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

A Precision Mental Health Model for Predicting Stability of 4-year-olds' Attention Deficit/Hyperactivity Disorder Symptoms to Age 6 Diagnostic Status

OBJECTIVE

Estimates of the stability of a preschooler's diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD) into early elementary school vary greatly. Identified factors associated with diagnostic instability provide little guidance about the likelihood a particular child will have ADHD in elementary school. This study examined an approach to predicting age 6 ADHD-any subtype (ADHD-any) from preschoolers' demographics and ADHD symptoms.

METHOD

Participants were 796 preschool children (Mage = 4.44; 51% boys; 54% White, non-Hispanic) recruited from primary pediatric care and school settings. Parents completed ADHD Rating Scales at child ages 4 and 5 years, and a structured diagnostic interview (DISC-YC) at ages 4 and 6. Classification tree analyses (CTAs) examined the predictive utility of demographic and symptom variables at ages 4 and 5 years for age 6 ADHD.

RESULTS

Over half (52.05%) of preschoolers meeting diagnostic criteria for ADHD-any at age 4 did not meet those criteria at age 6; more than half (52.05%) meeting criteria for ADHD-any at age 6 had not met those criteria at age 4. A CTA conducted at age 4 predicted age 6 ADHD-any diagnosis 65.82% better than chance; an age 5 CTA predicted age 6 ADHD-any 70.60% better than chance. At age 4, likelihood of age 6 ADHD-any diagnosis varied from <5% to >40% across CTA tree branches and from <5% to >78% at age 5.

CONCLUSIONS

Parent-reported patterns of preschool-age symptoms may differentially predict ADHD-any at age 6. Psychoeducation regarding these patterns may aid in decision about pursuing multidisciplinary evaluations or initiating treatment.

Use of healthcare services before diagnosis of attention-deficit/hyperactivity disorder: a population-based matched case-control study

OBJECTIVE

To compare use of healthcare services and reasons for attendance by children and young people (CYP) with attention-deficit/hyperactivity disorder (ADHD) versus non-ADHD controls.

DESIGN

Population-based matched case-control study.

SETTING

English primary care electronic health records with linked hospital records from the Clinical Practice Research Datalink, 1998-2015.

PARTICIPANTS

8127 CYP with an ADHD diagnosis aged 4-17 years at the time of diagnosis and 40 136 non-ADHD controls matched by age, sex and general practitioner (GP) practice.

MAIN OUTCOME MEASURES

Medical diagnoses, prescriptions, hospital admissions and hospital procedures in the 2 years before diagnosis (or the index date for controls).

RESULTS

CYP with ADHD attended healthcare services twice as often as controls (rate ratios: GP: 2.0, 95% CI=2.0, 2.1; hospital 1.8, 95% CI=1.8, 1.9). CYP with ADHD attended their GP, received prescriptions and were admitted to hospital for a wide range of reasons. The strongest association for GP attendances, comparing CYP with versus without ADHD, was for 'mental and behavioural disorders' (OR=25.2, 95% CI=23.3, 27.2). Common reasons for GP attendance included eye, ear, nose, throat, oral (OR=1.5, 95% CI=1.4, 1.5) and conditions such as asthma (OR=1.3, 95% CI=1.3, 1.4) or eczema (OR=1.2, 95% CI=1.0, 1.3).

CONCLUSIONS

Two years before diagnosis, CYP with ADHD attended healthcare services twice as often as CYP without. CYP with ADHD had increased rates of physical conditions, such as asthma and eczema. These contacts may be an opportunity for earlier recognition and diagnosis of ADHD.

Protocol for the mixed methods, Managing young people (aged 16-25) with Attention deficit hyperactivity disorder in Primary care (MAP) study: mapping current practice and co-producing guidance to improve healthcare in an underserved population

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children and adolescents, with an average worldwide prevalence of 5%. Up to 40% of young people continue to experience symptoms into adulthood. Young people with ADHD experience poorer outcomes than their peers across multiple domains, with treatment shown to reduce these risks. Primary care practitioners play an important role in healthcare provision for this group in the UK. However, many feel unsure about how best to provide support, reporting prescribing concerns and need for more evidence-based guidance. A lack of national data on primary care provision hinders efforts to improve access to care and optimise outcomes. This mixed-methods study aims to provide evidence that may be used to improve primary care services for young people aged 16-25 years with ADHD.

METHODS AND ANALYSIS

There are three interlinked work packages: (a) a mapping study including a survey of stakeholders (healthcare professionals, people with ADHD and commissioners) will map ADHD prescribing practice, shared-care arrangements, available support and practitioner roles by geographic locations across England for different respondent groups; (b) a qualitative study involving semi-structured interviews with stakeholders (10-15 healthcare professionals and 10-15 people with ADHD) will explore experiences of 'what works' and 'what is needed' in terms of service provision and synthesise findings; (c) workshops will integrate findings from (a) and (b) and work with stakeholders to use this evidence to codevelop key messages and guidance to improve care.

ETHICS AND DISSEMINATION

The protocol has been approved by Yorkshire and the Humber-Bradford Leeds Research Ethics Committee. Recruitment commenced in September 2022. Findings will be disseminated via research articles in peer-reviewed journals, conference presentations, public involvement events, patient groups and media releases. A summary of study findings will be shared with participants at the end of the study.

TRIAL REGISTRATION NUMBER

NCT05518435.

Juntos hacemos la diferencia [together we make the difference]: A network analysis of Latinx caregivers' use of youth support services

Latinx families face unique barriers to accessing traditional youth mental health services and may instead rely on a wide range of supports to meet youth emotional or behavioral concerns. Previous studies have typically focused on patterns of utilization for discrete services, classified by setting, specialization, or level of care (e.g., specialty outpatient, inpatient, informal supports), yet little is known about how youth support services might be accessed in tandem. This analysis used data from the Pathways to Latinx Mental Health study - a national sample of Latinx caregivers (N = 598) from across the United States collected at the start of the coronavirus pandemic (i.e., May-June 2020) - to describe the broad network of available supports that are used by Latinx caregivers. Using exploratory network analysis, we found that the use of youth psychological counseling, telepsychology, and online support groups was highly influential on support service utilization in the broader network. Specifically, Latinx caregivers who used one or more of these services for their child were more likely to report utilizing other related sources of support. We also identified five support clusters within the larger network that were interconnected through specific sources of support (i.e., outpatient counseling, crisis, religious, informal, and non-specialty). Findings offer a foundational look at the complex system of youth supports available to Latinx caregivers, highlighting areas for future study, opportunities to advance the implementation of evidence-based interventions, and channels through which to disseminate information about available services.

Parent-identified barriers to accessing exposure therapy: A qualitative study using process mapping

Background

Youth with anxiety and obsessive-compulsive disorder (OCD) rarely access exposure therapy, an evidence-based treatment. Known barriers include transportation, waitlists, and provider availability. Efforts to improve access to exposure require an understanding of the process that families take to find therapists, yet no prior studies have examined parents' perspectives of the steps involved.

Methods

Parents of children who have received exposure therapy for anxiety and/or OCD (N = 23) were recruited from a hospital-based specialty anxiety clinic where the majority of their children previously received exposure. Recruitment was ongoing until thematic saturation was reached. Parents completed questionnaires and attended an online focus group during which they were asked to describe each step they took-from recognizing their child needed treatment to beginning exposure. A process map was created and shown in real-time, edited for clarity, and emailed to parents for member checking. Authors analyzed process maps to identify common themes.

Results

Several themes emerged, as visually represented in a final process map. Participants identified a "search-outreach" loop, in which they repeated the cycle of looking for therapists, contacting them, and being unable to schedule an appointment due to factors such as cost, waitlists, and travel time. Parents often did not know about exposure and reported feeling guilty about their lack of knowledge and inability to find a suitable provider. Parents reported frustration that medical providers did not often know about exposure and sometimes dismissed parents' concerns. Participants emphasized the difficulty of navigating the mental health system; many reported that it took years to find an exposure therapist, and that the search was sometimes stalled due to fluctuating symptoms.

Conclusion

A common thread among identified barriers was the amount of burden placed on parents to find treatment with limited support, and the resultant feelings of isolation and guilt. Findings point to several directions for future research, such as the development of parent support groups for navigating the mental health system; enhancing coordination of care between medical and mental health providers; and streamlining referral processes.

Implementing a Canadian shared-care ADHD program in Beijing: Barriers and facilitators to consider prior to start-up

BACKGROUND

The shared care pathway for ADHD is a program developed in Canada with two main strategies: (a) implement a shared care pathway between general practitioners (GPs) and specialists, and (b) step up or down care so that the patient is treated at the most appropriate level of care, depending on the complexity or outcome of their illness. The current study aims to identify the challenges and facilitators of implementing this program in a Chinese mental health service setting.

METHODS

Two focus groups were conducted using semi-structured interviews with a total of 7 health care providers in Beijing. An adapted grounded theory methodology using open-ended, axial and selective coding was used for data analysis.

RESULTS

We identified three main levels related to barriers and facilitators: (1) a sociocultural level of patients' and health care providers' perspectives; (2) a structural level related to internal and external organizational environments; (3) and the level of the intervention itself with its characteristics. The project is generally aligned with the mandates and goals of the health system, but two of the main obstacles are the varying qualifications of physicians in hospitals of different levels, implying different needs and flexible and adapted training programs, and the lack of appropriate patient referral systems between the different hospital levels.

CONCLUSION

Our study highlights the importance of consultation to obtain a "lay of the land" for deciding on the implementation steps of an a priori well accepted model of care.

Differential Parent and Teacher Reports of ADHD Symptoms According to the Child's Country of Origin: A Quantitative Study From Denmark Exploring the Implication for Diagnosis

Objective: This study aimed to investigate differences in parent- and teacher-reported ADHD symptoms according to the child's country of origin. Method: We conducted a cross-sectional study of 4,207 nonimmigrant (Danish origin) and 233 immigrant (non-Danish origin) children including ratings of phenotypical ADHD symptoms on the Strengths and Difficulties Questionnaires. The association between ADHD symptoms and country of origin, separately for parents and teachers, was analyzed using multiple logistic regression. Results: Teachers reported similar numbers of ADHD symptoms for immigrant and nonimmigrant children (odds ratio [OR] = 0.95, confidence interval [CI] = [0.58, 1.54]), whereas immigrant parents were less likely than nonimmigrant parents to report ADHD symptoms (OR = 0.42, CI = [0.21, 0.84]). Conclusion: Immigrant parents were less likely than nonimmigrant parents to report ADHD symptoms, whereas the teachers reported similar amount of ADHD symptoms in the two groups of children. Our results emphasize the importance of paying attention to teacher reporting of ADHD symptoms when assessing immigrant children.

Parent-perceived barriers to accessing services for their child's mental health problems

BACKGROUND

Many children and adolescents with impairing mental health disorders are not in contact with specialized child and adolescent mental health services (CAMHS). In order to close the service gap, it is important to increase our knowledge of barriers to access. The aim of this study was to investigate parent perceived barriers to accessing services for their child's mental health problems to identify potential areas for improvement of access to CAMHS.

METHOD

In this cross-sectional observational study 244 parents of children and adolescents referred to outpatient psychiatric assessment were interviewed using the Children's services interview regarding barriers to accessing child mental health services across healthcare, educational services and social services. Parent reported barriers were analyzed in relation to the child's age, referral reason, symptom duration and impairment of the child.

RESULTS

The most commonly reported barriers were lack of information about were to seek help (60.3%), the perception that professionals did not listen (59.8%) and professionals refusing to initiate interventions or provide referral to services (53.7%). Lack of knowledge, stigmatization and unavailability of services were common themes across barriers to help-seeking. Long symptom duration and parent rated impairment was associated with increased risk of reporting several barriers to help-seeking.

CONCLUSION

Parents seeking help for their child's mental health encounter numerous barriers that could explain part of the treatment gap and long duration of mental health problems in children prior to referral to CAMHS.

Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement

Background: Despite evidence-based national guidelines for ADHD in the United Kingdom (UK), ADHD is under-identified, under-diagnosed, and under-treated. Many seeking help for ADHD face prejudice, long waiting lists, and patchy or unavailable services, and are turning to service-user support groups and/or private healthcare for help. Methods: A group of UK experts representing clinical and healthcare providers from public and private healthcare, academia, ADHD patient groups, educational, and occupational specialists, met to discuss shortfalls in ADHD service provision in the UK. Discussions explored causes of under-diagnosis, examined biases operating across referral, diagnosis and treatment, together with recommendations for resolving these matters. Results: Cultural and structural barriers operate at all levels of the healthcare system, resulting in a de-prioritization of ADHD. Services for ADHD are insufficient in many regions, and problems with service provision have intensified as a result of the response to the COVID-19 pandemic. Research has established a range of adverse outcomes of untreated ADHD, and associated long-term personal, social, health and economic costs are high. The consensus group called for training of professionals who come into contact with people with ADHD, increased funding, commissioning and monitoring to improve service provision, and streamlined communication between health services to support better outcomes for people with ADHD. Conclusions: Evidence-based national clinical guidelines for ADHD are not being met. People with ADHD should have access to healthcare free from discrimination, and in line with their legal rights. UK Governments and clinical and regulatory bodies must act urgently on this important public health issue.

Pathways to care in children- perspectives from a child guidance clinic in South India

PURPOSE

In India the pathways to care in children with mental health problems remain relatively unexplored. Investigating the factors that drive the pathway will help determine interventions and also draft policies for a streamlined Child and adolescent mental health service.

METHOD

Children who attended the Child Guidance Clinic sampled by WHO Pathways Encounter questionnaire. Statistical tests applied to find key influencers like gatekeepers, intermediate points of care, symptoms initiating referral, duration of untreated illness, time to arrive at appropriate care and primary diagnosis.

RESULTS

The most common diagnostic category was externalizing disorder 51(37.5 %). The gatekeepers identified were 111(81.6 %) Parents/Relatives/Guardians and teachers 25 (18.3 %). Academic concerns identified by teachers took a mean of 72 months (30.271) to arrive at appropriate care versus 50.4 months (23.18) when identified by Parents/Relatives/Guardians group. Significant delays were observed with Neurodevelopmental disorders arriving to care with delays up to 130.2 (70.11) months (p < 0.001) and having 64.2 (33.7) months (p < 0.001) duration of untreated illness. Externalizing disorders took a duration of 94.08 (54.17) months (p < 0.001) to arrive to appropriate care and had 54.2 (36.33) months (p < 0.001) duration of untreated illness. Teachers took longer time in detecting the indicators and this caused duration of untreated illness of 73.44 (36.05) months (p < 0.001) and a delay of 128.08 (71.23) months (p < 0.001) to arrive to appropriate care.

CONCLUSIONS

The pathways to care in children are characterized by long duration of untreated illness and undue time to care. Gatekeepers like teachers and intermediary points of care were associated with inadvertent delays along the pathway.

Sex Differences in the Meaning of Parent and Teacher Ratings of ADHD Behaviors: An Observational Study

Objective: To test explanations for the underrecognition of female ADHD by examining differences in adult ratings of boys and girls matched for levels of directly observed ADHD behaviors. Method: In a secondary analysis of a population-based sample, 3- to 4-year-olds (n = 153, 79 male) and 8- to 9-year-olds (n = 144, 75 male) were grouped according to levels of directly observed ADHD behaviors (low/moderate/high). Groups were then compared with parent/teacher ADHD ratings. Results: There were no sex differences in levels of directly observed ADHD behaviors within groups. For preschoolers, parents' ratings of males, but not females, significantly increased across groups-mirroring levels of observed behaviors. For older children, both parent and teacher mean ratings were significantly higher for males than females across groups. Conclusion: Identified differences in adult ratings of males and females matched for directly observed behaviors may contribute to understanding the substantial ADHD underrecognition in females.

Caregiver-Attributed Etiologies of Children's Attention-Deficit/Hyperactivity Disorder: A Study in Taiwan

The aim of this survey study was to examine the etiologies of attention-deficit/hyperactivity disorder (ADHD) attributed by caregivers of Taiwanese children with ADHD, particularly factors affecting such attribution. This study had 400 caregivers of children with ADHD as participants. We examined the caregiver-attributed etiologies of ADHD and factors affecting such attribution. Caregivers completed the self-report questionnaire to rate how likely they perceived various etiologies of ADHD to be; the Affiliate Stigma Scale for the level of affiliate stigma; and the short Chinese version of the Swanson, Nolan, and Pelham, Version IV Scale for child’s ADHD and oppositional symptoms. Brain dysfunction (84.8%) was the most commonly attributed etiology, followed by failure of caregivers in disciplining the child (44.0%); a poor diet, such as a sugar-rich diet (40.8%); a poor living environment (38.8%); the child imitating their peers’ improper behavior (37.3%); failure of school staff in disciplining the child (29.0%); the education system’s overemphasis on academic performance (27.3%); and supernatural beings or divination-based reasons (3.8%). Caregivers’ affiliate stigma was significantly associated with the attribution of several nonbiological etiologies other than brain dysfunction. Caregivers’ education level and children’s sex, hyperactivity/impulsivity, and oppositional symptoms were significantly associated with various caregiver-attributed etiologies. Therefore, to deliver more accurate knowledge about ADHD in educational programs, health professionals should consider those etiologies that are attributed by caregivers of children with ADHD.

Awareness of ADHD in primary care: stakeholder perspectives

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is underdiagnosed in many European countries and the process of accessing care and diagnosis is complex and variable. In many countries, general practitioners (GPs) refer on to secondary care where individuals receive an assessment and, if appropriate, a diagnosis and access to care. It is therefore essential that GPs have a clear understanding of the disorder and its care pathways. While previous studies have highlighted potential barriers in GPs' ADHD awareness, this qualitative study aims to further explore individual stakeholders' experiences.

METHODS

Semi-structured interviews explored the views of multiple stakeholders- GPs (n = 5), healthcare specialists (n = 5), patients (adults with ADHD n = 5) and parents (n = 5) with experience of the presentation and management of ADHD in primary care. These interviews were analysed using thematic analyses and following principles of grounded theory.

RESULTS

Stakeholders described ADHD assessment, diagnosis and treatment as an intricate process. Many factors affected this process such as complex pathways, lack of services, limited GP recognition and knowledge, and communicative difficulties between and within multiple stakeholders.

CONCLUSION

This analysis underlines the significant impact that receiving (or not) a diagnosis can have, and further explores muddled ADHD care pathways, highlighting key issues around GP identification and the shortage of adult services. Implications for practice and future research are discussed, suggesting a strong need for more commissioned pathways and GP specific educational programs.

Barriers and facilitators to understanding of ADHD in primary care: a mixed-method systematic review

Attention deficit hyperactivity disorder (ADHD) is a developmental disorder affecting up to 5% of children and adults and is underdiagnosed in many European countries. The process of access to care for this disorder is complex and variable across countries. In general, those affected, or their caregiver, will seek help through their primary care practitioners who are then often responsible for referral to other professionals for diagnosis and provision of treatment. Previous studies have highlighted that many barriers to recognition exist in primary care settings (such as misconceptions, lack of education or lack of resources), preventing access to care for this population and potentially affecting diagnosis rate. This systematic review aims to establish the barriers and facilitators with regard to attitudes, beliefs and experiences of ADHD within primary care. Electronic searches of multiple databases identified 3898 articles of which 48 met our inclusion criteria-primary care professionals from any country, understanding, knowledge, awareness, attitude and recognition of ADHD. Four main themes were identified: (1) need for education, (2) misconceptions and stigma, (3) constraints with recognition, management and treatment, and (4) multidisciplinary approach. The findings suggest many interacting factors are at play in the recognition of ADHD by primary care practitioners with a strong recurring theme of a significant need for better education on ADHD. Implications for research and practice are discussed, suggesting that educational interventions for primary care practitioners could improve the recognition of ADHD in this setting.

"Just keep pushing": Parents' experiences of accessing child and adolescent mental health services for child anxiety problems

BACKGROUND

Anxiety disorders are among the most common psychopathologies in childhood; however, a high proportion of children with anxiety disorders do not access effective treatments. The aim of the present qualitative study was to understand families' experiences of seeking help and accessing specialist treatment for difficulties with childhood anxiety.

METHODS

Parents of 16 children (aged 7-12 years) referred to a child mental health service for difficulties with anxiety were interviewed about their experiences of seeking and accessing treatment within Child and Adolescent Mental Health Service (CAMHS). All interviews were transcribed verbatim and thematically analysed for similarities and differences in families' experiences.

RESULTS

Factors that helped and/or hindered families accessing treatment related to (a) parental recognition, (b) contact with professionals, (c) reaching CAMHS, (d) parental effort, and (e) parental knowledge and concerns. High demands on services and parents' uncertainty surrounding the help-seeking process presented key hurdles for families. The critical role of parental persistence and support from general practitioners and school staff was evident across interviews.

CONCLUSIONS

Findings highlighted the need for information and guidance on identifying child anxiety difficulties and professional, peer, and self-help support, and ensuring sufficient provision is available to allow families prompt access to support.

The validity of the Strengths and Difficulties Questionnaire (SDQ) for children with ADHD symptoms

Background

The Strengths and Difficulties Questionnaire (SDQ) is widely used to assess child and adolescent mental health problems. However, the factor structure of the SDQ is subject to debate and there is limited evidence investigating measurement equivalence invariance (ME/I) between treatment groups, informants, and across time.

Method

A randomised controlled trial (RCT) recruited 250 participants (6–17 years) who had been referred for an attention deficit hyperactivity disorder (ADHD) assessment. Participants and their clinician either received or did not receive a QbTest report (computer task measuring attention, impulsivity and activity). Parents and teachers completed the SDQ at baseline and 6-months later. This study aimed to understand the factor structure of the SDQ in a clinic referred ADHD sample, and validate the scale as a screening/diagnostic aide and as a measure of treatment outcome both in clinical and research settings. Exploratory Structural Equation Modelling (ESEM) was performed to examine the factor structure, and ME/I was assessed between treatment groups, informants, and time points. The criterion validity of the SDQ predictive algorithm for ADHD was compared with clinician and research diagnoses using logistic regression and tests of diagnostic accuracy.

Results

A 5-factor structure provided the best fit with strong factorial invariance between treatment groups and across time points, but not across informants (parent and teacher ratings). SDQ ratings of ‘probable’ hyperactivity disorder were good predictors of clinical (OR = 10.20, 95%CI 2.18–48.71,p = 0.003) and research diagnoses of ADHD (OR = 6.82, 95%CI 1.95–23.84,p = 0.003), and research diagnoses of Hyperkinetic disorder (OR = 4.02, 95%CI 1.13–14.25,p = 0.031). Further examination of the SDQ hyperactivity ‘probable’ rating showed good specificity (84.5%-74.5%) but poor sensitivity (45.0–42.5%) for ADHD.

Conclusion

The findings indicate the SDQ is a valid outcome measure for use in RCTs and clinical settings. However, care should be taken when using the SDQ predictive algorithm to screen for ADHD in clinically referred samples.

Understanding parental causal explanations and help seeking in attention-deficit/ hyperactivity disorder: perspectives from a developing Asian nation

INTRODUCTION

Research on parental understanding of causation and help-seeking for ADHD comes from ethnic minorities in developed nations; research from Asia is scarce. Our purpose was to explore perceptions of Indian parents regarding causation and diagnosis of problematic childhood behaviors diagnosed as ADHD or hyperkinetic disorder, and to understand the process of decision making and help seeking using a qualitative study design.

METHOD

In-depth, semi-structured interviews were conducted with 52 parents (33 mothers and 19 fathers), focusing on initial emotional reactions and cognitive appraisals, decision making, parental causal explanations and perceptions regarding diagnosis and symptom labeling.

RESULTS

Mothers were decision makers for seeking professional help either singly or jointly in 76.1% of cases. Initial reactions ranged from those with negative valence (negative emotional reactions and cognitive appraisals) to ambi-valence (recognition of problems, but at the same time not accepting completely) and positive valence (sense of relief and hopefulness). Psycho-social explanations (63.46%) were more common than biological explanations (51.82%), with 19.23% reporting both explanations. Biological explanations included illness model (e.g. brain problem, obstetric complications), hereditary and intellectual disability. Psycho-social explanations included psychological (e.g. lack of motivation) and social (e.g. problems with disciplining at home) causations. Irrespective of initial reactions and causal explanations, a significant majority of parents were aware of the diagnosis and labeled problems as symptoms attributable to ADHD.

CONCLUSION

Our findings provide insights for development of culturally sensitive psycho-social interventions; from understanding of causal attributions, process of decision making and help seeking.

Pathways to mental health services for young people: a systematic review

PURPOSE

While early access to appropriate care can minimise the sequelae of mental illnesses, little is known about how youths come to access mental healthcare. We therefore conducted a systematic review to synthesise literature on the pathways to care of youths across a range of mental health problems.

METHODS

Studies were identified through searches of electronic databases (MEDLINE, PsycINFO, Embase, HealthSTAR and CINAHL), supplemented by backward and forward mapping and hand searching. We included studies on the pathways to mental healthcare of individuals aged 11-30 years. Two reviewers independently screened articles and extracted data.

RESULTS

Forty-five studies from 26 countries met eligibility criteria. The majority of these studies were from settings that offered services for the early stages of psychosis, and others included inpatient and outpatient settings targeting wide-ranging mental health problems. Generally, youths' pathways to mental healthcare were complex, involved diverse contacts, and, sometimes, undue treatment delays. Across contexts, family/carers, general practitioners and emergency rooms featured prominently in care pathways. There was little standardization in the measurement of pathways.

CONCLUSIONS

Except in psychosis, youths' pathways to mental healthcare remain understudied. Pathways to care research may need to be reconceptualised to account for the often transient and overlapping nature of youth mental health presentations, and the possibility that what constitutes optimal care may vary. Despite these complexities, additional research, using standardized methodology, can yield a greater understanding of the help-seeking behaviours of youths and those acting on their behalf; service responses to help-seeking; and the determinants of pathways. This understanding is critical to inform ongoing initatives to transform youth mental healthcare.

ADHD: science, stigma and service implications

We are delighted to dedicate an edition of the Irish Journal of Psychological Medicine to the topic of attention-deficit hyperactivity disorder (ADHD). ADHD accounts for the majority of clinical presentations to Child and Adolescent Mental Health Services, both in terms of new assessments and ongoing attendances. Papers presented in this edition reflect on the evolving construct of ADHD, drawing from science, clinical practice and public opinion. Current and evidenced-based assessment and treatment practice guidelines are reviewed. International longitudinal studies allow us to understand the personal and societal cost, which can persist for many years post-diagnosis. Despite continuation to adulthood in many young people, follow on adult services are lacking. It is fitting that submissions, by way of personal reflections and opinion pieces, are also included from adult colleagues as they reflect on their experiences in this area. Given the recent development of a national clinical programme in ADHD in Ireland, coupled with a growing evidence for effective interventions, it is hoped that this special edition will highlight the need for appropriate and accessible ADHD treatments across the lifespan.

Working Memory and Motor Activity: A Comparison Across Attention-Deficit/Hyperactivity Disorder, Generalized Anxiety Disorder, and Healthy Control Groups

Converging findings from recent research suggest a functional relationship between attention-deficit/hyperactivity disorder (ADHD)-related hyperactivity and demands on working memory (WM) in both children and adults. Excessive motor activity such as restlessness and fidgeting are not pathognomonic symptoms of ADHD, however, and are often associated with other diagnoses such as generalized anxiety disorder (GAD). Further, previous research indicates that anticipatory processing associated with anxiety can directly interfere with storage and rehearsal processes of WM. The topographical similarity of excessive motor activity seen in both ADHD and anxiety disorders, as well as similar WM deficits, may indicate a common relationship between WM deficits and increased motor activity. The relationship between objectively measured motor activity (actigraphy) and PH and visuospatial WM demands in adults with ADHD (n = 21), adults with GAD (n = 21), and healthy control adults (n = 20) was examined. Although all groups exhibited significant increases in activity from control to WM conditions, the ADHD group exhibited a disproportionate increase in activity, while activity exhibited by the GAD and healthy control groups was not different. Findings indicate that ADHD-related hyperactivity is uniquely related to WM demands, and appear to suggest that adults with GAD are no more active relative to healthy control adults during a cognitively demanding laboratory task.

Pathway to care and clinical profile of children with attention-deficit hyperactivity disorder in New Delhi, India

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is a common childhood neurobehavioral disorder, which may cause impairment in multiple domains. Understanding the pathway to care helps in planning effective early interventions. The study aims to provide a quantitative description of the factors affecting the help-seeking pathway.

MATERIALS AND METHODS

The study was conducted at an outpatients department of a tertiary care multispecialty hospital. Fifty consecutive consenting children aged 5-15 years were screened and diagnosed for ADHD using Conners' Parent Rating Scale-Revised: Short Form, Diagnostic and Statistical Manual of Mental Disorders fourth edition text revision criteria, and Kiddie Schedule for affective disorders and schizophrenia. A semi-structured questionnaire was used to study the pathway of care, using the WHO template. The data were analyzed using appropriate parametric and nonparametric tests in SPSS software.

RESULTS

The average delay from the onset of the illness to first consultation with a qualified health professional was 2.32 ± 1.9 years. Children with an urban background, from a nuclear family, with literate mothers, with a family income of more than Rs. 30,000/month, having hyperactive and combined type of ADHD, and who were referred by school teachers presented significantly earlier. The main source of referrals were school teachers and general medical practitioners. The most common parental beliefs for delay were the views that the "child is naughty" and that "hyperactivity is part of normal growth."

CONCLUSION

Parents' help-seeking behavior is affected by different sociocultural beliefs. Such factors as the lack of recognition and awareness of ADHD, resulting in the delay in seeking treatment should be addressed through health promotion programs.

What is known about pathways to mental health care for Australian Aboriginal young people?: a narrative review

OBJECTIVES

To (1) gain an understanding of current trajectories of Aboriginal young people through the mental health care system in Australia; (2) summarize what mental health care pathways have been developed or evaluated to guide mental health care delivery for Aboriginal young people; and (3) identify barriers and facilitators to the adoption of effective mental health care pathways for Aboriginal young people.

METHODS

Databases, including, AMED, Embase, Global Health, Health and Psychosocial Instruments, Healthstar, MEDLINE, PsychINFO via Ovid, CINAHL via EBSCO, The Cochrane Library, Indigenous Collections, Informit and Health Systems Evidence, were searched to identify evidence concerning mental health service delivery for Aboriginal young people in a primary care setting.

RESULTS

We did not identify any reports or publications explicitly describing the current trajectories of Aboriginal young people through the mental health care system in Australia. Furthermore, we were unable to locate any mental health-related treatment pathways which had been explicitly developed or modified to meet the needs of Aboriginal young people. The use of appropriate assessment tools, engagement of family and community, flexibility, and central coordination have been identified in the literature as potential facilitators of culturally appropriate mental health service delivery for Aboriginal children and adolescents.

CONCLUSIONS

Aboriginal children and adolescents may face additional difficulties navigating the mental health care system in Australia due to complex socio-cultural factors and the dearth of culturally appropriate and effective mental-health related treatment pathways. Additional research regarding (1) practice trends in Aboriginal settings and (2) how Aboriginal child and adolescent mental health can be improved is urgently needed to inform clinical practice and improve mental health service access and outcomes for Aboriginal young people in Australia.

ADHD research in India: A narrative review

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with no clear etiopathogenesis. Owing to unique socio cultural milieu of India, it is worthwhile reviewing research on ADHD from India and comparing findings with global research. Thereby, we attempted to provide a comprehensive overview of research on ADHD from India.

METHODS

A boolean search of articles published in English from September 1966 to January 2017 on electronic search engines Google Scholar, PubMed, IndMED, MedIND, using the search terms "ADHD", "Attention Deficit and Hyperactivity Disorder", "Hyperactivity" ,"Child psychiatry", "Hyperkinetic disorder", "Attention Deficit Disorder", "India"was carried out and peer - reviewed studies conducted among human subjects in India were included for review. Case reports, animal studies, previous reviews were excluded from the current review.

RESULTS

Results of 73 studies found eligible for the review were organized into broad themes such as epidemiology, etiology, course and follow up, clinical profile and comorbidity, assessment /biomarkers, intervention/treatment parameters, pathways to care and knowledge and attitude towards ADHD.

DISCUSSION

There was a gap noted in research from India in the domains of biomarkers, course and follow up and non-pharmacological intervention. The prevalence of ADHD as well as comorbidity of Bipolar Disorder was comparatively lower compared to western studies. The studies found unique to India include comparing the effect of allopathic intervention with Ayurvedic intervention, yoga as a non pharmacological intervention. There is a need for studies from India on biomarkers, studies with prospective research design, larger sample size and with matched controls.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What do general practitioners know about ADHD? Attitudes and knowledge among first-contact gatekeepers: systematic narrative review

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood disorder with international prevalence estimates of 5 % in childhood, yet significant evidence exists that far fewer children receive ADHD services. In many countries, ADHD is assessed and diagnosed in specialist mental health or neuro-developmental paediatric clinics, to which referral by General (Family) Practitioners (GPs) is required. In such 'gatekeeper' settings, where GPs act as a filter to diagnosis and treatment, GPs may either not recognise potential ADHD cases, or may be reluctant to refer. This study systematically reviews the literature regarding GPs' views of ADHD in such settings.

METHODS

A search of nine major databases was conducted, with wide search parameters; 3776 records were initially retrieved. Studies were included if they were from settings where GPs are typically gatekeepers to ADHD services; if they addressed GPs' ADHD attitudes and knowledge; if methods were clearly described; and if results for GPs were reported separately from those of other health professionals.

RESULTS

Few studies specifically addressed GP attitudes to ADHD. Only 11 papers (10 studies), spanning 2000-2010, met inclusion criteria, predominantly from the UK, Europe and Australia. As studies varied methodologically, findings are reported as a thematic narrative, under the following themes: Recognition rate; ADHD controversy (medicalisation, stigma, labelling); Causes of ADHD; GPs and ADHD diagnosis; GPs and ADHD treatment; GP ADHD training and sources of information; and Age, sex differences in knowledge and attitudes.

CONCLUSIONS

Across times and settings, GPs practising in first-contact gatekeeper settings had mixed and often unhelpful attitudes regarding the validity of ADHD as a construct, the role of medication and how parenting contributed to presentation. A paucity of training was identified, alongside a reluctance of GPs to become involved in shared care practice. If access to services is to be improved for possible ADHD cases, there needs to be a focused and collaborative approach to training.

Attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental disorder with a prevalence of 1·4-3·0%. It is more common in boys than girls. Comorbidity with childhood-onset neurodevelopmental disorders and psychiatric disorders is substantial. ADHD is highly heritable and multifactorial; multiple genes and non-inherited factors contribute to the disorder. Prenatal and perinatal factors have been implicated as risks, but definite causes remain unknown. Most guidelines recommend a stepwise approach to treatment, beginning with non-drug interventions and then moving to pharmacological treatment in those most severely affected. Randomised controlled trials show short-term benefits of stimulant medication and atomoxetine. Meta-analyses of blinded trials of non-drug treatments have not yet proven the efficacy of such interventions. Longitudinal studies of ADHD show heightened risk of multiple mental health and social difficulties as well as premature mortality in adult life.

A study of pathway of care in children and adolescents with attention deficit hyperactivity disorder

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) is associated with impairment in all aspects of the patient's life. Despite availability of effective treatments for ADHD, a majority of the patient lack access to or have a significant delay in seeking help. This study aimed to assess the pathway of care in ADHD among patients attending the outpatient psychiatric services of a tertiary care centre in India.

METHODS

57 newly registered cases of the age group 6-16 years with the diagnosis of ADHD as per DSM-IV-TR criteria were included in the study. Pathway of care was assessed on the semi structured proforma.

RESULTS

The mean duration of delay in seeking help for ADHD symptoms was 3.96 Years (SD=1.96). Only 50% of the subjects consulted psychiatrists as first contact. Majority of the patients (45.61%) were referred by school teachers. Major reason given by the family members was that the patient was naughty rather than having any disorder for not seeking treatment in (89.47%).

CONCLUSION

Our study showed that there was lack of recognition of ADHD at the level of other qualified practitioners and subsequent delay in referral to CAMHS. Sociocultural beliefs affected the help seeking by the parents.

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.

Working memory contributes to elevated motor activity in adults with ADHD: an examination of the role of central executive and storage/rehearsal processes

OBJECTIVE

The relationship between working memory (WM) and objectively measured motor activity was examined in adults with ADHD and healthy controls (HCs).

METHOD

Thirty-five adults (ADHD = 20, HC = 15) were grouped using self-report and collateral-report measures in addition to a semistructured clinical interview. All participants completed control conditions with minimal WM demands, and separate phonological (PH) and visuospatial (VS) WM tasks with recall demands ranging from four to seven stimuli.

RESULTS

The ADHD group exhibited significantly more motor activity relative to the HC group, and both groups exhibited greater activity during PH and VS WM tasks, relative to control conditions. Finally, the central executive (CE) and PH storage/rehearsal subsystems were associated with large-magnitude between-group differences in activity.

CONCLUSION

Findings suggest that increased demands on WM, particularly the CE and PH storage/rehearsal, contribute to ADHD-related hyperactivity, though a portion of excessive motor activity in adults with ADHD may occur independently of WM demands.

Study protocol for a randomized controlled trial comparing the efficacy of a specialist and a generic parenting programme for the treatment of preschool ADHD

Background

The New Forest Parenting Programme (NFPP) is a home-delivered, evidence-based parenting programme to target symptoms of attention-deficit/hyperactivity disorder (ADHD) in preschool children. It has been adapted for use with ‘hard-to-reach’ or ‘difficult-to-treat’ children. This trial will compare the adapted-NFPP with a generic parenting group-based programme, Incredible Years (IY), which has been recommended for children with preschool-type ADHD symptoms.

Methods/design

This multicentre randomized controlled trial comprises three arms: adapted-NFPP, IY and treatment as usual (TAU). A sample of 329 parents of preschool-aged children with a research diagnosis of ADHD enriched for hard-to-reach and potentially treatment-resistant children will be allocated to the arms in the ratio 3:3:1. Participants in the adapted-NFPP and IY arms receive an induction visit followed by 12 weekly parenting sessions of 1½ hours (adapted-NFPP) or 2½ hours (IY) over 2.5 years. Adapted-NFPP will be delivered as a one-to-one home-based intervention; IY, as a group-based intervention. TAU participants are offered a parenting programme at the end of the study. The primary objective is to test whether the adapted-NFPP produces beneficial effects in terms of core ADHD symptoms. Secondary objectives include examination of the treatment impact on secondary outcomes, a study of cost-effectiveness and examination of the mediating role of treatment-induced changes in parenting behaviour and neuropsychological function. The primary outcome is change in ADHD symptoms, as measured by the parent-completed version of the SNAP-IV questionnaire, adjusted for pretreatment SNAP-IV score. Secondary outcome measures are: a validated index of behaviour during child’s solo play; teacher-reported SNAP-IV (ADHD scale); teacher and parent SNAP-IV (ODD) Scale; Eyberg Child Behaviour Inventory - Oppositional Defiant Disorder scale; Revised Client Service Receipt Inventory - Health Economics Costs measure and EuroQol (EQ5D) health-related quality-of-life measure. Follow-up measures will be collected 6 months after treatment for participants allocated to adapted-NFPP and IY.

Discussion

This trial will provide evidence as to whether the adapted-NFPP is more effective and cost-effective than the recommended treatment and TAU. It will also provide information about mediating factors (improved parenting and neuropsychological function) and moderating factors (parent and child genetic factors) in any increased benefit.

Trial registration

Current Controlled Trials, ISRCTN39288126.

The prevalence and incidence, resource use and financial costs of treating people with attention deficit/hyperactivity disorder (ADHD) in the United Kingdom (1998 to 2010)

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is a common disorder that often presents in childhood and is associated with increased healthcare resource use. The aims of this study were to characterise the epidemiology of diagnosed ADHD in the UK and determine the resource use and financial costs of care.

METHODS

For this retrospective, observational cohort study, patients newly diagnosed with ADHD between 1998 and 2010 were identified from the UK Clinical Practice Research Datalink (CPRD) and matched to a randomly drawn control group without a diagnosis of ADHD. The prevalence and incidence of diagnosed ADHD were calculated. Resource utilisation and corresponding financial costs post-diagnosis were estimated for general practice contacts, investigations, prescriptions, outpatient appointments, and inpatient admissions.

RESULTS

Incidence of diagnosed ADHD (and percentage change using 1998 as a reference) increased from 6.9 per 100,000 population in 1998 to 12.2 per 100,000 (78%) in 2007 and then fell to 9.9 per 100,000 (44%) by 2009. The corresponding prevalence figures were 30.5, 88.9 (192%) and 81.5 (167%) per 100,000. Incidence and prevalence were higher in males than females. Mean annual total healthcare costs were higher for ADHD cases than controls (£1,327 versus £328 for year 1, £1,196 vs. £337 for year 2, £1,148 vs. £316 for year 3, £1,126 vs. £325 for year 4, and £1,112 vs. £361 for year 5).

CONCLUSIONS

The prevalence of diagnosed ADHD in routine practice in the UK was notably lower than in previous reports, and both prevalence and incidence of diagnosed ADHD in primary care have fallen since 2007. Financial costs were more than four times higher in those with ADHD than in those without ADHD.

Patient preferences and willingness-to-pay for ADHD treatment with stimulants using discrete choice experiment (DCE) in Sweden, Denmark and Norway

BACKGROUND

The choice between different attention-deficit/hyperactivity disorder (ADHD) medications depends on different drug attributes. Economic evaluations of drugs often disregard the utility of other attributes compare with the drugs' efficacy.

AIMS

The aim of this study was to assess patient's preferences and elicit willingness-to-pay (WTP) for different drug attributes in the treatment of ADHD.

METHODS

285 patients (117 parents for children below 15 years, 52 adolescents 15-17 years and 116 adults aged 18 years and above) from Sweden, Denmark and Norway completed a questionnaire concerning their ADHD drug treatment, and answered questions on their preferences using a discrete choice experiment (DCE). Included attributes were effectiveness, side-effects, dosing and price.

RESULTS

Effectiveness was the most important attribute, followed by side-effects and the number of dosings per day (all P < 0.001). The estimated monthly WTP for a drug generating full effectiveness, no side-effects and once-daily dosing was €790 for adolescents and €360 for adults. The estimated WTP for ADHD drugs with characteristics similar to existing drugs on the market was higher or in line with market prices (€37-180 for adolescents and €16-80 for adults). Regarding experience with current treatment, 19% of all patients in the study reported good functioning during the morning, day and evening.

CONCLUSIONS

The gap between the monetary valuation of existing products and an optimally valued product suggest that there is room for improvements in the clinical management of ADHD. The results suggest that DCE is a method that can be used to value not only hypothetical scenarios but also can be used to value and distinguish between real-life scenarios.

Stimulant treatment and injury among children with attention deficit hyperactivity disorder: an application of the self-controlled case series study design

OBJECTIVE

The aim of the present work was to assess the short-term effects of stimulant medication use on risk of injury among children diagnosed as having attention deficit hyperactivity disorder (ADHD).

METHODS

The study group for this self-controlled case series study was children aged 1-18 years old diagnosed as having ADHD who experienced an incident medically-attended injury event and received at least one prescription for stimulant medication between 1993 and 2008 (n=328), identified from The Health Improvement Network primary care database from the UK. Conditional Poisson regression was used to estimate incident rate ratios (IRR) and 95% CIs for injury comparing periods of time exposed to stimulant medication to unexposed periods.

RESULTS

Among children with ADHD prescribed stimulant medication, the rate of medically-attended injury was decreased during periods of stimulant medication use as compared to unexposed periods (IRR 0.68, 95% CI 0.50 to 0.91). There was evidence of a protective association among males and among children aged 10-14 years. This effect did not change over time on treatment.

CONCLUSIONS

Stimulant medication use may decrease the risk of injury among children treated for ADHD, although unmeasured time varying confounding may be an alternative explanation. Injury risk may be considered during the decision-making process with regard to medication continuation among children with ADHD.

Ethnic differences in problem perception and perceived need for care for young children with problem behaviour

BACKGROUND

 Problem perception and perceived need for professional care are important determinants that can contribute to ethnic differences in the use of mental health care. Therefore, we studied ethnic differences in problem perception and perceived need for professional care in the parents and teachers of 5- to 6-year-old children from the general population who were selected for having emotional and behavioural problems.

METHODS

A cross-sectional study with data of 10,951 children from grade two of the elementary schools in the Rotterdam-Rijnmond area, The Netherlands. Parents and teachers completed the strengths and difficulties questionnaire (SDQ) as well as questions on problem perception and perceived need for care. The SDQ was used to identify children with emotional and behavioural problems. We included Dutch, Surinamese, Antillean, Moroccan and Turkish children in our sample with high (>P90) SDQ scores (N = 1,215), who were not currently receiving professional care for their problems.

RESULTS

Amongst children with high SDQ scores, problem perception was lower in non-Dutch parents than in Dutch parents (49% vs. 81%, p < 0.01). These lower rates of problem perception could not be explained by differences in socioeconomic position or severity of the problems. No ethnic differences were found in parental perceived need and in problem perception and perceived need reported by teachers. Higher levels of problem perception and perceived need were reported by teachers than by parents in all ethnic groups (PP: 87% vs. 63% and PN: 48% vs. 23%).

CONCLUSIONS

Child health professionals should be aware of ethnic variations in problem perception as low problem perception in parents of non-Dutch children may lead to miscommunication and unmet need for professional care for the child.

Predictors of treatment attrition among an outpatient clinic sample of youths with clinically significant anxiety

Predictors of treatment attrition were examined in a sample of 197 youths (ages 5-18) with clinically-significant symptoms of anxiety seeking psychotherapy services at a community-based outpatient mental health clinic (OMHC). Two related definitions of attrition were considered: (a) clinician-rated dropout (CR), and (b) CR dropout qualified by phase of treatment (pre, early, or late phases) (PT). Across both definitions, rates of attrition in the OMHC sample were higher than those for anxious youths treated in randomized controlled trials, and comorbid depression symptoms predicted dropout, with a higher rate of depressed youths dropping out later in treatment (after 6 sessions). Using the PT definition, minority status also predicted attrition, with more African-American youths lost pre-treatment. Other demographic (age, gender, single parent status) and clinical (externalizing symptoms, anxiety severity) characteristics were not significantly associated with attrition using either definition. Implications for services for anxious youths in public service settings are discussed. Results highlight the important role of comorbid depression in the treatment of anxious youth and the potential value of targeted retention efforts for ethnic minority families early in the treatment process.

Help Seeking Process among Children Attending Psychiatry Clinic in Tirana, Albania

OBJECTIVE

The goal of this study was to investigate all the potential routes to Child/Adolescent Psychiatry Clinic-University Hospital Center (CAPC-UHC) in Tirana. The article provides demographic data, as well as further information on the types and amounts of services children/adolescents received during the process of seeking help related to different diagnoses.

METHOD

The study was conducted in CAPC-UHC in Tirana, during September 2006-September 2007. Data were collected from 162 children and their parents using Strengths and Difficulties Questionnaire (SDQ) and Pathways Encounter Form. The sample consisted of 53.1% (86) males and 46.9% (76) females. The mean age was 9.5+4.4 years.

RESULTS

Out of the total number of cases that sought care to CAPC; 55, 6% were referred by parents themselves, while the rest were referred by others. There was a significant effect of gender to intervals from the onset of problem to the first career (F=10.803, p=0.001), as well as a significant effect of gender to total time intervals from the onset till the specialist of child mental health problem (F=6.742, p=0.01).

CONCLUSIONS

This is the first study investigating the help seeking process to psychiatric care in CAPC Tirana-Albania and may serve as a good start in generating evidence based on child/adolescent mental health service. Further multicentre studies will enhance the values of the findings, since the present study was performed in a single service, and in a setting lacking previous works with similar scope that could have served as references.

Are Children Diagnosed With the Combined Form of ADHD Pervasively Hyperactive?

Diagnostic criteria specified by the Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR ; American Psychological Association [APA], 2000) require that motor excess be present across situations, at home and school, in order to establish that this condition is a characteristic of the child. The article discusses a study whose primary purpose was to use actigraphy to validate teacher and parent reports of hyperactivity at home and school. Continuous activity measurements were recorded for each minute of each 24-hr period (1,440 measurements per child per day) for a full 7-day week, during school and at home, on 9 children clinically diagnosed with the combined form of ADHD and 9 control children clinically examined at the same community mental health clinic and determined not to meet diagnostic criteria. The article highlights that the children with ADHD had not yet started medication, and the study findings reveal that only 1 of 9 children diagnosed with the combined form of ADHD was measurably pervasively hyperactive as DSM-IV-TR inclusion criteria require. Implications are discussed.

Examining the meaning attached to mental illness and mental health services among justice system-involved youth and their parents

A large percentage of youth involved in the juvenile justice system experience mental health problems, yet many do not receive mental health care. In this study, we used a process-focused framework of mental health decision making to gain insight into the use of mental health services among these youth. In-depth interviews were conducted with nine youth and nine parents participating in a program servicing youth with mental health problems who have been in detention. Themes related to problem recognition, the decision to seek and participate in services, subjective norms, and juvenile justice system involvement emerged. Most families acknowledged their youth was having problems, but few defined those problems in mental health terms. This did not prevent them from seeking services, although some were not able to access adequate services until the justice system became involved. Participants were aware of negative attitudes about mental illness, and might have limited their social networks to shield themselves.

The provision and nature of ADHD services for children/adolescents in the UK: results from a nationwide survey

The Attention Deficit Hyperactivity Disorder (ADHD) Observational Research in Europe (ADORE) project aims to describe the relationship between prescribed treatment regimen and quality of life in ADHD patients across Europe over a 2-year period. As an adjunct to the ADORE study, a survey was conducted to assess the availability and range of ADHD treatment services in the UK. A questionnaire was developed to assess service provision at 20 UK ADORE sites. These data give information regarding the assessment process (i.e. the formal psychological instrumentation used), whether information is requested from schools, and what other medical and allied health care specialities are frequently involved in the diagnosis. Results of the survey provide an important insight into the ADHD-related services provided by ADORE centres, as well as highlighting the availability and limitations of such services.

Epidemiology of attention-deficit/hyperactivity disorder in the community

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting around 5% of school-aged children. However, in the UK, the majority of children with ADHD remain undiagnosed. This article reviews the epidemiology of ADHD in terms of its prevalence, correlates, recognition and outcomes with regard to community and clinical samples.

Parents' representations of their children: an exploratory study using the Osgood Semantic Differential Scales

The results of an exploratory national study carried out in Italy using Osgood's Semantic Differential Scales (Osgood, Suci, & Tannenbaum, 1957) with parents of 100 normal 6- to 11-yr.-old children in mainstream classrooms are reported. The aim was to devise a simple tool to be used to explore parents' perceptions of their children in this age group. Parents were asked to rate "my child" using some of Osgood's Semantic Differential Scales especially adapted for this study. Participants were 97 fathers and 100 mothers. Fathers were 32 to 57 years of age (M = 43.2, SD = 5.4), mothers were 29 to 49 years of age (M = 39.7, SD =4.4). In factor analysis four factors were identified: Activity, Evaluation, Emotions evoked by the child, Personality/Physical contact. Average factor scores were significantly different. There were no significant differences between fathers and mothers on the four factor scores. Children were more positively evaluated the younger they were.

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.

Neuropsychological assessment of adult patients with attention-deficit/hyperactivity disorder

Adults with persistent attention-deficit/hyperactivity disorder (ADHD) may show cognitive deficits as compared to healthy control subjects. The aim of this study was to compare a sample of adult outpatients with ADHD on medication to healthy controls on a comprehensive neuropsychological assessment battery. Thirty adults with ADHD under stable psychopharmacological treatment and 27 healthy controls matched for age, gender, and IQ were assessed with ten tests measuring performance with regard to attention, memory, executive function, and fine motor control. Lower performance in patients as compared to controls was found in tests of verbal and visual memory, speed of visuo-motor search, set shifting, and divided attention. Indicators of response inhibition and simple response speed were less affected. Adults with ADHD show indicators of lowered cognitive performance under medication. These are related more to memory and attention under high mental load than to response inhibition or simple attention or motor performance.

How Parents Seek Help for Children with Mental Health Problems

Parents seeking help for their child's mental health problem face a complicated system of services. We examined how parents navigate the various services available. Sixty parents contacting a children's mental health center were interviewed regarding their efforts and rationale in seeking help for their child. On average, in the year prior to the interview parents sought help for two different child problems, contacted five different agencies or professionals for help, and parents and/or children received two different treatments. One fifth of the time parents said they accepted treatments that they did not want. Almost all parents (87%) were simultaneously in contact with more than one agency at some point within the previous year. Future help-seeking models need to capture the iterative referral process that many parents experience.