Abstract
National and international guidelines on the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents call for annual reviews to assess continuing need for medication by considering brief periods without medication, referred to as ‘Drug holidays’. However, drug holidays are reactively initiated by families, or recommended by practitioners if growth has been suppressed by medication rather than proactively to check the need. There is little evidence of planned, practitioner-initiated drug holidays from methylphenidate. The aim of this study was to identify what stops practitioners from routinely discussing planned drug holidays from methylphenidate with children, adolescents, and their parents. Practitioners involved in shared-care prescribing for children and adolescents with ADHD in one UK County were included. Interviews with 8 general practitioners (GPs) and 8 Child and Adolescent Mental Health Service (CAMHS) practitioners were conducted. Transcripts were analysed qualitatively against the components of the Capability–Opportunity–Motivation–Behaviour (COM-B) model. Possible interventions for increasing prescribers’ engagement with planned drug holidays were considered in response. Multiple barriers to practitioner engagement in planned drug holidays from methylphenidate were identified. Capability, in terms of knowledge and skills, was not a barrier identified for CAMHS practitioners but was for GPs. Opportunity was a main barrier for both groups, who reported lack of time and the absence of educational material about drug holidays. Motivation was more complex to define, with CAMHS practitioners questioning the need for drug holidays and GPs being more accepting due to worries about long-term medication side effects as well as cost savings. ‘Education’ and ‘enablement’ interventions were identified as key activities targeting all three components, which could feasibly increase uptake of practitioner-initiated planned drug holidays from methylphenidate. The application of the COM-B system identified a number of key barriers to practitioner engagement with drug holidays in children and adolescents with ADHD. Accordingly, a number of interventions could be developed to facilitate change. For example, educating and training GPs about ADHD management and drug holidays, and developing a decision aid to help families make informed decisions about whether or not to implement drug holidays could be used.
Highlights
Attention deficit hyperactivity disorder (ADHD) is characterised by hyperactivity/impulsivity and inattention, affecting around 5% of school-age children in the UK (NICE 2013)
The analysis of in-depth interviews using the COM-B system unveiled a diverse range of practitioner experiences with ADHD medications and the barriers to discussing/initiating drug holidays in children and adolescents with ADHD to test the continued need for medication
Two Child and Adolescent Mental Health Service (CAMHS) practitioners described that unintentional break from medication reported by parents was documented by CAMHS practitioners as effective trials without medication when filling the Commissioning for Quality and Innovation (CQUIN) form as shown below: So quite often I will find that I’m recording in the file that there was an effective trial off medication even though it wasn’t planned (CAMHS 8)
Summary
Attention deficit hyperactivity disorder (ADHD) is characterised by hyperactivity/impulsivity and inattention, affecting around 5% of school-age children in the UK (NICE 2013). Medication is the first-line treatment for school-aged children and young people with ADHD who have severe symptoms and impairment, and the second line for moderate impairment (NICE 2013). Studies have shown that ADHD medications (both stimulants and nonstimulants) are effective in reducing ADHD symptoms and enhancing academic functioning in children receiving treatment (Hechtman et al 2004; Pietrzak et al 2006; Wilson et al 2006). An 8-year prospective follow-up of children treated for ADHD in a multisite study (MTA— Multimodal Treatment of Attention Deficit Hyperactivity Disorder) showed no long-term advantage of medication beyond 2 years in most cases (Molina et al 2009). The short-term adverse effects such as suppression of appetite and growth in children and problems with sleeping present legitimate concerns for some families (Zachor et al 2006; Faraone et al 2008)
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