Improving psychostimulant adherence in children with ADHD

Continuation of Treatment in Children With ADHD: A Multicenter Turkish Sample Study

OBJECTIVES

The aim of this study was to investigate the variables that may affect treatment continuation in children aged 6 to 12 years who were newly diagnosed with ADHD.

METHODS

A total of 132 children diagnosed with ADHD and their parents participated in the study. Sociodemographic and clinical risk factors affecting continuation of treatment were examined using logistic regression analysis.

RESULTS

Multiple model examination revealed that greater age increased the risk of treatment discontinuation 1.824 times (p = .003) while a lower total length of paternal education increased the risk of discontinuation (1/0.835) 1.198 times (p = .022). Other variables emerging as significant in the univariate model lost that significance in the multiple model.

CONCLUSIONS

Understanding the variables associated with medication discontinuation in ADHD in different populations and taking these variables into account in the development of health policies, will be useful in improving the long-term devastating effects of the disorder.

Promoting Medication Adherence in Children with Attention Deficit Hyperactivity Disorder: A Mixed-Methods Systematic Review with Meta-analysis and Qualitative Comparative Analysis

OBJECTIVE

To evaluate the efficacy of ADHD medication adherence interventions and explore the pathways to effectiveness.

METHODS

A systematic review was conducted using multiple databases to identify relevant randomized controlled trials (RCTs). Pooled effect sizes were calculated for medication adherence and ADHD symptom outcomes. Qualitative Comparative Analysis (QCA) was used to identify pathways to effectiveness.

RESULTS

Six RCTs were included. The interventions significantly improved medication adherence (OR = 2.39, 95% CI [1.19, 4.79]) and ADHD symptoms (Hedges' g = -0.96, 95% CI [-1.38, -0.54]). Multi-regression analysis showed a positive relationship between medication adherence and ADHD symptom reduction. QCA revealed two paths for effectiveness: (1) Presence of ADHD drug education and absence of reminder and (2) Presence of tracking and absence of reminder.

CONCLUSION

ADHD medication adherence interventions have a positive impact on both medication adherence and ADHD symptoms. Interventions should consider including ADHD drug education or tracking to maximize effectiveness.

Assessment of medication adherence among Lebanese adult patients with non-communicable diseases during COVID-19 lockdown: a cross-sectional study

Background

Medical treatment is considered a cornerstone in non-communicable diseases (NCDs) management, lack of adherence remains the main challenge that may compromise optimal therapeutic outcome achievement.

Purpose

This study aimed to evaluate treatment adherence levels and associated factors among Lebanese adult patients with non-communicable diseases.

Materials and methods

A cross-sectional survey conducted during the COVID-19 lockdown imposed by the Lebanese Government (between September 2020 and January 2021) enrolled 263 adult patients through an anonymous online questionnaire to assess adherence to medications using the Lebanese Medication Adherence Scale (LMAS-14).

Results

Of the total sample, 50.2% showed low adherence with a total mean adherence score of 4.41 ± 3.94. The results showed that depression (β = 1.351) and peptic ulcer (β = 1.279) were significantly associated with higher LMAS scores (lower adherence). However, age between 50 and 70 (β = -1.591, p = 0.011), practicing physical exercise (β = -1.397, p = 0.006), having kidney disease (β = -1.701, p = 0.032), and an intermediate (β = -1.336, p = 0.006) to high income (β = -3.207, p < 0.001) were significantly associated with lower LMAS scores (higher adherence).

Conclusion

Our study shed light on the factors affecting medication adherence in patients with non-communicable diseases. It showed that depression and peptic ulcer were associated with lower adherence, contrary to older age, exercising, having chronic kidney disease, and a higher socioeconomic status.

A systematic review of interventions to enhance adherence and persistence with ADHD pharmacotherapy

Although high rates of poor adherence/persistence have been documented in ADHD, there is limited research targeting the problem. This systematic review evaluated interventions to address poor adherence/persistence to ADHD pharmacotherapy, with the aim of guiding the development of future interventions. An extensive search was conducted from January 1980 until January 2021. Thirteen studies were identified involving interventions based on psychoeducation, behavioural therapy, combined psychoeducation/behavioural therapy, technology-based interventions, written informed consent and a nursing support line. All 13 studies (including five RCTs) reported improvement in adherence/persistence and five studies (including four RCTs) also reported improvement in ADHD symptomatology. Almost all studies involved interventions utilising some form of education. Three RCTs of psychoeducation alone were included, with two of the three studies reporting adherence benefits at three and 12 months respectively. The third RCT was terminated early due to poor recruitment. A behavioural intervention RCT reported improved adherence six months post intervention (but not at 12 months), although a substantial drop-out rate was observed. A final included RCT used a Smartphone Application and reported a short term increase in adherence. The authors of the studies in this review make salient attempts at improving adherence and provide insight for future intervention development. We believe future interventions should involve combinations of strategies, have a theoretical framework and target the most common reasons for non-adherence. Interventions should also be integratable into routine care and include patient input to maximise sustainability.

Moderators and Other Predictors of Methylphenidate Response in Children and Adolescents with ADHD

Methylphenidate (MPH) is the treatment of first choice for developmental ADHD. To date, no reliable method to predict how patients will respond to MPH exists and conflicting results are reported on clinical characteristics of responders. The present study aims to give a more precise characterization of the patients who will respond best to MPH to help clinicians in defining the treatment plan. Age, neuropsychological functioning (i.e., attention and working memory), and behavioral/emotional symptoms of 48 drug-naïve children and adolescents with ADHD (42 boys and 6 girls, age-range 6–16 years, mean age 10.5 ± 2.5 years, mean IQ 101.3 ± 11.2) were studied to assess how these different characteristics affected a single-dose MPH response. Four hierarchical linear regression models were used to explore whether age, neuropsychological measures at baseline, and behavioral/emotional symptoms could predict attention and working memory measures after a single-dose MPH administration. We found that improvement in attention and working memory was predicted by age, neuropsychological measures at baseline, and severity of ADHD symptoms. No behavioral and emotional symptoms predicted single-dose MPH response with the exception of conduct symptoms.

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.

Use of Lisdexamfetamine or Amphetamine? Interpretation of Chiral Amphetamine Analyses

Amphetamine is frequently detected in forensic toxicological cases. Differentiating between the two isomers of amphetamine (d-amphetamine and l-amphetamine) and determining their relative proportion is fundamental to correctly interpret the results of toxicological analyses. The aim of this study was to examine the profile of amphetamine as well as storage stability of the isomers in authentic samples from patients chronically treated with lisdexamfetamine (LDX), the most prescribed medical amphetamine product in Sweden. Blood and urine samples were collected from 18 patients. The samples were analyzed with an achiral (racemate) method for quantification of amphetamine and with a chiral method to determine the proportion of each isomer of amphetamine. The median daily dose of LDX was 40 mg (range, 20-70 mg). The median amphetamine concentration was 0.06 µg/g (range, 0.02-0.15 µg/g) in blood and 6 µg/mL (range, 1-22 µg/mL) in urine. Only d-amphetamine was found in the blood and urine samples from the included patients. Furthermore, no formation of l-amphetamine occurred during storage for three months at 4°C, nine months at -20°C and three freeze-thaw cycles. The results from this study may be helpful in the interpretation of whether the source of identified amphetamine in biological samples are from LDX drug intake or not.

Examining Breaks and Resistance in Medication Adherence Among Adolescents With ADHD as Associated With School Outcomes

Objective: Pharmacological interventions combined with behavioral treatment have been associated with better outcomes for children with ADHD. Yet, as children age into adolescence and gain autonomy, they may choose not to adhere to taking a prescribed medication. The purpose of the current study was to examine school outcomes among adolescents with ADHD who take medication breaks versus resisting medication with respect to grades and school behaviors. Method: We statistically controlled for a variety of variables such as the child's age, sex, the presence of side effects, and parent's relationship with child. Approximately half of the sample of adolescents with ADHD exhibited some form of medication nonadherence. Results: The results of the current study suggest that more positive school outcomes in terms of behaviors and grades are associated with adolescents taking breaks from their ADHD medication rather than resisting their medication. Conclusion: This result would indicate that not all forms of medication nonadherence have the same association with school outcomes in terms of grades and behaviors.

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.

Influence of Methylphenidate on Long-Term Neuropsychological and Everyday Executive Functioning After Traumatic Brain Injury in Children with Secondary Attention Problems

OBJECTIVE

To investigate the effects of methylphenidate on long-term executive and neuropsychological functioning in children with attention problems following TBI, as well as the relationship between methylphenidate associated changes in lab-based neuropsychological measures of attentional control, processing speed, and executive functioning and parent- or self-report measures of everyday executive functioning.

METHOD

26 children aged 6-17 years, who were hospitalized for moderate-to-severe blunt head trauma 6 or more months previously, were recruited from a large children's hospital medical center. Participants were randomized into a double-masked, placebo-controlled cross-over clinical trial. Participants completed a comprehensive neuropsychological battery and parent- and self-report ratings of everyday executive functioning at baseline, and at 4 weeks and 8 weeks following upward titration of medication to an optimal dose or while administered a placebo.

RESULTS

Methylphenidate was associated with significant improvements in processing speed, sustained attention, and both lab-based and everyday executive functioning. Significant treatment-by-period interactions were found on a task of sustained attention. Participants who were randomized to the methylphenidate condition for the first treatment period demonstrated random or erratic responding, with slower and more variable response times when given placebo during the second period.

CONCLUSION

Results indicate that methylphenidate treatment is associated with positive outcomes in processing speed, sustained attention, and both lab-based and everyday measures of executive functioning compared to placebo group. Additionally, results suggest sustained attention worsens when discontinuing medication. (JINS, 2019, 25, 740-749).

Pharmacotherapy Adherence for Pediatric Anxiety Disorders: Predictors and Relation to Child Outcomes

Background

Pharmacotherapy is considered an evidenced-based treatment for anxious youth. There is a need to better understand the relation between medication adherence and child outcomes.

Objective

This study prospectively examined:1) baseline predictors of adherence and 2) the relation between medication adherence and clinical outcomes in children and adolescents with anxiety disorders.

Methods

Participants were 349 youth randomized to sertraline, pill placebo, or sertraline plus cognitive behavioral therapy in the Child/Adolescent Anxiety Multimodal Study (CAMS) and followed over 12 weeks. The measure of pharmacotherapy adherence used was pharmacotherapist (PT) ratings of adherence at each session. Four domains of baseline predictors were examined (demographics, child clinical variables, family/parent variables, and treatment variables).

Results

Multiple regression analyses revealed few significant predictors of adherence. The most robust predictors of greater adherence were living with two parents and parents' positive expectations that medication would lead to better outcomes. Pharmacotherapists' ratings of higher adherence predicted higher global functioning at post treatment and treatment responder status.

Conclusions

In order to increase adherence, improving expectations and instilling hope for positive outcomes and problem solving ways to overcome pragmatic barriers associated with single parent families is recommended.

Transition to College and Adherence to Prescribed Attention Deficit Hyperactivity Disorder Medication

OBJECTIVE

As youth with attention deficit hyperactivity disorder (ADHD) transition to adulthood, they must learn how to manage their ADHD treatment independently. This may be challenging because many of the skills necessary to adhere to treatment (e.g., organization, planning) are impaired in those with ADHD. Using electronic monitoring, we examine trajectories of adherence to medication in a cohort of college students with ADHD. Further, we examine the effect of transitioning to college and executive functioning on adherence.

METHODS

Electronic monitors tracked adherence for 51 undergraduate students with ADHD across an academic semester. Multilevel modeling examined individual trajectories in monthly adherence and the role of transition status and self-reported executive functioning on these trajectories.

RESULTS

Overall, participants adhered to 53.53% of prescribed doses. Transition status predicted the linear slope in adherence (β = -8.95, standard error [SE] = 3.61, p < .05), with lower initial adherence among undergraduates transitioning to independence (34.17%) compared with post-transition undergraduates (67.63%; β = 33.46, SE = 8.00, p < .001). Adherence demonstrated a curvilinear change (β = -7.23, SE = 1.25, p < .001). It increased from the beginning of the semester to midterms before subsequently declining through the rest of the semester, including during final exams. Executive functioning did not predict adherence (β = -.10, SE = .02, p = .54).

CONCLUSION

Only half of all doses were taken as prescribed. Adolescents transitioning to independence demonstrated the lowest levels of adherence, suggesting that the transition to independence is a high-risk period for poor self-management of ADHD.

Factors that Affect the Adherence to ADHD Medications during a Treatment Continuation Period in Children and Adolescents: A Nationwide Retrospective Cohort Study Using Korean Health Insurance Data from 2007 to 2011

OBJECTIVE

Several factors, such as male gender, older age, type of insurance, comorbid conditions, and medication type, have been associated with attention-deficit/hyperactivity disorder (ADHD) medication adherence rates, but the results have been inconsistent. We analyzed data to answer several questions: 1) How old were patients who first refilled their treatment medications used primarily for ADHD, regardless of the medication type? 2) What socio-demographic factors are associated with medication adherence? 3) What medical conditions, such as medication type and comorbid diagnosis, influence adherence?

METHODS

We analyzed National Health Insurance data, which comprised continuously enrolled Korean National Medical Insurance children (6-18 years) with at least 2 ADHD prescription claims (January 2008-December 2011). The persistence of use regarding the days of continuous therapy without a 30-day gap were measured continuously and dichotomously. Adherence, using a medication possession ratio (MPR), was measured dichotomously (80% cut-off).

RESULTS

The cumulative incidence of index cases that initiated medication refills for ADHD treatment during the 4 year period was 0.85%. The patients who exhibited a MPR greater than 80 comprised approximately 66%. The medication type, high school age groups, physician speciality, treatment at a private clinic, and comorbid conditions were associated with medication adherence during continuous treatment using a multivariate analysis.

CONCLUSION

A better understanding of ADHD treatment patterns may lead to initiatives targeted at the improvement of treatment adherence and persistence. Other factors, including the severity, family history, costs, type of comorbidities, and switching patterns, will be analyzed in future studies.

The impact of adjunctive guanfacine extended release on stimulant adherence in children/adolescents with attention-deficit/hyperactivity disorder

Aim: To assess stimulant adherence among children/adolescents with attention-deficit/hyperactivity disorder (ADHD) augmenting stimulants with guanfacine extended-release (GXR). Patients & methods: Inclusion criteria: 6–17 years, ≥1 ADHD diagnosis, ≥1 long-acting and/or short-acting stimulant with GXR augmentation. Modified medication possession ratio (mMPR; days medication available/days in period, excluding medication holidays) was assessed; mMPR <0.80 nonadherent. Regression models assessed change in mMPR adjusting for demographic and clinical characteristics. Results: Among patients nonadherent to stimulants pre-augmentation (n = 165), unadjusted mean (SD) pre- and post-stimulant mMPRs were 0.68 (0.11) and 0.87 (0.16). Adjusted mean change in mMPR was 0.20 for long-acting versus 0.18 for short-acting stimulants (p = 0.34). Conclusion: Among patients nonadherent to stimulants, GXR augmentation was associated with increased stimulant adherence.

The Effectiveness of Short- and Long-Acting Stimulant Medications for Adolescents With ADHD in a Naturalistic Secondary School Setting

OBJECTIVE

Stimulant medication is an efficacious and first-line approach to treating ADHD in adolescence. However, less is known about the effectiveness of this approach as a treatment in real-world settings. The complicated nature of the secondary school environment and documented adolescent nonadherence with stimulant medication may undermine the exportability of this approach.

METHOD

This study investigates stimulant medication effectiveness and adherence in a sample of adolescents with ADHD who were observed in their natural secondary school environment.

RESULTS

Results indicated that the effect of stimulant medication on adolescent functioning is smaller in naturalistic settings than in previous analogue studies. Long-acting pemoline produced greater adherence than the short-acting methylphenidate (MPH), but parents and adolescents preferred the short-acting MPH.

CONCLUSIONS

Overall, adolescents reported very low satisfaction with stimulant medication. Findings are discussed.

Factors affecting medication adherence in children receiving outpatient pharmacotherapy and parental adherence

Problem

Although pharmacotherapy is an effective treatment for many psychiatric disorders in children and adolescents, medication adherence rates among children are low. This study clarifies factors affecting children's medication adherence and the role of parental involvement.

Method

Patients aged 7–17 years with a history of psychotropic medication treatment and their mothers were included in this study. Each mother and child completed self‐administered questionnaires. Thirty mother–child pairs who fully completed the questionnaires were included in the analysis.

Results

Medication adherence was greater in children and mothers when mothers felt that “children's symptoms improved with treatment and medication.” Medication adherence in children and mothers significantly correlated with the child's reported trust in their parent.

Conclusions

The results suggest the need for psychosocial support that considers the influence of mothers on medication adherence in children treated in child psychiatry departments.

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.

Pharmacological interventions for ADHD: how do adolescent and adult patient beliefs and attitudes impact treatment adherence?

Adherence to medication can be problematic for patients, especially so for patients with attention deficit hyperactivity disorder (ADHD). Effective medications are available for the treatment of ADHD; however, nonadherence rates for ADHD medication range from 13.2%-64%. The reasons for nonadherence can be complex. This review aims to look at how the beliefs and attitudes of adolescents and adults impact ADHD treatment adherence.

Comparison of therapy augmentation and deviation rates from the recommended once-daily dosing regimen between LDX and commonly prescribed long-acting stimulants for the treatment of ADHD in youth and adults

OBJECTIVE

To compare therapy augmentation and deviation rates from the recommended once-daily dosing regimen in Attention Deficit Hyperactivity Disorder (ADHD) patients initiated on lisdexamfetamine (LDX) vs other once-daily Food and Drug Administration (FDA) approved stimulants.

METHODS

ADHD patients initiated on a long-acting ADHD stimulant medication (index medication) in/after 2007 were selected from a large U.S. administrative claims database. Patients were required to be persistent for ≥90 days and continuously enrolled in their healthcare plan for ≥12 months following treatment initiation date. Based on age and previous treatment status, patients were classified into treatment-naïve children and adolescents (6-17 years old), previously treated children and adolescents, treatment-naïve adults (≥18 years old), and previously treated adults. Furthermore, patients were classified into four mutually exclusive treatment groups, based on index medication: lisdexamfetamine (LDX), osmotic release methylphenidate hydrochloride long-acting (OROS MPH), other methylphenidate/dexmethylphenidate long-acting (MPH LA), and amphetamine/dextroamphetamine long-acting (AMPH LA). The average daily consumption was measured as the quantity of index medication supplied in the 12-month study period divided by the total number of days of supply. Therapy augmentation was defined as the use of another ADHD medication concomitantly with the index medication for ≥28 consecutive days. Therapy augmentation and deviation rates from the recommended once-daily dosing regimen were compared between treatment groups using multivariate logistic regression models.

RESULTS

Compared to the other treatment groups, LDX patients were less likely to augment with another ADHD medication (range odds ratios [OR]; 1.28-3.30) and to deviate from the recommended once-daily dosing regimen (range OR; 1.73-4.55), except for previously treated adult patients, where therapy augmentation differences were not statistically significant when compared to OROS MPH and MPH LA patients.

LIMITATION

This study did not control for ADHD severity.

CONCLUSION

Overall, compared to LDX-treated patients, patients initiated on other ADHD medications were equally or more likely to have a therapy augmentation and more likely to deviate from the recommended once-daily dosing regimen.

Determinants of patient adherence: a review of systematic reviews

PURPOSE

A number of potential determinants of medication non-adherence have been described so far. However, the heterogenic quality of existing publications poses the need for the use of a rigorous methodology in building a list of such determinants. The purpose of this study was a systematic review of current research on determinants of patient adherence on the basis of a recently agreed European consensus taxonomy and terminology.

METHODS

MEDLINE, EMBASE, CINAHL, Cochrane Library, IPA, and PsycINFO were systematically searched for systematic reviews published between 2000/01/01 and 2009/12/31 that provided determinants on non-adherence to medication. The searches were limited to reviews having adherence to medication prescribed by health professionals for outpatient as a major topic.

RESULTS

Fifty-one reviews were included in this review, covering 19 different disease categories. In these reviews, exclusively assessing non-adherence to chronic therapies, 771 individual factor items were identified, of which most were determinants of implementation, and only 47-determinants of persistence with medication. Factors with an unambiguous effect on adherence were further grouped into 8 clusters of socio-economic-related factors, 6 of healthcare team- and system-related factors, 6 of condition-related factors, 6 of therapy-related factors, and 14 of patient-related factors. The lack of standardized definitions and use of poor measurement methods resulted in many inconsistencies.

CONCLUSIONS

This study provides clear evidence that medication non-adherence is affected by multiple determinants. Therefore, the prediction of non-adherence of individual patients is difficult, and suitable measurement and multifaceted interventions may be the most effective answer toward unsatisfactory adherence. The limited number of publications assessing determinants of persistence with medication, and lack of those providing determinants of adherence to short-term treatment identify areas for future research.

Enhancing ADHD medication adherence: challenges and opportunities

Safe and effective medication for attention deficit hyperactivity disorder (ADHD) is available and recommended as first-line treatment for the core symptoms of inattention, overactivity and impulsiveness. Despite impaired functioning during adolescence, many discontinue medication treatment. For children, healthcare decisions are usually made by the parent; older youth make their own decisions. Beliefs and attitudes may differ widely. Some families understand that ADHD is a neurobiological condition and accept that medication is indicated, for others, such treatment is unacceptable. Converging evidence describes negative perceptions of the burden associated with medication use as well as concerns about potential short and long term adverse effects. Indeed experiences of adverse effects are a frequent explanation for discontinuation among youth. Ways to improve shared decision making among practitioners, parents and youth, and to monitor effectiveness, safety and new onset of concurrent difficulties are likely to optimize outcomes.

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

BACKGROUND

Despite evidence of efficacy, a substantial percentage of children with attention deficit hyperactivity disorder (ADHD) either do not begin medication prescribed for their core symptoms or fail to continue treatment.

OBJECTIVE

The purpose of this study was to understand (a) how parents decide to use medication to treat their child's ADHD and (b) the factors that influence their adherence to medication over time.

DESIGN

Grounded theory guided data collection and analysis. Sixteen semistructured interviews with parents (13 mothers, 3 fathers) of children with ADHD were conducted.

RESULTS

The substantive theory developed from the data demonstrates that in seeking to help their child and restore a sense of stability around family life, parents engage in a process of "doing what helps most" in deciding to use medication to treat their child's ADHD.

CONCLUSIONS

Interventions to support and guide parents throughout the decisional process are critical to meet the needs of families of children with ADHD.

Adherence with electronic monitoring and symptoms in children with attention deficit hyperactivity disorder

OBJECTIVE

The primary aim of this study was to compare electronic monitoring with other measures of adherence to Osmotic-controlled Release Oral delivery System methylphenidate in children with attention-deficit hyperactivity disorder (ADHD). The secondary aim was to analyze the relationships between adherence and clinical factors, including ADHD symptoms.

METHODS

Thirty-nine children diagnosed with ADHD were monitored for adherence to medication over the course of eight weeks. Medication adherence was assessed using the Medication Event Monitoring System (MEMS), which is a bottle cap with a microprocessor that records all instances and times that the bottle is opened; patient self-report; clinician rating; and pill count. Information, including demographic and clinical characteristics, symptom rating scale, and psychological test results, were also collected. The relationships between adherence and clinical factors, including ADHD rating scores of baseline and of the changes, were assessed.

RESULTS

The rate of non-adherence measured by the MEMS was found to be 46.2%, which was considerably higher than those of the patient self-report (17.9%), clinician rating (31.7%), and pill count (12.8%) of non-adherence. The rate of adherence measured by the MEMS was not significantly associated with baseline symptom severity or symptom changes over the eight weeks, although non-adherent group showed more severe baseline symptoms and inferior improvement.

CONCLUSION

Adherence as measured by the MEMS showed a discrepancy with other measures of adherence in patients with ADHD. The symptom severity and level of improvement were not related to adherence with MEMS. Further studies are needed to evaluate the variables that may impact medication adherence in children with ADHD.

Parent perspectives on the decision to initiate medication treatment of attention-deficit/hyperactivity disorder

OBJECTIVES

Despite substantial evidence supporting the efficacy of stimulant medication for children with attention-deficit/hyperactivity disorder (ADHD), adherence to stimulant treatment is often suboptimal. Applying social/cognitive theories to understanding and assessing parent attitudes toward initiating medication may provide insight into factors influencing parent decisions to follow ADHD treatment recommendations. This report describes results from formative research that used focus groups to obtain parent input to guide development of a provider-delivered intervention to improve adherence to stimulants.

METHODS

Participants were caregivers of children with ADHD who were given a stimulant treatment recommendation. Focus groups were recorded and transcribed verbatim. Data were analyzed by inductive, grounded theory methods as well as a deductive analytic strategy using an adapted version of the Unified Theory of Behavior Change to organize and understand parent accounts.

RESULTS

Five groups were conducted with 27 parents (mean child age=9.35 years; standard deviation [SD]=2.00), mean time since diagnosis=3.33 years (SD=2.47). Most parents (81.5%) had pursued stimulant treatment. Inductive analysis revealed 17 attitudes facilitating adherence and 25 barriers. Facilitators included parent beliefs that medication treatment resulted in multiple functional gains and that treatment was imperative for their children's safety. Barriers included fears of personality changes and medication side effects. Complex patterns of parent adherence to medication regimens were also identified, as well as preferences for psychiatrists who were diagnostically expert, gave psychoeducation using multiple modalities, and used a chronic illness metaphor to explain ADHD. Theory-based analyses revealed conflicting expectancies about treatment risks and benefits, significant family pressures to avoid medication, guilt and concern that their children required medication, and distorted ideas about treatment risks. Parents, however, took pride in successfully pursuing efforts to manage their child behaviorally and to avoid medication when possible.

CONCLUSIONS

Focus group data identified social, cognitive, and affective influences on treatment decision making. Results support prior research comparing family/social functioning, physician characteristics, and adherence. Findings suggest that parent attitudes to psychiatric care need to be assessed comprehensively at initial evaluation to aid the development of psychoeducational messages, and a more careful consideration about how parents interpret and respond to adherence-related questioning.

Medication refusal in children with oppositional defiant disorder or conduct disorder and comorbid attention-deficit/hyperactivity disorder: medication history and clinical correlates

Abstract Objective: This study examines the characteristics of 96 children with attention-deficit/hyperactivity disorder (ADHD) and their families who refused a recommendation for medication as part of their treatment for disruptive disorders.

METHODS

The ADHD cases were taken from a sample of 139 youth (age 6-11) who were recruited for a clinical trial that compared the administration of a modular psychosocial treatment in an outpatient clinic or community settings. Medication management was an optional treatment module for children with ADHD in both conditions. Children who were (vs. were not) taking medication at intake, and children who accepted (vs. refused) medication recommendations during the study were compared on diagnostic and clinical measures related to child, school, parent, and family domains of functioning.

RESULTS

Parents of 30% of the children refused study medication for ADHD. Parental medication acceptability and intake correlated highly with both medication history and study refusal of medication. Increased parental self-efficacy and emotional support for their youth correlated with medication refusal. No demographics and few child or school factors were associated with medication refusal. Medication use was associated with reductions in some key ADHD symptoms, but did not affect disruptive behaviors as did the psychosocial interventions.

CONCLUSION

Medication refusers remain poorly understood but certain correlates, such as parental self-efficacy, parental emotional support for their youth, and medication acceptability, warrant further evaluation.

Predictive factors for persistent use and compliance of immediate-release methylphenidate: a 36-month naturalistic study

AIM

The objective of this study was to evaluate predictors of long-term adherence to treatment with methylphenidate (MPH).

METHODS

A total of 134 children (ages 4-16) with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) determined by specific protocols, including a semistructured parent interview, Conners' Teacher/Parent Rating Scales, cognitive and learning evaluation, and child self-reports for anxiety and depression, were assessed monthly for up to 36 months. At the end of the study (36 months), three outcomes were evaluated (continuing medication, medication withdrawn due to functional remission, and medication withdrawn for other reasons including poor compliance). Outcomes were first analyzed by mean of the chi-squared test, Mann-Whitney-U test, or t-test, and predictive models were subsequently generated using Cox proportional hazards model analysis. Age, ADHD subtype, co-morbidity, cognitive functioning, side effects, and family and social characteristics were considered as independent variables.

RESULTS

Thirty-six months after starting MPH, 62 children (46%) were still on treatment, 32 (24%) had stopped MPH due to functional remission, and 40 (30%) had suspended MPH for other reasons. Within the last group, 20 suspended for poor compliance, 10 for decrease of efficacy, 5 for side effects, and 5 because they entered in an atomoxetine clinical trial. The presence of associated disorders, younger age, female gender, and not living with both parents were predictors for continuing medication until end of the study (36 months); absence of associated disorders and older age were predictors of discontinuation medication due to functional remission before the end of study, older age, and hyperactive subtype were predictors of discontinuing medication for other reasons.

CONCLUSION

Clinical outcome of ADHD treatment is heterogeneous: Specific clinical and social predictive parameters for long-term MPH use and compliance can be identified. An accurate tailoring of clinical intervention to the individual child appears crucial for good outcome.