Pathways to care in children at risk of attention-deficit hyperactivity disorder

Identification of children at risk of Attention Deficit/Hyperactivity Disorder: a school-based intervention

BACKGROUND

In many countries, the majority of children who have Attention Deficit/Hyperactivity Disorder (ADHD) are undiagnosed and there is limited recognition of child mental health problems in primary care. Teachers may be well placed to identify unrecognised children and to facilitate their referral to specialist services. Despite this, there has been limited intervention research addressing teacher identification of ADHD. This study aims to examine whether an educational intervention about ADHD for teachers improves their recognition of children at risk of ADHD.

METHOD

A before and after investigation of an educational intervention about ADHD for teachers took place in 6 primary schools (involving 96 class teachers and 2672 pupils). Teacher recognition was compared against a diagnostic algorithm for ADHD caseness that utilised both parent and teacher ratings. Changes in teacher recognition of children with probable ADHD, as well as predictors of recognition, were examined.

RESULTS

Following the intervention, there was an increase in the proportion of children regarded by teachers as having probable ADHD. There was also improved agreement between teacher recognition and the diagnostic algorithm. Teacher views that a child had probable ADHD were based on both the severity of symptoms and the impact of these problems on the teacher and the class.

CONCLUSIONS

It is feasible to deliver an educational intervention addressing teacher identification of ADHD in routine practice. This was associated with an improvement in the ability of teachers to more accurately identify children at risk of ADHD. The provision of a brief educational intervention for teachers could assist in improving the identification of undiagnosed children with ADHD in the community.

Ethnic differences in parental detection of externalizing disorders

BACKGROUND

Previous research has reported lower treatment rates for externalizing disorders among non-Western children as compared to Western children. Ethnic differences in parental detection may be an explanation for this discrepancy.

AIMS

In a cross-sectional study among the four largest ethnic groups in the Netherlands, namely Dutch, Moroccan, Turkish and Surinamese, we examined the influence of ethnicity on parental detection of behavioural disorders.

METHOD

A total of 270 children (aged 6-10 years) and their parents were interviewed regarding psychiatric disorders and socio-demographic data. Sensitivity and specificity were calculated by using standard definitions, with adjustment for parental educational level.

RESULTS

Sensitivity to detect any externalizing disorder and ADHD in particular was significantly lower among Moroccan and Surinamese parents when compared to Dutch parents. Sensitivity to detect ADHD tended to be lower among Turkish parents. Specificity to detect any externalizing disorder was higher among Moroccan and Turkish parents. Specificity to detect ADHD was higher among Moroccan parents and tended to be higher among Turkish parents.

CONCLUSIONS

The detection rate of externalizing disorders is markedly lower among non-Dutch parents than among Dutch parents. This finding emphasizes the importance of taking parents' cultural context into account when appraising their report on possible externalizing disorders in their children.

Annotation: Pathways to care for children with mental health problems

BACKGROUND

Although many children with mental health problems are in contact with primary health care services, few receive appropriate help.

METHODS

Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services.

RESULTS

Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services.

CONCLUSIONS

As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.

Barriers to the identification of children with attention deficit/hyperactivity disorder

BACKGROUND

In most countries, the majority of children with attention deficit/hyperactivity disorder (ADHD) are undiagnosed. In the United Kingdom, a major barrier to accessing specialist services is the limited recognition of disorders by general practitioners. However, it is unclear whether there are also barriers at other stages of the help-seeking process. For children with ADHD, this study aims to examine the correlates of the different stages of help-seeking.

METHOD

Children with ADHD (n = 232) were identified from the 1999 British Child and Adolescent Mental Health Survey. Rates and correlates of parental recognition of child mental health problems and contact with services for these problems were examined. Children who had used particular types of services were compared with those who had not.

RESULTS

Most (80%) parents of children with ADHD recognise that their child has a problem although few (35%) construe this in terms of hyperactivity. The impact of the symptoms on key adults, rather than child factors, best predicted parental recognition of problems. Most parents had been in contact with education-based professionals but few had consulted primary care for these problems or had sought help from relevant specialist health services. Parental recognition of problems and perceived burden, rather than child factors, were the main correlates of contact with services. Parental views that their child has hyperactivity were associated with greater severity of symptoms.

CONCLUSIONS

The main barrier to care for ADHD is the limited presentation of these problems to primary care. The majority of parents discuss their concerns with professionals based in education services. There is a need for parental education about ADHD and for health service input to support education professionals in their contact with concerned parents.

Treatment choices and experiences in attention deficit and hyperactivity disorder: relations to parents' beliefs and attributions

BACKGROUND

Despite their potential to influence treatment decisions, parents' beliefs and attitudes regarding attention deficit hyperactivity disorder (ADHD) have not been widely studied. This research examined relations between parents' beliefs and attitudes and their experiences with different treatments for their children's ADHD.

METHODS

Canadian parents of 73, 5- to 13-year-old, boys with ADHD completed questionnaires measuring beliefs about ADHD, attributions for ADHD behaviours, and treatment experiences.

RESULTS

Parents reported using primarily behaviour management and stimulant medications in treating ADHD. Approximately half of the families also used diet/vitamin therapies. Parents were knowledgeable about ADHD and held generally accurate beliefs. They saw ADHD symptoms as predominantly internal to the child and as relatively enduring and pervasive. Parents' beliefs were related to their use of different treatments and parents who used less empirically supported treatments were more likely to see ADHD behaviours as internal to the child, enduring and pervasive.

CONCLUSIONS

The findings highlight the importance of assessing parents' use of alternate treatments for ADHD and the potential role of parents' beliefs and attributions in shaping treatment choices.

Parent ratings of school behaviour in children at risk of attention deficit/hyperactivity disorder

OBJECTIVE

To investigate whether parents are accurate informants of child hyperactivity symptoms and impairment at school.

METHOD

Parents of a community sample of 93 children with pervasive hyperactivity completed rating scales about their child's behaviour at home and school. These were compared with teacher ratings.

RESULTS

Parent ratings about school correlate more closely with parent (home) than teacher ratings. Such ratings systematically under-estimate teacher ratings and are influenced by the child's behaviour at both home and school as well as parental mental health. However, a parental report of impairment for the child at school is likely to be accurate.

CONCLUSION

There are limitations in relying on parental accounts of school behaviour if teacher ratings are unavailable. As such ratings may under-identify children with ADHD and discrepancies between parent and teacher ratings may reflect actual differences in behaviour, this suggests that ratings are required from both sets of informants.

Health state utilities for childhood attention-deficit/hyperactivity disorder based on parent preferences in the United kingdom

OBJECTIVES

The purpose of this study was to use standard gamble (SG) utility interviews to assess parent preferences for health states of childhood attention-deficit/hyperactivity disorder (ADHD).

METHODS

The study was conducted in August 2003 in London, England. Parents (N=83) of children diagnosed with ADHD completed SG utility interviews, rating their child's current health and 14 hypothetical health states describing untreated ADHD and ADHD treated with a nonstimulant, immediate-release stimulant, or extended-release stimulant. Raw temporary utilities ranging from 0 (worst health) to 1 (best health) were adjusted to a chronic utility scale ranging from 0 (death) to 1 (best health) using a linear transformation. Parents rated the severity of their children's ADHD symptoms using the Attention-Deficit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS) and their children's health-related quality of life using the EuroQol EQ-5D.

RESULTS

Raw and adjusted SG ratings of hypothetical health states ranged from 0.63-0.90 and 0.88-0.96, respectively. Parents' raw SG scores of their child's current health state (mean=0.72) were significantly correlated with inattentive, hyperactive, and overall ADHD symptoms (r=-0.25, -0.27, -0.27; P <0.05) and the EQ-5D visual analogue scale (r=0.26; P <0.05).

CONCLUSION

This UK-based study suggests that parent SG interviews are a valid method for obtaining utilities for child ADHD-related health states. The utilities obtained in this study would be appropriate for use in a cost-utility analysis evaluating the costs and benefits of childhood ADHD treatments in the United Kingdom.

Family physicians' involvement and self-reported comfort and skill in care of children with behavioral and emotional problems: a population-based survey

Background

Little is known about general and family practitioners' (GP/FPs') involvement and confidence in dealing with children with common psychosocial problems and mental health conditions. The aims of this study were to ascertain GP/FPs' preferred level of involvement with, and perceived comfort and skill in dealing with children with behavioral problems, social-emotional difficulties, attention-deficit/hyperactivity disorder (ADHD), and mood disorders; and to identify factors associated with GP/FPs' involvement, comfort and skill.

Methods

Postal survey of a representative sample of 801 GP/FPs in British Columbia, Canada, which enquired about level of involvement (from primarily refer out to deal with case oneself); ratings of comfort/skill with assessment/diagnosis and management; beliefs regarding psychosocial problems in children; basic demographics; and practice information.

Results

Surveys were completed by 405 of 629 eligible GP/FPs (64.4%). Over 80% of respondents reported collaborative arrangements with specialists across problem and condition types, although for children with behavior problems or ADHD, more physicians primarily refer (χ² (1) = 9.0; P < 0.005; and χ² (1) = 103.9; P < 0.001, respectively). Comfort/skill levels (mean ± s.d) were higher for mood disorders (4.4 ± 1.3) than behavior problems (3.6 ± 1.1; F [3, 1155] = 84.0, P < .0001; effect size = 0.67), but not different from social-emotional difficulties (3.8 ± 1.1) or ADHD (3.9 ± 1.3). Taking primary responsibility for a case was consistently related to self-reported comfort/skill with each condition type (34% to 61% of variance across condition types), while comfort/skill ratings for each condition were related to exposure to relevant continuing medical education (all P ≤ 0.001), and beliefs that these problems are significant and that GP/FPs have a role to play in dealing with them (P values ranged from 0.01 to <0.001).

Conclusion

Supporting GP/FPs in their care for children with common psychosocial and mental health problems should include efforts to bolster their confidence and modify attitudes in relation towards these problems, especially behavior problems and ADHD, possibly within innovative continuing education programs.

Service Contacts Among the Children Participating in the British Child and Adolescent Mental Health Surveys

METHOD

  A third of the children from the 1999 British Child and Adolescent Mental Health Survey were followed up over 3 years. Parents provided summary information on service contacts for emotional, behavioural and concentration difficulties, with more detailed information being obtained by telephone interview for selected subgroups.

RESULTS

  Having a psychiatric disorder predicted substantially increased contact with social services, special educational needs resources, the youth justice system and mental health services (district CAMHS and tier four, but not tier two). Of those children with psychiatric disorders, 58% had been in contact with at least one of these services for help with emotional, behavioural or concentration difficulties, including 23% who had been in contact with mental health services.

CONCLUSIONS

  British children attend a wide variety of services for help with emotional, behavioural and concentration difficulties. The proportion seeing specialist mental health services is higher than that generally reported in the research literature.

Managing attention deficit/hyperactivity disorder: unmet needs and future directions

The management of attention deficit/hyperactivity disorder (ADHD) requires a multimodal approach. Although shared-care protocols are suggested, uptake by general practice has been tentative. Behavioural management, both on its own and in combination with pharmacotherapy, reduces core symptoms and associated behaviours, such as oppositional defiant disorder (ODD). Links with education and social support are also important for helping children and their families. Psychostimulants have shown to be effective in the treatment of ADHD, however, their short duration of action highlights potential limitations. Other drugs used in the management of ADHD and comorbid disorders include antidepressants, clonidine and its analogues, newer atypical neuroleptics, and atomoxetine, a novel, non-stimulant therapy that has potential to fulfil some unmet treatment needs. Further research is needed in preschool children, girls, those with epilepsy, young adults, and in those with associated sleep disturbance. Selected rating scales and careful history taking, allied to close links with schools, are vital for the initial and ongoing assessment of ADHD and its comorbidities.

Parent-proxy EQ-5D ratings of children with attention-deficit hyperactivity disorder in the US and the UK

BACKGROUND

The symptoms of attention-deficit hyperactivity disorder (ADHD) are associated with impairment in multiple domains of health-related quality of life (HR-QOL). HR-QOL of children with ADHD has been assessed by relatively long multidimensional questionnaires. A review of the literature found no studies using the brief, well established EuroQoL Five-Dimension Questionnaire (EQ-5D) to estimate the HR-QOL of children with ADHD. The objective of this study was to assess the HR-QOL of children with ADHD using parents' responses to the proxy version of the EQ-5D.

METHODS

Participants were recruited in the midwestern US and in the vicinity of London, England. All parents completed three questionnaires: the EQ-5D proxy version; a measure of ADHD symptoms based on Diagnostic and Statistical Manual of Mental Disorders (4th Edition) [DSM-IV] criteria (the Attention-Deficit/Hyperactivity Disorder Rating Scale-IV - Parent Version [ADHD-RS]); and either the Child Health Questionnaire - Parent Form 50 (CHQ-PF50) or the Child Health and Illness Profile - Child Edition (CHIP-CE), which are both generic multidimensional paediatric HR-QOL questionnaires.

RESULTS

A total of 126 parents of children with ADHD participated in the study: 43 in the US and 83 in the UK. On the EQ-5D, participants indicated that 78.6% of their children experienced some problems or extreme problems performing usual activities, while 64.8% believed their child demonstrated some or extreme anxiety or depression. The mean EQ-5D index score was 0.75 and the mean visual analogue scale (VAS) score was 73.9. The EQ-5D index and VAS scores were found to be significantly correlated (p < 0.05) with several domains of the CHQ-PF50 (e.g. Mental Health, Self-Esteem, Family Activities, Psychosocial Summary Score) and the CHIP-CE (e.g. Satisfaction, Comfort, Academic Performance, Peer Relations). The EQ-5D scales were also significantly correlated with the ADHD-RS scales (p < 0.001).

CONCLUSION

The proxy version of the EQ-5D, completed by parents, was able to detect impairment in children diagnosed with ADHD in the US and the UK. Furthermore, the EQ-5D index and VAS scores demonstrated construct validity among this sample through significant correlations with an ADHD symptom measure and previously validated multidimensional QOL instruments. These results suggest that parent-proxy EQ-5D ratings are feasible and valid for use as part of an overall health outcomes assessment in clinical studies of childhood ADHD.

The role of parental burden in child mental health service use: longitudinal study

OBJECTIVE

To examine the relative contributions of symptom severity, functional impairment, and parental burden in predicting the use of specialist child mental health services over a 4-year period.

METHOD

Between 1999 and 2000, parental Strengths and Difficulties Questionnaires were completed on a community-based sample of 1,168 (40% response rate) 5- to 11-year-olds in the United Kingdom. Using a prospective longitudinal design, these data were related to subsequent referral records (until 2003). Children who were and were not referred to specialist mental health services were compared. Changes in the association between predictor variables (symptoms, impairment, and burden) and referral over time were also examined.

RESULTS

Over 4 years, 5.1% of children were referred. After controlling for all other predictors, only severity of symptoms predicted future referrals (for each 1-point increase on the total symptoms score, odds ratio 1.15; 95% confidence interval=1.09-1.21). Burden was only associated with referrals made during the first year, whereas conduct and emotional problems predicted subsequent referrals.

CONCLUSIONS

In contrast to cross-sectional studies that have highlighted the roles of functional impairment and parental burden in predicting specialist service use, this longitudinal study indicates that symptom severity best predicts future referrals. For children with mental health problems, there is considerable delay in accessing specialist services.

The Interface Between Physical and Mental Health Problems and Medical Help Seeking in Children and Adolescents: A Research Perspective

This paper addresses child and adolescent psychopathology as it presents to general practitioners and paediatricians, and explores psychosocial aspects of unexplained medical symptoms in children and adolescents. High rates of psychopathology have been identified amongst children and adolescents attending general practice and paediatric services, most of it ''hidden'' at presentation and emotional in nature. It is often linked to poor physical well being and to maternal stress focused on the child. It may be of special relevance to medical help seeking in socio-economically advantaged areas. Co-morbid psychopathology, mainly emotional disorders, is common amongst children with unexplained medical symptoms. However, there are specific psychosocial aspects that differentiate these children from those with emotional disorders. They involve disease beliefs, illness behaviour and predicament. The latter may be characterised by special reactivity to stress in children with personality vulnerability, in a context of parents with high levels of mental distress, unexplained medical symptoms and emotional over-involvement with the child. There is comparatively little interface work between CAMHS and primary health care. An important research priority would seem to lie in the development of interventions that can be adapted for use by primary care staff. Similarly, there are few dedicated CAMHS paediatric liaison teams. Their more extensive development should help attend in a more informed and focused way than at present to children and adolescents suffering from unexplained physical symptoms and disorders. Further research is needed into vulnerability mechanisms and maintaining factors, health beliefs, treatment engagement and interventions.

ADHD is best understood as a cultural construct

Attention-deficit hyperactivity disorder (ADHD) has received significant research attention and is a problem that is rarely out of the news – whether it is concerns about treating children with amphetamines, its over- or underdiagnosis, or the long-term outcomes.

Parental perception of problems and mental health service use for hyperactivity

OBJECTIVE

To examine predictors of parental perception of hyperactivity as a serious problem and its role in determining the use of specialist mental health services.

METHOD

A community sample of 5- to 11-year-old children with pervasive hyperactivity (n = 93) was identified. Children whose parents perceived the hyperactivity as a serious problem were compared with those whose parents did not. Predictors of parental perception of problem and the roles of this and child and parent clinical factors in predicting service use were examined.

RESULTS

Controlling for child and parental mental health, the strongest predictor of parental perception of problems was the financial impact of the child's behavior on either parent's work (odds ratio [OR] = 17.43; 95% confidence interval [CI] 3.52-86.40). Other effects on the parent's working ability were also important. Parental perception of problems was the strongest predictor of service use (OR = 9.85; 95% CI 1.42-68.50).

CONCLUSIONS

The effects of child behavior difficulties on perceptions of caregivers are multidimensional. The impact of hyperactivity on parents' work and family finances is substantial. Mental health service use is increased if these impacts reach the threshold for the parent to perceive the child's behavior as a problem.