Background
Methods
Design
COM-B components | Definition | |
---|---|---|
Capability | Physical psychological | Capability refers to an individual’s psychological and physical ability to get involved in the specific activity under concern and it includes having the knowledge and skills necessary to engage in the activity |
Opportunity | Physical social | Opportunity is the different external factors that make the behaviour possible or prompt it. Opportunity barriers are external constraints on a provider’s enactment of a behaviour |
Motivation | Reflective automatic | Motivation is defined as the brain processes that boost and direct behaviour including: habitual processes, emotional response, as well as analytical decision making |
Sample
Procedure
Analysis
Results
COM-B system components | Barriers for CAMHS to discuss and undertake drug holidays | Barriers for GPs to discuss and undertake drug holidays |
---|---|---|
Physical capability | N/A |
Lack of skills and training about ADHD and drug holidays
We learnt about this when we were at medical school, and pick up bits and bobs from reading, but real knowledge No, we haven’t, no. (GP 1) I suspect most GPs are not particularly skills at ADHD. I don’t feel skilled at it (GP6) ‘we ought to have training sessions on, we’re talking about holidays and when to stop and when, so we can actually justify with evidence what we’re doing (GP 2)’ |
Psychological capability | N/A |
Unfamiliarity with guidelines’ and difficulties accessing them
No, I think perhaps that it would be useful for GPs to be more aware of the guidelines or to have the right guidelines more easily available. Well, they probably are but it’s just knowing where to find them because we get sent so many bits of information that it, it’s a constant thing (GP5) |
Social opportunity |
Parents’ rejection to consider breaks from medication due to concerns about interrupting the treatment
Most of the parents don’t want to stop medication…Do you want to try them, the treatment withdrawal trial, but I think it’s still parents views that it’s not helping (CAMHS 7) | N/A |
Physical opportunity |
Lack of educational materials about drug holidays
I don’t have any material available but I tell them to try, start trying this the weekend first, then try it more for, say 1 week or two, or if everything is ok then try it more and see how it goes (CAMHS 4) |
Time constraint
You could always make a case, I know, saying, oh, we should be involved more, but I think the truth is that it’s difficult because of the time constraint (GP 5) I mean basically my role is to check, is everything OK? Are you still taking the tablets? Are there issues with compliance? I’ll have a 10 min, per patient (GP1) |
Reflective motivation |
Perceiving their role as to make enquiry about drug holidays and empower families to make their own decision
I, well I say, I mean my whole line is that I’m not there to say you have to do this or you don’t have to do this, I’m there to advise, give information, support where possible. If a parent says, no way am I going to have a break, then that is their decision (CAMHS 1)
Uncertainty about the benefits of drug holidays
So I don’t think a withdrawal always is helpful. In many cases the withdrawal is not helpful, yeah, so we have to be careful (CAMHS 4) I think that two-thirds of the children on medication then end up going back on medication (CAMHS 5)
Disagreement with the content of the guidelines regarding and perceiving drug holiday more advisable at older age
Well yeah, I think, well I think, yeah, it’s very rarely considered for anybody young, it’s more, I think, useful in teenagers…So I think it’s very difficult for a young child to make sense of withdrawing them, I think it’s the parents’ decision (CAMHS 2)
Viewing ADHD as a chronic disease that need constant treatment
It’s an interesting one isn’t it? Because if you’ve been diagnosed with diabetes you don’t tend to take 2 weeks off your insulin and I just sort of, it’s interesting so I wonder where that idea has come from about why we might withdraw medication (CAMHS 7) |
Perceiving their role as limited to referral and continue prescribing
My role I see as signposting, I’m not trained in child psychiatry (GP2) I think, it’s not something that I would initiate, of course, but my role is to repeat prescribing (GP 6)
Relying heavily on specialists
We do what we are told, do you know what I mean? It’s, because it’s such a specialised thing and I think, I didn’t receive that much training in it either (GP 8) No, I’m all, I’m waiting for the initiative to come from secondary care (GP1)
Concerns about abrupt withdrawal symptoms
I think the withdrawal has to be done slowly, just like an antidepressant, with close supervision (GP 8) |
Automatic motivation |
Planned and unplanned drug holidays from ADHD medication are initiated by many parents, which makes practitioner-initiated drug holidays unnecessary.
Now any person who’s worked with ADHD will tell you the parent will occasionally forget to take the medication, give this child medication, and they will see the outcome, so they will notice, or the teacher will know that this child has not been medicated today. So most often you don’t need to do this specific 2 weeks (CAMHS 2) Quite often parents have tried it anyway, they said, well we just wanted to see what would happen (CAMHS 8)
Feeling that most children with ADHD need medication and are unable to function without it.
I don’t remember more than two or three cases who actually stopped and completely went out of without complaining about this (CAMHS 4) | N/A |
Identifying barriers to practitioner-initiated planned drug holidays
So quite often I will find that I’m recording in the file that there was an effective trial off medication even though it wasn’t planned (CAMHS 8)
So it’s unusual situation where people have been asked to do this but certainly in my mind, when we did the CQUIN for a whole year and nobody wanted to stop the medication (CAMHS 2).
We ought to have training sessions on, we’re talking about holidays and when to stop and when, so we can actually justify with evidence what we’re doing (GP 2).
You could always make a case, I know, saying, oh, we should be involved more, but I think the truth is that it’s difficult because of the time constraint (GP 5).
I don’t have any material available but I tell them to try, start trying this the weekend first, then try it more for, say one week or two, or if everything is ok then try it more and see how it goes (CAMHS 4)
Most of the parents don’t want to stop medication…Do you want to try them, the treatment withdrawal trial, but I think it’s still parents views that it’s not helping (CAMHS 4)
Other parents just think, well no I’m going to go back to doing, they’re going to go back to being what they were before, without even trying to have a holiday break (CAMHS 6)
Well do they still need it? Why should I give medication which is unnecessary? Should we be doing that especially in children with growing brains and all this sort of thing? (GP 1)
In principle I think it’s a good idea, yes. You, ultimately you would like all children with ADHD to be off medication if necessary, either because their condition improves or medication is no longer needed (GP 3)
I think one needs to be aware of the side effects and, as I say, from my perspective, I’m always keen to try and withdraw any medication with children, particularly a medication like methylphenidate if one worries about what the effects might be (GP 5)
Well as I said, for me the instance is a psycho-stimulant that works on the central nervous system, secondly the liver accumulates all the chemicals we put into it. Thirdly why prescribe when you don’t have to in terms of cost on NHS? (GP 2)
It’s an interesting one isn’t it? Because if you’ve been diagnosed with diabetes you don’t tend to take two weeks off your insulin and I just sort of, it’s interesting so I wonder where that idea has come from about why we might withdraw medication (CAMHS 7)
They (parents) are good checking it out themselves, they don’t need us to tell them when to try it. I think it’s, that’s my perception of why it’s happened (CAMHS 2)
Somebody’s ten year old, and he started medication at eight year old, then obviously the psychological intervention they may not be able to use it correctly. I don’t know but comparatively, compared to 10 years stopping, compared to 14 years stopping, the medication is more needed (CAMHS 4)
I would be reluctant to withdraw it without advice from the consultant. Yes, if you withdraw a stimulant abruptly then clearly there could be withdrawal effects from it and you would want to manage those (GP 3)
Discussion
Practical recommendations for successful drug holidays
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Drug holidays are more successful among stable cases where the child is symptom-free for a reasonable period of time.
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Drug holidays should be offered to everyone regardless of their type of diagnosis (i.e. hyperactive/impulsive type, inattention type, and combined type).
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Drug holidays are more successful when there is an agreement between the child and their parents about having a trial without the medication and where the surrounding environments (such as family members and school teachers) are supportive.
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Drug holidays might be more successful among children who are on a low dose of medication or those who don’t have other comorbidities (such as autistic syndrome or obsessive–compulsive disorder).