Attitudes and practices in the management of attention deficit hyperactivity disorder among Brazilian pediatric neurologists who responded to a national survey: a cross-sectional study

ABSTRACT BACKGROUND: Attention deficit hyperactivity disorder (ADHD) has a prevalence of 5.3% among children and adolescents. It is characterized by attention deficit, hyperactivity, and impulsivity. OBJECTIVE: We aimed to conduct a survey involving pediatric neurologists in the management of ADHD and compare the results with the current literature and guidelines. DESIGN AND SETTING: Descriptive analytical study of a virtual environment, was used Test of equality of proportions for comparison between two groups of pediatric neurologists (working as specialists for > 6 versus ≤ 6 years), with a significance level of P = 0.05. METHODS: This cross-sectional study used a virtual questionnaire covering the steps in the diagnosis and treatment of children with ADHD. The inclusion criteria were professionals who had completed their residency/specialization in pediatric neurology and clinical neurologists working in pediatric neurology. RESULTS: Among the 548 electronic invitations sent, 128 were considered valid. For all participants, the diagnosis was clinically based on the disease classification manuals. Combination treatment promotes improvement of symptoms (96.9%). Among psychostimulants, short-acting methylphenidate was the most commonly prescribed medication (85.2%). Headache was the most common side effect (77.3%). Altogether, 73.4% of the participants requested laboratory tests, 71.1% requested an electrocardiogram, and 42.2% requested an electroencephalogram. Pediatric neurologists working as specialists for ≤ 6 years had more frequent referrals to psycho-pedagogists for diagnosis (P = 0.03). CONCLUSIONS: The participants complied with clinical guidelines, emphasizing the relevance of diagnostic manuals and treatment guidelines for an eminently clinical situation and enabling uniformity in quality treatment.

pharmacological treatments, and non-pharmacological treatments for children with ADHD in the last 12 months of outpatient clinical care. A tool was used to guide the participants while filling out the questionnaire, making it impossible to move to the next page without properly filling out the current page, thereby preventing incomplete questionnaires.
The questionnaire was adapted to the Google Docs virtual platform and sent twice via e-mail and WhatsApp message to pediatric neurologists registered with the Brazilian Society of Pediatric Neurology. The time required to complete the questionnaire was approximately 10 minutes. No incentive was offered for participation and the questionnaire was only available in Brazilian Portuguese, the official language of Brazil.
The study included professionals who had completed their residency/specialization in pediatric neurology and clinical neurologists working in pediatric neurology. Specialists with laboratory conflicts of interest, professionals working as specialists for < 2 years, and professionals not working in Brazil were excluded.
The results obtained from the questionnaire were analyzed using descriptive statistics. In addition, the test of equality of proportions was used to compare two groups of pediatric neurologists (dichotomized according to the median time they worked as specialists), with a significance level of P = 0.05. In this test, the following variables were analyzed: request for evaluation and/or therapy with a multidisciplinary team (psychologists, psycho-pedagogists, speech therapists, occupational therapists); medical treatment in patients under 6 years of age (preschool age group), complementary tests before the beginning of treatment, option of performing continuous or intermittent treatment, and perception of symptomatic improvement in the face of the proposed treatment (medication with or without therapy with a multidisciplinary team).

Characterization of the participants
The data collection phase included 548 members of the Brazilian The most common side effect encountered by pediatric neurologists in clinical practice was headache, followed by hyporexia/ lack of appetite, and weight loss ( Table 2).
When asked about the need to discontinue or change the medications due to low tolerability, 111 (87%) participants answered in affirmative. However, 67 (60%) participants adopted this change in less than 10% of their patients.

Statistical analysis between the groups according to the time they worked as specialists
Sixty-eight (53.1%) pediatric neurologists worked as specialists for ≤ 6 years, while 60 (49.9%) worked as specialists for > 6 years.
Only one of the analyzed variables, namely "requesting a psychopedagogical evaluation" showed statistically significant difference between the groups.

DISCUSSION
The use of virtual environment has advantages as well as disad-  Another aspect of these classification systems and diagnostic criteria is their impact on the variation in the prevalence of ADHD.  Although initial results of the Multimodal Treatment of ADHD study emphasized the superiority of pharmacological treatment alone for symptomatic improvement, re-analyses and re-appraisals have highlighted the superiority of combination treatment for composite outcomes and for the domain of functional impairment. 21 However, respondents in the present survey reported symptomatic improvement following pharmacological treatment alone compared to exclusive psychotherapeutic intervention, highlighting the importance of pharmacological treatment for ADHD. 21,22 Analysis of the responses regarding indications of medication according to age group showed that the participants preferred pharmacological treatment for school-age children, which is consistent with the ADHD treatment guidelines that recommend the use of psychostimulants (first-line treatment) combined with behavioral interventions. 23,24 Pharmacological treatment aims to normalize the prefrontal cortex activity by restoring the normal concentrations of dopamine and noradrenaline, which have been recognized to play a role in the physiopathology of ADHD. Thus, by strengthening the prefrontal cortical impulse, patients can recognize important stimuli and separate them from unnecessary ones, reducing hyperactivity and improving attention. [25][26][27] Psychostimulants are the first-choice drugs for the treatment of ADHD and are widely used in children aged > 6 years, adolescents, and adults with ADHD. 1,3,9,10,[23][24][25][26] Methylphenidate has been the most frequently prescribed psychostimulant for children and adolescents since the 1990s, accounting for 77 to 87% of all prescriptions for psychostimulants. 28 Methylphenidate was the most frequently indicated medication for the initial treatment of ADHD by the specialists in the present study. Short-acting methylphenidate was the most frequently prescribed medication, followed by long-acting methylphenidate and amphetamine. Similarly, short-acting methylphenidate was the most frequently prescribed medication by physicians in the survey conducted by Fitzgerald and McNicholas, 11 although its dosing convenience differs from that of long-acting methylphenidate, which can be administered in a single daily dose. 1,11,[29][30][31] We believe that in addition to the possible benefits of short-acting medications such as a lower frequency of insomnia and weight loss, long-acting methylphenidate and amphetamines may eventually be prescribed less frequently, since they are more expensive and most of the respondents work at least part-time in the public health sector. 9,32-34 However, this issue as well as others that may interfere with the choice of medication (such as the patient's economic condition, presence of comorbidities at the time of ADHD diagnosis, and lack of response to psychostimulants) were not addressed in the present survey.
In contrast, 33.6% of participants reported the use of non-stimulant medications to treat ADHD. Approximately 30% of the children do not respond to or do not tolerate the initial stimulant and may benefit from medications such as tricyclic antidepressants, bupropion, clonidine, and atomoxetine (not commercialized in Brazil); which belong to drug classes other than methylphenidate or amphetamine. 35,36 These drugs were found to be efficacious in the treatment of ADHD, although with a lower therapeutic response than stimulants. In addition to their use as substitutes for stimulants, these medications may be used as adjuvants in the treatment of ADHD or even for the treatment of comorbidities. 1,9,10,31,37 Almost The side effects of stimulants in children and adolescents are: uncommon, short-lived, and responsive to dose adjustments or tolerated with time of use (transient). 23 Severe side effects (movement disorders such as tics, obsessive-compulsive thoughts, psychotic symptoms) are rare and reversed by discontinuation of the medication. 9,23 Pediatric neurologists participating in this study reported headache as the most commonly encountered side effect in clinical practice, followed by hyporexia/lack of appetite and weight loss. Our findings were similar to those reported in a Brazilian study by Carlini et al., 38 which was sponsored by a pharmaceutical company for the evaluation of main side effects of methylphenidate. Altogether, 7,500 questionnaires were sent to neurologists and psychiatrists and 892 (11.9%) questionnaires were answered.
It is important to emphasize that we discussed the side effects of all medications used to treat ADHD, while the survey by Carlini et al. 38 evaluated the side effects of methylphenidate.
Possibly, the most frequently reported side effects are due to the use of short-acting methylphenidate, since it is the most frequently prescribed medication. We observed an agreement between the main side effects reported by the participants and those commonly described in clinical studies. In a randomized, double-blind, placebo-controlled trial, Greenhill et al. 39 found that among patients using methylphenidate, the most frequent side effect was headache, followed by lack of appetite, stomach pain, and insomnia. The last debatable point in the management of patients was continuity of treatment. Considering the heterogeneity of the disorder, we found different management practices among our participants regarding the indication of continuous use of psychostimulants or pausing on weekends and/or during school vacations. Pausing the medication is generally indicated when the symptoms compromise school performance due to side effects such as insomnia, lack of appetite, weight loss, and growth retardation. 1,9,22,23,32 The two groups of specialists exhibited similar behavior regarding requests for evaluation and therapy by a multidisciplinary team. However, request for psycho-pedagogical evaluation was more frequent among pediatric neurologists who worked as specialists for ≤ 6 years, which could be attributed to concomitant learning disabilities at the time of ADHD diagnosis (a prevalence of 10 to 25%). 51,52

Limitations
It was not possible to accurately determine the response rate.
Hence, we could not extrapolate these behaviors to all Brazilian pediatric neurologists due to methodological limitations.

CONCLUSION
The present study evaluated aspects of ADHD