Awareness of ADHD in primary care: stakeholder perspectives

Wider health needs in attention deficit hyperactivity disorder from lived and professional experience: a qualitative framework analysis

OBJECTIVES

This study aimed to explore the perspectives of people with attention deficit hyperactivity disorder (ADHD), their supporters and primary care professionals (PCPs), on the wider physical and mental health needs of people with ADHD and the support currently available.

DESIGN

Qualitative semi-structured interviews, analysed using reflexive thematic analysis.

SETTING

Five general practice surgeries across England.

PARTICIPANTS

Participants with lived experience (people with ADHD and their supporters (n=11)) and PCPs (n=9) (eg, general practitioners and practice managers), recruited via clinical academic networks and previous work packages of this study.

RESULTS

We generated three major themes in relation to ADHD, using reflexive thematic analysis: understanding health, barriers to health and addressing health. Within these, participants reflected on mental and physical health challenges, as well as wider social difficulties and variability in support offered/accessed.

CONCLUSIONS

This study highlights that health problems in ADHD are complex and rooted both in individual factors (eg, mental health) and social factors (eg, support). This study also highlights the differences in expectations and fulfilment of healthcare.

The overlap of disordered eating, autism and ADHD: future research priorities as identified by adults with lived experience

The focus of mental health research in emerging fields should be driven by the priorities of people with relevant lived experience. Autism and ADHD are childhood-onset neurodevelopmental conditions that are associated with a range of health inequalities, including increased risk for eating disorders. The evidence base for how best to support neurodivergent individuals who experience disordered eating is still in its infancy, but research suggests that existing clinical approaches are not currently fit for purpose. In this Personal View, through community consultation with autistic people and people with ADHD who have experienced disordered eating, we present a comprehensive ranked list of research topics that people with lived experience prioritise. These priorities could be clustered into two areas: improving outcomes and identifying causal mechanisms. Within the theme of improving disordered eating outcomes, priorities are the improvement of treatment, the need for neurodiversity training in clinical services, and the identification and minimisation of unintended adverse effects of psychological intervention. Within the theme of identifying causal mechanisms, priorities are the identification of risk factors and a better understanding of the effect of autistic or ADHD neurocognitive profiles as potential contributors to eating disorder vulnerability. The final top ten research priorities are contextualised in terms of how they compare to the existing literature on the overlap between autism or ADHD and eating disorders, and concrete suggestions are made for how to implement these research priorities as testable hypotheses. Research informed by these priorities will build necessary understanding of the reasons behind the increased risk for eating disorders in neurodivergent people, and how to best support people who are affected by disordered eating to live positive and fulfilling lives.

Patient, supporter and primary healthcare professional perspectives on health risks in over 16s with attention deficit hyperactivity disorder (ADHD) in England: a national survey study

BACKGROUND

Current research suggests that people with attention deficit hyperactivity disorder (ADHD) are at higher risk of physical and mental health disorders. This study aimed to explore these health risks in ADHD from the perspectives of multiple stakeholders.

METHODS

This study forms part of the 'Managing young people with ADHD in Primary care (MAP) study'. A survey developed by the study team was distributed to over 16 year olds with ADHD, their supporters, primary healthcare professionals and health commissioners across England, via social media and through patient/clinical networks (September-October 2022). This survey contained two questions on health risks. Question one asked about views on health risks in ADHD (free text). Question two asked about advice given (options list and free text). Descriptive statistics summarised responses to questions one and two, and qualitative analysis (reflexive thematic analysis) was used to explore free text responses from question one.

RESULTS

782 participants responded to the MAP survey. Of these, 206 healthcare professionals, 157 people with ADHD and 88 supporters answered question one. The most mentioned perceived risks were substance misuse, sleep disorders, weight management and smoking. More people with ADHD reported disordered eating as a health risk (n = 32) than healthcare professionals (n = 5). Generated themes included perceived health risks, impact of living with ADHD, lack of adequate healthcare, and need for ADHD awareness. In respect to advice given (question two), based on responses from 258 professionals, 162 people with ADHD and 100 supporters, the most common advice discussed in consultation was mental health (n = 149, n = 50 and n = 17 respectively). High numbers of respondents reported not giving/receiving advice on wider health (n = 38, n = 88 and n = 61 respectively).

CONCLUSIONS

Findings demonstrate that respondents perceived a range of physical and mental health risks posed by ADHD. These related to difficulties with activities of daily living, as well as healthcare interactions and the impact of core features of ADHD (e.g. impulsivity, emotional dysregulation). These risks are not currently explicitly addressed in United Kingdom national guidance on ADHD. More work is needed to examine and address the broader health outcomes of people with ADHD.

[Pharmacological management of attention-deficit/hyperactivity disorders (ADHD) by generalists and specialists in Germany: a secondary data analysis]

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental health disorders among children, and it is rapidly surging among adults as well. The aim of this study was to investigate the role of community neurologists and psychiatrists as well as general practitioners and paediatricians in prescribing ADHD medications in Germany and whether their role has changed over the 10-year period from 2008 and 2018.

METHODS

In this secondary analysis of anonymized prescribing data, we calculated the absolute and relative frequencies of ADHD prescriptions by neurologists and psychiatrists, summarized as specialists, and family physicians and paediatricians, summarized as generalists, and how it has changed during the years 2008 to 2018.

RESULTS

A total of 620 practices delivered data on 77,504 patients diagnosed with ADHD, 38% (29,396/77,504) of them had received a prescription for ADHD medicine at least once in the study period. Over time, we observed a shift from generalists to specialists. While 59% of patients received their prescription from a generalist and 41% from a specialist in 2008, there was reverse in the ratio in 2018: only 37% received their medication from a generalist and the vast majority (63%) from a specialist. This trend was particularly evident among adults: 58% of them received their ADHD medication from a specialist in 2008, but 80% in 2018. The proportion of children and adolescents who received their prescriptions from a specialist rose from 38% to 51% over the same period.

CONCLUSION

There is a shift in drug prescription away from generalists to specialists, without any discussion of advantages or disadvantages so far. However, this would be desirable, not least because specialists alone may not have sufficient resources to care for all ADHD patients.

Primary care provision for young people with ADHD: a multi-perspective qualitative study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder. UK guidance states that primary care has a vital role in effective ADHD management, including referral, medication prescribing and monitoring, and providing broader mental health and wellbeing support. However, many GPs feel unsupported to provide health care for young people with ADHD. Inadequate health care is associated with rising costs for patients and society.

AIM

To investigate the experiences of young people with ADHD accessing primary care in England, from the perspectives of people with lived experience of ADHD and healthcare professionals (HCPs).

DESIGN AND SETTING

A qualitative study. Interviews were conducted with HCPs (GPs, practice managers, and a wellbeing worker) and people with lived experience of ADHD (young people aged 16-25 years and their supporters) located in integrated care systems across England.

METHOD

Semi-structured interviews were conducted with participants at five purposively selected general practices (varying by deprivation, ethnicity, and setting). Questions focused on experiences of accessing/providing health care for ADHD. Reflexive thematic analysis was undertaken within a critical realist framework to understand how provision works in practice and to explore potential improvements.

RESULTS

In total, 20 interviews were completed with 11 HCPs and nine people with lived experience. Three themes were generated: a system under stress, incompatibility between ADHD and the healthcare system, and strategies for change in ADHD primary care provision.

CONCLUSION

Standardisation of ADHD management in primary care, providing better information and support for HCPs, and advising on reasonable adjustments for people with lived experience could help improve access to effective treatments for young people living with ADHD.

Access to primary care for children and young people (CYP) in the UK: a scoping review of CYP's, caregivers' and healthcare professionals' views and experiences of facilitators and barriers

OBJECTIVES

To examine children and young people's (CYP), caregivers' and healthcare professionals' (HCPs) views or experiences of facilitators and barriers to CYP access to UK primary care services to better understand healthcare inequity. To explore differences across CYP subpopulations with greater health needs from deprived areas, identifying as ethnic minorities, with experiences of state care, special educational needs or disabilities, chronic conditions or mental health problems.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Included studies were in English, published 2012-2022 and reported: the views/experiences of CYP (0-25 years), caregivers or HCPs about accessing UK primary care; using quantitative or qualitative empirical methods.

DATA SOURCES

PubMed, CINAHL, Web of Science, PsycINFO and Scopus.

RESULTS

We included 47 reports (46 studies). CYP/caregivers' decision to access care was facilitated by CYP/caregivers' or their family/friends' ability to identify a health issue as warranting healthcare attention. Barriers to accessing care included perceived stigma (eg, being seen as a bad parent), embarrassment and discrimination experiences. CYP and caregivers believed longer opening hours could facilitate more timely access to care. Caregivers and HCPs reported that delayed or rejected referrals to secondary or adult care were a barrier to having needs met, especially for CYP with poor mental health. CYP and caregivers in numerous studies emphasised the importance of communication and trust with HCPs, including taking their concerns seriously, being knowledgeable and providing continuity of care for CYP. Common barriers reported across high-need subpopulations were caregivers needing knowledge and confidence to advocate for their child, gaps in HCP's knowledge and a lack of connectedness between primary and secondary care.

CONCLUSIONS

Connecting general practices and community health workers/services, improving CYP/caregivers' understanding of common childhood conditions, addressing HCP's knowledge gaps in paediatric care and integrated approaches between primary and secondary care may reduce inequity in access.

Social skill and social withdrawal outcomes in children following pediatric stroke

Pediatric stroke can result in long-term impairments across attention, functional communication and motor domains. The current paper utilized parent reports of the Behavioral Assessment System for Children 2nd Edition and the Pediatric Stroke Outcome Measure to examine children's social skills and withdrawal behavior within a pediatric stroke population. Using the Canadian Pediatric Stroke Registry at The Hospital for Sick Children, data were analyzed for 312 children with ischemic stroke. Children with ischemic stroke demonstrated elevated parent-reported social skills problems (observed = 20.51%, expected = 14.00%) and clinically elevated social withdrawal (observed = 11.21%, expected = 2.00%). Attentional problems significantly contributed to reduced social skills, F (3,164) = 30.68, p < 0.01, while attentional problems and neurological impairments accounted for increased withdrawal behavior, F (2, 164) = 7.47, p < 0.01. The presence of a motor impairment was associated with higher social withdrawal compared to individuals with no motor impairment diagnosis, t(307.73) = 2.25, p < .025, d = 0.25, 95% CI [0.42, 6.21]. The current study demonstrates that children with stroke who experience motor impairments, attentional problems, reduced functional communication skills, and neurological impairments can experience deficits in their social skills and withdrawal behavior.

General practitioners' attitudes and knowledge about attention-deficit hyperactivity disorder (ADHD): Insights from a survey

OBJECTIVE

The Review of health services for children, young people and families within the NSW Health system identified that novel models of care were needed to improve access to clinical management for people with ADHD. The present study aimed to evaluate GPs' knowledge of and attitudes towards ADHD and the challenges and opportunities for a more substantial role for GPs in ADHD management.

METHOD

An online survey of Australian GPs was conducted, with recruitment via email invitation.

RESULTS

Out of 230 respondents, 213 surveys could be analysed. Of these, 97% believed ADHD was a genuine condition, with 90% identifying inattention as a primary symptom. Most (92%) had seen and diagnosed ADHD within the past year. Prevalent concerns included inadequate access to specialist assessment and treatment; 77% felt that GPs should have a more substantial role in ADHD management. Barriers included lack of time, knowledge and experience.

CONCLUSIONS

There was willingness amongst respondents take on a greater role in managing individuals with ADHD. However, a need for further training and education was highlighted. The Australian Evidence-Based Clinical Practice Guideline for ADHD may resolve an identified need for clinical guidance.

Attention deficit/hyperactivity disorder in adults: A case study

Attention-Deficit/Hyperactivity Disorder (ADHD) is often misdiagnosed or mistreated in adults because it is often thought of as a childhood problem. If a child is diagnosed and treated for the disorder, it often persists into adulthood. In adult ADHD, the symptoms may be comorbid or mimic other conditions making diagnosis and treatment difficult. Adults with ADHD require an in-depth assessment for proper diagnosis and treatment. The presentation and treatment of adults with ADHD can be complex and often requires interdisciplinary care. Mental health and non-mental health providers often overlook the disorder or feel uncomfortable treating adults with ADHD. The purpose of this manuscript is to discuss the diagnosis and management of adults with ADHD.

Evaluation of the German Version of the Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5 as a Screening Tool for Adult Attention-Deficit/Hyperactivity Disorder in Primary Care

Adult attention-deficit/hyperactivity disorder (ADHD) is common, but often undiagnosed. A valid and time-efficient screening tool for primary care is needed. Objective of this study is to evaluate the German version of the Adult ADHD Self-Report Scale for DSM-5 (ASRS-5) and its feasibility, acceptability, and reliability as a screening tool for adult ADHD in primary care. A multi-centered prospective, diagnostic study was performed. We recruited 262 patients in primary care practices and at an ADHD Outpatient Service of a department of psychiatry in Germany. Patients from 18 to 65 years with suspected or diagnosed ADHD were included by medical doctors, as well as non-ADHD patients as "negative controls." Participants filled in the ASRS-5 and a sociodemographic questionnaire. The Integrated Diagnosis of Adult ADHD, revised version (IDA-R) performed by trained interviewers was used for validation. Feasibility, acceptability, and credibility in primary care practices were examined through a semi-structured interview. The German version of the ASRS-5 showed comparable psychometric properties to the English original version (sensitivity 95.6% and specificity 72.3%). For factor structure, a parallel analysis suggested one latent dimension. Performing confirmatory factor analysis, the best fit was achieved for a general factor with one correlated error. Internal consistency results in Raykovs Omega = 0.86 and Cronbach's α = 0.88. The ASRS-5 was assessed positively in terms of feasibility, acceptability, and credibility by interviewed general practitioners. Potential problems were raised for "treatment options," "stigmatization," and "knowledge gaps." In conclusion, the German version of the ASRS-5 offers a promising tool to improve adult ADHD patients' diagnosis and healthcare.