Use of health and school-based services in Australia by young people with attention-deficit/hyperactivity disorder

Access to early diagnosis for attention-deficit/hyperactivity disorder among children and adolescents in Mexico City at specialized mental health services

BACKGROUND

In Mexico, this pioneering research was undertaken to assess the accessibility of timely diagnosis of Dyads [Children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) and their primary caregivers] at specialized mental health services. The study was conducted in two phases. The first phase involved designing an "Access Pathway" aimed to identify barriers and facilitators for ADHD diagnosis; several barriers, with only the teacher being identified as a facilitator. In the second phase, the study aimed to determine the time taken for dyads, to obtain a timely diagnosis at each stage of the Access Pathway. As well as identify any disparities based on gender and socioeconomic factors that might affect the age at which children can access a timely diagnosis.

METHOD

In a retrospective cohort study, 177 dyads participated. To collect data, the Acceda Survey was used, based on the robust Conceptual Model Levesque, 2013. The survey consisted of 48 questions that were both dichotomous and polytomous allowing the creation of an Access Pathway that included five stages: the age of perception, the age of search, the age of first contact with a mental health professional, the age of arrival at the host hospital, and the age of diagnosis. The data was meticulously analyzed using a comprehensive descriptive approach and a nonparametric multivariate approach by sex, followed by post-hoc Mann-Whitney's U tests. Demographic factors were evaluated using univariable and multivariable Cox regression analyses.

RESULTS

71% of dyads experienced a late, significantly late, or highly late diagnosis of ADHD. Girls were detected one year later than boys. Both boys and girls took a year to seek specialized mental health care and an additional year to receive a formal specialized diagnosis. Children with more siblings had longer delays in diagnosis, while caregivers with formal employment were found to help obtain timely diagnoses.

CONCLUSIONS

Our findings suggest starting the Access Pathway where signs and symptoms of ADHD are detected, particularly at school, to prevent children from suffering consequences. Mental health school-based service models have been successfully tested in other latitudes, making them a viable option to shorten the time to obtain a timely diagnosis.

Treatment Rates for Mental Disorders Among Children and Adolescents: A Systematic Review and Meta-Analysis

Importance

Mental disorders among children and adolescents are global health concerns. Published studies have provided discordant results regarding treatment rates for mental disorders among youths.

Objective

To estimate combined treatment rates for several common psychiatric disorders among children and adolescents.

Data Sources

PubMed, Web of Science, PsycINFO, Scopus, and Embase were searched from database inception until September 23, 2022, and supplemented with hand-searching of reference lists.

Study Selection

Included studies were those that used validated methods to report treatment rates for any mental disorder, depressive disorders, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and behavior disorders among children and adolescents.

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Two reviewers independently assessed study eligibility, extracted data, and scored quality. Studies with a Joanna Briggs Institute score of 5 or more were included in the meta-analysis. Treatment rates were pooled using random-effects models. Subgroup analyses were performed to investigate the association with treatment rates of factors, such as year of data collection, World Health Organization region, age, income level, timeframe of diagnosis, informant source, service type, sample origin, and internalizing or externalizing disorder.

Main Outcomes and Measures

Treatment rates for mental disorders among children and adolescents were the main outcomes, measured as percentage estimates.

Results

Forty studies were included in the analysis, comprising 310 584 children and adolescents, with boys accounting for 39% of participants (sex was not reported in 10 studies). The pooled treatment rate was 38% (95% CI, 30%-45%) for any mental disorder, 36% (95% CI, 29%-43%) for depressive disorders, 31% (95% CI, 21%-42%) for anxiety disorders, 58% (95% CI, 42%-73%) for ADHD, and 49% (95% CI, 35%-64%) for behavior disorders. Age, income level, and region were significantly associated with the combined treatment rates of mental disorders in children and adolescents. The treatment rate for depressive disorders was higher among adolescents than children (36% [95% CI, 25%-46%] vs 11% [95% CI, 0%-25%]), whereas the treatment rate for anxiety disorders was higher among children than adolescents (64% [95% CI, 52%-75%] vs 20% [95% CI, 9%-30%]). The treatment rate for any mental disorder in lower-middle income countries was 6% (95% CI, 2%-14%), in upper-middle income countries was 24% (95% CI, 2%-47%), and in high-income countries was 43% (95% CI, 35%-52%). For depressive disorders, treatment rates were higher in the Americas (40% [95% CI, 30%-51%]) than in Europe (28% [95% CI, 13%-43%]) and the Western Pacific region (6% [95% CI, 1%-16%]).

Conclusions and Relevance

This study suggests that, in general, the treatment rates for mental disorders among children and adolescents were low, especially for depression and anxiety. Targeted intervention policies and effective measures should be designed and implemented to improve treatment rates of psychiatric disorders among youths.

censusADHD Study: An Australian-wide medication-based recruitment study for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder affects over 5% of children and is characterised by a persistent pattern of problems with focussing or maintaining attention and/or hyperactivity-impulsivity. The censusADHD Study is a richly phenotyped nationwide cohort of Australian children with attention-deficit/hyperactivity disorder. The overarching aims of the study are to examine attention-deficit/hyperactivity disorder medication utilisation patterns and treatment response, the impact of children's attention and behavioural problems on caregivers, and costs related to attention-deficit/hyperactivity disorder.

METHODS

Families of potential attention-deficit/hyperactivity disorder cases aged between 6 and 11 years were identified using Pharmaceutical Benefits Scheme prescription records for attention-deficit/hyperactivity disorder medications held by Services Australia and sent a study information letter. Data were collected from 1574 primary caregivers via online survey in 2015, including the behavioural profile of the child, the child's medication use and experiences with side effects and the impact of the child's behaviour on the caregiver. Approximately 81% of caregivers also consented to record linkage of the child's Pharmaceutical Benefits Scheme and Medicare Benefits Schedule claims to directly assess prescription dispensing history and health service usage to estimate costs to the family and Medicare health system.

RESULTS

Boys were diagnosed with attention-deficit/hyperactivity disorder earlier (p = 0.021), more likely to present as the combined and predominantly hyperactive subtypes (p = 0.001) and at higher risk of experiencing a school suspension (p < 0.001) or expulsion (p = 0.043). Overall, children presenting as the combined subtype had higher rates of psychiatric comorbidities (p < 0.001). Finally, prescription costs for each family and the Pharmaceutical Benefits Scheme significantly increased in the year following attention-deficit/hyperactivity disorder diagnosis (p < 0.001).

CONCLUSION

Research examining the psychosocial and financial impact of attention-deficit/hyperactivity disorder on Australian children and their families is needed. Our findings demonstrate the importance of examining both gender and attention-deficit/hyperactivity disorder subtype presentation in future studies.

Parental Barriers in Seeking Mental Health Services for Attention Deficit Hyperactivity Disorder in Children: Systematic Review

OBJECTIVE

Many children at risk for negative outcomes related to untreated attention deficit hyperactivity disorder (ADHD) do not receive necessary mental healthcare. Parents' mental health-seeking behavior is important in the early identification of ADHD and preventing comorbidities with ADHD. Parents may experience some barriers that may delay or stop parents from seeking mental healthcare for their children.

METHOD

This systematic review summarized existing evidence of parents' barriers to seeking mental healthcare for their children at risk of ADHD.

RESULTS

This review included 21 studies that address different parental barriers under the three levels of the social-ecological model, including individual, interpersonal, and community levels.

CONCLUSION

Raising parents' awareness of the process of seeking mental healthcare has the potential to help identify children at risk for ADHD earlier. Developing psychoeducational intervention that improves parents' seeking behavior and reduces barriers toward seeking mental healthcare is needed.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Parent perspectives on children and young people's mental health services in Victoria - What's wrong and how to fix it: A multi-site qualitative study

AIM

The number of children and young people presenting to emergency departments (EDs) with anxiety and depression is increasing. We aimed to determine parent perspectives on: (i) barriers to accessing non-ED mental health services; and (ii) improving access in the paediatric mental health service system.

METHODS

Qualitative study with parents of children and young people aged 0-19 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression.

EXCLUSION CRITERIA

child or young person without a parent/guardian, or presented with self-harm or suicide attempt. Eligible participants completed semi-structured phone interviews. Interviews were recorded and transcripts were coded and analysed using content analysis.

RESULTS

A total of 72 parents completed interviews. The average child age was 14 years (standard deviation 2.5) and two thirds identified as female (64%). A total of 57% of children and young people presented with a primary diagnosis of anxiety. Parents reported barriers in accessing care including: service shortages and inaccessibility, underresourced schools, lack of clinician mental health expertise, lack of child-clinician rapport, inconsistent care, financial constraints, lack of mental health awareness among parents, and stigma. Parents want expanded and improved access to services, more respite and support services, supportive schools, and improved mental health education for parents.

CONCLUSIONS

Parents of children and young people attending the ED for anxiety and depression are generally dissatisfied with services for child mental health. Solutions that enable parents to better care for their child in the community are needed to improve care.

Factors Associated With Educational Support in Young Adolescents With ADHD

Objective: This study aimed to examine patterns of use and factors associated with education support use in students with ADHD during early adolescence. Method: Participants were 130 adolescents (M = 13.7 years, SD = 1.1) with ADHD. Educational support use and the factors associated with use were collected by parent and teacher questionnaires and standardized academic tests during the 2014-2015 school years. Support rates and categories are described. Logistic regression models examine individual, family, and school variables associated with support versus no support. Results: About two thirds of students with ADHD (60%) had accessed education support in the current school year, which included social support (36%), Individualized Educational Plans (IEPs; 22%), Student Support Groups (SSGs; 18%), counseling (17%), mentoring (15%), and homework support (9%). Academic risk (adjusted odds ratio [OR] = 2.30, 95% confidence interval [CI] = [1.03, 5.14], p = .04), behavioral problems (adjusted OR = 1.47, 95% CI = [1.01, 2.14], p = .047), and attending a Catholic school (adjusted OR = 5.10, 95% CI = [1.59, 16.42], p = .006) were associated with receiving support independent of adolescent age, gender, ADHD medication use, and socioeconomic status. Conclusions: Future research needs to determine whether education support makes a difference to long-term outcomes for students with ADHD and to determine why some students at academic risk receive no support.

Patterns and Predictors of Service Utilization Among Youth With ADHD-Predominantly Inattentive Presentation

Objective: This study examined rates and predictors of educational and mental health service utilization among youth with ADHD-predominantly inattentive presentation (ADHD-I). Method: Participants were 199 children with ADHD-I in Grades 2 to 5. Parents reported past-year child service utilization. Parents and teachers rated child ADHD and oppositional defiant disorder (ODD) symptom severity and functional impairment. Children completed an academic achievement test. Results: All children had impairment at school and home. Most received some sort of school service (79%), but only 23% received community-based services. ADHD symptom severity was unrelated to service utilization. However, higher parent-rated functional impairment predicted community service utilization. Academic underachievement and higher teacher-rated functional impairment predicted school service utilization. Conclusion: Many youth with ADHD-I experience impairment across domains without receiving adequate services for these problems. Functional impairment appears to be a stronger predictor of service utilization than ADHD symptom severity, demonstrating the importance of impairment in understanding service needs for ADHD-I.

Mental disorders in Australian 4- to 17- year olds: Parent-reported need for help

OBJECTIVE

To describe the extent to which parents report that 4- to 17-year-olds with symptoms meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria for mental disorders need help, the types of help needed, the extent to which this need is being met and factors associated with a need for help.

METHOD

During 2013-2014, a national household survey of the mental health of Australia's young people (Young Minds Matter) was conducted, involving 6310 parents (and carers) of 4- to 17-year-olds. The survey identified 12-month mental disorders using the Diagnostic Interview Schedule for Children - Version IV ( n = 870) and asked parents about the need for four types of help - information, medication, counselling and life skills.

RESULTS

Parents of 79% of 4- to 17-year-olds with mental disorders reported that their child needed help, and of these, only 35% had their needs fully met. The greatest need for help was for those with major depressive disorder (95%) and conduct disorder (93%). Among these, 39% of those with major depressive disorder but only 19% of those with conduct disorder had their needs fully met. Counselling was the type of help most commonly identified as being needed (68%). In multivariate models, need for counselling was higher when children had autism or an intellectual disability, in blended families, when parents were distressed, and in the most advantaged socioeconomic areas.

CONCLUSIONS

Many children and adolescents meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria for mental disorders have a completely unmet need for help, especially those with conduct disorders. Even with mild disorders, lack of clinical assessment represents an important missed opportunity for early intervention and treatment.

What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies

A minority of children and adolescents with mental health problems access treatment. The reasons for poor rates of treatment access are not well understood. As parents are a key gatekeeper to treatment access, it is important to establish parents' views of barriers/facilitators to accessing treatment. The aims of this study are to synthesise findings from qualitative and quantitative studies that report parents' perceptions of barriers/facilitators to accessing treatment for mental health problems in children/adolescents. A systematic review and narrative synthesis were conducted. Forty-four studies were included in the review and were assessed in detail. Parental perceived barriers/facilitators relating to (1) systemic/structural issues; (2) views and attitudes towards services and treatment; (3) knowledge and understanding of mental health problems and the help-seeking process; and (4) family circumstances were identified. Findings highlight avenues for improving access to child mental health services, including increased provision that is free to service users and flexible to their needs, with opportunities to develop trusting, supportive relationships with professionals. Furthermore, interventions are required to improve parents' identification of mental health problems, reduce stigma for parents, and increase awareness of how to access services.

Prevalence and correlates of ADHD among adolescents in a Beirut community sample: results from the BEI-PSY Study

BACKGROUND

This study aims to investigate the prevalence, correlates and treatment seeking behavior related to ADHD among adolescents from Lebanon.

METHODS

Five hundred and ten adolescents were recruited through multistage stratified cluster sampling of households in Beirut, and separately interviewed along with one parent/legal guardian, using the DAWBA. All adolescents completed the PRQ and the SDQ; the parent/legal guardian also completed the SDQ and provided basic demographic information, including attitudes towards seeking mental health services.

RESULTS

10.20% of the adolescents were diagnosed with ADHD. Having ADHD was associated with having academic difficulties and being involved in bullying. Adolescents with ADHD also had higher odds of drinking alcohol, smoking cigarettes, and having comorbid emotional and conduct disorders (compared to those without ADHD). Adolescents with ADHD and their parents reported a higher burden of illness and were more likely to consider seeing a mental health professional than healthy adolescents and their parents.

CONCLUSION

ADHD among adolescents in Lebanon warrants closer attention, mainly increased awareness in the larger public, and stronger commitment to increase treatment resources to the community.

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.

The diagnosis of attention-deficit/hyperactivity disorder in Australian children: Current paediatric practice and parent perspective

AIMS

In a sample of newly diagnosed children with attention-deficit/hyperactivity disorder (ADHD), the aims were to examine (1) paediatrician assessment and management practices; (2) previous assessments and interventions; (3) correspondence between parent-report and paediatrician identification of comorbidities; and (4) parent agreement with diagnosis of ADHD.

DESIGN

cross-sectional, multi-site practice audit with questionnaires completed by paediatricians and parents at the point of ADHD diagnosis.

SETTING

private/public paediatric practices in Western Australia and Victoria, Australia.

MAIN OUTCOME MEASURES

paediatricians: elements of assessment and management were indicated on a study-designed data form. Parents: ADHD symptoms and comorbidities were measured using the Conners 3 ADHD Index and Strengths and Difficulties Questionnaire, respectively. Sleep problems, previous assessments and interventions, and agreement with ADHD diagnosis were measured by questionnaire.

RESULTS

Twenty-four paediatricians participated, providing data on 137 patients (77% men, mean age 8.1 years). Parent and teacher questionnaires were used in 88% and 85% of assessments, respectively. Medication was prescribed in 75% of cases. Comorbidities were commonly diagnosed (70%); however, the proportion of patients identified by paediatricians with internalising problems (18%), externalising problems (15%) and sleep problems (4%) was less than by parent report (51%, 66% and 39%). One in seven parents did not agree with the diagnosis of ADHD.

CONCLUSIONS

Australian paediatric practice in relation to ADHD assessment is generally consistent with best practice guidelines; however, improvements are needed in relation to the routine use of questionnaires and the identification of comorbidities. A proportion of parents do not agree with the diagnosis of ADHD made by their paediatrician.

Willingness to use ADHD Self-Management: Mixed Methods Study of Perceptions by Adolescents and Parents

Little is known about perceptions surrounding self-management for attention deficit hyperactivity disorder (ADHD), although such interventions appear commonly used and are considered essential components of the chronic care model. Our research is part of a mixed methods study that followed students at high and low risk for ADHD over 11 years. During the final study years, area-representative samples of 148 adolescents (54.8% participation; 97 ADHD high-risk group; 51 low-risk peers) and 161 parents (59.4% participation; 108 parents of high-risk adolescent; 53 parents of low-risk peer) completed a cross-sectional survey on community-identified self-management interventions for ADHD (activity outlets, sleep regulation, dietary restriction, homework help, family rules, and prayer). Respondents also answered open-ended questions addressing undesirable self-management effects, which were analyzed using grounded theory methods. High-risk adolescents expressed significantly lower willingness towards all self-management interventions than did adult respondents, except for increased activity outlets. They also reported lower receptivity towards sleep regulation and dietary restriction than did their low-risk peer group. No gender or race differences in self-management willingness were found, except for higher receptivity to prayer in African American respondents. Cost, perceived ineffectiveness, disruptions to routines, causation of interpersonal conflicts, and reduced future self-reliance were seen as potential undesirable effects. Findings suggest that activity-based ADHD interventions appear particularly acceptable across all demographic and risk groups, unlike sleep regulation and dietary approaches. Further research on self-care effectiveness is needed to incorporate adolescents' viewpoints about ADHD self-management, as interventions may be acceptable to adults, but resisted by adolescents.

Service use in children aged 6-8 years with attention deficit hyperactivity disorder

OBJECTIVE

This study investigated prevalence, types and predictors of professional service use in families of children identified with attention deficit hyperactivity disorder (ADHD) in the community.

SETTING

children with ADHD were identified through 43 schools using parent and teacher screening questionnaires (Conners 3 ADHD Index) followed by case confirmation using the Diagnostic Interview Schedule for Children Version IV. Parents completed a survey about professional service use in the last 12 months.

MAIN OUTCOME MEASURES

data on variables potentially associated with service use were collected from parents (interview and questionnaires), teachers (questionnaires) and children (direct assessment). Logistic regression was used to examine predictors of service use in univariate and multivariable analyses.

RESULTS

The sample comprised 179 children aged 6-8 years with ADHD. Over one-third (37%) had not received professional services in the last 12 months. The strongest predictors of service use were older child age (adjusted OR=3.0, 95% CI 1.0 to 8.9, p=0.05), and the degree to which the child's behaviour impacted on the family (adjusted OR=2.0, 95% CI 1.3 to 3.3, p=0.007), after controlling for ADHD subtype and severity, externalising comorbidities, academic achievement and parent-reported impairment.

CONCLUSIONS

A substantial proportion of children with ADHD are not accessing professional services. Our findings suggest that the child's age and the impact of the child's behaviour on the family are the strongest predictors of service use. Given the demonstrated benefits from various interventions in ADHD, there is a need to improve case identification and referral for services.

Practitioner Review: Pathways to care for ADHD - a systematic review of barriers and facilitators

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder starting in childhood that may persist into adulthood. It can be managed through carefully monitored medication and nonpharmacological interventions. Access to care for children at risk of ADHD varies both within and between countries. A systematic literature review was conducted to investigate the research evidence related to factors which influence children accessing services for ADHD.

METHOD

Studies investigating access to care for children at risk of ADHD were identified through electronic searches of the international peer-reviewed and grey literature. Databases were searched from inception till 30th April 2012. This identified 23,156 articles which were subjected to three levels of screening (title, abstract and full text) by a minimum of two independent reviewers. Due to the heterogeneity in the study designs, a narrative approach was used to present the findings.

RESULTS

Twenty-seven papers met the inclusion criteria; these were grouped into four main themes, with some papers being included in more than one. These were wider determinants (10 papers); identification of need (9 papers); entry and continuity of care (13 papers) and interventions to improve access (4 papers). Barriers and facilitators to access were found to operate at the individual, organisational and societal level. Limited evidence of effective interventions to improve access was identified.

CONCLUSION

This review explored the multilayered obstacles in the pathway to care for children at risk of ADHD and the lack of evidence-based interventions designed to address these issues, thereby indicating areas for service development and further evaluative research.

Predictors of and barriers to service use for children at risk of ADHD: longitudinal study

Many children with, or at risk of, ADHD do not receive healthcare services for their difficulties. This longitudinal study investigates barriers to and predictors of specialist health service use. This is a 5-year follow-up study of children who participated in a cluster randomised controlled trial, which investigated school-level interventions (provision of books with evidence-based information and/or feedback of names of children) for children at risk of ADHD. 162 children who had high levels of ADHD symptoms at age 5 (baseline) were followed up at age 10 years. Using baseline data and follow-up information collected from parents and teachers, children who had and had not used specialist health services over the follow-up period were compared and predictors (symptom severity, comorbid problems, parental perception of burden, parental mental health, and socio-demographic factors) of specialist service use investigated. The most common parent-reported barrier reflected lack of information about who could help. Amongst children using specialist health services who met criteria for ADHD at follow-up, 36% had been prescribed stimulant medication. Specialist health service use was associated with each one-point increase in teacher-rated symptoms at baseline [inattention symptoms (adjusted OR = 1.40; 95% CI 1.12-1.76) and hyperactivity/impulsivity symptoms (adjusted OR = 1.23; 95% CI 1.05-1.44)]. Parental mental health problems were also independently associated with service use (for each one-point increase in symptoms, adjusted OR = 1.41; 95% CI 1.04-1.91). Severity of teacher-rated ADHD symptoms in early school years is a determinant of subsequent service use. Clinicians and teachers should be aware that parental mental health problems are independently associated with service use for children at risk of ADHD.

Development and validation of a question prompt list for parents of children with attention-deficit/hyperactivity disorder: a Delphi study

OBJECTIVES

Question prompt lists (QPLs) are structured lists of disease and treatment-specific questions intended to encourage patient question-asking during consultations with clinicians. The aim of this study was to develop a QPL intended for use by parents of children affected by attention-deficit/hyperactivity disorder (ADHD).

METHODS

The QPL content (111 questions) was derived through thematic analysis of existing ADHD- and QPL-related resources. A modified Delphi method, involving a three-round web-based survey, was used to reach consensus about the QPL content. Thirty-six experts were recruited into either a professional [paediatricians, child and adolescent psychiatrists, psychologists, researchers (n =28)] or non-professional panel [parents of children diagnosed with ADHD, ADHD consumer advocates (n = 8)]. Panel members were asked to rate the importance of the QPL content using a five-point scale ranging from 'Essential' to 'Should not be included'.

RESULTS

A total of 122 questions, including 11 new questions suggested by panellists, were rated by both panels. Of these, 88 (72%) were accepted for inclusion in the QPL. Of the accepted questions, 39 were re-rated during two follow-up survey rounds and 29 (74%) were subsequently accepted for inclusion. The questions covered key topics including diagnosis, understanding ADHD, treatment, health-care team, monitoring ADHD, managing ADHD, future expectations and support and information.

CONCLUSIONS

To our knowledge, this is the first ADHD-specific QPL to be developed and the first use of the Delphi method to validate the content of any QPL. It is anticipated that the QPL will assist parents in obtaining relevant, reliable information and empowering their treatment decisions by enhancing the potential for shared decision making with clinicians.

Barriers to evidence-based treatment for children with attention-deficit/hyperactivity disorder

A number of evidence-based treatments are available for attention-deficit/hyperactivity disorder (ADHD), including pharmacological, psychosocial, or a combination of the two treatments. For a significant number of children diagnosed with ADHD, however, these treatments are not utilized or adhered to for the recommended time period. Given that adherence to treatment regimens is necessary for reducing the symptoms of ADHD, it is crucial to develop a comprehensive understanding of why adherence rates are so low. The current review examines the literature to date that has directly explored utilization and adherence issues related to the treatment of ADHD in order to identify the key barriers to treatment. This review focused on four main factors that could account for the poor rates of treatment utilization and adherence: personal characteristics (socio-demographic characteristics and diagnostic issues), structural barriers, barriers related to the perception of ADHD, and barriers related to perceptions of treatment for ADHD. This review included 63 papers and covered a variety of barriers to treatment that have been found in research to have an impact on treatment adherence. Based on this review, we conclude that there are complex and interactive relationships among a variety of factors that influence treatment utilization and adherence. Four main gaps in the literature were identified: (1) there is limited information about barriers to psychosocial interventions, compared to pharmacological interventions; (2) there is a limited variety of research methodology being utilized; (3) treatment barrier knowledge is mostly from parents' perspectives; and (4) treatment utilization and treatment adherence are often studied jointly. Information from this review can help practitioners to identify potential barriers to their clients being adherent to treatment recommendations.

Mental health services use predicted by number of mental health problems and gender in a total population study

We examined the relationship between service use and the number of problem areas as reported by parents and teachers on questionnaires among children aged 7–9 years old in the Bergen Child Study, a total population study including more than 9000 children. A problem area was counted as present if the child scored above the 95th percentile on parent and/or teacher questionnaire. A total number of 13 problem areas were included. Odd ratios (ORs) for contact with child and adolescent mental health services (CAMH), school psychology services (SPS), health visiting nurse/physician, and school support were calculated with gender as covariate. The number of symptom areas was highly predictive of service use, showing a dose-response relationship for all services. Children scoring on ≥4 problem areas had a more than hundredfold risk of being in contact with CAMH services compared to children without problems. The mean number of problem areas for children in CAMH and SPS was 6.1 and 4.4 respectively, strongly supporting the ESSENCE model predicting multisymptomatology in children in specialized services. Even after controlling for number of problem areas, boys were twice as likely as girls to be in contact with CAMH, replicating previous findings of female gender being a strong barrier to mental health services.

Inattention, hyperactivity, and emergent literacy: different facets of inattention relate uniquely to preschoolers' reading-related skills

Although extant studies indicate that there is a strong association between attention deficit/hyperactivity disorder and reading ability in elementary school children, knowledge regarding the relation between inattentive and hyperactive/impulsive behaviors and emergent literacy in preschool children is less established. This study examined the unique and overlapping relations between measures that assess inattention and hyperactivity/impulsivity and emergent literacy skills in preschool children. Participants included 204 preschool children (M age = 56 months, 50.9% female, 79.8% European American). Behavioral rating scales were completed by teachers, and the Continuous Performance Test (CPT) and the Test of Preschool Early Literacy were completed by the preschoolers. Across measures, inattention was a unique correlate of emergent literacy skills, whereas hyperactivity/impulsivity was not. Both rating scales and the CPT indices of inattention were uniquely associated with emergent literacy skills. These results suggest that these measures are assessing different manifestations of inattention that are both unique correlates of early reading skills.

Improving visual memory, attention, and school function with atomoxetine in boys with attention-deficit/hyperactivity disorder

OBJECTIVE

Atomoxetine is efficacious in reducing symptoms of attention- deficit/hyperactivity disorder (ADHD), but its effect on visual memory and attention needs more investigation. This study aimed to assess the effect of atomoxetine on visual memory, attention, and school function in boys with ADHD in Taiwan.

METHOD

This was an open-label 12 week atomoxetine treatment trial among 30 drug-naíve boys with ADHD, aged 8-16 years. Before administration of atomoxetine, the participants were assessed using psychiatric interviews, the Wechsler Intelligence Scale for Children, 3rd edition (WISC-III), the school function of the Chinese version of the Social Adjustment Inventory for Children and Adolescents (SAICA), the Conners' Continuous Performance Test (CPT), and the tasks of the Cambridge Neuropsychological Test Automated Battery (CANTAB) involving visual memory and attention: Pattern Recognition Memory, Spatial Recognition Memory, and Reaction Time, which were reassessed at weeks 4 and 12.

RESULTS

Our results showed there was significant improvement in pattern recognition memory and spatial recognition memory as measured by the CANTAB tasks, sustained attention and response inhibition as measured by the CPT, and reaction time as measured by the CANTAB after treatment with atomoxetine for 4 weeks or 12 weeks. In addition, atomoxetine significantly enhanced school functioning in children with ADHD.

CONCLUSION

Our findings suggested that atomoxetine was associated with significant improvement in visual memory, attention, and school functioning in boys with ADHD.

Having a Co-Twin With Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD) is a common childhood disorder which occurs more often in twins than singletons. This article focuses on the psychosocial consequences of having a co-twin with ADHD. Specifically, the level of anxiety (generalized and separation) in non-ADHD children who have a co-twin with ADHD is examined using data from the Australian Twin ADHD Project (ATAP). Parental report data on 501 dizygotic (DZ) twin pairs aged 6 to 15 and their siblings were used to examine (i) anxiety symptoms in twin pairs discordant for ADHD, (ii) how the effects of an ADHD twin on their co-twin and siblings are related to the type of ADHD, and (iii) whether the effects are greater for the nonaffected twin than nontwin siblings. Results show that anxiety was high in co-twins of children with the combined subtype of ADHD, with increased symptoms of both generalized and separation anxiety. Inattentive ADHD had smaller effects, which were confined to generalized anxiety and were specific to the co-twin rather than other siblings. These results have clinical implications in managing the entire multiple birth family where one twin has ADHD, and also has implications for genetic analysis in modeling the relationship of ADHD to internalizing disorders.

Emotional/behavioral problems and functional impairment in clinic- and community-based children with attention-deficit/hyperactivity disorder in Taiwan

Using a sample of 268 patients and 137 community-based children with DSM-IV ADHD, and 268 school controls, aged 6-15, this study aimed to compare the emotional/behavioral problems and functional impairment between clinic- and community-based children with ADHD. Children's ADHD-related symptoms, a wide range of emotional/behavioral problems, and functional impairments were assessed by the psychiatric interviews and self-, parent- and teacher-reported questionnaires. Both ADHD groups scored higher in parent- and teacher-reported ADHD-related symptoms, wide-ranging emotional/behavioral problems, and impairments in the school, peer, family, and leisure time domains than school controls. However, clinic-based children with ADHD had more physical/developmental problems, more severe functional impairments and teacher-reported hyperactivity/impulsivity symptoms, and higher family burdens than their community counterparts. Our findings suggest that a higher maternal educational level, parent's perceived child functional impairment, teacher's perceived impaired peer relationship and hyperactivity-impulsivity, and child physical and developmental problems may be related to the psychiatric referrals of children with ADHD.

Do parental reports of child hyperkinetic disorder symptoms at school predict teacher ratings?

BACKGROUND

Clinical practice guidelines for the evaluation of children with suspected hyperkinetic disorder or ADHD recommend that information is collected from teachers.

METHODS

Using the development and well-being assessment, parents of 5-16 year olds participating in the 1999 and 2004 British Child and Adolescent Mental Health Surveys were asked about symptoms relating to hyperkinetic disorder and reports of teacher complaints about these symptoms. We examined whether parental reports about symptoms at school reflect teacher ratings and can be relied upon by clinicians.

RESULTS

Parent reports about symptoms at school were moderately correlated with teacher ratings. If children potentially met criteria for hyperkinetic disorder based on parental ratings only, the positive predictive value (PPV) for a research diagnosis of hyperkinetic disorder was 47%. When parents reported high levels of symptoms at school in addition to sufficient parent-rated symptoms and impairment, the PPV for a diagnosis of hyperkinetic disorder increased to 59%.

CONCLUSIONS

In a community sample, we found that parental reports about symptoms at school have limited utility in predicting teacher ratings. Our findings highlight that it is desirable and worthwhile for clinicians to obtain direct information from the teacher. If this is unavailable, clinicians and researchers should be aware that "second-hand" information about symptoms at school is second best.

Changes in use of psychostimulant medication for ADHD in South Australia (1990-2006)

OBJECTIVE

The aim of the present study was to undertake a retrospective analysis of archival data on psychostimulant prescriptions from South Australia for the periods 1990-2000 and 2001-2006 for 7849 youths aged from birth to 18 years.

METHOD

A person-based data set was used to assess: (i) rate of new prescriptions by age group; (ii) demographic characteristics (age of psychostimulant start, male: female ratio); (iii) duration of psychostimulant use; and (iv) geographic variation in psychostimulant prescription.

RESULTS

Four major findings were observed: (i) the rate of new prescriptions was highly variable both for 1990-2000 and 2000-2006; (ii) demographic characteristics such as start age and male:female ratio declined over both periods; (iii) the duration of psychostimulant use was approximately 2.5 years for 1990-2000 and 2.0 years for 2000-2006; and (iv) there was geographic variation in both periods with a significant correlation between socioeconomic status and prescription rate per region.

CONCLUSIONS

The patterns of psychostimulant use in Australia closely parallel the USA. Physicians' prescribing practice may be extremely volatile. Duration of psychostimulant treatment should receive increased attention. There is pronounced geographic variability in prescription rates, which may be related to socioeconomic status.

Parental beliefs about the nature of ADHD behaviours and their relationship to referral intentions in preschool children

BACKGROUND

Parental beliefs about child problem behaviour have emerged as closely related to referral intentions to mental health services.

METHODS

This study compared beliefs of severity, impact and advice seeking for attention deficit/hyperactivity disorder (ADHD) behaviours of parents whose preschool children present ADHD behaviours with those of parents whose children do not display such behaviours. Both parents of 295 preschoolers, aged 4-6 years, enrolled in kindergartens in Athens, filled in: (i) a questionnaire composed by a vignette describing a hypothetical 5-year-old child presenting ADHD symptoms followed by rating scales assessing dimensions of severity, impact and referral intention, and (ii) the 'Strengths and Difficulties Questionnaire' for screening ADHD behaviours in their own child.

RESULTS

Results showed that almost half of the parents who reported ADHD behaviours in their own child replied that they had never met a child exhibiting such behaviours. These parents also perceived such behaviours as being less severe and with less negative family impact than parents who did not report such behaviours in their own child.

CONCLUSIONS

Parents whose preschool child displays ADHD behaviours tend to perceive them as normal developmental patterns and may suspend the referral of the child. Implications of these findings for early identification of ADHD are discussed.

Are ADHD gender patterns moderated by sample source?

OBJECTIVE

To examine whether ADHD gender patterns with respect to social-demographic characteristics, comorbidity, and impairment vary as a function of service use for emotional or behavioral problems.

METHOD

Two hundred and seventy-nine males and 119 females meeting ADHD symptom criteria identified in a nationally representative sample of Australian youth ages 6 to 17 are stratified according to whether they had attended a service in the previous 6 months.

RESULTS

ADHD gender patterns vary across service use on only 2 of the 31 comparisons made. The two exceptions were child's age at interview (females were older than males among service attendees but younger among nonattendees) and depressive disorders (females had higher rates than males among service attendees but lower rates among nonattendees).

CONCLUSION

Systematic differences in methods of case identification rather than sample source may be responsible for the discrepant ADHD patterns found between clinic and community-based studies.

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.

Psychosoziale Situation bei Familien von Kindern mit ADHS

Erste Studien belegen, dass die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) nicht nur mit einer ungünstigen Entwicklung des erkrankten Kindes oder Jugendlichen verbunden ist, sondern auch Auswirkungen auf die psychosoziale Situation aller Familienmitglieder hat. Die Pilotstudie ging der Frage nach, ob sich die Lebensqualität der Eltern von Kindern mit ADHS von der Lebensqualität der Eltern gesunder Kinder unterscheidet. Außerdem war von Interesse, inwieweit das Ausmaß des hyperkinetischen Verhaltens des erkrankten Kindes mit der psychosozialen Anpassung der gesunden Geschwister und der Lebensqualität der Eltern verbunden ist. Insgesamt 48 Elternteile beurteilten das Ausmaß hyperkinetischen Verhaltens der gesunden Geschwister sowie ihre eigene Lebensqualität. Die Eltern mit einem an ADHS erkrankten Kind schätzten zusätzlich das Ausmaß hyperkinetischen Verhaltens des erkrankten Kindes sowie die psychischen Auffälligkeiten der gesunden Geschwister ein. Die Ergebnisse legen nahe, dass das psychische Wohlbefinden der Eltern mit einem an ADHS erkrankten Kind gegenüber Eltern gesunder Kinder beeinträchtigt ist. Des Weiteren hing das Ausmaß des hyperkinetischen Verhaltens des erkrankten Kindes positiv mit den internalisierenden und Aufmerksamkeitsproblemen der gesunden Geschwister zusammen. Das Ausmaß des hyperkinetischen Verhaltens des erkrankten Kindes war außerdem mit einem beeinträchtigten psychischen Wohlbefinden des Elternteils assoziiert. Die Befunde unterstreichen die Forderung nach familienorientierten Interventionsmaßnahmen in der Behandlung von ADHS, die die psychosoziale Anpassung aller Familienmitglieder berücksichtigen.