed with ADHD between 2015-2023 who had purchased at least one ADHD stimulant and had at least 1 year of follow-up. Patients were classified as persistent users once they purchased at least eight prescriptions over a fixed 12-month period, with each purchase covering a 30-day period, and there were no gaps of 90 days or more; others were defined as Results: The cohort comprised of 43,825 children with ADHD, of which 18,783 (43%) were Persistent users. Persistent users were more often of male sex (67.5% vs. 55.4%), lower socioeconomic status (44.7% vs. 42.4% with low or very low SES), and initiated treatment at a younger age (76.4% vs. 52.9% initiated treatment at 6-12 years). Lisdexamfetamine was associated with the highest odds of treatment persistence when used as the initial stimulant, compared with the reference group (OR = 2.2, CI = 1.86-2.59), although this finding was based on a relatively small sample (n = 654). Conclusion and Relevance: In this retrospective cohort study of pediatric patients with ADHD, male sex, low socioeconomic status, early treatment initiation, and first-line lisdexamfetamine were associated with higher persistence.