Caught in the eye of the storm: explaining the lack of engagement with methylphenidate drug holidays in children with ADHD

Ibrahim, Kinda (2014) Caught in the eye of the storm: explaining the lack of engagement with methylphenidate drug holidays in children with ADHD. International Journal of Pharmacy Practice, 22 (Suppl_1), 2-27. (doi:10.1111/ijpp.12101).

Record type: Meeting abstract

Abstract

Attention deficit hyperactivity disorder (ADHD) can be managed medically with stimulant medication such as methylphenidate. Although effective, the long-term impact of methylphenidate on children’s developing brains is unknown and serious side-effects include growth retardation. UK guidelines recommend doctorinitiated 2-week breaks from stimulants after two years of prescribing to test the continuing need for medication [1]. Locally too, shared-care arrangements between consultants at Berkshire Healthcare NHS Foundation Trust (BHFT) and General Practitioners (GPs) encourage both groups to consider and discuss these drug holidays with parents of children prescribed methylphenidate. But evidence suggested little engagement with this practice. Our aim was to understand and explain why methylphenidate drug holidays rarely take place in actual practice. Semi-structured interviews were conducted with Child and Adolescent Mental Health Services (CAMHS) consultants (n = 8), GPs (n = 8), and teachers (n = 3) who deal with children with ADHD in Berkshire, UK. Both CAMHS consultants and teachers were approached via email through a secondary source; GPs were approached through the post. All interviews were audio-recorded, transcribed and then analyzed using Grounded theory methodology[2]. Future parent interviews are planned as part of the ongoing validation process. This work was approved by the University of Reading Research Ethics Committee, BHFT R&D office and the Thames Valley Primary Care Research Partnership. Five main categories emerged from primary analyses during this study and these were integrated into one core category labelled ‘caught in the eye of the storm’ that neatly explains the low uptake of drug holidays in ADHD. Before medication, children’s behaviour at home and school results in distress in both environments. When they seek medical input, doctors advise parents to start medication for the management of their child’s ADHD. Stimulant medication then helps decrease the child’s impulsiveness and hyperactive behaviour, improving their academic performance as a result. Everyone is therefore appreciative of the power of the medication which is perceived as a mercy that moves the child, to some extent the school, and of course the parents from a position in amidst the storm to the safety of the eye of the storm. Fear of losing this stable state of affairs by agreeing to stop medication, even for a short time accounts for the poor practice ofplanned drug holidays. The children in effect are caught in the eye of a storm from which it is difficult if not impossible to escape until adolescence where they themselves become the decision-makers and many stop their medication altogether at that juncture. Grounded theory has explained the lack of engagement with methylphenidate drug holidays. With parents as the main decision makers until children reach adolescence, performance at school, safety of children at school, and adults’ (parents’ and teachers’) inability to cope with the child’s behaviour become the main drivers for continuing with medication. The risk of losing this sense of security by interrupting treatment impedes efforts to introduce methylphenidate drug holidays. Help with risk assessing drug holidays might improve parents’ decision making in the future. 1. NICE, Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adult. NICE clinical guideline 72, 2008, NICE: London. 2. Glaser B. G. and Strauss A. L, The discovery of grounded theory: strategies for qualitative research. 1967: New York: Adline de Gruyter.

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