Prescribing medications for attention-deficit/hyperactivity disorder in children: a retrospective analysis of a Japanese health insurance claims database

Prescribing medications for attention-deficit/hyperactivity disorder in children: a retrospective analysis of a Japanese health insurance claims database | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prescribing medications for attention-deficit/hyperactivity disorder in children: a retrospective analysis of a Japanese health insurance claims database Ryutaro Suzuki, Ryosuke Kumazawa, Takumi Miyoshi, Junsei Tanaka, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7008746/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Despite pharmacotherapy being a significant treatment protocol for attention-deficit/hyperactivity disorder (ADHD), an increasingly common neurodevelopmental condition among children in Japan, prescribing practices for ADHD medications remain underexplored. This study examined prescribing patterns of medications for ADHD in children and adolescents aged 0–17 years in Japan and analyzed drug selection trends on the basis of patients’ backgrounds, including sex, age group, and medical department. Methods In this retrospective database study using a large Japanese health insurance claims database, we analyzed prescription patterns from April 2018 to August 2023. We examined the proportion of patients prescribed each of the four ADHD medications, namely, methylphenidate extended-release (OROS-MPH), atomoxetine (ATX), guanfacine (GXR), and lisdexamfetamine (LDX), their combination patterns, and new prescription proportions across different demographic groups and medical departments. The Jonckheere–Terpstra trend test was employed to assess trends in prescription proportions over time. The Mann‒Whitney U test was employed to compare time series data on the proportion of monotherapy prescriptions in psychiatric and nonpsychiatric settings. Results From 2018 to 2023, OROS-MPH prescriptions significantly decreased from 64.7% to 47.5%, whereas GXR prescriptions significantly increased from 19.3% to 46.4%. GXR was prescribed most frequently for female patients and children aged 6–12 years. For new patients, GXR prescriptions began exceeding those of OROS-MPH from late 2019 onward, comprising 41.3% of new prescriptions by 2023. The percentage of patients receiving monotherapy decreased from 82.3% to 79.6%, with OROS-MPH plus GXR being the most common combination therapy. Conclusions In Japan, GXR has become an increasingly preferred medication for ADHD, particularly for female patients and children aged 6–12 years, with new prescriptions exceeding those of OROS-MPH since late 2019. This trend may be attributed to GXR not being subject to the same distribution control regulations as central nervous system stimulants and to its distinctive pharmacological mechanisms that differ from those of other ADHD medications. Continuous monitoring of prescription practices is necessary as treatment options continue to evolve. Attention Deficit Disorder with Hyperactivity Child Adolescent Drug Prescriptions Practice Patterns Japan Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Background Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition typically characterized by hyperactivity, impulsivity, and inattention, which often persist in adulthood and negatively affect schoolwork, employment, and relationships [ 1 , 2 ]. The global prevalence of ADHD is estimated to be approximately 5.0% in children and adolescents [ 3 ], and epidemiological studies in Japan estimate the prevalence of ADHD in children to be 5.8% [ 4 ], with an increase in the estimated incidence [ 5 ]. However, prevalence varies considerably across countries, with some reporting rates as low as 1% [ 6 ]. Psychosocial treatments and pharmacotherapy tailored to an individual patient’s condition are recommended for ADHD [ 7 ]. Pharmacotherapy for ADHD is effective in children and adolescents [ 8 ] and is associated with a decreased risk of various functional outcomes associated with ADHD [ 9 ]. Pharmacotherapy is also recommended in treatment guidelines in Europe, the United States, and Japan [ 10 – 13 ]. Despite the effectiveness of pharmacotherapy and its recommendation in guidelines, many patients with ADHD remain untreated with central nervous system (CNS) stimulants, particularly in smaller countries. This situation may be influenced by various factors including regulatory restrictions and prescribing practices [ 14 ]. Over the past few decades, the prevalence of ADHD and the use of ADHD medications have increased in several countries [ 15 – 17 ], along with concerns about potential overdiagnosis and inappropriate prescription of ADHD medications [ 18 , 19 ]. In the 2000s, the abuse of short-acting methylphenidate, which is used to treat conditions such as depression and pediatric ADHD in Japan (used off-label for the latter disorder), became a social problem [ 20 ]. Methylphenidate extended-release (OROS-MPH) and atomoxetine (ATX) were subsequently administered to pediatric patients with ADHD between October 2007 and June 2009. Because of dependence and abuse, since 2008, distribution control regulations have been implemented for OROS-MPH, a CNS stimulant. Additionally, the fourth edition of the Japanese guidelines for the diagnosis and treatment of ADHD published in 2016 [ 21 ] lists the use of only OROS-MPH and ATX as medication options for ADHD. Guanfacine (GXR) and lisdexamfetamine (LDX) began being administered in June 2017 and December 2019, respectively. Currently, the registration of details of patients, prescribing physicians (who must be physicians with expertise), medical institutions, and dispensing pharmacies is required to prescribe the two CNS stimulants (OROS-MPH and LDX), and there is a 30-day limit on prescription. The latest guidelines (5th edition), published in 2022, list several ADHD medications, such as OROS-MPH, LDX, ATX, and GXR [ 12 ]. The guidelines list non-CNS stimulants ATX and GXR as first-line agents, along with OROS-MPH, and recommend their use as monotherapy. International evidence demonstrates that CNS stimulants have medium to large effect sizes and are generally more effective than non-stimulants [ 22 ]. Accordingly, guidelines in the United States and Europe recommend CNS stimulants as first-line agents [ 11 – 13 ]. In contrast, Japan regulates the distribution of these CNS stimulants, consequently creating a unique treatment environment where non-stimulants are positioned equally as first-line options. Since ADHD medications are intended for continuous use, the choice of therapeutic agent is critically important. The selection is based on patients’ individuality and physicians’ experiences with reference to guidelines, which are areas where further evidence needs to be accumulated. Knowing which drugs are most likely to be used for each patient will guide future drug selection. In addition, CNS stimulants carry the risks of dependence and abuse [ 23 ]. Therefore, to ensure safe drug use, prescription practices, such as changes in the therapeutic environment after a new drug is introduced, should be surveyed. In Japan, psychiatrists and pediatricians are mainly involved in the treatment of ADHD, and differences in the choice of therapeutic agents on the basis of physicians’ backgrounds are relatively unknown. Understanding the unique Japanese treatment environment for ADHD requires accumulating evidence on actual prescribing practices. Previous studies in Japan have examined ADHD medication prescription patterns stratified by patient demographics and department type [ 24 – 27 ]. However, as these studies were based on data collected prior to LDX approval in December 2019, they could not examine the full therapeutic landscape with all four medications available. Additionally, comprehensive analyses of specific combination therapy patterns have remained limited. This study provides updated analyses using health insurance claims data from April 2018 to August 2023, including the period after all four medications became available. The study aims to clarify recent drug selection patterns based on patient backgrounds, examine trends in medications prescribed to newly initiating patients, and investigate detailed combination therapy patterns in current Japanese practice. 2. Methods 2.1 Data sources Data were extracted from a large health insurance claims database developed and managed by the DeSC Healthcare Corporation (Tokyo, Japan). The DeSC database includes three types of insurance: national health insurance, employer-based health insurance, and the late-stage senior citizens’ healthcare system. All residents are included in Japan’s health insurance system. The type of public insurance does not affect medical care. Differences in public insurance are based on age, occupation, and employment status. DeSC contains epidemiological claims data for approximately 12 million insurance enrollees, and the age and sex distributions of individuals listed in the database are similar to those in Japanese population estimates [ 28 ]. Since this study aimed to focus on early childhood and school-age children, it covers insurance claimants of national health insurance and employer-based health insurance. Children are covered by their parents’ insurance regardless of their medical condition. Therefore, they are consistently included in insurance claims data, minimizing the possibility of selection bias. Insurance claims include all inpatient, outpatient, and pharmacy claims received by the insurer, including those related to diagnoses, medical procedures, and prescribed drugs. Data were recorded even if the participants changed healthcare providers or used multiple providers. To our knowledge, this is the first study to use the DeSC database to examine ADHD medication prescribing patterns in a pediatric population. 2.2 Patient Selection We adopted a retrospective database study design to understand prescribing practices while analyzing background factors. The dataset under consideration—the DeSC insurance claims database—was collected from April 1, 2014, to August 31, 2023. The analysis period was from April 1, 2018, to August 31, 2023. In this study, each period from April of one year to March of the following year was defined as one year. This period was further subdivided into four three-month periods. The temporal framework under consideration encompasses the following quarters: the initial quarter (Q1), from April to June; the second quarter (Q2), from July to September; the third quarter (Q3), from October to December; and the fourth quarter (Q4), from January to March of the following year. The initial month of this period was designated April in accordance with the Japanese school calendar. The study population consisted of males and females aged 0–17 years who were diagnosed with ADHD and were registered in the DeSC database between April 1, 2014, and August 31, 2023 (ICD-10 code: F90). Furthermore, the participants were required to have received at least one dose of ADHD medication during the analysis period. The age of the participants was determined as the age on the first day of each period, that is, the first day of April, July, and October of one year, and January of the following year. The proportion of new prescriptions was determined by including patients for whom ADHD medications were initiated for the first time during the study period, as defined by the following criteria. Inclusion criteria for new prescription analysis: Patients were included in the new prescription analysis if they: (1) had no record of any ADHD medication prescription from the data access start date (April 1, 2014) to the index prescription date, (2) had at least 180 days of data enrollment before the index prescription, and (3) received their first ADHD medication prescription during the analysis period (April 1, 2018 to August 31, 2023). Although the DeSC database includes diagnostic codes for all medical encounters, we did not extract or analyze data on psychiatric or medical comorbidities in this study. The focus was on overall prescribing patterns rather than examining the influence of specific comorbid conditions on medication selection. This limitation is discussed in the Limitations section. 2.3 Outcomes The outcome measures included the proportion of patients prescribed each ADHD medication relative to all patients prescribed any ADHD medication (prescription proportion), the proportion of each combination pattern of ADHD medications (prescription pattern proportion), the monotherapy proportion, and the proportion of patients newly initiating each ADHD medication (new prescription proportion). For each time period, we identified the number of unique patients who met the inclusion criteria and were prescribed ADHD medications. For prescription proportion calculations, each medication was evaluated independently. Patients receiving combination therapy were included in the count for each medication prescribed. For example, a patient receiving both OROS-MPH and GXR was counted in both the OROS-MPH prescription proportion and the GXR prescription proportion. Consequently, the sum of prescription proportions across all four medications may exceed 100%. These outcome measures were examined according to sex, age group (0–5, 6–12, and 13–17 years), and department (psychiatry/nonpsychiatry) at each time point. 2.4 Statistical analysis This retrospective database study included all patients who met the inclusion criteria, as this was a descriptive epidemiological study without hypothesis testing. The medications used to treat ADHD included various formulations of the following four drugs: OROS-MPH, LDX, ATX, and GXR. There was no minimum requirement for the number of prescriptions; patients prescribed medication only once were included if they met the criteria. The proportion of prescriptions was calculated in the following manner. The duration of drug therapy was calculated from the start date and the number of days on which each drug was prescribed. The drug was considered to have been prescribed to patients during the duration of the drug. For each of the four medications (OROS-MPH, LDX, ATX, and GXR), we identified all patients who were prescribed that medication during each period. The prescription proportion for each medication was calculated using the number of patients prescribed that medication as the numerator and the total number of patients prescribed any ADHD medication as the denominator. Patients receiving combination therapy were counted in the numerator for each medication prescribed; thus, the same patient could be counted in multiple medication groups simultaneously. The proportion of new prescriptions was calculated similarly. The proportion of the prescription pattern was calculated in the following manner. Fifteen distinct combinations of concomitant prescriptions, contingent on the prescription of each of the four drug groups, existed (monotherapy: four patterns; two-drug combination: six patterns; three-drug combination: three patterns; four-drug combination: one pattern). To calculate the proportion of prescription patterns in each period, the number of patients per prescription pattern was designated the numerator, and the total number of patients for whom ADHD medications were prescribed was designated the denominator. A minimum of three distinct pharmacological agents were aggregated into a single category. The monotherapy proportion was calculated using the total of four monotherapy patterns as the numerator and the total number of patients prescribed ADHD medications as the denominator. Psychiatric versus nonpsychiatric care was distinguished on the basis of billing codes indicating psychotherapy services, which are generally calculated via insurance coverage in psychiatric institutions in Japan. The Jonckheere–Terpstra trend test was employed to assess trends in prescription proportions over time. The Mann‒Whitney U test was employed to compare time series data on the proportion of monotherapy prescriptions in psychiatric and nonpsychiatric settings. The significance level was set at 5%. Bonferroni correction was used to address the issue of multiplicity. Microsoft SQL Server (version 2022) was used for database processing, whereas SAS (version 9.4) and R Studio (version 4.4.0) were used for data analysis. 2.5 Ethics The Research Ethics Review Committee of Meiji Pharmaceutical University approved this study on June 27, 2024 (registration number: 202408). As the data used in this study were unlinked and anonymous, informed consent was not needed. 3. Results 3.1 Trends in prescription proportions A total of 72,609 patient observations were analyzed across 22 quarterly periods (Q1/2018 to Q2/2023). Table 1 shows the patient profiles. Boys outnumbered girls, and the 6–12 age group comprised the highest number of patients. Detailed trends in prescription are shown with numerical data in Appendix Table S1 . The proportion of prescriptions for each ADHD medication is outlined in Fig. 1 , with sex- and age-specific trends shown in Fig. 2 a–d. A significant downward trend of 64.7% to 47.5% ( P < 0.001) was observed for OROS-MPH from Q1/2018 to Q2/2023; a significant downward trend ( P < 0.001) of 34.4% to 22.4% for ATX; and a significant upward trend ( P < 0.001) of 19.3% to 46.4% for the GXR. The GXR surpassed ATX in Q1/2019, most recently, in terms of the proportion of OROS-MPH prescriptions. LDX showed a significant increasing trend ( P < 0.001) from Q4/2019 (market launch) to Q2/2023, reaching 5.2%. In terms of sex (Figs. 2 a and 2 b), the GXR was greater than the OROS-MPH in girls at Q3/2021. By age group (Figs. 2 c and 2 d), the GXR exceeded the OROS-MPH in the middle of the observation period in the 6–12 age group, but the OROS-MPH consistently exceeded the GXR in the 13–17 age group. By department (Table 2 ), OROS-MPH was the most prescribed drug in nonpsychiatric departments, whereas GXR surpassed OROS-MPH in the middle of the observation period in psychiatric departments, and GXR surpassed OROS-MPH in the most recent period. Table 1 Characteristics of the prescribed patients Year 2018 2019 2020 2021 2022 2023 Period¹ 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 Total 2874 3013 3128 3096 3304 3448 3525 3457 3524 3737 3889 3893 3849 3927 4069 4014 3328 3323 3313 3059 1542 1297 Boys 2385 2499 2597 2565 2723 2826 2878 2835 2893 3042 3138 3133 3083 3147 3237 3193 2618 2600 2595 2421 1209 1025 0–5 years 10 19 24 21 16 17 18 12 9 21 24 23 17 18 24 16 12 16 9 8 4 1 6–12 years 1626 1702 1740 1700 1839 1916 1925 1888 1941 2024 2047 2010 1951 2004 2049 1993 1586 1583 1578 1467 732 594 13–17 years 749 778 833 844 868 893 935 935 943 997 1067 1100 1115 1125 1164 1184 1020 1001 1008 946 473 430 Girls 489 514 531 531 581 622 647 622 631 695 751 760 766 780 832 821 710 723 718 638 333 272 0–5 years 3 3 4 3 1 2 4 1 5 9 7 5 5 5 5 4 6 8 2 4 0 0 6–12 years 307 320 325 314 349 388 393 362 365 407 430 439 428 434 467 464 396 402 400 359 184 141 13–17 years 179 191 202 214 231 232 250 259 261 279 314 316 333 341 360 353 308 313 316 275 149 131 ¹Periods represent three-month quarters: Period 1 (April–June), Period 2 (July–September), Period 3 (October–December), and Period 4 (January–March of the following year), following the Japanese fiscal year. Table 2 Comparison of psychiatric and nonpsychiatric prescriptions for ADHD medications Year 2018 2019 2020 2021 2022 2023 Period¹ 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 Psychiatry Total 139 146 159 170 190 213 217 205 195 206 204 211 203 218 220 205 155 171 175 170 58 49 OROS-MPH² 89 88 99 91 103 115 112 95 81 86 87 90 95 96 103 97 73 72 75 67 18 18 LDX³ 0 0 0 0 0 0 0 3 5 5 6 5 6 6 6 4 4 8 10 13 3 3 ATX⁴ 46 41 36 35 45 54 53 47 46 43 47 46 51 45 46 51 48 54 46 46 19 16 GXR⁵ 26 40 54 69 76 93 96 99 100 100 90 105 92 105 103 93 64 79 74 74 28 22 Nonpsychiatry Total 2753 2892 2995 2951 3139 3264 3341 3283 3369 3573 3718 3712 3676 3759 3883 3850 3199 3191 3172 2913 1492 1253 OROS-MPH² 1781 1802 1887 1853 1949 1983 2015 1893 1831 1955 2018 1971 1963 1937 1962 1946 1602 1572 1573 1416 717 599 LDX³ 0 0 0 0 0 0 0 4 11 26 40 45 62 71 83 98 82 102 107 113 59 65 ATX⁴ 945 936 888 867 879 874 852 851 901 947 966 918 887 910 918 897 707 743 729 680 343 277 GXR⁵ 535 730 817 834 947 1085 1157 1246 1356 1430 1515 1561 1520 1599 1720 1712 1482 1487 1475 1371 708 581 ¹Periods represent three-month quarters: Period 1 (April–June), Period 2 (July–September), Period 3 (October–December), and Period 4 (January–March of the following year), following the Japanese fiscal year. ²OROS-MPH: Osmotic controlled-release oral delivery system-methylphenidate, ³LDX: Lisdexamfetamine, ⁴ATX: Atomoxetine, ⁵GXR: Guanfacine Tables 1 and 2 near here Figures 1 and 2 a–d near here 3.2 Trends in New Prescription Table 3 shows the profiles of patients receiving new prescriptions. Detailed trends in new prescription are shown with numerical data in Appendix Table S2. The proportion of new prescriptions for each ADHD medication (Fig. 3 ) significantly decreased from 47.9% to 25.3% for OROS-MPH from Q1/2018 to Q2/2023 ( P = 0.0083). In contrast, an increasing trend of 20.9% to 26.7% ( P = 0.16) and a significantly increasing trend of 27.4% to 41.3% ( P = 0.0021) were observed for ATX and the GXR, respectively. LDX changed from 0% to 1.3% ( P = 0.030), and ADHD medication combinations changed from 3.7% to 5.3% ( P = 0.45). Since Q4/2019, the GXR has surpassed OROS-MPH and has remained at approximately 40%. In particular, in Q4/2019, the increase in the GXR and decrease in OROS-MPH were more noticeable than they were in the periods before and after it. Table 3 Characteristics of new prescription patients Year 2018 2019 2020 2021 2022 2023 Period¹ 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 Total 215 247 272 226 261 291 267 202 199 252 279 284 274 298 349 273 204 250 212 198 110 75 Boys 161 191 212 171 205 217 203 154 140 185 195 202 199 218 251 194 139 174 148 140 78 54 0–5 years 1 5 5 2 0 4 3 1 2 8 8 2 1 4 3 1 1 2 0 0 1 1 6–12 years 125 139 160 111 163 170 152 119 103 141 148 151 154 181 201 139 97 134 117 107 57 35 13–17 years 35 47 47 58 38 44 50 33 29 36 45 50 44 33 47 54 41 38 31 33 20 18 Girls 54 56 60 55 56 74 64 48 59 67 84 82 75 80 98 79 65 76 64 58 32 21 0–5 years 1 0 1 0 0 1 0 0 2 3 1 1 1 1 0 0 1 0 0 1 0 0 6–12 years 34 36 37 30 30 47 37 21 28 38 52 38 42 41 63 42 37 43 36 32 18 10 13–17 years 19 20 22 25 26 26 27 27 29 26 31 43 32 38 35 37 27 33 28 25 14 11 ¹Periods represent three-month quarters: Period 1 (April–June), Period 2 (July–September), Period 3 (October–December), and Period 4 (January–March of the following year), following the Japanese fiscal year. Tables 3 near here Figure 3 near here 3.3 Trends in prescription pattern proportions The prescription pattern proportions are shown in Fig. 4 , with detailed numerical data provided in Appendix Table S3. The overall monotherapy proportion for ADHD medications decreased significantly from 82.3% in Q1/2018 to 79.6% in Q2/2023 (P = 0.0011). When analyzed by department, the monotherapy proportion among psychiatric departments changed from 85.6% to 79.6%, but the trend was not consistent (P = 0.054), whereas the monotherapy proportion among nonpsychiatric departments significantly decreased from 82.2% to 79.7% (P < 0.001). A statistically significant difference between psychiatry and nonpsychiatry regarding the proportion of patients receiving monotherapy ( P < 0.001) was also observed. When restricted to prescriptions for two or more drugs (Fig. 4 ), OROS-MPH + GXR showed a significant increasing trend from 45.5% to 58.0% between Q1/2018 and Q2/2023 ( P = 0.0017). For medications administered concomitantly with LDX, the LDX + ATX proportion was 1.1% in Q2/2023, and the LDX + GXR proportion was 9.1% in Q2/2023. For the concomitant use of three or more drugs, the proportion changed from 4.3% to 5.3% from Q1/2018 to Q2/2023 ( P = 0.82). Figure 4 near here 4. Discussion 4.1 Prescription Proportions To our knowledge, this study is the first to investigate prescription patterns of four ADHD medications since they became available in Japan. GXR prescriptions are increasing for both sexes and all ages, representing the overall trend in ADHD medication use. Distribution control regulations suppress CNS stimulant prescriptions [ 29 ]. Since GXR is not subject to these regulations, it is prescribed more readily than CNS stimulants because more physicians and medical institutions can prescribe it. Japan's regulatory approach to CNS stimulants and its impact on prescribing patterns contrast sharply with international practices. Most international guidelines, including those from the United States [ 13 ], Europe [ 11 ], and Canada [ 10 ], explicitly recommend CNS stimulants as preferred first-line agents based on their medium to large effect sizes and robust evidence base [ 16 , 22 ]. While some countries, such as Spain, position CNS stimulants and non-stimulants as parallel treatment options in clinical guidelines [ 30 ], methylphenidate remains the predominant choice, accounting for 91% of patients in Spain [ 31 ]. Similarly, in Asian countries where both methylphenidate and atomoxetine are listed as treatment options, methylphenidate is typically the primary medication in clinical practice [ 32 ]. Japan is unique in both guideline positioning and actual prescribing patterns, where non-stimulant use (particularly GXR at 46.4%) has reached levels equivalent to or exceeding stimulant use (OROS-MPH at 47.5% in Q2/2023). Japan's high non-stimulant prescription rate appears primarily driven by strict regulatory constraints on stimulant distribution. In Slovenia, the introduction of new medications and intensified pharmaceutical marketing led to decreased prescription of guideline-recommended first-line medications [ 33 ]. Investigating actual prescribing practices when new medications become available is important to monitor potentially inappropriate prescribing patterns. During the COVID-19 pandemic, ADHD medication consumption increased in Europe, the United States, and Japan; however, in Europe and the United States, the share of CNS stimulants did not decrease [ 34 , 35 ]. The United States and Europe eased restrictions on prescribing CNS stimulants. In Japan, regional states of emergency were declared intermittently (April–May 2020, January–March 2021, April–June 2021, and July–September 2021). During these periods, telehealth allowed only continued OROS-MPH prescriptions for patients already receiving treatment; new OROS-MPH prescriptions and all LDX prescriptions were not permitted via telehealth. This more restrictive telemedicine policy for CNS stimulants may have influenced the increase in non-CNS stimulants in Japan. In recent years, awareness of ADHD has increased, and patients diagnosed with ADHD now include individuals with less severe presentations [ 36 ]. Non-CNS stimulants may be preferred for patients who can be treated without CNS stimulants. Among non-CNS stimulants, GXR has demonstrated superior efficacy compared with ATX in clinical trials [ 37 – 39 ], and unlike ATX, GXR maintains effectiveness even in patients with prior CNS stimulant exposure [ 40 ]. Therefore, GXR is more likely prescribed for patients after CNS stimulant use. Nonadherence to psychotropic medication is influenced by missed doses [ 41 ], and patients taking fewer daily doses are more likely to adhere to treatment [ 42 ]. ADHD's developmental characteristics, such as inattentive tendencies, may also contribute to nonadherence [ 43 ]. From a dosage perspective, GXR, a once-daily medication, may be more likely selected than ATX, a twice-daily medication. In girls, GXR prescriptions exceeded OROS-MPH prescriptions. Females are less severely affected by ADHD characteristics than males, suggesting that a larger proportion of patients can be treated with non-CNS stimulants. Female patients are often diagnosed primarily with inattentive ADHD and have fewer externalizing problem behaviors, which may contribute to missed diagnoses [ 44 ] or lower likelihood of initiating pharmacotherapy unless they have significant externalizing problems [ 45 ]. The highest proportion of GXR prescriptions was for children aged 6–12 years. Compared with placebo, GXR improved the Conners' subscale score for defiant challenge and total ADHD Rating Scale scores in children with ADHD aged 6–12 with defiant challenge tendencies [ 46 ]. GXR may be used for children who are not physically large or for preadolescents. Most studies on GXR efficacy for pediatric ADHD have focused on children aged 6–17 years, and further evidence is needed regarding ADHD medication efficacy in subdivided age groups. Child psychiatrists had significantly more follow-up visits after initiating pharmacotherapy than primary care physicians [ 47 ]. In Japan's outpatient insurance system, child psychiatrists tend to have longer consultation times than nonpsychiatrists. Psychiatric consultations have a minimum requirement of at least 5 minutes for insurance reimbursement purposes, whereas in nonpsychiatric settings (mainly pediatrics), children with ADHD are often seen alongside patients presenting with physical symptoms such as colds and fever, resulting in a higher number of patients seen per hour compared to psychiatric settings. Nonpsychiatric departments face greater difficulty in allocating sufficient time to individual patients, primarily due to economic constraints. Psychiatrists, with more frequent follow-up opportunities and longer consultation times, can provide more intensive nonpharmacological interventions, potentially leading to a higher proportion of patients being treated with non-CNS stimulants. While differences in consultation practices between specialties have been observed, the overall capacity of the healthcare system to provide ADHD care also warrants consideration. As of December 2022, there were 17,781 pediatricians (5.4% of all physicians) and 16,817 psychiatrists (5.1%) in Japan [ 48 ]. However, not all pediatricians provide ADHD care, and some psychiatrists do not treat children; therefore, the actual number of physicians involved in ADHD care remains unknown. The observed differences in prescribing patterns between psychiatric and nonpsychiatric settings may reflect broader systemic factors in ADHD care delivery. While the present study focused on prescription patterns rather than healthcare system structures, these findings suggest that care delivery models warrant further consideration. International approaches, such as the United Kingdom's shared care arrangement where general practitioners conduct routine follow-up after specialist-led diagnosis and treatment initiation [ 49 ], represent potential frameworks for consideration, though their applicability and effectiveness in the Japanese healthcare context require further investigation. 4.2 New Prescription Proportions GXR has become increasingly preferred among new prescriptions. The proportion of LDX in new prescriptions was 1.3%, and concomitant use was 5.3%. Time series data show that new prescriptions generally started with OROS-MPH, ATX, or GXR as monotherapy, consistent with guideline recommendations. A temporary change was observed in time series data for Q4/2019. This period coincided with the COVID-19 pandemic onset, during which outpatient visits to pediatric clinics decreased [ 50 ]. Uncertainty regarding healthcare system outlook may have influenced OROS-MPH avoidance, which has a limited prescription duration. 4.3 Prescription Pattern Proportions In recent years, GXR was more likely chosen than ATX in combination with OROS-MPH. The overall trend for ADHD medications is the greater likelihood of selecting GXR, which influences the increasing proportion of prescription patterns involving GXR in combination therapy. Previous studies on combination therapy, including literature reviews [ 51 ], have compared OROS-MPH and ATX with placebo [ 52 ], OROS-MPH and GXR with placebo [ 53 ], and GXR with CNS stimulants, including OROS-MPH and LDX, with placebo [ 51 , 54 ]. However, no studies have directly compared combination therapies. Pharmacologically, OROS-MPH inhibits dopamine and noradrenergic transporters, whereas ATX inhibits the noradrenergic transporter; both share the same noradrenergic transporter inhibitory effect. Conversely, GXR's pharmacological action is the selective activation of α2A receptors, a mechanism different from OROS-MPH and ATX. GXR may be more likely an adjunctive agent for OROS-MPH when monotherapy is inadequate and more likely used in combination with drugs with different pharmacological actions. Further studies are warranted to establish optimal combination therapy use. The increasing use of combination therapy raises important considerations for patient management. Given the potential for cumulative or overlapping adverse effects from multiple medications, clinicians should carefully monitor adverse events in patients receiving combination therapy. It is important to establish systematic approaches to evaluate incremental benefit and tolerability when adding a second medication, rather than assuming combination therapy is uniformly superior to optimized monotherapy. Clinicians should avoid continuing combination therapy without clear clinical rationale and should periodically reassess whether both medications remain necessary for optimal symptom control. Increased drug therapy options led to increased combination therapy options, and the overall monotherapy proportion declined. Significant differences were observed in monotherapy proportions between psychiatry and nonpsychiatry departments, with no trend in increase or decrease among psychiatry departments. Monotherapy is recommended in psychiatry for other psychiatric disorders, such as schizophrenia and depression, which may influence the monotherapy proportion among psychiatrists aware of its benefits. Compared with monotherapy proportions for other psychiatric disorders of 57.1% for schizophrenia and 58.6% for depression [ 55 , 56 ], the approximately 80% monotherapy proportion for ADHD medications is high. 5. Limitations This study has several limitations that should be considered when interpreting the results. First, administrative claims data used in this retrospective database study have inherent limitations. Claims data primarily capture billed services and dispensed medications, and may not fully reflect clinical decision-making processes, treatment rationale, or patient-specific factors that influence medication selection. The database does not include information about the clinical context of prescribing decisions, such as symptom severity, treatment response, or reasons for medication changes. Furthermore, we analyzed prescription patterns at the population level and cannot determine outcomes at the individual patient level. Second, several important data limitations affect this study. The severity of ADHD was not considered in this study because it was not included in the database. The timing of data provision by insurance associations to DeSC varies; in some instances, the preceding year's data were enrolled as lump sums at the conclusion of the subsequent year. As the data presented herein were collected in January 2024, a decline in the number of enrolled patients has been observed since 2022. Consequently, the number of eligible patients, particularly for new prescription and combination therapy analyses, was minimal, which impedes our capacity to conduct extensive analyses stratified by sex, age, and department. Subsequent analyses will require accumulation of sufficient patient numbers in the database, and use of alternative databases should also be considered. Additionally, in the selection of new prescribing patients, the first prescriptions for patients who had been registered in the database for at least six months were identified; prescriptions prior to March 31, 2014, were not registered in the database. Consequently, individuals who were taking medications prior to March 31, 2014, and resumed taking them after April 1, 2018, may have been incorrectly classified as newly prescribed patients. Furthermore, if a patient transferred from an alternative insurance association and subsequently registered in the database, a patient who resumed medication after a withdrawal period of six months or longer would be treated as a new prescriber, because the medication status of patients more than six months prior is unknown. Third, the classification of psychiatric versus nonpsychiatric care was based on the presence of billing codes for psychotherapy services on the same insurance claim as the ADHD medication prescription. Because this definition relies on claim-level co-occurrence rather than the actual clinical setting, the number of patients classified as receiving psychiatric care may not accurately reflect the true number of patients treated by psychiatrists. Fourth, ADHD frequently coexists with various psychiatric and neurodevelopmental disorders, such as autism spectrum disorder, anxiety disorders, mood disorders, and learning disabilities. These comorbidities can significantly influence medication selection, treatment response, and overall treatment strategies. We did not examine comorbid diagnoses or concomitant use of other psychotropic medications (e.g., antidepressants, antipsychotics, anxiolytics), which may confound the observed prescription patterns. Fifth, this study examined prescription patterns but could not assess actual medication adherence or treatment persistence. In claims databases, a prescription does not guarantee that the patient actually took the medication as prescribed. The dispensing of a medication indicates only that a prescription was filled, not that the medication was consumed or taken according to instructions. Non-adherence to ADHD medications is common and may vary across different medications, patient ages, and clinical contexts. Without adherence measures and clinical outcomes data, it is difficult to fully evaluate the real-world clinical implications of these prescribing patterns. Future research combining prescription data with adherence measures and treatment outcomes would provide valuable insights into the clinical significance of these prescribing trends. Sixth, in the context of combination therapy, the analytical approach employed in this study involves categorizing each medication modification as combination therapy, irrespective of alterations in individual medications implemented over a three-month period. Consequently, the prescription proportion for combination therapy may exceed the actual proportion of patients receiving truly concurrent combination therapy, whereas the proportion for monotherapy may fall below the actual proportion. This methodological approach means that patients who switched from one medication to another within a three-month period would be counted as receiving combination therapy, even if the medications were not used simultaneously. 6. Conclusion In Japan, a trend toward a growing proportion of GXR prescriptions for ADHD has been observed. In particular, GXR has been identified as the most frequently prescribed medication among female patients and pediatric patients aged 6–12 years. GXR has become the preferred first-line medication for new patients and is increasingly chosen for combination therapy regimen. This trend may be attributed to GXR not being a CNS stimulant; consequently, it is not subject to the same distribution control regulations as OROS-MPH and LDX. Furthermore, the different pharmacological effects of GXR compared with those of OROS-MPH and ATX may also contribute to this trend. Future studies should evaluate the long-term clinical effectiveness and safety of these shifting prescription patterns, particularly the increased use of the GXR, to optimize ADHD treatment strategies for Japanese children. Abbreviations ADHD Attention-deficit/hyperactivity disorder OROS-MPH Methylphenidate extended release ATX Atomoxetine GXR Guanfacine LDX Lisdexamfetamine CNS Central nervous system Declarations The Research Ethics Review Committee of Meiji Pharmaceutical University approved this study on June 27, 2024 (registration number: 202408). As the data used in this study were unlinked and anonymous health insurance claims data, the need for informed consent from individual participants was waived by the approving ethics committee. Ethics approval and consent to participate The Research Ethics Review Committee of Meiji Pharmaceutical University approved this study on June 27, 2024 (registration number: 202408). As the data used in this study were unlinked and anonymous, informed consent was not needed. Consent for publication Not applicable Clinical trial number Not applicable Competing Interests Ken Inada has received personal fees from the following companies over the past three years:EA Pharma Co., Ltd., Viatris Pharmaceuticals Japan Inc., Eisai Co., Ltd., MSD K.K., Otsuka Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Kyowa Kirin Co., Kowa Pharmaceutical Co., Ltd., Shionogi & Co., Ltd., Sumitomo Pharma Co., Ltd., Daiichi Sankyo Co., Limited., Takeda Pharmaceutical Company Limited, Mitsubishi Tanabe Pharma Corporation., Nipro Corporation, Nippon Chemiphar Co., Ltd., Eli Lilly Japan K.K., Boehringer Ingelheim Japan, Inc., Nexera Pharma K.K., Novartis Pharma K.K., Nobelpharma Co., Ltd., Pfizer Japan Inc., Meiji Seika Pharma Co., Ltd., Mochida Pharmaceutical Co., Ltd., Janssen Pharmaceutical K.K., Lundbeck Japan K.K., and Yoshitomi Pharmaceutical Industries, Ltd. Manabu Akazawa has received speaker honoraria and consultancy fees from Astellas Pharma Inc., Mitsubishi Tanabe Pharma Corporation, Janssen Pharmaceutical K.K., Merck & Co., Ltd. The other authors declare that they have no competing interests. Funding This research was funded in 2024 by Inokashira Hospital Grants for Psychiatry Research (Grant No. IHGPR2024-02). Author Contribution RS, RK, TM, JT, TN, HM, MA, and KI were involved in the study design and data interpretation. RS, RK, TM, JT, and MA were involved in the data analysis. All authors critically revised the report, commented on drafts of the manuscript, and approved the final report. Acknowledgement We would like to thank Editage (www.editage.jp) for English language editing. Data Availability The data supporting the findings of this study were obtained from DeSC Healthcare Corporation (Tokyo). The use of these data is subject to restrictions and was licensed for use in this study. 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Prescription patterns in patients with schizophrenia in Japan: first-quality indicator data from the survey of Effectiveness of Guidelines for Dissemination and Education in psychiatric treatment (EGUIDE) project. Neuropsychopharmacol Rep. 2020;40:281–6. Iida H, Iga J, Hasegawa N, Yasuda Y, Yamamoto T, Miura K, et al. Unmet needs of patients with major depressive disorder - findings from the ‘Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE)’ project: a nationwide dissemination, education, and evaluation study. Psychiatry Clin Neurosci. 2020;74:667–9. Additional Declarations Competing interest reported. Ken Inada has received personal fees from the following companies over the past three years: EA Pharma Co., Ltd., Viatris Pharmaceuticals Japan Inc., Eisai Co., Ltd., MSD K.K., Otsuka Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Kyowa Kirin Co., Kowa Pharmaceutical Co., Ltd., Shionogi & Co., Ltd., Sumitomo Pharma Co., Ltd., Daiichi Sankyo Co., Limited., Takeda Pharmaceutical Company Limited, Mitsubishi Tanabe Pharma Corporation., Nipro Corporation, Nippon Chemiphar Co., Ltd., Eli Lilly Japan K.K., Boehringer Ingelheim Japan, Inc., Nexera Pharma K.K., Novartis Pharma K.K., Nobelpharma Co., Ltd., Pfizer Japan Inc., Meiji Seika Pharma Co., Ltd., Mochida Pharmaceutical Co., Ltd., Janssen Pharmaceutical K.K., Lundbeck Japan K.K., and Yoshitomi Pharmaceutical Industries, Ltd. Manabu Akazawa has received speaker honoraria and consultancy fees from Astellas Pharma Inc., Mitsubishi Tanabe Pharma Corporation, Janssen Pharmaceutical K.K., Merck & Co., Ltd. The other authors declare that they have no competing interests. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Apr, 2026 Editor assigned by journal 23 Apr, 2026 Reviews received at journal 05 Apr, 2026 Reviews received at journal 14 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviewers invited by journal 27 Feb, 2026 Submission checks completed at journal 21 Feb, 2026 First submitted to journal 20 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7008746","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594747425,"identity":"3c4838cc-0281-49ad-be26-6c19d49cb71c","order_by":0,"name":"Ryutaro 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LDX: Lisdexamfetamine, ATX: Atomoxetine, GXR: Guanfacine\u003c/p\u003e\n\u003cp\u003eDetailed numerical data are provided in Appendix Table S1.\u003c/p\u003e","description":"","filename":"12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7008746/v1/44fa8ac34145ac4ca8bdfc13.jpg"},{"id":103563050,"identity":"64e9133a-9d26-4b8c-9caf-88e9ae36a69b","added_by":"auto","created_at":"2026-02-27 06:27:59","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":340644,"visible":true,"origin":"","legend":"\u003cp\u003eNew prescription proportions of ADHD medications\u003c/p\u003e\n\u003cp\u003eOROS-MPH: Osmotic controlled-release oral delivery system methylphenidate, LDX: Lisdexamfetamine, ATX: Atomoxetine, GXR: Guanfacine\u003c/p\u003e\n\u003cp\u003eDetailed numerical data are provided in Appendix Table S2.\u003c/p\u003e","description":"","filename":"13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7008746/v1/13ddae85117727c3f331f71c.jpg"},{"id":104399057,"identity":"468d70da-86c1-4b6c-983d-f2f7f59d5372","added_by":"auto","created_at":"2026-03-11 12:04:35","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":335342,"visible":true,"origin":"","legend":"\u003cp\u003eTrends in combination therapy patterns of ADHD medications\u003c/p\u003e\n\u003cp\u003eOROS-MPH: Osmotic controlled-release oral delivery system methylphenidate, LDX: Lisdexamfetamine, ATX: Atomoxetine, GXR: Guanfacine\u003c/p\u003e\n\u003cp\u003eDetailed numerical data are provided in Appendix Table S3.\u003c/p\u003e","description":"","filename":"14.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7008746/v1/9364485aec9336a69e516dcc.jpg"},{"id":104407492,"identity":"15477516-c2ee-471e-9a00-1347314a7e99","added_by":"auto","created_at":"2026-03-11 12:38:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2717913,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7008746/v1/ff602cf4-b086-4a54-9338-0a2f4374c995.pdf"},{"id":103563046,"identity":"03d6b138-7d75-41c9-832d-6766170da854","added_by":"auto","created_at":"2026-02-27 06:27:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":68811,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7008746/v1/2f7867dd0b257ddc1b7ae15c.docx"}],"financialInterests":"Competing interest reported. Ken Inada has received personal fees from the following companies over the past three years:\nEA Pharma Co., Ltd., Viatris Pharmaceuticals Japan Inc., Eisai Co., Ltd., MSD K.K., Otsuka Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Kyowa Kirin Co., Kowa Pharmaceutical Co., Ltd., Shionogi \u0026 Co., Ltd., Sumitomo Pharma Co., Ltd., Daiichi Sankyo Co., Limited., Takeda Pharmaceutical Company Limited, Mitsubishi Tanabe Pharma Corporation., Nipro Corporation, Nippon Chemiphar Co., Ltd., Eli Lilly Japan K.K., Boehringer Ingelheim Japan, Inc., Nexera Pharma K.K., Novartis Pharma K.K., Nobelpharma Co., Ltd., Pfizer Japan Inc., Meiji Seika Pharma Co., Ltd., Mochida Pharmaceutical Co., Ltd., Janssen Pharmaceutical K.K., Lundbeck Japan K.K., and Yoshitomi Pharmaceutical Industries, Ltd. Manabu Akazawa has received speaker honoraria and consultancy fees from Astellas Pharma Inc., Mitsubishi Tanabe Pharma Corporation, Janssen Pharmaceutical K.K., Merck \u0026 Co., Ltd. The other authors declare that they have no competing interests.","formattedTitle":"Prescribing medications for attention-deficit/hyperactivity disorder in children: a retrospective analysis of a Japanese health insurance claims database","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAttention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition typically characterized by hyperactivity, impulsivity, and inattention, which often persist in adulthood and negatively affect schoolwork, employment, and relationships [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The global prevalence of ADHD is estimated to be approximately 5.0% in children and adolescents [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and epidemiological studies in Japan estimate the prevalence of ADHD in children to be 5.8% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], with an increase in the estimated incidence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, prevalence varies considerably across countries, with some reporting rates as low as 1% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Psychosocial treatments and pharmacotherapy tailored to an individual patient\u0026rsquo;s condition are recommended for ADHD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Pharmacotherapy for ADHD is effective in children and adolescents [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and is associated with a decreased risk of various functional outcomes associated with ADHD [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Pharmacotherapy is also recommended in treatment guidelines in Europe, the United States, and Japan [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Despite the effectiveness of pharmacotherapy and its recommendation in guidelines, many patients with ADHD remain untreated with central nervous system (CNS) stimulants, particularly in smaller countries. This situation may be influenced by various factors including regulatory restrictions and prescribing practices [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Over the past few decades, the prevalence of ADHD and the use of ADHD medications have increased in several countries [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], along with concerns about potential overdiagnosis and inappropriate prescription of ADHD medications [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the 2000s, the abuse of short-acting methylphenidate, which is used to treat conditions such as depression and pediatric ADHD in Japan (used off-label for the latter disorder), became a social problem [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Methylphenidate extended-release (OROS-MPH) and atomoxetine (ATX) were subsequently administered to pediatric patients with ADHD between October 2007 and June 2009. Because of dependence and abuse, since 2008, distribution control regulations have been implemented for OROS-MPH, a CNS stimulant. Additionally, the fourth edition of the Japanese guidelines for the diagnosis and treatment of ADHD published in 2016 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] lists the use of only OROS-MPH and ATX as medication options for ADHD. Guanfacine (GXR) and lisdexamfetamine (LDX) began being administered in June 2017 and December 2019, respectively. Currently, the registration of details of patients, prescribing physicians (who must be physicians with expertise), medical institutions, and dispensing pharmacies is required to prescribe the two CNS stimulants (OROS-MPH and LDX), and there is a 30-day limit on prescription. The latest guidelines (5th edition), published in 2022, list several ADHD medications, such as OROS-MPH, LDX, ATX, and GXR [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The guidelines list non-CNS stimulants ATX and GXR as first-line agents, along with OROS-MPH, and recommend their use as monotherapy. International evidence demonstrates that CNS stimulants have medium to large effect sizes and are generally more effective than non-stimulants [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Accordingly, guidelines in the United States and Europe recommend CNS stimulants as first-line agents [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In contrast, Japan regulates the distribution of these CNS stimulants, consequently creating a unique treatment environment where non-stimulants are positioned equally as first-line options. Since ADHD medications are intended for continuous use, the choice of therapeutic agent is critically important. The selection is based on patients\u0026rsquo; individuality and physicians\u0026rsquo; experiences with reference to guidelines, which are areas where further evidence needs to be accumulated. Knowing which drugs are most likely to be used for each patient will guide future drug selection. In addition, CNS stimulants carry the risks of dependence and abuse [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, to ensure safe drug use, prescription practices, such as changes in the therapeutic environment after a new drug is introduced, should be surveyed. In Japan, psychiatrists and pediatricians are mainly involved in the treatment of ADHD, and differences in the choice of therapeutic agents on the basis of physicians\u0026rsquo; backgrounds are relatively unknown.\u003c/p\u003e \u003cp\u003eUnderstanding the unique Japanese treatment environment for ADHD requires accumulating evidence on actual prescribing practices. Previous studies in Japan have examined ADHD medication prescription patterns stratified by patient demographics and department type [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, as these studies were based on data collected prior to LDX approval in December 2019, they could not examine the full therapeutic landscape with all four medications available. Additionally, comprehensive analyses of specific combination therapy patterns have remained limited. This study provides updated analyses using health insurance claims data from April 2018 to August 2023, including the period after all four medications became available. The study aims to clarify recent drug selection patterns based on patient backgrounds, examine trends in medications prescribed to newly initiating patients, and investigate detailed combination therapy patterns in current Japanese practice.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data sources\u003c/h2\u003e \u003cp\u003eData were extracted from a large health insurance claims database developed and managed by the DeSC Healthcare Corporation (Tokyo, Japan). The DeSC database includes three types of insurance: national health insurance, employer-based health insurance, and the late-stage senior citizens\u0026rsquo; healthcare system. All residents are included in Japan\u0026rsquo;s health insurance system. The type of public insurance does not affect medical care. Differences in public insurance are based on age, occupation, and employment status.\u003c/p\u003e \u003cp\u003eDeSC contains epidemiological claims data for approximately 12\u0026nbsp;million insurance enrollees, and the age and sex distributions of individuals listed in the database are similar to those in Japanese population estimates [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Since this study aimed to focus on early childhood and school-age children, it covers insurance claimants of national health insurance and employer-based health insurance. Children are covered by their parents\u0026rsquo; insurance regardless of their medical condition. Therefore, they are consistently included in insurance claims data, minimizing the possibility of selection bias. Insurance claims include all inpatient, outpatient, and pharmacy claims received by the insurer, including those related to diagnoses, medical procedures, and prescribed drugs. Data were recorded even if the participants changed healthcare providers or used multiple providers. To our knowledge, this is the first study to use the DeSC database to examine ADHD medication prescribing patterns in a pediatric population.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Patient Selection\u003c/h2\u003e \u003cp\u003eWe adopted a retrospective database study design to understand prescribing practices while analyzing background factors. The dataset under consideration\u0026mdash;the DeSC insurance claims database\u0026mdash;was collected from April 1, 2014, to August 31, 2023. The analysis period was from April 1, 2018, to August 31, 2023. In this study, each period from April of one year to March of the following year was defined as one year. This period was further subdivided into four three-month periods. The temporal framework under consideration encompasses the following quarters: the initial quarter (Q1), from April to June; the second quarter (Q2), from July to September; the third quarter (Q3), from October to December; and the fourth quarter (Q4), from January to March of the following year. The initial month of this period was designated April in accordance with the Japanese school calendar.\u003c/p\u003e \u003cp\u003eThe study population consisted of males and females aged 0\u0026ndash;17 years who were diagnosed with ADHD and were registered in the DeSC database between April 1, 2014, and August 31, 2023 (ICD-10 code: F90). Furthermore, the participants were required to have received at least one dose of ADHD medication during the analysis period. The age of the participants was determined as the age on the first day of each period, that is, the first day of April, July, and October of one year, and January of the following year. The proportion of new prescriptions was determined by including patients for whom ADHD medications were initiated for the first time during the study period, as defined by the following criteria. Inclusion criteria for new prescription analysis: Patients were included in the new prescription analysis if they: (1) had no record of any ADHD medication prescription from the data access start date (April 1, 2014) to the index prescription date, (2) had at least 180 days of data enrollment before the index prescription, and (3) received their first ADHD medication prescription during the analysis period (April 1, 2018 to August 31, 2023).\u003c/p\u003e \u003cp\u003eAlthough the DeSC database includes diagnostic codes for all medical encounters, we did not extract or analyze data on psychiatric or medical comorbidities in this study. The focus was on overall prescribing patterns rather than examining the influence of specific comorbid conditions on medication selection. This limitation is discussed in the Limitations section.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Outcomes\u003c/h2\u003e \u003cp\u003eThe outcome measures included the proportion of patients prescribed each ADHD medication relative to all patients prescribed any ADHD medication (prescription proportion), the proportion of each combination pattern of ADHD medications (prescription pattern proportion), the monotherapy proportion, and the proportion of patients newly initiating each ADHD medication (new prescription proportion). For each time period, we identified the number of unique patients who met the inclusion criteria and were prescribed ADHD medications. For prescription proportion calculations, each medication was evaluated independently. Patients receiving combination therapy were included in the count for each medication prescribed. For example, a patient receiving both OROS-MPH and GXR was counted in both the OROS-MPH prescription proportion and the GXR prescription proportion. Consequently, the sum of prescription proportions across all four medications may exceed 100%. These outcome measures were examined according to sex, age group (0\u0026ndash;5, 6\u0026ndash;12, and 13\u0026ndash;17 years), and department (psychiatry/nonpsychiatry) at each time point.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eThis retrospective database study included all patients who met the inclusion criteria, as this was a descriptive epidemiological study without hypothesis testing. The medications used to treat ADHD included various formulations of the following four drugs: OROS-MPH, LDX, ATX, and GXR. There was no minimum requirement for the number of prescriptions; patients prescribed medication only once were included if they met the criteria. The proportion of prescriptions was calculated in the following manner. The duration of drug therapy was calculated from the start date and the number of days on which each drug was prescribed. The drug was considered to have been prescribed to patients during the duration of the drug. For each of the four medications (OROS-MPH, LDX, ATX, and GXR), we identified all patients who were prescribed that medication during each period. The prescription proportion for each medication was calculated using the number of patients prescribed that medication as the numerator and the total number of patients prescribed any ADHD medication as the denominator. Patients receiving combination therapy were counted in the numerator for each medication prescribed; thus, the same patient could be counted in multiple medication groups simultaneously. The proportion of new prescriptions was calculated similarly.\u003c/p\u003e \u003cp\u003eThe proportion of the prescription pattern was calculated in the following manner. Fifteen distinct combinations of concomitant prescriptions, contingent on the prescription of each of the four drug groups, existed (monotherapy: four patterns; two-drug combination: six patterns; three-drug combination: three patterns; four-drug combination: one pattern). To calculate the proportion of prescription patterns in each period, the number of patients per prescription pattern was designated the numerator, and the total number of patients for whom ADHD medications were prescribed was designated the denominator. A minimum of three distinct pharmacological agents were aggregated into a single category. The monotherapy proportion was calculated using the total of four monotherapy patterns as the numerator and the total number of patients prescribed ADHD medications as the denominator.\u003c/p\u003e \u003cp\u003ePsychiatric versus nonpsychiatric care was distinguished on the basis of billing codes indicating psychotherapy services, which are generally calculated via insurance coverage in psychiatric institutions in Japan.\u003c/p\u003e \u003cp\u003eThe Jonckheere\u0026ndash;Terpstra trend test was employed to assess trends in prescription proportions over time. The Mann‒Whitney U test was employed to compare time series data on the proportion of monotherapy prescriptions in psychiatric and nonpsychiatric settings. The significance level was set at 5%. Bonferroni correction was used to address the issue of multiplicity. Microsoft SQL Server (version 2022) was used for database processing, whereas SAS (version 9.4) and R Studio (version 4.4.0) were used for data analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Ethics\u003c/h2\u003e \u003cp\u003e The Research Ethics Review Committee of Meiji Pharmaceutical University approved this study on June 27, 2024 (registration number: 202408). As the data used in this study were unlinked and anonymous, informed consent was not needed.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Trends in prescription proportions\u003c/h2\u003e \u003cp\u003eA total of 72,609 patient observations were analyzed across 22 quarterly periods (Q1/2018 to Q2/2023). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the patient profiles. Boys outnumbered girls, and the 6\u0026ndash;12 age group comprised the highest number of patients. Detailed trends in prescription are shown with numerical data in \u003cspan refid=\"Sec18\" class=\"InternalRef\"\u003eAppendix\u003c/span\u003e Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e. The proportion of prescriptions for each ADHD medication is outlined in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with sex- and age-specific trends shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003ea\u0026ndash;d. A significant downward trend of 64.7% to 47.5% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was observed for OROS-MPH from Q1/2018 to Q2/2023; a significant downward trend (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) of 34.4% to 22.4% for ATX; and a significant upward trend (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) of 19.3% to 46.4% for the GXR. The GXR surpassed ATX in Q1/2019, most recently, in terms of the proportion of OROS-MPH prescriptions. LDX showed a significant increasing trend (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) from Q4/2019 (market launch) to Q2/2023, reaching 5.2%. In terms of sex (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003ea and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003eb), the GXR was greater than the OROS-MPH in girls at Q3/2021. By age group (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003ec and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003ed), the GXR exceeded the OROS-MPH in the middle of the observation period in the 6\u0026ndash;12 age group, but the OROS-MPH consistently exceeded the GXR in the 13\u0026ndash;17 age group. By department (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), OROS-MPH was the most prescribed drug in nonpsychiatric departments, whereas GXR surpassed OROS-MPH in the middle of the observation period in psychiatric departments, and GXR surpassed OROS-MPH in the most recent period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCharacteristics of the prescribed patients\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"23\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c22\" colnum=\"22\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c23\" colnum=\"23\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYear\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c23\" namest=\"c22\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePeriod\u0026sup1;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e3849\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e3927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e4069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e4014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e3328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e3323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e3313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e3059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e1542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e1297\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBoys\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2597\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2565\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2723\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2835\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e3083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e3147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e3237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e3193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e2618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e2600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e2595\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e2421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e1209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e1025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;5 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e6\u0026ndash;12 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1925\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1888\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e2049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e1993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e1583\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e1578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e1467\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e732\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e594\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e13\u0026ndash;17 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e749\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e833\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e935\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e935\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e943\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e1100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e1125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e1164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e1184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e1001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e1008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e946\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e430\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGirls\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e647\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e751\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e780\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e723\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e638\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;5 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e6\u0026ndash;12 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e325\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e439\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e434\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e467\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e464\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e13\u0026ndash;17 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"23\"\u003e\u0026sup1;Periods represent three-month quarters: Period 1 (April\u0026ndash;June), Period 2 (July\u0026ndash;September), Period 3 (October\u0026ndash;December), and Period 4 (January\u0026ndash;March of the following year), following the Japanese fiscal year.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eComparison of psychiatric and nonpsychiatric prescriptions for ADHD medications\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"23\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c22\" colnum=\"22\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c23\" colnum=\"23\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYear\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c23\" namest=\"c22\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePeriod\u0026sup1;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychiatry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOROS-MPH\u0026sup2;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLDX\u0026sup3;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eATX⁴\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGXR⁵\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNonpsychiatry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2892\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3712\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e3676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e3759\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e3883\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e3850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e3199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e3191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e3172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e2913\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e1492\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e1253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOROS-MPH\u0026sup2;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1887\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1853\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1831\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1955\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e1971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1963\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e1937\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e1962\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e1946\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e1572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e1573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e1416\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e717\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e599\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLDX\u0026sup3;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eATX⁴\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e888\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e966\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e918\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e887\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e918\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e897\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e743\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e680\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGXR⁵\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e730\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e817\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e834\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e1561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e1599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e1720\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e1712\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e1487\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e1475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e1371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e708\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e581\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"23\"\u003e\u0026sup1;Periods represent three-month quarters: Period 1 (April\u0026ndash;June), Period 2 (July\u0026ndash;September), Period 3 (October\u0026ndash;December), and Period 4 (January\u0026ndash;March of the following year), following the Japanese fiscal year.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"23\"\u003e\u0026sup2;OROS-MPH: Osmotic controlled-release oral delivery system-methylphenidate, \u0026sup3;LDX: Lisdexamfetamine, ⁴ATX: Atomoxetine, ⁵GXR: Guanfacine\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e near here\u003c/p\u003e \u003cp\u003eFigures\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003ea\u0026ndash;d near here\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Trends in New Prescription\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the profiles of patients receiving new prescriptions. Detailed trends in new prescription are shown with numerical data in \u003cspan refid=\"Sec18\" class=\"InternalRef\"\u003eAppendix\u003c/span\u003e Table S2. The proportion of new prescriptions for each ADHD medication (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e) significantly decreased from 47.9% to 25.3% for OROS-MPH from Q1/2018 to Q2/2023 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0083). In contrast, an increasing trend of 20.9% to 26.7% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.16) and a significantly increasing trend of 27.4% to 41.3% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0021) were observed for ATX and the GXR, respectively. LDX changed from 0% to 1.3% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030), and ADHD medication combinations changed from 3.7% to 5.3% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.45). Since Q4/2019, the GXR has surpassed OROS-MPH and has remained at approximately 40%. In particular, in Q4/2019, the increase in the GXR and decrease in OROS-MPH were more noticeable than they were in the periods before and after it.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCharacteristics of new prescription patients\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"23\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c22\" colnum=\"22\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c23\" colnum=\"23\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYear\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c20\" namest=\"c19\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c23\" namest=\"c22\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePeriod\u0026sup1;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBoys\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;5 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e6\u0026ndash;12 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e13\u0026ndash;17 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGirls\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;5 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e6\u0026ndash;12 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e13\u0026ndash;17 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c18\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c19\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c20\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c21\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c22\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c23\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"23\"\u003e\u0026sup1;Periods represent three-month quarters: Period 1 (April\u0026ndash;June), Period 2 (July\u0026ndash;September), Period 3 (October\u0026ndash;December), and Period 4 (January\u0026ndash;March of the following year), following the Japanese fiscal year.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e near here\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e near here\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Trends in prescription pattern proportions\u003c/h2\u003e \u003cp\u003eThe prescription pattern proportions are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003e, with detailed numerical data provided in \u003cspan refid=\"Sec18\" class=\"InternalRef\"\u003eAppendix\u003c/span\u003e Table S3. The overall monotherapy proportion for ADHD medications decreased significantly from 82.3% in Q1/2018 to 79.6% in Q2/2023 (P\u0026thinsp;=\u0026thinsp;0.0011). When analyzed by department, the monotherapy proportion among psychiatric departments changed from 85.6% to 79.6%, but the trend was not consistent (P\u0026thinsp;=\u0026thinsp;0.054), whereas the monotherapy proportion among nonpsychiatric departments significantly decreased from 82.2% to 79.7% (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A statistically significant difference between psychiatry and nonpsychiatry regarding the proportion of patients receiving monotherapy (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was also observed. When restricted to prescriptions for two or more drugs (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003e), OROS-MPH\u0026thinsp;+\u0026thinsp;GXR showed a significant increasing trend from 45.5% to 58.0% between Q1/2018 and Q2/2023 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0017). For medications administered concomitantly with LDX, the LDX\u0026thinsp;+\u0026thinsp;ATX proportion was 1.1% in Q2/2023, and the LDX\u0026thinsp;+\u0026thinsp;GXR proportion was 9.1% in Q2/2023. For the concomitant use of three or more drugs, the proportion changed from 4.3% to 5.3% from Q1/2018 to Q2/2023 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.82).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003e near here\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Prescription Proportions\u003c/h2\u003e \u003cp\u003eTo our knowledge, this study is the first to investigate prescription patterns of four ADHD medications since they became available in Japan. GXR prescriptions are increasing for both sexes and all ages, representing the overall trend in ADHD medication use. Distribution control regulations suppress CNS stimulant prescriptions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Since GXR is not subject to these regulations, it is prescribed more readily than CNS stimulants because more physicians and medical institutions can prescribe it.\u003c/p\u003e \u003cp\u003eJapan's regulatory approach to CNS stimulants and its impact on prescribing patterns contrast sharply with international practices. Most international guidelines, including those from the United States [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], Europe [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and Canada [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], explicitly recommend CNS stimulants as preferred first-line agents based on their medium to large effect sizes and robust evidence base [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. While some countries, such as Spain, position CNS stimulants and non-stimulants as parallel treatment options in clinical guidelines [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], methylphenidate remains the predominant choice, accounting for 91% of patients in Spain [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Similarly, in Asian countries where both methylphenidate and atomoxetine are listed as treatment options, methylphenidate is typically the primary medication in clinical practice [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Japan is unique in both guideline positioning and actual prescribing patterns, where non-stimulant use (particularly GXR at 46.4%) has reached levels equivalent to or exceeding stimulant use (OROS-MPH at 47.5% in Q2/2023). Japan's high non-stimulant prescription rate appears primarily driven by strict regulatory constraints on stimulant distribution. In Slovenia, the introduction of new medications and intensified pharmaceutical marketing led to decreased prescription of guideline-recommended first-line medications [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Investigating actual prescribing practices when new medications become available is important to monitor potentially inappropriate prescribing patterns.\u003c/p\u003e \u003cp\u003eDuring the COVID-19 pandemic, ADHD medication consumption increased in Europe, the United States, and Japan; however, in Europe and the United States, the share of CNS stimulants did not decrease [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The United States and Europe eased restrictions on prescribing CNS stimulants. In Japan, regional states of emergency were declared intermittently (April\u0026ndash;May 2020, January\u0026ndash;March 2021, April\u0026ndash;June 2021, and July\u0026ndash;September 2021). During these periods, telehealth allowed only continued OROS-MPH prescriptions for patients already receiving treatment; new OROS-MPH prescriptions and all LDX prescriptions were not permitted via telehealth. This more restrictive telemedicine policy for CNS stimulants may have influenced the increase in non-CNS stimulants in Japan.\u003c/p\u003e \u003cp\u003eIn recent years, awareness of ADHD has increased, and patients diagnosed with ADHD now include individuals with less severe presentations [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Non-CNS stimulants may be preferred for patients who can be treated without CNS stimulants. Among non-CNS stimulants, GXR has demonstrated superior efficacy compared with ATX in clinical trials [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and unlike ATX, GXR maintains effectiveness even in patients with prior CNS stimulant exposure [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Therefore, GXR is more likely prescribed for patients after CNS stimulant use. Nonadherence to psychotropic medication is influenced by missed doses [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], and patients taking fewer daily doses are more likely to adhere to treatment [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. ADHD's developmental characteristics, such as inattentive tendencies, may also contribute to nonadherence [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. From a dosage perspective, GXR, a once-daily medication, may be more likely selected than ATX, a twice-daily medication.\u003c/p\u003e \u003cp\u003eIn girls, GXR prescriptions exceeded OROS-MPH prescriptions. Females are less severely affected by ADHD characteristics than males, suggesting that a larger proportion of patients can be treated with non-CNS stimulants. Female patients are often diagnosed primarily with inattentive ADHD and have fewer externalizing problem behaviors, which may contribute to missed diagnoses [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] or lower likelihood of initiating pharmacotherapy unless they have significant externalizing problems [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe highest proportion of GXR prescriptions was for children aged 6\u0026ndash;12 years. Compared with placebo, GXR improved the Conners' subscale score for defiant challenge and total ADHD Rating Scale scores in children with ADHD aged 6\u0026ndash;12 with defiant challenge tendencies [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. GXR may be used for children who are not physically large or for preadolescents. Most studies on GXR efficacy for pediatric ADHD have focused on children aged 6\u0026ndash;17 years, and further evidence is needed regarding ADHD medication efficacy in subdivided age groups.\u003c/p\u003e \u003cp\u003eChild psychiatrists had significantly more follow-up visits after initiating pharmacotherapy than primary care physicians [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. In Japan's outpatient insurance system, child psychiatrists tend to have longer consultation times than nonpsychiatrists. Psychiatric consultations have a minimum requirement of at least 5 minutes for insurance reimbursement purposes, whereas in nonpsychiatric settings (mainly pediatrics), children with ADHD are often seen alongside patients presenting with physical symptoms such as colds and fever, resulting in a higher number of patients seen per hour compared to psychiatric settings. Nonpsychiatric departments face greater difficulty in allocating sufficient time to individual patients, primarily due to economic constraints. Psychiatrists, with more frequent follow-up opportunities and longer consultation times, can provide more intensive nonpharmacological interventions, potentially leading to a higher proportion of patients being treated with non-CNS stimulants. While differences in consultation practices between specialties have been observed, the overall capacity of the healthcare system to provide ADHD care also warrants consideration. As of December 2022, there were 17,781 pediatricians (5.4% of all physicians) and 16,817 psychiatrists (5.1%) in Japan [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. However, not all pediatricians provide ADHD care, and some psychiatrists do not treat children; therefore, the actual number of physicians involved in ADHD care remains unknown. The observed differences in prescribing patterns between psychiatric and nonpsychiatric settings may reflect broader systemic factors in ADHD care delivery. While the present study focused on prescription patterns rather than healthcare system structures, these findings suggest that care delivery models warrant further consideration. International approaches, such as the United Kingdom's shared care arrangement where general practitioners conduct routine follow-up after specialist-led diagnosis and treatment initiation [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], represent potential frameworks for consideration, though their applicability and effectiveness in the Japanese healthcare context require further investigation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.2 New Prescription Proportions\u003c/h2\u003e \u003cp\u003eGXR has become increasingly preferred among new prescriptions. The proportion of LDX in new prescriptions was 1.3%, and concomitant use was 5.3%. Time series data show that new prescriptions generally started with OROS-MPH, ATX, or GXR as monotherapy, consistent with guideline recommendations. A temporary change was observed in time series data for Q4/2019. This period coincided with the COVID-19 pandemic onset, during which outpatient visits to pediatric clinics decreased [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Uncertainty regarding healthcare system outlook may have influenced OROS-MPH avoidance, which has a limited prescription duration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Prescription Pattern Proportions\u003c/h2\u003e \u003cp\u003eIn recent years, GXR was more likely chosen than ATX in combination with OROS-MPH. The overall trend for ADHD medications is the greater likelihood of selecting GXR, which influences the increasing proportion of prescription patterns involving GXR in combination therapy. Previous studies on combination therapy, including literature reviews [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], have compared OROS-MPH and ATX with placebo [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], OROS-MPH and GXR with placebo [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], and GXR with CNS stimulants, including OROS-MPH and LDX, with placebo [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. However, no studies have directly compared combination therapies. Pharmacologically, OROS-MPH inhibits dopamine and noradrenergic transporters, whereas ATX inhibits the noradrenergic transporter; both share the same noradrenergic transporter inhibitory effect. Conversely, GXR's pharmacological action is the selective activation of α2A receptors, a mechanism different from OROS-MPH and ATX. GXR may be more likely an adjunctive agent for OROS-MPH when monotherapy is inadequate and more likely used in combination with drugs with different pharmacological actions. Further studies are warranted to establish optimal combination therapy use.\u003c/p\u003e \u003cp\u003eThe increasing use of combination therapy raises important considerations for patient management. Given the potential for cumulative or overlapping adverse effects from multiple medications, clinicians should carefully monitor adverse events in patients receiving combination therapy. It is important to establish systematic approaches to evaluate incremental benefit and tolerability when adding a second medication, rather than assuming combination therapy is uniformly superior to optimized monotherapy. Clinicians should avoid continuing combination therapy without clear clinical rationale and should periodically reassess whether both medications remain necessary for optimal symptom control.\u003c/p\u003e \u003cp\u003eIncreased drug therapy options led to increased combination therapy options, and the overall monotherapy proportion declined. Significant differences were observed in monotherapy proportions between psychiatry and nonpsychiatry departments, with no trend in increase or decrease among psychiatry departments. Monotherapy is recommended in psychiatry for other psychiatric disorders, such as schizophrenia and depression, which may influence the monotherapy proportion among psychiatrists aware of its benefits. Compared with monotherapy proportions for other psychiatric disorders of 57.1% for schizophrenia and 58.6% for depression [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], the approximately 80% monotherapy proportion for ADHD medications is high.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis study has several limitations that should be considered when interpreting the results. First, administrative claims data used in this retrospective database study have inherent limitations. Claims data primarily capture billed services and dispensed medications, and may not fully reflect clinical decision-making processes, treatment rationale, or patient-specific factors that influence medication selection. The database does not include information about the clinical context of prescribing decisions, such as symptom severity, treatment response, or reasons for medication changes. Furthermore, we analyzed prescription patterns at the population level and cannot determine outcomes at the individual patient level. Second, several important data limitations affect this study. The severity of ADHD was not considered in this study because it was not included in the database. The timing of data provision by insurance associations to DeSC varies; in some instances, the preceding year's data were enrolled as lump sums at the conclusion of the subsequent year. As the data presented herein were collected in January 2024, a decline in the number of enrolled patients has been observed since 2022. Consequently, the number of eligible patients, particularly for new prescription and combination therapy analyses, was minimal, which impedes our capacity to conduct extensive analyses stratified by sex, age, and department. Subsequent analyses will require accumulation of sufficient patient numbers in the database, and use of alternative databases should also be considered. Additionally, in the selection of new prescribing patients, the first prescriptions for patients who had been registered in the database for at least six months were identified; prescriptions prior to March 31, 2014, were not registered in the database. Consequently, individuals who were taking medications prior to March 31, 2014, and resumed taking them after April 1, 2018, may have been incorrectly classified as newly prescribed patients. Furthermore, if a patient transferred from an alternative insurance association and subsequently registered in the database, a patient who resumed medication after a withdrawal period of six months or longer would be treated as a new prescriber, because the medication status of patients more than six months prior is unknown. Third, the classification of psychiatric versus nonpsychiatric care was based on the presence of billing codes for psychotherapy services on the same insurance claim as the ADHD medication prescription. Because this definition relies on claim-level co-occurrence rather than the actual clinical setting, the number of patients classified as receiving psychiatric care may not accurately reflect the true number of patients treated by psychiatrists. Fourth, ADHD frequently coexists with various psychiatric and neurodevelopmental disorders, such as autism spectrum disorder, anxiety disorders, mood disorders, and learning disabilities. These comorbidities can significantly influence medication selection, treatment response, and overall treatment strategies. We did not examine comorbid diagnoses or concomitant use of other psychotropic medications (e.g., antidepressants, antipsychotics, anxiolytics), which may confound the observed prescription patterns. Fifth, this study examined prescription patterns but could not assess actual medication adherence or treatment persistence. In claims databases, a prescription does not guarantee that the patient actually took the medication as prescribed. The dispensing of a medication indicates only that a prescription was filled, not that the medication was consumed or taken according to instructions. Non-adherence to ADHD medications is common and may vary across different medications, patient ages, and clinical contexts. Without adherence measures and clinical outcomes data, it is difficult to fully evaluate the real-world clinical implications of these prescribing patterns. Future research combining prescription data with adherence measures and treatment outcomes would provide valuable insights into the clinical significance of these prescribing trends. Sixth, in the context of combination therapy, the analytical approach employed in this study involves categorizing each medication modification as combination therapy, irrespective of alterations in individual medications implemented over a three-month period. Consequently, the prescription proportion for combination therapy may exceed the actual proportion of patients receiving truly concurrent combination therapy, whereas the proportion for monotherapy may fall below the actual proportion. This methodological approach means that patients who switched from one medication to another within a three-month period would be counted as receiving combination therapy, even if the medications were not used simultaneously.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eIn Japan, a trend toward a growing proportion of GXR prescriptions for ADHD has been observed. In particular, GXR has been identified as the most frequently prescribed medication among female patients and pediatric patients aged 6\u0026ndash;12 years. GXR has become the preferred first-line medication for new patients and is increasingly chosen for combination therapy regimen. This trend may be attributed to GXR not being a CNS stimulant; consequently, it is not subject to the same distribution control regulations as OROS-MPH and LDX. Furthermore, the different pharmacological effects of GXR compared with those of OROS-MPH and ATX may also contribute to this trend. Future studies should evaluate the long-term clinical effectiveness and safety of these shifting prescription patterns, particularly the increased use of the GXR, to optimize ADHD treatment strategies for Japanese children.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAttention-deficit/hyperactivity disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOROS-MPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMethylphenidate extended release\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATX\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAtomoxetine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGXR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGuanfacine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDX\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLisdexamfetamine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral nervous system\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe Research Ethics Review Committee of Meiji Pharmaceutical University approved this study on June 27, 2024 (registration number: 202408). As the data used in this study were unlinked and anonymous health insurance claims data, the need for informed consent from individual participants was waived by the approving ethics committee.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe Research Ethics Review Committee of Meiji Pharmaceutical University approved this study on June 27, 2024 (registration number: 202408). As the data used in this study were unlinked and anonymous, informed consent was not needed.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eKen Inada has received personal fees from the following companies over the past three years:EA Pharma Co., Ltd., Viatris Pharmaceuticals Japan Inc., Eisai Co., Ltd., MSD K.K., Otsuka Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Kyowa Kirin Co., Kowa Pharmaceutical Co., Ltd., Shionogi \u0026amp; Co., Ltd., Sumitomo Pharma Co., Ltd., Daiichi Sankyo Co., Limited., Takeda Pharmaceutical Company Limited, Mitsubishi Tanabe Pharma Corporation., Nipro Corporation, Nippon Chemiphar Co., Ltd., Eli Lilly Japan K.K., Boehringer Ingelheim Japan, Inc., Nexera Pharma K.K., Novartis Pharma K.K., Nobelpharma Co., Ltd., Pfizer Japan Inc., Meiji Seika Pharma Co., Ltd., Mochida Pharmaceutical Co., Ltd., Janssen Pharmaceutical K.K., Lundbeck Japan K.K., and Yoshitomi Pharmaceutical Industries, Ltd. Manabu Akazawa has received speaker honoraria and consultancy fees from Astellas Pharma Inc., Mitsubishi Tanabe Pharma Corporation, Janssen Pharmaceutical K.K., Merck \u0026amp; Co., Ltd. The other authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was funded in 2024 by Inokashira Hospital Grants for Psychiatry Research (Grant No. IHGPR2024-02).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRS, RK, TM, JT, TN, HM, MA, and KI were involved in the study design and data interpretation. RS, RK, TM, JT, and MA were involved in the data analysis. All authors critically revised the report, commented on drafts of the manuscript, and approved the final report.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the findings of this study were obtained from DeSC Healthcare Corporation (Tokyo). The use of these data is subject to restrictions and was licensed for use in this study. Therefore, supporting data are not available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed., text revision. Washington: American Psychiatric Association; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSayal K, Prasad V, Daley D, Ford T, Coghill D. 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Soc Psychiatry Psychiatr Epidemiol. 2010;45:47\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrivastava K, Arora A, Kataria A, Cappelleri JC, Sadosky A, Peterson AM. Impact of reducing dosing frequency on adherence to oral therapies: a literature review and meta-analysis. Patient Prefer Adherence. 2013;7:419\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSafren SA, Duran P, Yovel I, Perlman CA, Sprich S. Medication adherence in psychopharmacologically treated adults with ADHD. J Atten Disord. 2007;10:257\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGershon J. A meta-analytic review of gender differences in ADHD. J Atten Disord. 2002;5:143\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMowlem FD, Rosenqvist MA, Martin J, Lichtenstein P, Asherson P, Larsson H. Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment. Eur Child Adolesc Psychiatry. 2019;28:481\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConnor DF, Findling RL, Kollins SH, Sallee F, L\u0026oacute;pez FA, Lyne A, et al. Effects of guanfacine extended release on oppositional symptoms in children aged 6\u0026ndash;12 years with attention-deficit hyperactivity disorder and oppositional symptoms: a randomized, double-blind, placebo-controlled trial. CNS Drugs. 2010;24:755\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel A, Medhekar R, Ochoa-Perez M, Aparasu RR, Chan W, Sherer JT, et al. Care provision and prescribing practices of physicians treating children and adolescents with ADHD. Psychiatr Serv. 2017;68:681\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Labour and Welfare. Survey of Physicians, Dentists and Pharmacists 2022. Last updated Dec 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/ishi/22/dl/R04_kekka-1.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/ishi/22/dl/R04_kekka-1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 8 Dec 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsherson P, Leaver L, Adamou M, Arif M, Askey G, Butler M, Cubbin S, Newlove-Delgado T, Kustow J, Lanham-Cook J, Findlay J, Maxwell J, Mason P, Read H, van Rensburg K, M\u0026uuml;ller-Sedgwick U, Sedgwick-M\u0026uuml;ller J, Skirrow C. Mainstreaming adult ADHD into primary care in the UK: guidance, practice, and best practice recommendations. BMC Psychiatry. 2022;22(1):640.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamaguchi S, Okada A, Sunaga S, Ikeda Kurakawa K, Yamauchi T, Nangaku M, et al. Impact of COVID-19 pandemic on healthcare service use for non-COVID-19 patients in Japan: retrospective cohort study. BMJ Open. 2022;12:e060390.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaker M, Huefner JC, Bellonci C, Hilt R, Carlson GA. Polypharmacy in the management of attention-deficit/hyperactivity disorder in children and adolescents: a review and update. J Child Adolesc Psychopharmacol. 2021;31:148\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlson GA, Dunn D, Kelsey D, Ruff D, Ball S, Ahrbecker L, et al. A pilot study for augmenting atomoxetine with methylphenidate: safety of concomitant therapy in children with attention-deficit/hyperactivity disorder. Child Adolesc Psychiatry Ment Health. 2007;1:10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCracken JT, McGough JJ, Loo SK, Levitt J, Del\u0026rsquo;Homme M, Cowen J, et al. Combined stimulant and guanfacine administration in attention-deficit/hyperactivity disorder: a controlled, comparative study. J Am Acad Child Adolesc Psychiatry. 2016;55:657\u0026ndash;e6661.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Stralen JPM. A controlled trial of extended-release guanfacine and psychostimulants on executive function and ADHD. J Atten Disord. 2020;24:318\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIchihashi K, Hori H, Hasegawa N, Yasuda Y, Yamamoto T, Tsuboi T, et al. Prescription patterns in patients with schizophrenia in Japan: first-quality indicator data from the survey of Effectiveness of Guidelines for Dissemination and Education in psychiatric treatment (EGUIDE) project. Neuropsychopharmacol Rep. 2020;40:281\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIida H, Iga J, Hasegawa N, Yasuda Y, Yamamoto T, Miura K, et al. Unmet needs of patients with major depressive disorder - findings from the \u0026lsquo;Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE)\u0026rsquo; project: a nationwide dissemination, education, and evaluation study. Psychiatry Clin Neurosci. 2020;74:667\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Attention Deficit Disorder with Hyperactivity, Child, Adolescent, Drug Prescriptions, Practice Patterns, Japan","lastPublishedDoi":"10.21203/rs.3.rs-7008746/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7008746/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite pharmacotherapy being a significant treatment protocol for attention-deficit/hyperactivity disorder (ADHD), an increasingly common neurodevelopmental condition among children in Japan, prescribing practices for ADHD medications remain underexplored. This study examined prescribing patterns of medications for ADHD in children and adolescents aged 0\u0026ndash;17 years in Japan and analyzed drug selection trends on the basis of patients\u0026rsquo; backgrounds, including sex, age group, and medical department.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this retrospective database study using a large Japanese health insurance claims database, we analyzed prescription patterns from April 2018 to August 2023. We examined the proportion of patients prescribed each of the four ADHD medications, namely, methylphenidate extended-release (OROS-MPH), atomoxetine (ATX), guanfacine (GXR), and lisdexamfetamine (LDX), their combination patterns, and new prescription proportions across different demographic groups and medical departments. The Jonckheere\u0026ndash;Terpstra trend test was employed to assess trends in prescription proportions over time. The Mann‒Whitney U test was employed to compare time series data on the proportion of monotherapy prescriptions in psychiatric and nonpsychiatric settings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom 2018 to 2023, OROS-MPH prescriptions significantly decreased from 64.7% to 47.5%, whereas GXR prescriptions significantly increased from 19.3% to 46.4%. GXR was prescribed most frequently for female patients and children aged 6\u0026ndash;12 years. For new patients, GXR prescriptions began exceeding those of OROS-MPH from late 2019 onward, comprising 41.3% of new prescriptions by 2023. The percentage of patients receiving monotherapy decreased from 82.3% to 79.6%, with OROS-MPH plus GXR being the most common combination therapy.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn Japan, GXR has become an increasingly preferred medication for ADHD, particularly for female patients and children aged 6\u0026ndash;12 years, with new prescriptions exceeding those of OROS-MPH since late 2019. This trend may be attributed to GXR not being subject to the same distribution control regulations as central nervous system stimulants and to its distinctive pharmacological mechanisms that differ from those of other ADHD medications. Continuous monitoring of prescription practices is necessary as treatment options continue to evolve.\u003c/p\u003e","manuscriptTitle":"Prescribing medications for attention-deficit/hyperactivity disorder in children: a retrospective analysis of a Japanese health insurance claims database","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 06:27:53","doi":"10.21203/rs.3.rs-7008746/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-23T08:38:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-23T08:35:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-05T10:12:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T02:23:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22416175184102760219057253057021030759","date":"2026-03-02T20:20:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209850249397799927308225193511364783979","date":"2026-02-27T20:50:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-27T13:10:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-21T05:13:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2026-02-20T16:06:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9283ea89-de87-4db3-85bc-dd24aaff7400","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T17:53:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 06:27:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7008746","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7008746","identity":"rs-7008746","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}