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ADHD Institute Register

30 Jul 2018

Ibrahim K, Donyai P. Atten Defic Hyperact Disord 2018; 10: 273-283

Medication breaks, or drug holidays, from medication are used by some parents of children with ADHD and involve a “deliberate interruption of pharmacotherapy for a defined period of time and for a specific clinical purpose”, primarily at weekends or during school holidays. There is evidence to suggest that planned medication breaks may be beneficial for children with ADHD, and some national and international guidelines recommend planned medication breaks in some settings, but despite this, most drug holidays are initiated by parents and not clinicians. The aim of this study was to identify the barriers that prevent UK practitioners from discussing and implementing formal planned drug holidays for individuals with ADHD.

A sample of Child and Adolescent Mental Health Services (CAMHS) practitioners and general practitioners (GPs) were invited* to participate in this qualitative research study. A semi-structured interview, which focused on beliefs about ADHD medication and personal experiences with ADHD drug holidays, was conducted with each practitioner; interviews lasted for an average of 20 minutes with GPs and 40 minutes with CAMHS practitioners. All interviews were audio-recorded, transcribed verbatim and anonymised. Data collected from transcripts were analysed using the Capability–Opportunity–Motivation–Behaviour (COM-B) model; the researchers independently coded the data from each transcript, subsequently comparing their coding and resolving any discrepancies through discussion, before matching the identified codes to COM-B components.

In total, eight CAMHS practitioners from four National Health Service (NHS) CAMHS clinics across four towns, and eight GPs from six different practices across four towns agreed to participate in the study. The findings from the analysis of the practitioners’ interview transcripts using the COM-B system were as follows:

Capability

  • Practitioners’ self-assessment of their capability to discuss and initiate ADHD medication breaks in children and adolescents with ADHD varied according their speciality.
  • CAMHS practitioners possessed the necessary knowledge and skills to discuss and implement formal drug holidays with families, and were aware that they needed to have annual formal discussions with individuals with ADHD to assess the need for continued medication.
  • Although CAMHS practitioners were aware that these annual discussions were required for them to receive payment from the Commissioning for Quality and Innovation in the Primary Care Trust, this did not affect their initiation of drug holidays.
  • The specific recommendations regarding drug holidays were more unfamiliar to GPs; this lack of awareness was attributed to difficulties accessing guidelines and shared-care protocols, as well as general work pressure and document overload.
  • GPs were not prepared to initiate drug holidays without specialist involvement or specific training, as they felt they lacked the appropriate skills for management of ADHD.

Opportunity

  • Physical and social opportunity were identified as important barriers to initiation of drug holidays for both CAMHS practitioners and GPs.
  • Time constraint was a major barrier for GPs, as 10-minute appointment slots only allowed enough time for prescription refill and not for a discussion on how to withdraw from medication. However, long appointment slots and regular 6-monthly reviews allowed CAMHS practitioners to conduct a full detailed review, and provided the opportunity to discuss planned drug holidays with families.
  • With no consensus guideline on the information that should be provided to families about drug holidays, CAMHS practitioners reported that they do this verbally, without the use of aids. This suggests that CAMHS practitioners’ perceptions of drug holidays may impact on the information that is provided to families, and whether families are willing to try it or not.
  • CAMHS practitioners felt that their role was to discuss drug holidays with parents, but that the decision is ultimately made by the families. Negative parental perceptions about drug holidays prevent some CAMHS practitioners from further exploring drug holidays, while other parents initiate medication breaks without the practitioner’s recommendation.
  • CAMHS practitioners reported that some parents were against drug holidays due to worries about the child’s academic life, fears of teachers’ complaints and negative experiences with unintentional non-adherence incidents. They also indicated that some parents were worried about their inability to cope with their child without medication, or that their child would return to their previous state (before the medication was initiated).

Motivation

  • All GPs had positive opinions regarding planned drug holidays. Four GPs favoured stopping medication temporarily, while five GPs saw drug holidays as an opportunity to identify children who might not need to take the medication anymore and avoid putting them on unnecessary medication, which could possibly save NHS resources.
  • Opinions regarding planned drug holidays were more varied amongst CAMHS practitioners, and although one argued that the need for medication cannot be assessed without stopping it, one viewed ADHD as a chronic condition that needs to be continuously treated.
  • A drug holiday was viewed as generally unhelpful by some CAMHS practitioners, as most felt that children with ADHD cannot function well without their medication, and there were concerns regarding the possible impact of temporarily stopping medication on family life and academic achievement. They also perceived that planned drug holidays are preferable in adolescents but less advisable in younger children.
  • Abrupt withdrawal of ADHD medication and the associated withdrawal effects as a result of drug holidays was a concern for GPs but not for CAMHS practitioners. GPs felt that ADHD was a specialist area and that their role was to initiate referral of families for CAMHS assessment and to later repeat the prescription for medication.

Practitioners who took part in the study recommended that drug holidays of ≥1 week in duration should be offered after a child has been on medication for 2 years, and then annually. They also recommended that drug holidays should continue for as long as the behaviour is manageable, and are more advisable in older children with ADHD and during school holidays. The practitioners emphasised that the decision to implement a drug holiday should fully involve both the parents and the individual with ADHD, and that the usefulness of the drug holiday should be based on parental and child feedback.

However, the experiences and opinions regarding drug holidays presented in this study are limited to those of CAMHS practitioners and GPs from one English county, and therefore these views may not be fully representative of other practitioners inside or outside of the UK. The authors emphasised that the purpose of this study was not to provide recommendations or identify a protocol for how to implement ADHD drug holidays.

The authors concluded that this study highlighted possible barriers to the discussion and implementation of formal drug holidays in children with ADHD. The authors stated that training and educating GPs about ADHD and introducing a decision-making tool to help families make an informed choice about drug holidays could improve engagement in discussion about drug holidays. It is possible that drug holidays could be cost-effective for the NHS through preventing unnecessary prescribing of medication in children with ADHD who no longer need it.

Read more about what prevents practitioners from discussing and implementing ADHD drug holidays here

 

*CAMHS practitioners were approached via a CAMHS specialist consultant who emailed an invitation letter and information sheet to all practitioners within a community and mental health hospital trust. GPs were recruited via an invitation letter and information sheet, which was posted to 150 randomly selected GPs in the same county from publicly available NHS addresses
The semi-structured interview guide was drafted and refined by agreement with an external CAMHS consultant and was piloted in three volunteer participants to ensure the questions were workable and feasible. Open-ended questions were used to enable flexibility to ask questions in response to the conversation
The COM-B model explains that human behaviour is best understood through the interaction between the three components of capability (physical and psychological ability to get involved in the specific activity under concern, including possessing the knowledge and skills necessary to engage in this activity), opportunity (the different external factors that prompt or make possible a social or physical behaviour) and motivation (the brain processes that boost and direct behaviour, including habitual processes, emotional responses and analytical decision-making)

Ibrahim K, Donyai P. What stops practitioners discussing medication breaks in children and adolescents with ADHD? Identifying barriers through theory-driven qualitative research. Atten Defic Hyperact Disord 2018; 10: 273-283.

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