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Paediatricians’ decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder S-J. Chow,* E. Sciberras,*† L. H. Gillam,‡§ J. Green†¶** and D. Efron*†** *Centre for Community Child Health, The Royal Children’s Hospital, Melbourne, Vic., Australia †Murdoch Childrens Research Institute, Melbourne, Vic., Australia ‡Children’s Bioethics Centre, The Royal Children’s Hospital, Melbourne, Vic., Australia §School of Population Health, The University of Melbourne, Melbourne, Vic., Australia ¶Parenting Research Centre, Melbourne, Vic., Australia, and **Department of Paediatrics, The University of Melbourne, Melbourne, Vic., Australia Accepted for publication 3 December 2012 Keywords attention-deficit/ hyperactivity disorder, doctor decision making, qualitative, stimulant medication Correspondence: Emma Sciberras, Community Child Health, Murdoch Childrens Research Institute, The Royal Children’s Hospital, Flemington Road, Parkville, Vic. 3052, Australia E-mail: emma.sciberras@ mcri.edu.au Abstract Background Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for children with ADHD, to reduce symptoms and improve function. In this study we investigated the factors that influence paediatricians’ decisions about prescribing stimulant medications. Method In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who were purposively recruited so as to sample a broad demographic of paediatricians working in diverse clinical settings. Paediatricians were recruited from public outpatient and private paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their demographic and practice characteristics. Results Our findings showed that the decision to prescribe is a dynamic process involving two key domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along the journey to prescribing. Five themes relating to this process emerged from data analysis: comprehensive assessments that include history, examination and information from others; influencing factors such as functional impairment and social inclusion; previous success; facilitating parental understanding including addressing myths and parental confusion; and decision-making model. Conclusions Paediatricians’ decisions to prescribe stimulant medications are influenced by multiple factors that operate concurrently and interdependently. Paediatricians do not make decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients, to arrive at a collective, well-informed decision. Introduction Attention-deficit/hyperactivity disorder (ADHD) affects approximately 5% of children worldwide (Polanczyk et al. 2007) and is associated with an increased risk of educational and social problems for affected children. Paediatricians are the main doctors diagnosing ADHD (Concannon & Tang 2005) and prescribing stimulant medications for children with ADHD Child: care, health and development Original Article doi:10.1111/cch.12036 © 2013 John Wiley & Sons Ltd 301

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Page 1: Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder

Paediatricians’ decision making about prescribingstimulant medications for children withattention-deficit/hyperactivity disorder

S-J. Chow,* E. Sciberras,*† L. H. Gillam,‡§ J. Green†¶** and D. Efron*†**

*Centre for Community Child Health, The Royal Children’s Hospital, Melbourne, Vic., Australia†Murdoch Childrens Research Institute, Melbourne, Vic., Australia‡Children’s Bioethics Centre, The Royal Children’s Hospital, Melbourne, Vic., Australia§School of Population Health, The University of Melbourne, Melbourne, Vic., Australia¶Parenting Research Centre, Melbourne, Vic., Australia, and**Department of Paediatrics, The University of Melbourne, Melbourne, Vic., Australia

Accepted for publication 3 December 2012

Keywordsattention-deficit/hyperactivity disorder,doctor decision making,qualitative, stimulantmedication

Correspondence:Emma Sciberras,Community Child Health,Murdoch ChildrensResearch Institute, TheRoyal Children’s Hospital,Flemington Road,Parkville, Vic. 3052,AustraliaE-mail: [email protected]

AbstractBackground Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a

child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for

children with ADHD, to reduce symptoms and improve function. In this study we investigated the

factors that influence paediatricians’ decisions about prescribing stimulant medications.

Method In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who

were purposively recruited so as to sample a broad demographic of paediatricians working in

diverse clinical settings. Paediatricians were recruited from public outpatient and private

paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed

verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their

demographic and practice characteristics.

Results Our findings showed that the decision to prescribe is a dynamic process involving two key

domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along

the journey to prescribing. Five themes relating to this process emerged from data analysis:

comprehensive assessments that include history, examination and information from others;

influencing factors such as functional impairment and social inclusion; previous success; facilitating

parental understanding including addressing myths and parental confusion; and decision-making

model.

Conclusions Paediatricians’ decisions to prescribe stimulant medications are influenced by

multiple factors that operate concurrently and interdependently. Paediatricians do not make

decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients,

to arrive at a collective, well-informed decision.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) affects

approximately 5% of children worldwide (Polanczyk et al.

2007) and is associated with an increased risk of educational

and social problems for affected children. Paediatricians are the

main doctors diagnosing ADHD (Concannon & Tang 2005)

and prescribing stimulant medications for children with ADHD

bs_bs_banner Child: care, health and developmentOriginal Article doi:10.1111/cch.12036

© 2013 John Wiley & Sons Ltd 301

Page 2: Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder

in Australia (Western Australian Department of Health 2005).

In a recent Australian practice audit, 18% of patients attending

general or community paediatricians had ADHD, making

ADHD the most common diagnosis seen by paediatricians

(Hiscock et al. 2011).

Stimulant medication has been demonstrated to be the most

effective treatment for core ADHD symptoms (The MTA Coop-

erative Group 1999). In Australia, regulations in most states

and territories limit the prescribing of stimulant medications to

paediatricians and child and adolescent psychiatrists. Although

data collection systems for stimulant medication are variable,

best estimates are that approximately 1% of boys and 0.5%

of girls in the Australian population aged 10–14 years (peak

age of prescription) are prescribed stimulant medication

(Hollingworth et al. 2011), with some regional variation

(Berbatis et al. 2002; Reid et al. 2002; Calver et al. 2007).

Furthermore, in recent years more adults are being diag-

nosed with ADHD and treated with stimulant medications

(Salmelainen 2004).

Recent research has reported a rise in the prevalence of

ADHD, as well as stimulant medication prescription (Reid et al.

2002). Published guidelines from American Academy of Paedi-

atrics (Committee on Quality Improvement, Subcommittee on

Attention-Deficit/Hyperactivity Disorder 2000; Subcommittee

on Attention-Deficit/Hyperactivity Disorder & Committee

on Quality Improvement 2001), National Institute of Health

and Clinical Excellence (National Institute for Health and

Clinical Excellence 2009), as well as Australia’s draft National

Health and Medical Research Council (National Health and

Medical Research Council 2009) are available to guide paedia-

tricians in ADHD assessment and management. However, each

patient is unique. Presenting problems, symptom severity and

co-morbidities vary between patients, as do family background,

and parental beliefs and expectations. In behavioural medicine,

few patients fit neatly into a clinical management box, rendering

therapeutic decision making challenging.

Although the efficacy of stimulant medication has been

established in treating core ADHD symptoms (The MTA Coop-

erative Group 1999), some paediatricians may be hesitant

to prescribe stimulant medications because of potential side

effects or the risk of patients or others abusing their medica-

tions (Stockl et al. 2003; Wilens et al. 2003; Katragadda &

Schubiner 2007); while others may be reluctant to treat behav-

ioural problems with medication for philosophical reasons

(Safer 2000). This qualitative study aimed to investigate how

paediatricians make decisions about whether to prescribe

stimulant medication for children with ADHD including the

factors which shape decision making in different contexts.

Methods

Sample

Participants were general paediatricians in Victoria, Australia,

sourced from the Royal Australasian College of Physicians

membership list. Participants were purposively sampled from

diverse settings to ensure a spread across a range of provider

characteristics including: (1) type of service model (public out-

patient versus private clinics); (2) clinic location (metropolitan

versus rural); and (3) paediatrician’s level of experience. Ethics

approval for the study was obtained from the Royal Children’s

Hospital Human Research Ethics Committee.

Data collection

Interviews were individual and semi-structured with open-

ended questions based on the published literature. The in-depth

interview is a powerful methodology that enables a researcher

to understand informants’ views through responses shaped by

informants themselves (Popay & Williams 1996), without pre-

supposing the parameters of discussion (Morse 1991). With

their capacity for producing elaborate and detailed accounts

(Seale 2004), interviews are frequently used in the health field to

understand how people view a particular issue, behave a certain

way or change their practices (Silverman 2006; Daly et al. 2007).

Interview duration ranged from 15 to 102 min. Interviews

were audio-recorded, de-identified and transcribed for analysis.

Paediatricians also completed a questionnaire detailing their

demographic and practice characteristics. We ceased data col-

lection when data saturation was reached.

Data analysis

In accordance with the preferred practice in qualitative research,

data analysis occurred alongside data collection to allow for

integration of new concepts and questions into the interview

schedule (Gibbs et al. 2007), providing opportunities to explore

additional issues that arose during the course of the research

(Denzin & Lincoln 2000). Interview data were analysed using

thematic analysis, with four key steps: (i) immersion in the data;

(ii) coding; (iii) creating conceptual categories; and (iv) identi-

fication of themes by linking categories with theoretical models

of physician’s decision making from the literature review

(Green et al. 2007). Codes and categories were discussed within

the team to ensure interpretive rigour. Data collected from the

demographic questionnaire were de-identified, grouped and

analysed using descriptive statistical methods.

302 S-J. Chow et al.

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Results

Sample characteristics

We interviewed 13 paediatricians. Participant characteristics are

outlined in Table 1. The number of patients with ADHD seen by

paediatricians was wide-ranging, as was paediatricians’ levels of

experience. Participants’ confidence in managing patients with

ADHD was high, with 85% of paediatricians self-rating as ‘very

confident’.

Domains and themes

The thematic analysis identified two principal domains encap-

sulating five discrete themes. The two domains were ‘weighing

up clinical factors’ and ‘journey to prescribing’. Together, they

highlight that the decision to prescribe is a dynamic process

involving an interplay between firstly, weighing up clinical

factors and secondly, interacting with parents and the patient in

the journey to prescribing. Each domain revealed emerging

themes (T1–5) (Fig. 1) which are detailed and illustrated below

using excerpts from the data.

Domain 1: Weighing up clinical factors

Theme 1: Comprehensive assessments Paediatricians conducted

comprehensive assessments to diagnose ADHD and assess the

child’s functional impairment. Assessments included a detailed

medical, family and social history, as well as a physical exami-

nation, and direct information from teachers. Validated ques-

tionnaires and psychological assessments, particularly cognitive

assessments, were used by some paediatricians, but not all.

Theme 2: Influencing factors Key factors related to the child

were the severity of functional impairment and social exclusion.

While academic failure was a major determinant in prescribing

stimulant medication, paediatricians commonly considered

social impairment a stronger impetus to prescribe:

The important things are quality of life . . . which brings

on the issue of when it is justified to use medications.

What does that mean? That means when it is affecting

their mental health, when it is affecting their self-esteem,

when it is affecting their peer relationships and when it is

affecting their family life adversely. (Paediatrician 9)

Our findings highlighted that paediatricians prescribed more

cautiously in younger children and with children with complex

co-morbidities:

Age is obviously one of those issues, we have children

who are four and it is pretty clear that the diagnosis is

ADHD but you would prefer not to start the medication

early unless there were some really severe behavioural

consequences. (Paediatrician 4)

Behavioural and educational strategies were utilized in conjunc-

tion with medication as first-line management to treat children

with ADHD. However, some tended to reserve medication until

non-medication treatments had been exhausted, especially for

younger children:

All the strategies have been implemented anyway. And

when they’re coming to you, you know they’ve already

done all of that . . . And the child’s not getting anywhere.

(Paediatrician 13)

Paediatricians identified family dysfunction as a major contrib-

uting factor. In particular, they considered discussing medica-

tion as a treatment option sooner, if the family was not coping:

Table 1. Characteristics of study participants

Characteristic n (%)

Age (years)30–39 3 (23)40–49 2 (15)50–59 5 (39)60–69 3 (23)

GenderFemale 5 (38)Male 8 (62)

Number of years working with children with ADHD0–9 3 (23)10–19 2 (15)20–29 6 (46)30–39 2 (15)

Number of ADHD patients per week<5 3 (23)5–10 4 (31)11–20 4 (31)>20 2 (15)

Practice type100% public patients 4 (31)Mixed public and private patients 6 (46)100% private patients 3 (23)

Location of practiceMetropolitan 9 (69)Outer metropolitan 2 (15)Rural 2 (15)

Confidence in ADHD management (out of 5)<3 0 (0)3–3.9 1 (8)4–4.9 1 (8)5 11 (85)

ADHD, attention-deficit/hyperactivity disorder.

Paediatricians’ decision making in ADHD 303

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If the child is at a crisis situation that would certainly

push me towards discussing medication earlier. (Paedia-

trician 5)

When parents were reluctant or uncertain about medication,

particularly when inter-parental conflicts were encountered,

initiation of medication was delayed as paediatricians contin-

ued discussions over a number of visits. Paediatricians sought to

explore parents’ understanding and ensure that both parents

were fully informed and educated:

This is a really important decision for these families, so,

I don’t care how long it takes. The easy bit is prescribing

and supervising the medication. The complex bit is

getting to the point of doing that and it can be ten con-

sultations if they want it. (Paediatrician 7)

Theme 3: Significance of previous success Paediatricians

acknowledged the complexity of managing ADHD, yet were

simultaneously confident in prescribing largely due to their

own past experience of success in using stimulant medications.

Evidence of the efficacy and safety of stimulant medications also

contributed to their confidence:

My experience is very much governed by the success I’ve

had with treatments also, so success leads to success.

ADHD is really one of the few conditions in paediatrics

full stop where you can make such a big difference to

the child, the education, the self-esteem, the family . . .

(Paediatrician 8)

Although some paediatricians expressed reluctance and dis-

comfort about prescribing stimulant medications on the basis

that they were giving medications for behavioural problems,

they still recognized that it is an effective treatment modality:

Unfortunately, medication is possibly the best thing to

do in this situation and even though you nor I like the

thought of it. I really try and put in the context of the

things that people know from research and experience.

(Paediatrician 6)

Domain 2: The journey to prescribing

This domain describes the interactions between the paediatri-

cian, parents and patient during the consultation. In particular,

parental understanding and preferences play an integral part in

the paediatrician’s decision.

Theme 4: Facilitating parental understanding Communication

with parents forms the basis of the journey to prescribing

stimulant medication. The way in which paediatricians com-

municated with parents was aimed at shaping and facilitating

discussions, leading to parental understanding of the diagnosis

and management.

Figure 1. Domains (D) and themes (T).

304 S-J. Chow et al.

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There were variations in the explanation of ADHD that

paediatricians reported giving to parents, but descriptions

of the core symptoms of ADHD were common across all

paediatricians’ accounts. Additionally, paediatricians also tried

to explain the condition in relation to the individual child’s

presentation and context:

There could be a whole lot of factors coming into it and

I like to try and give them a picture of why their child

appears to be the way that he or she is. (Paediatrician 4)

To further facilitate the parents’ understanding of ADHD,

paediatricians identified myths surrounding ADHD in society

and helped steer parents away from the confusion:

I find that there are a lot of myths which are perpetrated

by the media . . . this is not a new diagnosis, but it’s a

condition which has been around and treated for a long

time. (Paediatrician 7)

Theme 5: Decision-making model: (a) Roles and responsibilities

in decisions Paediatricians actively enlisted the participation

of parents in the decision-making process. The role of parents

varied from being joint decision makers, final decision makers

to more commonly, being guided by the recommendations

offered by paediatricians. However, paediatricians tended to

view the ultimate decision to medicate was to be made by

parents:

I would give them all the options, and then say this would

be my recommendation, but you know, obviously the

ultimate decision is with them. (Paediatrician 13)

Many emphasized that parents must not feel that they are being

forced to give their children medications. Instead, they should

be given the time and accurate information to enable them to

arrive at an informed decision:

The one thing that I don’t want to do is make people feel

they’re being railroaded into it. I’ll say ‘look you need a

little time to think about it’. (Paediatrician 9)

Theme 5: Decision-making model: (b) Involvement of child We

found that paediatricians could be uncomfortable when pre-

scribing medications and saw it as their responsibility to ensure

that they were acting in the child’s best interest. Participation

of the child in decision making was encouraged by some

paediatricians:

I know that the evidence is strongly in favour of medica-

tion being beneficial or more beneficial than anything

else but I still don’t like the idea of giving a child some-

thing that modifies how that child brain works. Because

what we are doing is we are acting in what we think are

the child’s best interests. We are putting ourselves on

the line in terms of responsibility . . . If it comes to the

stage of us thinking about medication, (I) will introduce

the proposition to not just the parents but the child.

(Paediatrician 6)

Discussion

Therapeutic decision making involves a complex analytical

process. Paediatricians integrate multiple variables including

clinical symptoms, co-morbidities and child/family factors

when making treatment decisions (Cebul & Beck 1985). Our

study demonstrated that paediatrician decision making regard-

ing whether to initiate stimulant medication is a dynamic

process involving two primary domains. These domains are not

isolated entities. Rather, they are interwoven in the paediatri-

cians’ practice, concurrently and interdependently.

To elaborate, the paediatrician first weighs up clinical

factors that would be in support of or militate against a deci-

sion to prescribe, including symptom severity and functional

impairment. Decision making is also influenced by the pae-

diatrician’s previous experiences. After the paediatrician has

considered these factors, they often make a preliminary deci-

sion that a trial of medication would be in the patient’s best

interest.

The second domain of decision making occurs predomi-

nantly during the interaction with the parents, where parental

understanding and preferences play a role. Style of communi-

cation plays an important role in gauging and facilitating paren-

tal understanding of aetiology, diagnosis and treatment. The

child, especially if older, is often involved. The ethics of prac-

tising medicine calls for the exercise of clinical judgement in

response to patient and parent needs, and respect for patient

autonomy is now recognized as an important element in any

clinical care plan (Mandell 2008). Interactions with parents may

consolidate or delay paediatricians’ decision to prescribe. In this

study, paediatricians emphasized that they were at pains for

parents not to feel that they are being forced to give their child

medication.

One critical factor which influenced the decision to prescribe

stimulant medications was severity of functional impairment.

This view is reflected in the higher rate of treatment for children

aged 7–15 years, as academic and social impairments become

more noticeable (Salmelainen 2002; Preen et al. 2007). The

child’s level of functional impairment was also reported to be

Paediatricians’ decision making in ADHD 305

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Page 6: Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder

influential in a qualitative study examining treatment decision

making by parents of children with ADHD (Brinkman et al.

2009). Paediatricians were more cautious when prescribing

for children under the age of 6 and children with complex

co-morbidities, where non-pharmacological treatments tended

to be implemented first. This prescribing pattern is consis-

tent with recommendations in ADHD practice guidelines, and

appears to be shared by the wider paediatric community

(Guevara et al. 2001; Jick et al. 2004; Preen et al. 2007;

National Health and Medical Research Council 2009).

Our study indicated that paediatricians were confident but

careful prescribers. This was influenced by the combination

of their previous clinical experience and research documenting

the efficacy and safety of stimulant medications. These converge

when they exercised clinical judgment, reflecting a similar con-

vergence in other medical decision making where evidence,

inference and experience were not competing ideologies but

‘complementary methodologies for synthesizing empirical

data’ (Marshall 2006). These findings are consistent with other

studies which have examined the prescribing practices of

doctors (Prosser & Walley 2006; Lin et al. 2011). Despite recent

reports that the prescribing rates for stimulant medications

for ADHD have increased (Reid et al. 2002), our data suggest

that paediatricians put considerable thought into the decision

to prescribe. Paediatricians assessed the presenting problem,

constructed a multi-informant picture, gave recommendations

and offered treatment options.

This study had some limitations. The sample of paedia-

tricians participating was Victorian, and decision making

may be different for paediatricians working in different

regions. We interviewed a relatively small number of paedia-

tricians; however, interviews ceased because data saturation

was reached; this approach is consistent with other qualitative

studies examining doctors’ decision making (Prosser & Walley

2006).

Decision making in relation to the prescription of stimulant

medication is a ‘science meets art’ area of paediatric medicine. It

requires excellent communication skills to build collaborative

partnerships with parents and children. The findings from our

study can be used to highlight areas where further emphasis

may be required in paediatric training, and raise paediatricians’

awareness in the evaluation and reflection of their clinical deci-

sion making. Although paediatricians in this study reported

that they work closely with parents when making decisions,

previous research has reported that shared decision making

between parents and paediatricians is low and that higher levels

of shared decision making is predicted by higher family socio-

economic status (Brinkman et al. 2011). Future research should

examine how shared decision making can be fostered in paedi-

atric consultations.

Decision making in prescribing for ADHD is a dynamic

process, involving the interplay of multiple factors, including

the child’s functional impairment, in navigating the journey to

prescribing. Overall, paediatricians are confident prescribers

shaped by their clinical experiences and knowledge of best

practice evidence. Paediatricians do not make decisions about

prescribing in isolation; rather, they actively involve parents,

teachers and patients. They provide education and strive to

allow the parents and the patients, in particular adolescents, to

arrive at a well-informed decision.

Key messages

• Published guidelines are available to guide paediatricians

in ADHD assessment and treatment. However, many indi-

vidual factors including symptom severity, co-morbidities,

family background and parental management preferences

vary between patients.

• This study found that decision making in prescribing for

ADHD is a dynamic process, involving the interplay of

multiple factors, including the child’s functional impair-

ment, in navigating the journey to prescribing.

• The findings can be used to raise paediatricians’ awareness

in the evaluation and reflection of their clinical decision

making.

Conflict of interests

The authors have indicated that they have no financial relation-

ship relevant to this article to disclose. All authors had full access

to all of the data (including statistical reports and tables) in the

study.

Acknowledgements

Dr Sciberras’ position was funded by an Australian National

Health and Medical Research Council (NHMRC) Population

Health Capacity Building Grant 436914 and an NHMRC Early

Career Research Fellowship (1037159) for the duration of this

manuscript’s preparation. Dr Green was partially funded by an

NHMRC Post-Doctoral Fellowship (607419). This research was

supported by the Victorian Government’s Operational Infra-

structure Support Program to the MCRI. We thank all of the

participating paediatricians for their contribution to this study.

306 S-J. Chow et al.

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