Evaluation of Attention-Deficit/Hyperactivity Disorder Medications, Externalizing Symptoms, and Suicidality in Children

Gal Shoval, Elina Visoki, Tyler M. Moore, Grace E. Didomenico, Stirling T. Argabright, Nicholas J. Huffnagle, Aaron F. Alexander-Bloch, Rebecca Waller, Luke Keele, Tami D. Benton, Raquel E. Gur, Ran Barzilay*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Importance: Childhood suicidality (ie, suicidal ideation or attempts) rates are increasing, and attention-deficit/hyperactivity disorder (ADHD) and externalizing symptoms are common risk factors associated with suicidality. More data are needed to describe associations of ADHD pharmacotherapy with childhood suicidality. Objective: To investigate the associations of ADHD pharmacotherapy with externalizing symptoms and childhood suicidality. Design, Setting, and Participants: In this cohort study, cross-sectional and 1-year-longitudinal associations were examined using data (collected during 2016-2019) from the Adolescent Brain Cognitive Development (ABCD) Study, a large, diverse US sample of children aged 9 to 11 years. Data analysis was performed from November to December 2020. Exposures: Main and interaction associations of externalizing symptoms (hyperactivity ADHD symptoms, oppositional defiant, and conduct disorder symptoms) and ADHD medication treatment (methylphenidate and amphetamine derivatives, α-2-agonists, and atomoxetine) at baseline assessment. Main Outcomes and Measures: Child-reported suicidality (past and present at baseline; current at longitudinal assessment). Covariates were age, sex, race/ethnicity, parents' education, marital status, and concomitant child psychiatric pharmacotherapy (antidepressants and antipsychotics). Results: Among 11 878 children at baseline assessment (mean [SD] age, 9.9 [0.6] years; 6196 boys [52.2%]; 8805 White [74.1%]), 1006 (8.5%) were treated with ADHD medication and 1040 (8.8%) reported past or current suicidality. Externalizing symptoms (median [range], 1 [0-29] symptom count) were associated with suicidality (for a change of 1 SD in symptoms, odds ratio [OR], 1.34; 95% CI, 1.26-1.42; P <.001), as was ADHD medication treatment (OR, 1.32; 95% CI, 1.06-1.64; P =.01). ADHD medication use was associated with less suicidality in children with more externalizing symptoms (significant symptom-by-medication interaction, B = -0.250; SE = 0.086; P =.004), such that for children who were not receiving ADHD medications, there was an association between more externalizing symptoms and suicidality (for a change of 1 SD in symptoms, OR, 1.42; 95% CI, 1.33-1.52; P <.001); however, for children who were receiving ADHD medication, there was no such association (OR, 1.15; 95% CI, 0.97-1.35; P =.10). The association with medication remained even when covarying for multiple confounders, including risk and protective factors for suicidality in ABCD, and was replicated in 1-year longitudinal follow-up. Sensitivity analyses matching participants with high numbers of externalizing symptoms taking and not taking ADHD medication treatment confirmed its association with less suicidality. Conclusions and Relevance: 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..

Original languageEnglish
Article numbere2111342
JournalJAMA network open
Issue number6
StatePublished - 4 Jun 2021


FundersFunder number
Lifespan Brain Institute of Children’s Hospital of Philadelphia
Penn Medicine, University of Pennsylvania
National Institutes of HealthU01DA051039, U01DA051016, U01DA051038, U01DA051018, U01DA051037, U01DA041106, U01DA041117, U01DA041028, U01DA041148, U24DA041147, U01DA041048, U01DA041025, U24DA041123, U01DA041134, U01DA041156, U01DA041089, U01DA041022, U01DA041120, U01DA041174, U01DA050987, U01DA050988, U01DA050989, U01DA041093
National Institute of Mental HealthRO1MH117014, K23MH120437, R21MH123916


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