This article was downloaded by: [University of Kent] On: 01 December 2014, At: 09:58 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20

A comparison between South African psychiatrists' and paediatricians' knowledge, attitudes and current practices regarding the management of children with Attention Deficit/Hyperactivity Disorder André Venter , Gidea van der Linde , Jan du Plessis & Gina Joubert Published online: 12 Nov 2009.

To cite this article: André Venter , Gidea van der Linde , Jan du Plessis & Gina Joubert (2004) A comparison between South African psychiatrists' and paediatricians' knowledge, attitudes and current practices regarding the management of children with Attention Deficit/Hyperactivity Disorder, Journal of Child & Adolescent Mental Health, 16:1, 11-18, DOI: 10.2989/17280580409486558 To link to this article: http://dx.doi.org/10.2989/17280580409486558

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

Copyright © NISC Pty Ltd

Journal of Child and Adolescent Mental Health 2004, 16(1): 11–18 Printed in South Africa — All rights reserved

JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1682–6108

A comparison between South African psychiatrists’ and paediatricians’ knowledge, attitudes and current practices regarding the management of children with Attention Deficit/Hyperactivity Disorder André Venter1*, Gidea van der Linde1, Jan du Plessis2 and Gina Joubert2 Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Free State, PO Box 339 (G69), Bloemfontein 9300, South Africa 2 Department of Biostatistics, Faculty of Health Sciences, University of the Free State, PO Box 339 (G69), Bloemfontein 9300, South Africa * Corresponding author, e-mail: [email protected]

Downloaded by [University of Kent] at 09:58 01 December 2014

1

The objective of this study was to determine the knowledge, attitudes and current practices of psychiatrists and paediatricians in South Africa regarding the management of children with Attention Deficit/Hyperactivity Disorder (ADHD), to determine if there are significant differences between them. Three hundred and forty psychiatrists and 517 paediatricians were identified from the address list of the Health Professionals Council of South Africa. Each specialist was sent a survey questionnaire with a letter explaining the objectives and aims of the research. The questionnaire explored four themes: demographic data; attitudes to caring for children with ADHD; management of these children and knowledge about the use of stimulants. One hundred and seventy three (57.6%) psychiatrists and 316 (61%) paediatricians responded. Of these 145 and 278 respectively were practising medicine, and 51.7% (75) of the psychiatrists and 61% (169) of the paediatricians indicated that they manage children with ADHD. The results of the survey indicate that paediatricians and psychiatrists have adequate knowledge of ADHD and its management. Possibly because of the organisation of their practices psychiatrists were not as concerned as paediatricians about the time spent on each patient, but they were less likely to refer to other professionals. On the other hand, paediatricians had more of an interdisciplinary approach to the management of children with ADHD, but found them time consuming, remuneration inadequate and had little time to prepare extensive reports or liase with other professionals or schools. Psychiatrists appear to function within a neuro-biological model and have more knowledge on neuro-pharmacology and physiology. Paediatricians have a greater educational and family awareness, possibly reflecting differences in training. Both groups use methylphenidate as the medication of choice and both have adequate knowledge of its benefits, side effects and contra-indications.

Introduction Attention Deficit/Hyperactivity Disorders (ADHD) are recognised as the most common neuro-behavioural disorders of childhood, affecting children from infancy into adult life. Despite the fact that 3–5% of children have attention deficit disorders, the diagnosis and management remain controversial (Kwasman et al. 1995, Rappley et al. 1995). There has been some concern about who should primarily diagnose ADHD in children and initiate the prescription of stimulants as part of the management of ADHD, as it has been argued that the same medical professionals should also be able to address psychological, educational and family issues if necessary (Levy 1998, Sayal 1998). Even though there has been concern regarding the lack of ‘ownership’ of the diagnosis of ADHD by the medical profession (Rasch 1994), it is perceived that there is also a lack of knowledge regarding these conditions among medical specialists. The absence of definitive tests to diagnose these conditions further serves to complicate matters. Although recent studies have identified both dysfunction of cerebral executive functions as well as a high inheritability (Castellanos, Giedd and Marsh 1996, Levy et al. 1997), the aetiology of these conditions is still shrouded in mystery in the popular press and alternative explanations abound.

Because of the visibility and accessibility of these points of view, both parents and the medical profession may be unduly influenced, both in the way they perceive these conditions and the management they may recommend. Two modalities have been identified as important in the treatment of ADHD: behaviour modification (O’Leary et al. 1996) and stimulant medication. Many studies have shown positive effects with stimulants for the majority of children with ADHD (Barkley 1977, Elia, Borcherding and Rapoport 1991, Masellis et al. 2002, Wender 2001). Side effects are usually not a concern if the medication is adequately monitored and concerns about addiction have not been justified (Wilens et al. 2003). In fact, recent studies have shown a superior effect of stimulant medication when compared to behavioural management alone or ‘community’ management of ADHD (MTA Cooperative Group 1999). One previous study investigated the knowledge and attitudes of paediatricians in the United States of America (Kwasman, Tinsley and Lepper 1995). A survey was performed using a 48-item questionnaire, which was sent to a national sample of 1 000 paediatricians. The response rate was 38%. The majority of respondents appeared to be interested in treating their patients with ADHD effectively. The

Downloaded by [University of Kent] at 09:58 01 December 2014

12

problems they experienced in doing so were: the time that these patients require, inadequate reimbursement and follow-up reporting. Methylphenidate was the drug most widely used. Thirty-seven percent of the respondents believed that stimulants have a paradoxical effect, although this point of view has been challenged (Whalen and Henker 1991). Similar studies on psychiatrists have not been reported. Because of their training, their consultative style and organisation of their practices, psychiatrists may have different attitudes towards managing children with ADHD than paediatricians. The purpose of the present study was to determine current practices and attitudes of psychiatrists and paediatricians in South Africa with respect to diagnosis and management of paediatric patients with ADHD. The aim of the survey was to assess their understanding of the aetiology of ADHD and the implications of the diagnosis, as well as their attitudes to management with particular reference to their knowledge regarding medication. This information would be important regarding the referral of children suspected of having ADHD and also has implications for health management and planning. Method All registered psychiatrists and paediatricians in South Africa were identified using the address list of the Health Professionals Council of South Africa. All specialists were sent a survey questionnaire with a letter explaining the aims and objectives of the study, together with a self addressed envelope. In order to improve the response rate, the survey questionnaire was sent to all specialists twice. The survey questionnaire, in English only, was developed specifically for this study based on a questionnaire developed by Kwasman et al. (1995) for a similar survey of paediatricians. The questionnaire consisted of four major sections: Section A, demographic data; Section B, attitudes towards caring for children with ADHD; Section C, management of children with ADHD and Section D, knowledge about the use of stimulants. Items were added to the original questionnaire developed by Kwasman et al. after a review of the relevant research, particularly regarding the use of stimulants. For most statements respondents were expected to mark the statements they agreed with only, but for some items they had to mark an option that most accurately reflected their opinion, such as ‘agree’, ‘neutral’ and ‘disagree’. Items were also included that reflected ‘alternative’ points of view regarding aetiology and management to assess to what degree these were considered by specialists in their practice. Only specialists in active practice at the time of the survey were requested to complete the anonymous questionnaire. All respondents were requested to complete section A, while only those who managed children with ADHD had to complete sections B, C and D as well. Results were summarised by frequencies and percentages. The responses of psychiatrists and paediatricians were compared statistically by 95% Confidence Intervals (CIs) for the differences between percentages.

Venter, Van der Linde, Du Plessis and Joubert

Results Questionnaires were mailed to 388 psychiatrists and 546 paediatricians (Table 1). Of these, 41 addressed to psychiatrists and 21 to paediatricians were returned as ‘address unknown’, four psychiatrists and two paediatricians had passed away and three and six respectively had emigrated. Of the 340 questionnaires that were therefore appropriately mailed to psychiatrists, 173 (57.6%) were returned and of the 517 to paediatricians, 316 (61.1%) were returned. 28 psychiatrists and 38 paediatricians indicated that they were not practising any more. Therefore, there were 145 questionnaires from psychiatrists available for analysis and 278 from paediatricians. 75 (51.7%) psychiatrists and 169 (61%) paediatricians indicated that they treat children with ADHD. The majority of paediatricians managed toddlers, preschoolers and school-aged children with ADHD, whereas the majority of psychiatrists treated school-aged children, adolescents and adults. The demographic data of the respondents who treat children with ADHD are summarised in Table 2. As not all the respondents answered every item, totals are not always the same. For both specialist groups the ratio of males to female was about 2:1. The majority of respondents were between 40–49 years (41.3% and 45.2% respectively). In both groups the majority of respondents were in private practice (52.0% and 50.6%). A third of the respondents had been in practice between five and ten years. Results of the responses of the different items will be given in the same order as they appeared in the questionnaire. The attitudes of the two groups regarding the management of children with ADHD in their practice are summarised in Table 3. There were no statistically significant differences between the responses of psychiatrists and paediatricians to questions such as whether they enjoy seeing children with ADHD, avoid them, feel ‘burnt out’ by them, or whether they disrupt their schedules. More than a third indicated that they enjoyed seeing these patients and more than 60% would not actively avoid them. Relatively few found them exhausting (8.3% and 13.6% respectively). Only 14.1% of psychiatrists and 21.29% of paediatricians considered them to disrupt their schedules. A statistically significant difference was found regarding the statement that these children take up too much time (16.9% of psychiatrists vs 49.7% of paediatriTable 1: Details of the number of respondents Respondents Questionnaires mailed Address unknown Deceased Emigrated Appropriately mailed Returned Practising Not practising Manage ADHD

Psychiatrists 388 41 4 3 340 173 (57.6%) 145 28 75 (51.7%)

Paediatricians 546 21 2 6 517 316 (61.1%) 278 38 169 (61%)

Journal of Child and Adolescent Mental Health 2004, 16: 11–18

13

Table 2: Descriptive data of respondents who treat children with ADHD

Gender Age

Type of practice

Downloaded by [University of Kent] at 09:58 01 December 2014

Years in practice

Psychiatrists (n = 75) n % 53 70.7 22 29.3 17 22.7 31 41.3 19 25.3 8 10.7 39 52.0 12 16.0 4 5.3 2 2.7 10 13.3 8 10.7 19 25.3 29 38.7 10 12.3 5 6.7 12 16.0

Male Female 30–39 40–49 50–59 60+ Private only Mixed Part time Academic Hospital based Other 20

Paediatricians (n = 16) n % 129 76.8 39 23.2 41 24.4 76 45.2 34 20.2 17 10.1 85 50.6 34 20.2 9 5.4 10 6.0 16 9.5 14 8.3 26 15.5 56 33.3 28 16.7 27 16.0 31 18.5

Table 3: Attitudes towards managing children with ADHD

Enjoy patients with ADHD Avoid patients with ADHD Do they cause burn out? Disrupt schedules Take too much time Poor reimbursement Difficult to co-ordinate interventions Difficult liasing with schools Difficult liasing with other.professionals Writing reports is problematic Dealing with difficult parents

Psychiatrists (n = 75) Disagree Neutral Agree n % n % n % 3 4.1 45 61.6 25 34.2 47 64.4 22 30.1 4 5.5 42 58.3 24 33.3 6 8.3 45 63.4 16 22.5 10 14.1 41 57.7 18 25.4 12 16.9 31 44.9 24 34.8 14 20.3 18 25.0 14 19.4 40 55.6 18 24.7 11 15.1 44 60.3 31 43.7 20 28.2 20 28.2 34 33.3 31 43.1 17 23.6 27 37.5 27 37.5 18 25.0

cians). Similarly, significantly more paediatricians experience difficulties writing reports (38.4% vs 23.6%) and were of the opinion that they were poorly reimbursed for the time spent on these children (52.7% vs 20.3%). About 50% in both groups indicated that it was difficult to co-ordinate interventions and liasing with schools. Twenty five percent of the psychiatrists and 31.7% of paediatricians experienced problems with difficult parents. Both professional groups found that they had to set aside more time for the assessment of ADHD children in their practice than their other patients. Significantly more paediatricians indicated that this was the case (89%) than psychiatrists (54.9%). The majority of psychiatrists (59.1%) indicated that a consultation may last 60–90 minutes or more, whereas the majority of paediatricians (71.7%) indicated that the consultation generally lasted 30–60 minutes or less. Once diagnosed, the majority of psychiatrists followed the children up at monthly intervals (66.7%), and paediatricians every two to six months (81%). Blood tests are never done on these children by 21.1% of psychiatrists and 39.4% of paediatricians, while 42% in each

Paediatricians (n = 169) Disagree Neutral Agree n % n % n % 19 11.2 81 47.9 69 40.8 112 66.3 45 26.6 12 7.1 87 51.5 59 34.9 23 13.6 75 45.5 55 33.3 35 21.2 52 31.1 32 19.2 83 49.7 37 22.2 42 25.1 88 52.7 43 26.2 32 19.5 89 54.3 36 22.0 46 28.0 82 50.0 71 43.3 44 26.8 49 29.8 38 23.2 63 38.4 63 38.4 61 36.5 53 31.7 53 31.7

95% CI for difference in % who Agree –19.3; 6.8 –7.6; 5.7 –12.9; 3.7 –16.7; 3.7 –43.4;–20.4 –43.9;–19.9 –12.5; 14.8 –3.5; 23.5 –13.9; 11.1 –26.5; –2.0 –18.5; 5.9

group indicated that they would do blood tests less often than annually. The respondents in both groups were of the opinion that the management of children with ADHD could be improved through improved teacher education (95.9% and 97%), parental education (97.3% and 97%), interdisciplinary contact (83.6% and 94.6%) and education of medical professionals (90.4% and 93.4%). Statistically significantly more paediatricians than psychiatrists indicated that improved interdisciplinary contact would improve the management of children with ADHD. Half of both specialist groups (51.4% and 51.8%) indicated that improved remuneration of medical professionals would improve care (Table 4). As the management of children with ADHD is considered a multi-disciplinary task, an item specifically dealt with the specialists’ referral patterns of patients with ADHD. In this item respondents could select one of four options: ‘always’, ‘often’, ‘seldom’ and ‘never’. In order to simplify the reporting, the number of responses for ‘always’ and ‘often’ were combined, as well as ‘seldom’ and never’. The data are given in

14

Venter, Van der Linde, Du Plessis and Joubert

Table 4: Attitudes regarding improving care of children with ADHD

Improve Improve Improve Improve Improve

Psychiatrists (n = 75) Disagree Neutral Agree n % n % n % teacher education 1 1.4 2 2.7 70 95.9 parent education 0 0 2 2.7 71 97.3 inter-disciplinary contact 1 1.4 11 15.1 61 83.6 remuneration 9 12.9 25 35.7 36 51.4 education of medical professionals 0 0 7 9.6 66 90.4

Paediatricians (n = 169) Disagree Neutral Agree n % n % n % 1 0.6 4 2.4 160 97 1 0.6 4 2.4 162 97 1 0.6 8 4.8 158 94.6 29 17.7 50 30.5 85 51.8 1 0.6 10 6.0 156 93.4

95% CI for difference in % who Agree –7.3; 3.8 –5.3; 4.5 –20.6; –2.2 –14.3; 13.4 –11.4; 4.3

Table 5: Specialists’ patient referral (patterns) to other professionals Psychiatrists (n = 75) Always/Often Seldom/Never n % n % Dietician 7 9.9 64 90.2 Educational therapist 44 62.0 27 38.0 Homeopath 1 1.4 69 98.6 Neurologist 28 38.9 44 61.1 Occupational therapist 52 72.2 20 27.7 Paediatrician / Developmentalist 29 41.4 41 58.6 Physiotherapist 4 5.6 68 94.5 Psychiatrist – – – – Psychologist 47 65.3 25 34.7 Social worker 17 23.6 55 76.4 Speech therapist 14 19.5 58 80.5 Support group 25 35.2 46 64.8

Downloaded by [University of Kent] at 09:58 01 December 2014

Referral

Table 5. Neither group generally refers to homeopaths and and neither is likely to refer to dieticians, physiotherapists and social workers, although psychiatrists were significantly more likely than paediatricians to refer to social workers. A third in each group would consider referral to a support group. Both groups tended to refer to occupational therapists, psychologists and educational psychologists, but paediatricians were significantly more likely than psychiatrists to refer these children to educational therapists and occupational therapists. Although differences were not significant paediatricians also refer to psychologists more often than psychiatrists, and more psychiatrists may refer these children to neurologists than paediatricians would. Paediatricians were significantly more likely than psychiatrists to refer children to physiotherapists and speech therapists. About 80% of respondents ‘often’ or ‘always’ obtain information from the schools as part of their assessment. Eighty three percent of paediatricians would ‘always’ or ‘often’ refer children with ADHD for educational assessment, whereas 48% of psychiatrists indicated that they would. Likewise, 66.8% of paediatricians would refer these children for a psychological assessment compared to only 48% of psychiatrists. Generally both groups found schools to be co-operative in making the diagnosis, offering remedial teaching, dispensing medication, giving feedback and supervising behaviour modification programs, although psychiatrists were generally less convinced than paediatricians. About 70% of both groups indicated that they would refer children suspected of ADHD either for an educational or a psychological evaluation before commencing therapy.

Paediatricians (n = 169) Always/Often Seldom/Never n % n % 8 5.1 150 94.9 125 77.1 37 22.9 0 0 157 100 43 26.2 121 73.8 147 88.5 19 11.4 – – – – 32 19.8 130 80.2 12 7.5 149 92.5 123 75 41 25.0 19 11.6 145 88.4 83 50.3 82 49.7 53 32.9 108 67.1

95% CI for difference in % Always/Often –2.5; 13.2 –28.1; –2.3 –1.3; 5.6 –0.3; 25.7 –27.8; –5.1 – –21.6; –5.2 – –22.6; 2.9 1.4; 23.2 –41.9; –18.2 –10.7; 15.6

The number of patients treated annually and their age groups varied considerably between practices and could not be summarised in a table. In order to assess the belief systems regarding the management of ADHD, specific interventions were listed and respondents had to indicate to what extent they agreed that the listed interventions were relevant (Table 6). These answers generally correlated with the responses illustrated in Table 5. Behaviour modification, family therapy, medication, occupational therapy and remedial teaching were considered important in more than 80% of respondents in both groups. Compared to psychiatrists, paediatricians indicated significantly more often that remedial therapy and speech therapy are important. Significantly more psychiatrists than paediatricians considered psychotherapy important. Very few specialists indicated ‘alternative therapies’ such as biofeedback and treatment of fungal infections, although 23.9% of psychiatrists and 37.6% of paediatricians highlighted ‘treatment of inner-ear problems’. The specialists were asked to indicate how often they would consider using various medications (Table 7). Methylphenidate is used ‘always’ or ‘often’ by 91.7% of psychiatrist and 95.7% of paediatricians. Antidepressants were the most common second line medication, indicated by 62.8% of the psychiatrists and 16.9% of the paediatricians, a difference that was statistically significant. Psychiatrists prescribed clonidine and fluoxetine significantly more often than did paediatricians. Other medications listed, but not commonly in use, were: phenobarbitone, hydroxyzine, trichloral hydrate, vitamin supplements and ‘natural remedies’. There

Journal of Child and Adolescent Mental Health 2004, 16: 11–18

15

Table 6: Important modules of treatment in ADHD

Downloaded by [University of Kent] at 09:58 01 December 2014

Treatment modality

Psychiatrists (n = 75) Disagree Neutral Agree n % n % n % Behaviour modification 3 4.1 6 8.2 64 87.7 EEG Biofeedback 26 36.6 35 49.3 10 14.1 Dietary manipulation 27 38.0 27 38.0 17 23.9 Family therapy 2 2.7 7 9.6 64 87.7 Homeotherapy 48 67.6 21 29.6 2 2.8 Medication 1 1.4 5 6.8 67 91.8 Nutritional supplementation 31 43.7 27 38.0 13 18.3 Occupational therapy 3 4.2 11 15.5 57 80.3 Psychotherapy 3 4.2 14 19.4 55 76.4 Physiotherapy 20 28.2 41 57.7 10 14.1 Remedial teaching 2 2.7 8 11.0 63 86.3 Speech therapy 9 12.7 37 52.1 25 35.2 Social skills training 4 5.5 11 15.1 58 79.5 Treatment of fungal infections 43 60.6 27 38.0 1 1.4 Treatment of inner-ear problems 21 29.6 33 46.5 17 23.9

Paediatricians (n = 169) Disagree Neutral Agree n % n % n % 5 3.0 19 11.6 140 85.4 79 48.7 64 39.0 21 12.8 66 40 57 34.5 42 25.5 1 0.6 23 13.8 143 85.6 124 75.2 40 24.2 1 0.6 0 0 14 8.3 154 91.7 68 41.2 78 47.3 19 11.5 6 3.6 23 13.6 140 82.8 13 7.9 47 28.7 104 63.4 54 33.1 68 41.7 41 25.2 1 0.6 6 3.6 160 95.8 11 6.6 59 35.5 96 57.8 5 3.0 40 24.2 120 72.7 114 69.9 42 25.8 7 4.3 50 30.3 53 32.1 62 37.6

95% CI for difference in % who Agree –7.6; 11.1 –7.8; 11.4 –13.0; 10.8 –7.8; 10.8 –1.6; 7.3 –8.2; 7.2 –3.0; 7.4 –13.8; 7.8 0.2; 24.6 –20.8; 0.1 –22.0; –6.1 –35.4; –8.8 –5.2; 17.7 –6.7; 2.4 –25.4; –0.8

Table 7: Medication used for treating ADHD Medications

Anti-depressants Carbamazepine Clonidine Fluoxetine Methylphenidate Pemoline Thioridazine

Psychiatrists (n = 75) Always/Often Seldom/Never n % n % 44 62.8 26 37.2 20 28.2 51 71.9 6 8.8 62 91.2 7 10.1 62 89.8 66 91.7 6 8.3 15 21.7 54 78.3 13 18.8 56 81.2

were no obvious trends or differences between the groups as far as the frequency of stimulant prescription was concerned. The factors considered to play an important role in the aetiology of ADHD are listed in Table 8. Significantly more psychiatrists than paediatricians indicated that the aetiology of ADHD was related to abnormal cerebral function, such as ‘abnormal arousal modulation’, ‘chemical imbalance’ and malfunction of the anterior cerebral lobes and reticular activation system. Significantly more paediatricians than psychiatrists were concerned about increased educational pressure. There was consensus that ‘cerebral transmitter imbalance’, ‘chaotic home situation’, ‘genetic influences’, and ‘poor parenting’ are important in the aetiology of ADHD. Few respondents supported controversial or alternative explanations of ADHD. The final section of the questionnaire dealt with knowledge and perceptions of methylphenidate. The first item dealt with perceptions regarding the pharmacological effects of methylphenidate (Table 9). The most common answer was that it acted as a general stimulant (41.1% and 42.5%). Significantly more psychiatrists (53.4%) than paediatricians (31.7%) indicated that methylphenidate has a paradoxical effect and they also indicated more often that it causes direct stimulation of the frontal lobes and increases levels of noradrenaline. Statistically more paediatricians (29.9%) than

Paediatricians Always/Often n % 26 16.9 8 5.2 2 1.3 1 0.7 157 95.7 22 14.5 15 9.7

(n = 169) Seldom/Never n % 128 83.1 146 94.8 152 98.7 152 99.3 7 4.3 130 85.5 140 90.3

95% CI for difference in % Always/Often 32.6; 57.9 12.0; 34.0 0.9; 15.2 2.6; 17.4 –11.9; 2.6 –3.6; 18.8 –0.8; 19.9

psychiatrists (15.1%) indicated that the effects of stimulants were not known. The responses regarding expected benefits of methylphenidate are given in Table 10. In general, there were no significant differences between the two groups except for three items. More paediatricians indicated that methylphenidate improves handwriting and helps students to complete their work, while more psychiatrists marked the item ‘makes less “silly” mistakes at school’. Significant numbers in both groups indicated that beneficial effects include improved attention span and decreased aggressive or noisy behaviour, hyperactivity, impulsivity and disruptiveness. The outcome of an item regarding the contra-indications of methylphenidate is summarised in Table 11. More than 90% of psychiatrists and 80% of paediatricians (significant difference) considered uncontrolled epilepsy and 94.5% and 73.7% (significant difference) respectively considered psychosis as a significant contra-indication. Significantly more paediatricians than psychiatrists considered methylphenidate contra-indicated in mental retardation (33.5% vs 20.5%) and pre-school aged children (41.3% vs 27.4%). Few respondents in both groups considered the use of stimulants contraindicated in adolescents, adults and in children with developmental disorders, although 30% in both groups were of the opinion that stimulants should not be used in children with

16

Venter, Van der Linde, Du Plessis and Joubert

Table 8: Responses to the question: Which of the following may be important in the aetiology of ADHD?

Downloaded by [University of Kent] at 09:58 01 December 2014

Abnormal arousal modulation Cerebral transmitter imbalance Chaotic home situation Chemical imbalance Educational pressure Fungal overgrowth Genetic influences Malalignment of the skull Malfunction of anterior cerebral lobes Malfunction of the reticular activation centre Middle-ear problems Over stimulation Poor diet Poor parenting

Psychiatrists (n = 72) n % 53 73.6 48 66.7 50 69.4 39 54.2 21 29.2 0 0 59 81.9 2 2.8 30 41.7 47 65.3 20 27.8 19 26.4 19 26.4 40 55.6

Paediatricians (n = 166) n % 78 47.0 102 61.4 108 65.1 66 39.8 88 53.0 2 1.2 132 79.5 0 0 39 23.5 54 32.5 66 39.8 41 24.7 50 30.1 105 63.3

95% CI for difference in % 13.4; 38.6 –11.6; 14.3 –8.7; 16.8 0.6; 27.8 –36.1; –10.4 –3.1; 2.2 –8.9; 12.7 –0.8; 7.7 5.1; 31.1 19.2; 45.2 –24.2; 1.1 –10.0; 14.1 –15.6; 8.9 –21.2; 5.8

Psychiatrists (n = 173) n % 30 41.1 0 0 18 24.7 24 32.9 23 31.5 22 30.1 5 6.8 11 15.1 39 53.4 18 24.7

Paediatricians (n = 167) n % 71 42.5 2 1.2 18 10.8 48 28.7 47 28.1 26 15.6 8 4.8 50 29.9 53 31.7 54 32.3

95% CI for difference in % –14.7; 12.2 –3.1; 2.1 3.2; 25.0 –8.3; 17.0 –9.0; 16.2 2.9; 26.5 –4.2; 9.5 –24.9; –3.5 8.1; 34.7 –19.3; 4.9

Psychiatrists (n = 73) n % 70 95.9 34 46.6 56 76.7 46 63.0 26 35.6 28 38.4 16 21.9 30 41.4 25 34.2 48 65.8 27 37.0 35 47.9 66 90.4 63 86.3 0 0 7 9.6 38 52.1

Paediatricians (n = 167) n % 162 97.0 81 48.5 153 91.6 103 61.7 68 40.7 46 27.5 31 18.6 102 61.1 45 26.9 116 69.5 79 47.3 78 46.7 149 89.2 145 86.8 1 0.6 12 7.2 3 1.8

95% CI for difference in % –7.3; 3.8 –15.5; 11.7 –25.7; –4.6 –12.1; 14.3 –18.0; 8.3 –2.1; 23.8 –7.4; 14.9 –33.0; –6.3 –5.3; 20.1 –16.7; 8.9 –23.3; 3.3 –12.4; 14.9 –7.7; 8.9 –10.5; 8.4 –2.2; 2.5 –5.0; 10.9 38.1; 61.2

Table 9: Pharmacological action of methylphenidate Possible actions Acts as a general stimulant Corrects inner-ear dysfunction Direct stimulation of frontal lobes Direct stimulation of reticular activation centre Increases levels of dopamine Increases levels of noradrenalin Increases glucose uptake in brain Not known Paradoxical effects Restores neurotransmitter imbalance

Table 10: Expected benefits of methylphenidate Benefit Attention improves More alert Complete work Decreased aggressive behaviour Improved auditory processing Improved language abilities Improved long term memory Improved handwriting Improved mathematics Decreased noisy behaviour Improved reading Improved short term memory Decreased hyperactivity Decreased impulsivity / disruptiveness Cure for ADHD Lasting effect into adulthood Less silly mistakes at school

marked emotional disturbance or Tourette syndrome (58%). The last section contained 22 items and explored the perceived significant side effects of methylphenidate. Few of the respondents were under the impression that there were

no side effects, although one psychiatrist and seven paediatricians indicated that they were not sure what the side effects might be. Anorexia and insomnia were considered the most significant side effects by both groups (>70% of

Journal of Child and Adolescent Mental Health 2004, 16: 11–18

17

Table 11: Contra-indications for the use of methylphenidate Contra-indications

Downloaded by [University of Kent] at 09:58 01 December 2014

Adolescents Adults Developmental disorders Emotional disturbances Gilles de la Tourette Mental retardation Pre-school children Psychosis Pure learning disorders Uncontrolled epilepsy

Psychologists (n = 75) n % 12 16.4 18 24.7 15 20.5 23 31.5 43 58.8 15 20.5 20 27.4 69 94.5 43 58.9 67 91.8

respondents). Five side effects were indicated significantly more often by psychiatrists than paediatricians, namely, convulsions (45.8% vs 27.5%), drug abuse (38.9% vs 16.8%), dysphoria (48.6% vs 34.1%), rebound effects (45.8% vs 30.5%) and significant weight loss (48.6% vs 26.3%). Discussion This study was able to demonstrate that significant differences exist between psychiatrists and paediatricians in South Africa regarding their knowledge and attitudes towards the management of children with ADHD. A response rate of 57.6% and 61.1% respectively is acceptable for a study of this nature (compared to the return rate of 38% in the study of Kwasman et al. 1996) and the data collected could be considered fairly representative of the specialist population. More than half of the responding psychiatrists (51.7%) and paediatricians (61%) indicated that they manage children with ADHD. Demographic data were similar for both groups. More than a third in each group indicated that they enjoy managing children with ADHD, compared to the 66% in the study of Kwasman et al. A few found them exhausting and felt that they disrupt their schedules. Significantly more paediatricians than psychiatrists were of the opinion that they took up too much time. Paediatricians were also more inclined to find report writing burdensome and felt poorly reimbursed. These findings probably reflect the difference in the way practices are managed by psychiatrists and paediatricians. The majority of psychiatrists spend more than an hour per patient, while paediatricians generally spend less than an hour (usually 30 minutes) per consultation. It must be presumed that psychiatrists generally set aside more time to see individual patients. They also follow patients up more regularly than paediatricians. Paediatricians, on the other hand, probably have limited time in their busy practices to dedicate to children with ADHD and are therefore more likely to experience children with ADHD as time consuming and have to set aside specific time to see these patients. They would also find the writing of reports, liasing with schools and dealing with parents burdensome. Again, the reimbursement structure of psychiatrists takes cognisance of the time they spend with patients, while this is not the case with paediatricians. Paediatricians would, therefore, be more inclined to be discontented with their remu-

Paediatricians (n = 168) n % 18 10.8 33 19.8 33 19.8 66 39.5 98 58.7 56 33.5 69 41.3 123 73.7 76 45.5 137 82.0

95% CI for difference in % –3.7; 15.8 –6.3; 16.7 –9.8; 12.2 –20.5; 5.2 –13.3; 13.5 –24.1; –0.8 –26.0; –0.9 11.4; 28.6 –0.3; 26.6 0.4; 17.7

neration when managing these children, yet more than half of the respondents in both groups were of the opinion that improved remuneration of medical professionals would lead to improved care of children with ADHD. Nearly all the respondents agreed that improved care could also be brought about by improved education of parents, teachers and medical professionals. Significantly more paediatricians than psychiatrists indicated that improved interdisciplinary contact would also improve care. This sentiment may reflect the differences in the types of practices, as already discussed. As part of the interdisciplinary group, paediatricians were significantly more inclined to refer these patients to educational, occupational, speech and physical therapists. They were also more inclined to refer these children to psychologists. Although not to a statistically significant extent, psychiatrists were more likely to refer to neurologists. These referral patterns probably reflect the different skills and approaches of the two specialities. While paediatricians would prefer to have information regarding the children’s developmental functioning and psychological assessment, psychiatrists are more interested in neurological factors affecting their management (such as petit mal epilepsy). Although there were statistically significant differences in the referral patterns of the two specialist groups, it must be pointed out that in general, referral patterns tended to be quite similar. These data are in stark contrast to the American study (Kwasman et al. 1996) where less than 20% of paediatricians indicated that they would consider referring these children to other professionals, especially in educational fields. Few specialists considered alternative therapies important. The question on the treatment of inner-ear problems, which was selected by 23.9% of psychiatrists and 37.6% of paediatricians, could have been misleading. The item referred to auditory integration therapy. Some specialists may have confused this with treating middle-ear problems, which could be common in children with ADHD because of the high incidence of allergies in this population group. Methylphenidate was the medication of choice for both groups, as also described in the study of Kwasman et al. Other stimulants are not available in South Africa. Antidepressants were the most important second choice for psychiatrists, but significantly less so for paediatricians. Generally, psychiatrists used a larger repertoire of medications than paediatricians.

Downloaded by [University of Kent] at 09:58 01 December 2014

18

As far as the aetiology of ADHD was concerned, significantly more psychiatrists than paediatricians referred to a neuro-biological model, probably a reflection of their training, but there was consensus in both groups that some level of ‘cerebral transmitter imbalance’ was responsible, as are genetic influences, chaotic home situation and poor parenting. Paediatricians were also concerned about educational pressure, which, although probably not strictly speaking an aetiological factor, does play a role in the referral of these children. The majority of respondents did not support more controversial or alternative explanations for ADHD. As the majority of respondents use methylphenidate in their practices, it was relevant that the last section dealt with knowledge and perceptions regarding this medication. In general, psychiatrists were more knowledgeable regarding the pharmacological actions of methylphenidate, probably reflecting their training. Although significantly more psychiatrists than paediatricians indicated that methylphenidate has a paradoxical effect, this is not universally accepted any more (Whalen and Henker 1991). Both groups knew the benefits of methylphenidate, although there were a few differences in their responses. Both groups correctly considered uncontrolled epilepsy and psychosis absolute contraindications for the use of methylphenidate. Paediatricians were more wary of using it for pre-school children and children with mental retardation. It is not surprising that for more controversial conditions, such as Tourette syndrome, there was a near fifty-fifty split. The majority of respondents were aware of the major side-effects of methylphenidate, although again, psychiatrists were significantly more aware of some side-effects such as convulsions, dysphoria, rebound effects and significant weight loss. They were also more concerned with drug abuse, which has been refuted in recent publications (Wilens et al. 2003). In general, it can be suggested that both paediatricians and psychiatrists have adequate knowledge of the ADHD and its management. Psychiatrists appear to be in a position to spend more time with these children and follow up visits are planned more frequently. They also are less likely to refer to other professionals than paediatricians. Because of the organisation of their practices, psychiatrists may be less concerned about the time it takes to manage these children. It may also be possible that they are consulted by an older spectrum of children who may be less stressful to manage. On the other hand, paediatricians have more of an interdisciplinary approach to the management of children with ADHD, but find them time consuming, remuneration inadequate and have little time to prepare extensive reports or liase with other professionals or schools. This probably represents the mixed practices that paediatricians have to manage where time has to be set aside daily for emergencies as well as other acutely ill patients. Both groups highlighted that improved remuneration could improve the care of these children, a matter that needs to be discussed with health funding managements. Psychiatrists appear to function within a neuro-biological model and have more knowledge of neuro-pharmacology

Venter, Van der Linde, Du Plessis and Joubert

and physiology, but paediatricians have a greater educational and family awareness, reflecting the differences in training. Both groups use methylphenidate as the medication of choice and have adequate knowledge of its benefits, sideeffects and contra-indications. In a country such as South Africa where specialists are not commonly available, especially in more remote rural areas, it is unlikely that one specialist group should manage these children in preference to the other. Both groups will have to be involved. Fortunately, different approaches withstanding, both groups appear to be trained to take on this task. References Barkley RA (1977) A review of stimulant drug research with hyperactive children. Archives of General Psychiatry 18: 137–165 Castellanos FX, Giedd JN and Marsh WL (1996) Quantitative brain magnetic resonance imaging in attention deficit hyperactivity disorder. Archives of General Psychiatry 53: 607–616 Elia J, Borcherding BG and Rappaport JL (1991). Methylphenidate and dextro-amphetamine treatments of hyperactivity: are there any true non-responders? Psychiatric Research 36: 141–155 Kwasman A, Tinsley BJ and Lepper HS (1995) Paediatricians’ knowledge and attitudes concerning diagnosis and treatment of Attention deficit and Hyperactivity disorders. Archives of Pediatric and Adolescent Medicine 149: 1211–1216 Levy F (1998) Attention deficit hyperactivity disorder: There are no easy answers whether to medicate or not. British Medical Journal 314: 225 (Editorial) Levy F, Hay D, McStephen M, Wood C and Waldman I (1997) Attention deficit hyperactivity disorder: A category or a continuum? Genetic analysis of a large scale twin study. Journal of the American Academy of Child and Adolescent Psychiatry 36: 737–734 Masellis M, Basile VS, Muglia P, Özdemir V, Macciardi FM and Kennedy JL (2002). Psychiatric pharmacogenetics: personalizing psychostimulant therapy in attention-deficit/hyperactivity disorder. Behavioural Brain Research 130: 85–90 MTA Cooperative Group (1999) A 14-month randomised clinical trial of treatment strategies for attention-deficit/Hyperactivity Disorder. Archives of General Psychiatry 56: 1073–1086 O’Leary KD, Pelham WE, Rosenbaum A and Price GH (1996) Behavioural treatment of hyperkinetic children: an experimental evaluation of its usefulness. Clinical Pediatrics 15: 510–515 Rappley MD, Gardiner JC, Jetton JR and Houng RT (1995) The use of methylphenidate in Michigan. Archives of Pediatric and Adolescent Medicine 149: 675–679 Rasch BW (1994) Attention Deficit Disorder: Is there a doctor in the house? American Journal of Psychiatry 151: 1397 (Letter) Sayal K (1998) Debate is needed over who provides drug treatment in Attention deficit hyperactivity disorder. British Medical Journal 316: 704 (Letter) Whalen CK and Henker B (1991) Therapies for hyperactive children: comparisons, combinations and compromises. Journal of Consulting Clinical Psychology 1191(94): 462–464 Wender EH (2001) Managing stimulant medicine for Attention deficit/Hyperactivity Disorder. Pediatrics in Review 22: 183–189 Wilens TE, Faraone SV, Biederman J and Gunawardene S (2003) Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta analytic review of the literature. Pediatrics 111: 179–185

Hyperactivity Disorder.

The objective of this study was to determine the knowledge, attitudes and current practices of psychiatrists and paediatricians in South Africa regard...
148KB Sizes 3 Downloads 7 Views