1. Barriers for implementing drug holidays in ADHD
Identifying opportunity as the barrier to ADHD drug holidays: application of the behavioural change wheel.
Introduction
A variety of reasons have been identified for non-adherence to guidelines including individual as well as organisational factors. The National Institute for Health and Care Excellence recommends an annual review of medication in the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents. Although the impact of brief periods of no treatment is to be taken into account, ‘drug holidays’ (DHs) are mainly recommended by NICE if growth has been suppressed by medication. However, locally, prescribers are asked to plan two-week DHs after two years of treatment to test continuing need for medication under shared-care arrangements, which our research shows is rarely practised [1] despite robust evidence that DHs in ADHD can benefit patients in multiple ways. The aim of this study was to identify barriers to prescribers’ engagement with planned DHs in ADHD by applying a behavioural change system [2].
Methods
The “COM-B system” was used to identify barriers according to three components; capability, opportunity, and motivation [2]. Health professionals involved in shared-care prescribing for children and adolescents with ADHD were included. Transcripts from interviews with GPs (n=8), and Child and Adolescent Mental Health Service (CAMHS) practitioners (n=8), were analysed against 14 Theoretical Framework Domains that map onto the COM-B components. The behaviour change wheel, which includes the COM-B system as the hob, was then used in order to identity possible interventions for increasing prescribers’ engagement with planned DHs.
Figure 1. COM-B system and the behavioural change wheel [2]
Results
Different barriers to prescribers’ engagement with DHs in ADHD were identified as presented in Table 1:
Capability (knowledge, skills, memory, and behavioural regulations) was not a barrier for CAMHS practitioners but was for GPs needing more education and training about ADHD and worrying about possible withdrawal effects.
Opportunity was a main barrier for both GPs and CAMHS practitioners, who cited lack of time and lack of educational material for families, respectively.
Motivation was more complex to define for both CAMHS practitioners and GPs, with the former accepting DHs on reflection and the latter more compliant due to worries about long-term medication side-effects as well as cost savings.
Table 1. Mapping of behaviour change barriers for considering DHs to theoretical constructs
On mapping these barriers to the behaviour change wheel as illustrated in Figure 1, ‘enablement’ was identified as a key activity targeting all three components, which could feasibly increase prescribers’ engagement with planned DHs (see Table 2).
Conclusion
The application of the behavioural change wheel identified key barriers to prescribers’ engagement with DHs in children and adolescents with ADHD.
‘Education & training’ and ‘enablement’ were identified as potential behaviour change interventions.
An example of an ‘enablement’ intervention is a decision aid that provides families with balanced information about potential risks and benefits of planned DHs allowing them to compare options and reach an informed decision.
COM-B system constructs
Theoretical Domain Framework components
Barriers for implementing drug holidays in ADHD
CAMHS
GPs
Physical Capability
Physical skills
Lack of skills to introduce DHs.
Psychological Capability
Knowledge, Memory, Behavioural regulation
Unaware of guidelines’ recommendations about DHs.
Lack of training and education about ADHD and its management.
Reflective Motivation 
Professional role and identity,
Beliefs about capabilities,
Goals,
Intentions and motivation,
Beliefs about consequences
Disagreement with the content of the guidelines.
Beliefs that the majority of children with ADHD need the medication and will restart the medication soon after stopping.
Goals to maintain the child’s symptoms under control.
Positive views about the medication.
A belief that parents are the decision-maker to accept or refuse planned DHs. CAMHS role is to make enquiry about DHs.
GPs perceive their roles are limited to recognising children who might have ADHD symptoms and referring families to CAMHS and then continue prescribing.
GPs’ concerns about the possible withdrawal symptoms associated with DHs. 
 Automatic Motivation
Pessimism, Reinforcement Emotions
Uncertainty about the benefits of DHs
Positive motivation: Receive payment from PCT, Follow guidelines recommendations, and nobody should be on medication that they don’t need, and some effort should be made from time to time to find out if children still need it or not
Giving priority to more common conditions.
Positive motivation: Worries about the medication long term side- effects on children’s brains and “Cost issues“ related to avoiding the waste of NHS resources unnecessarily.
Social Opportunity 
Social influences
Parents’ negative attitudes towards DHs
Parents’ lack of trust in GPs in relation to management of ADHD.
Physical Opportunity
Environmental context and resources
No formal written information available about DHs to give to parents.
No formal written information available about DHs to give parents.
Time constraint.
Difficulties accessing guidelines and shared-care protocols.
Table 2. Link between components of the ‘COM-B’ model of behaviour and the intervention functions
Model of behaviour: resources
GPs
CAMHS
Targeted interventions
Physical Capability ++
Training, education, and enablement
Psychological Capability
Reflective Motivation +
Incentivisation, coercion, and persuasion,
Automatic Motivation
Incentivisation, coercion, persuasion, and enablement
Social Opportunity
Restriction, environmental restriction, and enablement
Physical Opportunity
References
1. Ibrahim K, Masters K, Donyai P. 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 2014; 22 (S1): 2-27.
2. Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science 2011; 6: 42. doi: /
Contact information
Department of Pharmacy Practice, University of Reading, Whiteknights, RG6 6AH |