How parents make decisions to use medication to treat their child's ADHD: a grounded theory study

Use of Medication to Treat Attention-Deficit/Hyperactivity Disorder in Young Children: The Role of Maternal History of Psychotropic Medication Use

We examine whether, among children diagnosed with ADHD, are those whose mothers have a history of psychotropic medication use more likely to treat their ADHD with medication? Children born in Manitoba, Canada from 2000 to 2010 diagnosed with ADHD between their 4th and 8th birthday. Maternal psychotropic medication use was assessed from one year before the child's birth to the child's fourth birthday. Logistic regression models examine the relationship between maternal history of psychotropic medication use and the use of medication to treat ADHD in children. Among the 2384 children diagnosed with ADHD, the rate of ADHD medication use was higher for those whose mother had a history of psychotropic medication use (76.6%) than for those whose mothers did not (72.5%) (OR 1.24, 95% CI 1.03, 1.49). Children whose mothers have a history of psychotropic medication use are more likely to have their ADHD treated with medication.

Diagnosis and management of ADHD: a pediatric perspective on practice and challenges in Switzerland

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders in childhood. In Switzerland, the complex diagnosis and treatment are being carried out by adolescent-/child psychiatrists, and pediatricians. Guidelines recommend a multimodal therapy for patients with ADHD. However, it has been questioned whether health professionals follow this approach or favor drug therapy. This study aims to provide insights into the practice of pediatricians in Switzerland regarding diagnosis and treatment of ADHD and their perceptions of these processes.

METHOD

An online survey (self-report) about current practices of diagnosis and management as well as challenges regarding ADHD was distributed to office-based pediatricians in Switzerland. One hundred fifty-one pediatricians participated. Results show that therapy options were almost always discussed with parents and older children. Exchange with parents (81%) and level of child's suffering (97%) were central when selecting therapy options.

RESULTS

Therapies about which pediatricians informed most often were: pharmacological therapy, psychotherapy, and multimodal therapy. Challenges voiced were the subjectivity of diagnostic criteria and dependence on third parties, low availability of psychotherapy, and a rather negative public attitude towards ADHD. Needs that were expressed were further education for all professionals, support for coordination with specialists and schools as well as improvement of information on ADHD.

CONCLUSIONS

Pediatricians do consider a multimodal approach when treating ADHD and take the families` and children's opinions into account. Improvements of the availability of child and youth psychotherapy, the strengthening of the interprofessional cooperation with therapists and schools, and efforts to increase public knowledge about ADHD are proposed.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Parental intervention in school, academic pressure, and childhood diagnoses of ADHD

Childhood diagnoses of attention-deficit/hyperactivity disorder (ADHD) have increased dramatically in the U.S. in recent decades. Prior research has alluded to the possibility that high levels of parental intervention in school are associated with increased diagnoses of ADHD, but this relationship remains understudied. This study investigates: 1) whether the children of intervening parents are more likely to be diagnosed with ADHD, and; 2) whether parental intervention moderates the extent to which children's pre-diagnosis behavioral problems and exposure to strict educational accountability policies predict ADHD diagnosis. Analyses of longitudinal, population-level data from the Early Childhood Longitudinal Study-Kindergarten Cohort of 1998-99 (n = 9,750) reveal that a standard deviation increase above the mean on parental intervention in school is associated with a 20% increase in the odds of ADHD diagnosis among elementary school children. This relationship is robust to differences in children's pre-diagnosis behavioral problems, academic achievement, parental knowledge of/exposure to ADHD, and school selection, and can arise because parents who intervene in school on average exhibit heightened sensitivity to behavioral problems and academic pressure from accountability-based educational policies. In light of prior work establishing both social class and racial/ethnic differences in parental intervention in school, this positive relationship between parental intervention in school and children's diagnoses of ADHD may carry important implications for the production of inequality in children's mental health and educational opportunities.

Problematizing Perceptions of STEM Potential: Differences by Cognitive Disability Status in High School and Postsecondary Educational Outcomes

The STEM (science, technology, engineering, and mathematics) potential of youth with cognitive disabilities is often dismissed through problematic perceptions of STEM ability as natural and of youth with cognitive disabilities as unable. National data on more than 15,000 adolescents from the High School Longitudinal Study of 2009 first suggest that, among youth with disabilities, youth with medicated attention-deficit/hyperactivity disorder (ADHD) have the highest levels of STEM achievement, and youth with learning or intellectual disabilities typically have the lowest. Undergraduates with medicated ADHD or autism appear to be more likely to major in STEM than youth without cognitive disabilities, and youth with autism have the most positive STEM attitudes. Finally, results suggest that high school STEM achievement is more salient for college enrollment than STEM-positive attitudes across youth with most disability types, whereas attitudes are more salient than achievement for choosing a STEM major.

Exploring Factors Influencing Medication Adherence From Initiation to Discontinuation in Parents and Adolescents With Attention Deficit Hyperactivity Disorder

This study explored factors influencing parents' and adolescents' decisions to initiate, continue, and discontinue medication for attention deficit hyperactivity disorder (ADHD). Three focus groups were conducted with parents (n = 23) of children with ADHD, and 2 with adolescents diagnosed with ADHD (n = 11). Parents and adolescents independently discussed the complexities surrounding their decisions to adhere to ADHD medication. Parents' negative beliefs about medication (fear of side effects) discouraged them from initiating therapy. Once initiated, parents struggled in balancing the need to medicate (improvements in learning and behavior) and concerns (weight loss, perceived delayed development) about the medication. Parents who had more concerns about the medication were more in favor of discontinuation. For adolescents, the desire for self-expression without being medicated was the primary factor determining nonadherence and/or discontinuation of the medication. Adolescents' medication-related concerns were relatively different from the parents. Phase- and group-specific interventions are required to improve medication adherence in people with ADHD.

A Review of Factors Influencing the Three Phases of Medication Adherence in People with Attention-Deficit/Hyperactivity Disorder

Objectives: Factors affecting adherence to medications in people with attention-deficit/hyperactivity disorder (ADHD) are not well understood in the context of their influence on the different phases of adherence, that is, initiation, implementation, and discontinuation. This review aimed to identify the factors affecting the three phases of medication adherence in people with ADHD. Methods: Six electronic databases, including Medline, PubMed, IPA, CINAHL, Embase, and PsycINFO, were systematically searched from inception through October 2018 with the limitations of English language and human studies. The search strategy was based on three concepts (adherence, ADHD, and factors) and their relevant terminologies. Results: Considerable variability was observed with regards to the criteria used to define adherence in identified studies (n = 48). Most studies focused on the implementation phase of adherence (n = 27), while only a handful focused on the initiation (n = 6) and discontinuation (n = 5) phase of adherence. The remaining studies (n = 10) examined multiple phases of adherence. Conflicting information received about medication, medication frequency, and fears of medication's effect on growth were the unique factors impacting initiation, implementation, and discontinuation, respectively. Moreover, factors within each phase of adherence also differed with different populations such as parents, children, adolescents, and adults. Fear of addiction, medication effectiveness, psychiatric comorbidity, and medication side effects were the most common factors identified in all three phases of adherence. Conclusions: This review found some unique factors in each phase of adherence while some overlap was also noted. Future interventions to improve adherence should be phase- and group specific rather than consider adherence as a single variable.

What stops practitioners discussing medication breaks in children and adolescents with ADHD? Identifying barriers through theory-driven qualitative research

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.

The Construction and Validation of Child, Adolescent and Parental Decision Aids for Considering Methylphenidate Drug Holidays in ADHD

Guidelines recommend encouraging young people with attention deficit hyperactivity disorder (ADHD) who are taking medication long-term, to discuss their preferences for stopping or changing their treatment, including a discussion about 'drug holidays', with their doctor. Yet, to date, no written information has been available to empower children and adolescents with ADHD and their parents to make informed decisions about drug holidays. The aim of this study was to design and develop a suite of decision aids to help families decide if they want to take a drug holiday from methylphenidate. The material was designed with reference to the literature and in consultation with a secondary-care specialist, and validated with two panels composed of specialists and parents using content validity questionnaires and interviews; before being finished and branded by a design service. Three decision aids were produced, with parental and adolescent versions composed of a booklet and a pull-out form for self-completion, and the child version being a booklet for reading and self-completion. Existing research calls for suitable written materials to feasibly increase the uptake of practitioner-initiated planned drug holidays from methylphenidate. We envisage these materials will open up the space to discuss drug holidays in ADHD during annual reviews, in line with UK government guidelines.

What are the implications for practice that arise from studies of medication taking? A systematic review of qualitative research

Background

Despite several decades of evidence supporting the benefits of taking medications in various diseases and healthcare settings, a significant proportion of prescribed treatments are not taken. This review sought to synthesise qualitative research exploring experiences of medication taking around the world, and to determine whether there were consistent messages arising from these studies.

Methods and findings

5 databases (MEDLINE, PsycINFO, EMBASE, SCOPUS, CINAHL) were systematically searched to identify published research papers using qualitative methodologies, which explored medication-taking experiences in patients, citizens, carers, relatives and clinicians. Data were extracted independently by at least two clinician reviewers. Implications for practice from individual papers were charted and coded using thematic content analysis. These were then cross-tabulated with research paper categories to explore emergent patterns with particular implications for practice. 192 papers from 34 different countries were included in the review. Implications for practice fitted into 11 categories: increase family involvement, increase clinician involvement, promote personalised management, address practical barriers, provide ongoing support, promote self-management, adopt a patient-centred approach, improve patient education, address system barriers, increase access to non-prescribing clinicians and improve clinician training. These implications for practice were generally evenly spread across research paper categories.

Conclusions

Implications for practice from the published qualitative literature exploring medication-taking are notably consistent across research methods, disease categories and geographical settings. More recent clinical trials of interventions to improve adherence have started to draw on these findings by focussing on improving clinical interactions and involving patients in healthcare decisions. Promoting patient education and self-management have been widely advocated, and improvements at a system level have been frequently cited in studies from developing countries and those relating to communicable diseases. Regardless of the setting, clinicians and policymakers around the world can focus efforts to improve medication-taking by considering a number of consistently emerging findings.

Medication-taking experiences in attention deficit hyperactivity disorder: a systematic review

Background

Although attention deficit hyperactivity disorder (ADHD) is a common condition for which pharmacotherapy is considered an effective treatment, guidelines on the treatment of ADHD have been challenging to implement. Considering the views of patients and caregivers involved in medication-taking could help shed light on these challenges.

Objective

This review combines the findings of individual studies of medication-taking experiences in ADHD in order to guide clinicians to effectively share decisions about treatment.

Methods

Five databases (MEDLINE, Embase, PsycINFO, SCOPUS and CINAHL) were systematically searched for relevant published research articles. Articles were assessed for quality using a Critical Appraisal Skills Programme checklist, and synthesis was performed using meta-ethnography.

Results

Thirty-one articles were included in the final synthesis, comprising studies of caregivers, paediatric patients and adult patients across seven countries. Findings were categorized into five different constructs, including coming to terms with ADHD, anticipated concerns about medication, experiences of the effects of medication, external influences and the development of self-management. The synthesis demonstrates that decisions surrounding medication-taking for ADHD evolve as the child patient enters adulthood and moves towards autonomy and self-management. In all parts of this journey, decisions are shaped by a series of 'trade-offs', where potential benefits and harms of medication are weighed up.

Conclusions

This review offers a comprehensive insight into medication-taking experiences in ADHD. By considering the shifting locus of decision-making over time and the need for individuals and families to reconcile a variety of external influences, primary care and mental health clinicians can engage in holistic conversations with their patients to share decisions effectively.

Personal Accounts of Discontinuing Neuroleptic Medication for Psychosis

We conducted this study to explore personal accounts of making choices about taking medication prescribed for the treatment of psychosis (neuroleptics). There are costs and benefits associated with continuing and discontinuing neuroleptics. Service users frequently discontinue neuroleptics; therefore, we specifically considered these decisions. We used a grounded theory approach to analyze transcripts from interviews with 12 participants. We present a preliminary grounded theory of the processes involved in making choices about neuroleptic medication. We identified three tasks as important in mediating participants' choices: (a) forming a personal theory of the need for, and acceptability of taking, neuroleptic medication; (b) negotiating the challenges of forming alliances with others; and (c) weaving a safety net to safeguard well-being. Progress in the tasks reflected a developmental trajectory of becoming an expert over time and was influenced by systemic factors. Our findings highlight the importance of developing resources for staff to facilitate service user choice.

The racialized construction of exceptionality: Experimental evidence of race/ethnicity effects on teachers' interventions

Scholars, policy-makers, and practitioners have long argued that students of color are over-represented in special education and under-represented in gifted education, arguing that educators make racially/ethnically biased decisions to refer and qualify students with disabilities and giftedness. Recent research has called this into question, focusing on the role of confounders of race/ethnicity. However, the role of educator decisions in the disproportionality is still unclear. In this study, I examine the role of student race/ethnicity in teachers' categorization of student needs as "exceptional" and in need of special or gifted education services. I use an original survey experiment in which teachers read case studies of fictional male students in which the race/ethnicity, English Language Learner status, and exceptionality characteristics were experimentally manipulated. The teachers are then asked whether they would refer the student for exceptionality testing. My findings suggest a complex intersection of race/ethnicity and exceptionality, in which white boys are more likely to be suspected of having exceptionalities when they exhibit academic challenges, while boys of color are more likely to be suspected when they exhibit behavioral challenges. This suggests that the racialized construction of exceptionalities reflects differential academic expectations and interpretations of behavior by race/ethnicity, with implications for the subjectivity of exceptionality identification and for the exacerbation of racial/ethnic inequalities in education.

Caught in the eye of the storm: a qualitative study of views and experiences of planned drug holidays from methylphenidate in child and adolescent ADHD treatment

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) can be treated with stimulant medication such as methylphenidate. Although effective, methylphenidate can cause serious side-effects, including suppressed appetite, growth retardation and sleep problems. A drug holiday is a deliberate interruption of pharmacotherapy for a defined period of time and for a specific clinical purpose, for example for appeasing side-effects. While some international guidelines recommend introducing drug holidays in ADHD treatment, this is not practised routinely. Our aim was to examine the views and experiences of planned drug holidays from methylphenidate with adults who have responsibility for treatment decisions in children and adolescents with ADHD.

METHOD

In-depth interviews were carried out. Child and Adolescent Mental Health Services practitioners (n = 8), General practitioners (n = 8), teachers (n = 5) and mothers of children with ADHD (n = 4) were interviewed in a UK setting. Interview transcripts were analysed using grounded theory.

RESULTS

Methylphenidate eases the experience of the child amid problems at home and at school and once started is mostly continued long term. Some families do practise short-term drug holidays at weekends and longer term ones during school holidays. The decision to introduce drug holidays is influenced by the child's academic progress, the parents' ability to cope with the child, as well as medication beliefs. Trialling a drug holiday is thought to allow older children to self-assess their ability to manage without medication when they show signs of wanting to discontinue treatment prematurely.

CONCLUSIONS

Planned drug holidays could address premature treatment cessation by enabling adolescents to assess repercussions under medical supervision.

Mindfulness-based psychoeducation for parents of children with attention-deficit/hyperactivity disorder: an applied clinical project

TOPIC

Attention-deficit/hyperactivity disorder (ADHD) affects more than 5 million American children; the likelihood of their parents experiencing stress is high, which may lead to negative outcomes. Mindful parenting is a parent training modality that teaches compassion, listening, and creative engagement with one's child, and has been shown to be effective in decreasing levels of parental stress.

PURPOSE

An 8-week evidence-based applied clinical project (N = 7) was designed to answer the question: In parents of children with the diagnosis of ADHD, or exhibiting ADHD traits, what is the effect of providing mindful parenting psychoeducation in addition to standard of care treatment on levels of parental stress post intervention?

SOURCES USED

An exhaustive literature search was performed using the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, Psyc-INFO, and PubMed.

CONCLUSIONS

Outcomes were measured using the Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF). Scores on the Total Stress scale decreased significantly after 8 weeks (p = .018); a significant decrease also occurred across two of the three PSI-4-SF subscales (Parental Distress and Parent-Child Dysfunctional Interaction). Recommendations for practice change, suggestions for future clinical inquiry, and project limitations are discussed.

Barriers to evidence-based treatment for children with attention-deficit/hyperactivity disorder

A number of evidence-based treatments are available for attention-deficit/hyperactivity disorder (ADHD), including pharmacological, psychosocial, or a combination of the two treatments. For a significant number of children diagnosed with ADHD, however, these treatments are not utilized or adhered to for the recommended time period. Given that adherence to treatment regimens is necessary for reducing the symptoms of ADHD, it is crucial to develop a comprehensive understanding of why adherence rates are so low. The current review examines the literature to date that has directly explored utilization and adherence issues related to the treatment of ADHD in order to identify the key barriers to treatment. This review focused on four main factors that could account for the poor rates of treatment utilization and adherence: personal characteristics (socio-demographic characteristics and diagnostic issues), structural barriers, barriers related to the perception of ADHD, and barriers related to perceptions of treatment for ADHD. This review included 63 papers and covered a variety of barriers to treatment that have been found in research to have an impact on treatment adherence. Based on this review, we conclude that there are complex and interactive relationships among a variety of factors that influence treatment utilization and adherence. Four main gaps in the literature were identified: (1) there is limited information about barriers to psychosocial interventions, compared to pharmacological interventions; (2) there is a limited variety of research methodology being utilized; (3) treatment barrier knowledge is mostly from parents' perspectives; and (4) treatment utilization and treatment adherence are often studied jointly. Information from this review can help practitioners to identify potential barriers to their clients being adherent to treatment recommendations.