Are Clinicians Following Guidelines When Prescribing ADHD Medication?

What you need to know

• Clinicians’ adherence to guidelines for prescribing ADHD medication did not decrease between 2008 and 2012, despite a large increase in prescriptions during this period.
• Mental health settings showed better adherence to guidelines than pediatric settings when prescribing ADHD medication.
• There is significant room for improvement in adherence to clinical guidelines, particularly regarding the use of structured interviews and providing psychoeducation.

Understanding ADHD medication prescribing practices

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children and adolescents. The most widely prescribed medication for ADHD is methylphenidate, which accounts for over 90% of ADHD prescriptions in some countries. Between 2008 and 2012, there was a substantial increase in methylphenidate prescriptions in many European countries, including a 35.6% increase in the Netherlands.

This rise in prescriptions has led to concerns about potential overdiagnosis of ADHD and overtreatment with medication. To ensure that children receive appropriate care, it’s crucial that healthcare providers follow clinical guidelines when diagnosing ADHD and prescribing medication. These guidelines provide evidence-based recommendations for assessment and treatment.

A team of researchers in the Netherlands conducted a study to examine whether the increase in methylphenidate prescriptions was accompanied by a decrease in clinicians’ adherence to guidelines. They were particularly interested in whether there were changes in diagnostic procedures that could lead to overdiagnosis, or changes in prescribing practices that could indicate overtreatment.

How the study was conducted

The researchers reviewed the medical records of 506 children and adolescents who received their first methylphenidate prescription in either 2008 or 2012. These records came from mental health clinics and pediatric outpatient clinics across the Netherlands.

They assessed adherence to seven key guideline recommendations:

1. Obtaining information from the child’s school
2. Using a structured interview with parents
3. Conducting a separate diagnostic session with the child
4. Assessing for other co-existing conditions (comorbidities)
5. Specifying ADHD severity
6. Providing education to parents about ADHD
7. Providing education to the child’s teacher about ADHD

The researchers also looked at whether the medication was prescribed “off-label” - meaning for children under 6 years old or for conditions other than ADHD.

Key findings on guideline adherence

No decrease in guideline adherence over time

Contrary to what might be expected given the large increase in prescriptions, the study found no significant decrease in overall guideline adherence between 2008 and 2012. The average adherence to the seven recommendations was 43% in 2008 and 45% in 2012.

This suggests that the increase in methylphenidate prescriptions during this period was not due to clinicians becoming less careful in their diagnostic and prescribing practices.

Differences between mental health and pediatric settings

The study revealed that clinicians in mental health settings showed better adherence to guidelines than those in pediatric settings:

• Use of structured parent interviews: 22% in mental health vs. 3% in pediatrics
• Separate diagnostic session with the child: 81% in mental health vs. 63% in pediatrics
• Assessment of comorbidities: 95% in mental health vs. 76% in pediatrics
• Providing parent education: 51% in mental health vs. 24% in pediatrics

Overall guideline adherence was 48% in mental health settings compared to 36% in pediatric settings.

Areas of strength and weakness in guideline adherence

Some guideline recommendations were followed more consistently than others:

Strengths:

• 89% of records showed assessment of comorbidities
• 75% reported obtaining information from the child’s school
• 75% conducted a separate diagnostic session with the child

Weaknesses:

• Only 1% of records specified ADHD severity
• Only 16% used a structured interview with parents
• Only 42% provided education to parents
• Only 1% provided education to teachers

Changes in first-line treatment

Interestingly, the study found that methylphenidate was less often used as the first treatment choice in 2012 compared to 2008 (64% vs. 78%). This suggests that over time, clinicians became more likely to try non-medication treatments first.

Off-label use of methylphenidate

The study found that a significant proportion of methylphenidate prescriptions were for “off-label” use - either for children under 6 years old or for conditions other than ADHD. Off-label use accounted for about 30-35% of prescriptions in both 2008 and 2012.

Common reasons for off-label use included:

• Autism spectrum disorder
• Oppositional defiant disorder
• Mood disorders
• Learning disorders

The high rate of off-label use suggests that methylphenidate is often prescribed for a broader range of attention and behavior problems beyond just ADHD.

Implications for clinical practice

The findings of this study have several important implications for improving ADHD care:

1. Need for better documentation: The low rates of adherence to some guideline recommendations may partly reflect poor documentation rather than poor practice. Clinicians should ensure they thoroughly document their diagnostic and treatment decisions.

2. Importance of structured assessments: The infrequent use of structured parent interviews is concerning, as these can help ensure a comprehensive evaluation. Clinics should consider implementing standardized assessment protocols.

3. Gaps in psychoeducation: The low rates of providing education to parents and teachers represent a missed opportunity. Education about ADHD can help families and schools better support the child.

4. Specifying ADHD severity: Almost no records specified ADHD severity, despite this being important for treatment planning. Clinicians should be encouraged to formally assess and document symptom severity.

5. Differences between settings: The better guideline adherence in mental health settings compared to pediatric settings suggests a need for more ADHD-specific training for pediatricians.

6. Off-label prescribing: The high rate of off-label use indicates a need for more research on the effectiveness of methylphenidate for other conditions, and potentially updated guidelines to address this common practice.

Conclusions

• Guideline adherence for ADHD assessment and treatment did not decrease between 2008-2012, despite increased prescriptions.
• Mental health settings showed better adherence to guidelines than pediatric settings.
• There is significant room for improvement in following clinical guidelines, particularly in using structured assessments and providing psychoeducation.

This study provides valuable insights into real-world clinical practices for ADHD. While it’s reassuring that guideline adherence did not decrease as prescriptions increased, the findings highlight several areas where ADHD care could be improved. By addressing these gaps, clinicians can help ensure that children with attention and behavior problems receive optimal, evidence-based care.