In many countries, assessment and diagnosis of ADHD in children takes place in specialised secondary services following a referral by a general practitioner (GP). In view of this central role of the GP in determining whether children will receive appropriate ADHD care, a team of researchers aimed to answer the following questions based on a systematic review of the literature:
- How do referring GPs self-rate their recognition of ADHD in children and young people?
- Do GPs recognise ADHD as a valid diagnosis?
- What, in the GPs’ opinion, is the underlying cause of ADHD?
- Which treatment do GPs believe to be the most effective?
- What role do GPs perceive for themselves in the pathway to ADHD specialist service referral?
An electronic search of different databases* using the following three main terms and their variations was conducted: general (family), physician (doctor, primary care, practitioner) and attention deficit hyperactivity disorder (ADHD, attention deficit). Studies were only considered if they were conducted in a country where GPs are the first-contact ‘gatekeepers’, if they addressed GPs’ attitudes/knowledge regarding ADHD in children/adolescents, if they were published after the issuance of the Diagnostic and Statistical Manual of Mental Disorders – 4th Edition (during or after 1994) and prior to January 2015, if results for GPs were reported separately from those of other health professionals, and if they were in English language and from peer-reviewed publications. A total of 11 papers† (publication date 2000–2010) were retained for the final analysis, and findings were categorised under different themes.‡
According to three self-report studies from the UK, Canada and Australia, ADHD was under-recognised in primary care settings. Surveys and focus groups in the UK, Australia and Iran indicated that GPs had generally mixed feelings about ADHD and raised scepticism about medicalising childhood behaviour and concern about ADHD stigma.
GPs believed that ADHD was multifactorial: 45–77% of GPs cited biological/neurological factors, while 45–97% cited parenting-related factors such as ineffective discipline, chaotic families, marital or family discord, or parental drug abuse. Other causative factors that were reported included environmental factors and nutrition.
Most GPs had low confidence in their diagnostic abilities due to a lack of training and the complexity of ADHD, and 71–94% believed that oversight of a specialist was required for ADHD treatment. The attitudes towards pharmacotherapy were mixed. For example, in Australia, 43% of GPs viewed stimulants as an appropriate first-line treatment, whereas 17% believed this type of pharmacotherapy was always inappropriate. However, in the UK, most GPs stressed a combination approach (medication with psychosocial techniques).
Only a few studies reported on ADHD-specific GP training, and those that did indicated that 6% of GPs in the UK and 10% in Iran had received training. With regard to age and sex differences in knowledge and attitudes, there was no pattern of findings in the few studies which reported on this.
The small number of studies considered and the bias of the publication dates towards the earlier part of the decade limit the interpretation of the results of this review. In addition, the use of different questionnaires in each study calls for caution when drawing conclusions about attitudes across the studies. However, the findings still highlight the knowledge gaps and mixed attitudes regarding ADHD among referring GPs, and emphasise the need for education and training in this group.
Read more about the knowledge and attitudes of referring GPs here
*MEDLINE, EMBASE (Elsevier), CINAHL Plus (EBSCO), Scopus, PsycArticles (Proquest), PsycINFO (Proquest), Social Services Abstracts, Applied Social Sciences Index and Abstracts (ASSIA)
†UK (n=6); Australia (n=2); Canada (n=1); Finland (n=1); Iran (n=1)
‡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
Tatlow-Golden M, Prihodova L, Gavin B, et al. What do general practitioners know about ADHD? Attitudes and knowledge among first-contact gatekeepers: systematic narrative review. BMC Fam Pract 2016; 17: 129.