Adult ADHD patient experiences of impairment, service provision and clinical management in England: a qualitative study

Advancing services for adult ADHD: the development of the ADHD Star as a framework for multidisciplinary interventions

BACKGROUND

Attention Deficit Hyperactivity Disorder is prevalent in adulthood, resulting in serious impairment across multiple domains of living. Despite clinical guidance recommendations, the relative infancy of research on service provision for adults with ADHD, along with the evidence transfer gap, means that there is a lack of specific frameworks for service delivery. Igniting research and developing service delivery frameworks within adult ADHD is an essential step in the provision of effective services for adults with ADHD.

METHOD

Following the methodology used in previous related research that utilises a Participatory Action Research approach, we gathered data from clinicians and service users on the domains of living in which they wish to create change, and the steps and end point of the change process. This data was utilised, alongside data gathered from previous research and policies, to develop the domains of assessment for the ADHD Star, and the scale on which change is assessed.

RESULTS

The resulting tool, the ADHD Star, consists of eight domains: understanding your ADHD, focus and attention, organising yourself, friends and social life, thinking and reacting, physical health, how you feel and meaningful use of time. Each domain is rated on a five-point scale, the 'ladder of change', ranging from 'stuck' to 'choice'.

CONCLUSIONS

The ADHD Star offers a guiding framework for the development of care pathways and subsequent service provision for adults with ADHD, based on multi-disciplinary, holistic and person-centred care.

Young patients' views about provided psychiatric care

BACKGROUND

Psychiatric illness is common among young adults, but there are only a few studies examining their views about the care they receive. There is a paradigm shift towards person-centred care and, therefore, a need for patients' perspectives in the development of clinical guidelines.

AIM

The aim of this study was to examine the views about provided psychiatric care in a group of young adult psychiatric patients.

METHOD

This study was part of a larger study. Patients between the ages of 19-29 years old (n = 127) diagnosed with bipolar disorder, borderline personality disorder, and/or attention deficit hyperactivity disorder were interviewed. Participants answered open-ended questions concerning their views about provided psychiatric care in six different areas.

RESULT

The results were categorized into six themes: (1) Wish for better diagnostic assessments, (2) Dissatisfaction with treatment, (3) Inadequate information, (4) Lack of professional attitude, (5) Feeling abandoned, and (6) Satisfaction with care.

CONCLUSION

Young psychiatric patients expressed a need for improvement of services that, if implemented, could make psychiatric care more person-centred.

Integrating care for neurodevelopmental disorders by unpacking control: A grounded theory study

BACKGROUND

To establish integrated healthcare pathways for patients with neurodevelopmental disorders (ND) such as autism spectrum disorder and attention-deficit hyperactivity disorder is challenging. This study sets out to investigate the main concerns for healthcare professionals when integrating ND care pathways and how they resolve these concerns.

METHODS

Using classic grounded theory (Glaser), we analysed efforts to improve and integrate an ND care pathway for children and youth in a Swedish region over a period of 6 years. Data from 42 individual interviews with a range of ND professionals, nine group interviews with healthcare teams, participant observation, a 2-day dialogue conference, focus group meetings, regional media coverage, and reports from other Swedish regional ND projects were analysed.

RESULTS

The main concern for participants was to deal with overwhelming ND complexity by unpacking control, which is control over strategies to define patients' status and needs. Unpacking control is key to the professionals' strivings to expand constructive life space for patients, to squeeze health care to reach available care goals, to promote professional ideologies, and to uphold workplace integrity. Control-seeking behaviour in relation to ND unpacking is ubiquitous and complicates integration of ND care pathways.

CONCLUSIONS

The Unpacking control theory expands central aspects of professions theory and may help to improve ND care development.

Clinical service use as people with Attention Deficit Hyperactivity Disorder transition into adolescence and adulthood: a prospective longitudinal study

Background

While Attention Deficit Hyperactivity Disorder (ADHD) often persists into adulthood, little is known about the needs and service use among adolescents and young adults with ADHD. The present study followed-up a cohort diagnosed with ADHD as children and assessed their: 1) needs, 2) correlates of contact with clinical services, and 3) experiences of transition from child to adult health services.

Methods

Ninety one young people aged 14–24 were recruited from the UK subset of the International Multi-Centre ADHD Genetics (IMAGE) Project. Affected young people and parents conducted face-to-face interviews and self-completion questionnaires including a modified version of the Client Services Receipt Inventory, The Barkley’s ADHD rating scale, The Clinical Interview Schedule-Revised, and the Zarit Burden Interview. Changes in key need characteristics (e.g. ADHD symptoms and impairments) over a 3-year period were examined using fixed effect models. Generalised Estimating Equations (GEE) were used to explore how key characteristics (such as ADHD symptoms) were associated with contact with clinical services across the three years.

Results

At baseline 62 % met diagnostic criteria for ADHD and presented with a range of ADHD related impairments, psychiatric comorbidities, and significant caregiver burden. While ADHD symptoms and related impairments lessened significantly over the three years, psychiatric comorbidities and caregiver burden remained stable. The strongest correlate of contact with clinical services was age (OR 0.65 95 % CI 0.49–0.84) with the odds of reported contact with clinical services decreasing by 35 % for each year increase in age at baseline and by 25 % for each year increase in age over time. Only 9 % of the sample had experienced a transfer to adult services, with the majority reporting unmet needs in healthcare transition.

Conclusions

Despite continuing needs, few were in contact with adult health services or had received sufficient help with transition between child and adult health services. The main determinant of health service use for adolescents and young adults with ADHD is age – not needs. Service models should address the needs of ADHD individuals who are no longer children.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1509-0) contains supplementary material, which is available to authorized users.

"It has to be fixed": a qualitative inquiry into perceived ADHD behaviour among affected individuals and parents in Western Australia

BACKGROUND

The use of stimulant medication for Attention Deficit Hyperactivity Disorder (ADHD) to improve classroom behaviour and sustained concentration is well known. Achieving a better academic grade has been reported as the prime motivation for stimulant use and is an increasingly discussed topic. The proliferation of stimulant use for ADHD has been a cause for public, medical and policy concern in Australia. This paper explores individuals' perceptions of ADHD, the meaning that the diagnosis carries for them and their attitudes to stimulant medication treatment.

METHODS

This qualitative study was underpinned by a social constructivist approach and involved semi-structured interviews with eight participants. The participants were parents of children with ADHD or were adults who themselves had been diagnosed with ADHD. Interviews were audiotaped, transcribed verbatim and thematically analysed.

RESULTS

There were three interrelated yet contradictory overarching themes: (i) An impairment to achieving success, which can be a double-edged sword, but has to be fixed; (ii) Diagnosis as a relief that alleviates fault and acknowledges familial inheritance; (iii) Responsibility to be normal and to fit in with societal expectations. Collectively, these perceptions and meanings were powerful drivers of stimulant use.

CONCLUSIONS

Paying attention to perceptions of ADHD and reasons for seeking or not seeking stimulant treatment is important when planning appropriate interventions for this condition.

Implications of DSM-5 for recognising adults with developmental coordination disorder (DCD)

Introduction

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders has attempted to recognise the pervasiveness of developmental coordination disorder across the lifespan. However, it falls short at describing the non-motoric symptomology such as executive functioning, social, emotional and psychiatric difficulties commonly reported in adults. Consequently, at the point of entry the self-reported functional difficulties of an adult with developmental coordination disorder may not be immediately associated with an underlying deficit within a motor domain, potentially resulting in inappropriate referrals.

Method

This study aimed to explore the reasons why 16 adults without a previous diagnosis of developmental coordination disorder referred themselves for a clinical assessment and consider whether their significant motor difficulties would be apparent.

Results

The primary self-reported concerns related to executive functioning difficulties, activities of daily living, changes in routine and social interaction and engagement. The least common self-reported concerns included gross motor skills.

Conclusion

Practitioners at the point of entry need to be mindful that adults with significant motor difficulties may not identify motor difficulties as their primary concern. It is, therefore, important to include screening for motor difficulties and for a future clinical landscape to comprise a referral pathway to adult neurodevelopmental clinics incorporating multidisciplinary teams.

Experiences of adolescents and young adults with ADHD in Hong Kong: treatment services and clinical management

BACKGROUND

Specialist services for the treatment of attention deficit hyperactivity disorder (ADHD) in adulthood in Hong Kong are yet to be developed. This study aims to explore the experiences of adolescents and young adults with ADHD in accessing treatment and services, coping with ADHD-related impairment, and their expectations of future treatment in Hong Kong.

METHOD

Qualitative interviews were conducted with a semi-structured guide. Forty young adult patients aged between 16 and 23 were included in the study. The interview recordings were transcribed verbatim and anonymised. Data were analysed with a thematic approach based on key principles of Grounded Theory.

RESULTS

Four meta-themes were developed: Accessing ADHD diagnosis and treatment services; ADHD-related impairment; Experience of ADHD treatments; and Attitudes and expectations of future ADHD treatment. The role of parents and schools were highly significant in accessing services for patients diagnosed with ADHD in childhood. In general, ADHD affected every aspect of patients' lives including academic outcome, employment, family and social relationships. Medications were the principal treatment for ADHD amongst the interviewees and were reported to be generally effective. Half of the patients received non-pharmacological treatments in childhood but these effects were reported to be temporary. There was general consensus that the needs of patients with ADHD could not be met by the current service. In particular, there is a lack of specialist service for adults with ADHD, follow-up by different clinicians, and insufficient provision of non-pharmacological treatments.

CONCLUSION

The findings suggest that further development of specialist ADHD services and non-pharmacological options for young adults are essential to meet their diverse needs with a holistic approach.

Mindfulness Meditation Training for Attention-Deficit/Hyperactivity Disorder in Adulthood: Current Empirical Support, Treatment Overview, and Future Directions

Research examining nonpharmacological interventions for adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) has expanded in recent years and provides patients with more treatment options. Mindfulness-based training is an example of an intervention that is gaining promising preliminary empirical support and is increasingly administered in clinical settings. The aim of this review is to provide a rationale for the application of mindfulness to individuals diagnosed with ADHD, describe the current state of the empirical basis for mindfulness training in ADHD, and summarize a treatment approach specific to adults diagnosed with ADHD: the Mindful Awareness Practices (MAPs) for ADHD Program. Two case study examples are provided to demonstrate relevant clinical issues for practitioners interested in this approach. Directions for future research, including mindfulness meditation as a standalone treatment and as a complementary approach to cognitive-behavioral therapy, are provided.

Who is in the transition gap? Transition from CAMHS to AMHS in the Republic of Ireland

OBJECTIVE

The ITRACK study explored the process and predictors of transition between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) in the Republic of Ireland.

METHOD

Following ethical approval, clinicians in each of Ireland's four Health Service Executive (HSE) areas were contacted, informed about the study and were invited to participate. Clinicians identified all cases who had reached the transition boundary (i.e. upper age limit for that CAMHS team) between January and December 2010. Data were collected on clinical and socio-demographic details and factors that informed the decision to refer or not refer to the AMHS, and case notes were scrutinised to ascertain the extent of information exchanged between services during transition.

RESULTS

A total of 62 service users were identified as having crossed the transition boundary from nine CAMHS [HSE Dublin Mid-Leinster (n=40, 66%), HSE South (n=18, 30%), HSE West (n=2, 3%), HSE Dublin North (n=1, 2%)]. The most common diagnoses were attention deficit hyperactivity disorder (ADHD; n=19, 32%), mood disorders (n=16, 27%), psychosis (n=6, 10%) and eating disorders (n=5, 8%). Forty-seven (76%) of those identified were perceived by the CAMHS clinician to have an 'on-going mental health service need', and of these 15 (32%) were referred, 11 (23%) young people refused and 21 (45%) were not referred, with the majority (12, 57%) continuing with the CAMHS for more than a year beyond the transition boundary. Young people with psychosis were more likely to be referred [χ 2 (2, 46)=8.96, p=0.02], and those with ADHD were less likely to be referred [χ 2 (2, 45)=8.89, p=0.01]. Being prescribed medication was not associated with referral [χ 2 (2, 45)=4.515, p=0.11]. In referred cases (n=15), there was documented evidence of consent in two cases (13.3%), inferred in another four (26.7%) and documented preparation for transition in eight (53.3%). Excellent written communication (100%) was not supported by face-to-face planning meetings (n=2, 13.3%), joint appointments (n=1, 6.7%) or telephone conversations (n=1, 6.7%) between corresponding clinicians.

CONCLUSIONS

Despite perceived on-going mental health (MH) service need, many young people are not being referred or are refusing referral to the AMHS, with those with ADHD being the most affected. CAMHS continue to offer on-going care past the transition boundary, which has resource implications. Further qualitative research is warranted to understand, in spite of perceived MH service need, the reason for non-referral by the CAMHS clinicians and refusal by the young person.

Experienced consequences of being diagnosed with ADHD as an adult - a qualitative study

BACKGROUND

Despite increasing knowledge of attention deficit hyperactivity disorder (ADHD) across the life span, there is still little research on adults' own experiences of being diagnosed with ADHD. The aim of the present study was to explore and describe patients' experiences and perceptions of being diagnosed with ADHD in adulthood. The study can be seen as an attempt to validate the diagnosis from a patient perspective.

METHODS

Twenty-one adults diagnosed with ADHD were individually interviewed. The interviews were open-ended and exploratory, analysed with a qualitative phenomenographical approach, and the results were described in categories.

RESULTS

Positive experiences were dominant, but there was a complex intra- and inter-individual variation of experiences. Descriptions focused on the diagnosis, on identity, and on life. The diagnosis was described as explaining a previously inexplicable life history, but was also questioned, both as a phenomenon and in relation to the individual (the diagnosis in focus). It was experienced as providing self-knowledge and increased value, but could also cause devaluation and concern about identity (identity in focus). It meant help to achieve a better life, but was also perceived to restrict possibilities and cause disappointment over lack of professional help. It could lead to a wish for an earlier diagnosis that could have spared suffering, as well as to a changed view of the participants' relatives (life in focus). All but one of the interviewees expressed important positive consequences of being diagnosed with ADHD. About half of them acknowledged negative aspects of being diagnosed, but none regretted going through the neuropsychiatric evaluation.

CONCLUSIONS

From a patient perspective, there are major positive consequences of being diagnosed with ADHD, compared to the undiagnosed situation. Knowledge of the individual's combination of experiences is important for professionals, as these experiences can affect well-being and interfere with treatment. Negative experiences in particular might need to be addressed in the treatment work.

The influence of early modified constraint-induced movement therapy training on the longitudinal development of hand function in children with unilateral cerebral palsy

AIM

There is evidence that modified constraint-induced movement therapy (mCIMT) has a short-term positive effect on hand function in children with unilateral cerebral palsy (CP), but the long-term effect is unknown. The aim of this study was to investigate whether or not a single block of mCIMT (2h/d for 2mo) at age 2 to 3 years influences the course of development of bimanual hand function at around 8 years of age.

METHOD

A convenience sample of 45 children (24 males, 21 females) with unilateral CP and mean (SD) age at first assessment 32 months (13mo) was included in this study. The participants were divided into the mCIMT group (n=26) and the reference group (no mCIMT; n=19). Brain lesion characteristics were available for 32 children. The children were measured repeatedly with the Assisting Hand Assessment (AHA) for a mean period of 4 years and 6 months. Development curves were created and compared with a non-linear mixed effects model.

RESULTS

Children who were receiving mCIMT had an upper limit of development of bimanual hand function that was 8.5 AHA units higher than in the reference group (p=0.022). However, when controlling for brain lesion characteristics and baseline in a subgroup of 32 children, the difference was considerably smaller and no longer significant.

CONCLUSION

mCIMT may have a positive impact on long-term development of bimanual hand function, but the results are inconclusive and further research is necessary.

Difficulties in everyday life: young persons with attention-deficit/hyperactivity disorder and autism spectrum disorders perspectives. A chat-log analysis

This study focuses on the everyday life of young persons with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). There are follow-up studies describing ADHD, and ASD in adults, and residual impairments that affect life. Few qualitative studies have been conducted on the subject of their experiences of everyday life, and even fewer are from young persons' perspectives. This study's aim was to describe how young persons with ADHD and ASD function and how they manage their everyday life based on analyses of Internet-based chat logs. Twelve young persons (7 males and 5 females aged 15-26) diagnosed with ADHD and ASD were included consecutively and offered 8 weeks of Internet-based Support and Coaching (IBSC). Data were collected from 12 chat logs (445 pages of text) produced interactively by the participants and the coaches. Qualitative content analysis was applied. The text was coded and sorted into subthemes and further interpreted into themes. The findings revealed two themes: "fighting against an everyday life lived in vulnerability" with the following subthemes: "difficult things," "stress and rest," and "when feelings and thoughts are a concern"; and the theme "struggling to find a life of one's own" with the following subthemes: "decide and carry out," "making life choices," and "taking care of oneself." Dealing with the problematic situations that everyday encompasses requires personal strength and a desire to find adequate solutions, as well as to discover a role in society. This study, into the provision of support and coaching over the Internet, led to more in-depth knowledge about these young persons' everyday lives and revealed their ability to use IBSC to express the complexity of everyday life for young persons with ADHD and ASD. The implications of the findings are that using online coaching makes available new opportunities for healthcare professionals to acknowledge these young persons' problems.

Pharmacological interventions for ADHD: how do adolescent and adult patient beliefs and attitudes impact treatment adherence?

Adherence to medication can be problematic for patients, especially so for patients with attention deficit hyperactivity disorder (ADHD). Effective medications are available for the treatment of ADHD; however, nonadherence rates for ADHD medication range from 13.2%-64%. The reasons for nonadherence can be complex. This review aims to look at how the beliefs and attitudes of adolescents and adults impact ADHD treatment adherence.