Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder

censusADHD Study: An Australian-wide medication-based recruitment study for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder affects over 5% of children and is characterised by a persistent pattern of problems with focussing or maintaining attention and/or hyperactivity-impulsivity. The censusADHD Study is a richly phenotyped nationwide cohort of Australian children with attention-deficit/hyperactivity disorder. The overarching aims of the study are to examine attention-deficit/hyperactivity disorder medication utilisation patterns and treatment response, the impact of children's attention and behavioural problems on caregivers, and costs related to attention-deficit/hyperactivity disorder.

METHODS

Families of potential attention-deficit/hyperactivity disorder cases aged between 6 and 11 years were identified using Pharmaceutical Benefits Scheme prescription records for attention-deficit/hyperactivity disorder medications held by Services Australia and sent a study information letter. Data were collected from 1574 primary caregivers via online survey in 2015, including the behavioural profile of the child, the child's medication use and experiences with side effects and the impact of the child's behaviour on the caregiver. Approximately 81% of caregivers also consented to record linkage of the child's Pharmaceutical Benefits Scheme and Medicare Benefits Schedule claims to directly assess prescription dispensing history and health service usage to estimate costs to the family and Medicare health system.

RESULTS

Boys were diagnosed with attention-deficit/hyperactivity disorder earlier (p = 0.021), more likely to present as the combined and predominantly hyperactive subtypes (p = 0.001) and at higher risk of experiencing a school suspension (p < 0.001) or expulsion (p = 0.043). Overall, children presenting as the combined subtype had higher rates of psychiatric comorbidities (p < 0.001). Finally, prescription costs for each family and the Pharmaceutical Benefits Scheme significantly increased in the year following attention-deficit/hyperactivity disorder diagnosis (p < 0.001).

CONCLUSION

Research examining the psychosocial and financial impact of attention-deficit/hyperactivity disorder on Australian children and their families is needed. Our findings demonstrate the importance of examining both gender and attention-deficit/hyperactivity disorder subtype presentation in future studies.

Who is prescribing psychotropic medications in a public developmental-behavioural clinical service and how often?

AIM

Psychotropic prescribing by paediatricians is increasingly common, and there is considerable variation in care provided. The aims of this study were to examine current rates of psychotropic prescribing in the developmental-behavioural outpatient clinics at the Royal Children's Hospital's Centre for Community Child Health, and to compare rates between paediatric consultants and advanced trainees.

METHODS

Data were extracted for appointment encounters from electronic medical records across 12 months in 2017. Patient demographics, provider and medication order data were analysed using Excel and STATA to calculate logistic regression, standard deviation, percentages and means.

RESULTS

From 5069 encounters, there were 847 (16.7%) that included psychotropic prescribing. Advanced trainees prescribed psychotropic medications in only 4.4% of their encounters compared with consultants who prescribed these medications in 23% of encounters (P < 0.001). Stimulants were the most commonly prescribed psychotropic medication (62%), either alone (86.3%) or in combination (13.7%).

CONCLUSIONS

Psychotropic prescribing rates were lower than expected. Advanced trainees may need more experience in psychotropic prescribing.

Clinical factors associated with decision to recommend methylphenidate treatment for children with ADHD in France

European guidelines advise on best practices for the diagnosis and non-pharmacological and pharmacological treatment of attention-deficit hyperactivity disorder (ADHD). This study aimed to (1) assess whether clinician's decisions to initiate methylphenidate treatment in children diagnosed with ADHD are in accordance with European guidelines and (2) identify clinical factors associated with the decision to recommend methylphenidate prescription. 5 to 13-year-old patients with an ADHD diagnosis were consecutively evaluated in an outpatient child and adolescent psychiatry clinic in France. Patients underwent a multidisciplinary evaluation including a diagnostic interview, symptom severity assessments with parent questionnaires, and IQ testing. We compared children with (n = 105) and without (n = 55) recommended methylphenidate treatment using Student's t test or Wilcoxon Mann-Whitney test and Chi-square or Fisher's test. Multivariate logistic regression was implemented to determine the respective influence of each variable on treatment recommendation. Recommendation to initiate methylphenidate treatment was associated with (1) ADHD combined presentation, (2) co-occurring Oppositional Defiant Disorder/Conduct Disorder (ODD/CD), Developmental Coordination Disorder (DCD) and Learning Disorder (LD), (3) clinical severity and impairment indicated on parent questionnaires, and (4) reduced perceptual reasoning. Using a multivariate regression model, ADHD combined presentation [combined versus predominantly hyperactive/impulsive and unspecified OR 4.52 (1.23-16.55), p = 0.023], age [OR 1.46 (1.14-1.88), p = 0.003], ODD/CD [OR 5.53 (2.19-14.01), p < 0.001], DCD [OR 4.22 (1.70-10.48), p = 0.002], PRI [OR 0.97 (0.94-0.99), p = 0.01] were significantly associated with recommendation of methylphenidate treatment. Our results indicate that clinicians' treatment decision-making complies with European guidelines and is furthermore associated with the type and severity of ADHD symptoms but also with co-occurring disorders.