In Amsterdam in the Netherlands, children and adolescents with ADHD requiring intensive psychiatric treatment may be referred to specialised general outpatient clinics by general practitioners. At these clinics, the aim is to reduce symptoms of ADHD and improve psychosocial functioning via medication, behavioural therapy, psychoeducation, organisation/planning/social-skills training and parental support. For children and adolescents with more severe ADHD symptoms, individuals may be referred to youth Assertive Community Treatment (youth-ACT), which is an outreach-orientated treatment for those with severe psychiatric and psychosocial problems. At youth-ACT, a multidisciplinary team of mental health care professionals provide treatment (GGZ Nederland, 2013). To enhance the understanding of the care needs of individuals with ADHD receiving treatment in specialised mental health care, this study aimed to assess the met and unmet care needs in a general outpatient setting versus youth-ACT.
This was a cross-sectional study conducted between 2015 and 2017 in participants diagnosed with ADHD aged between 6 and 17 years.* Psychiatric diagnoses were assessed using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-Kid) in combination with a clinical diagnosis of ADHD based on the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5TM). Unmet care needs were assessed using the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS).†
In total, 52 participants were included in the general outpatient sample and 53 in the youth-ACT sample. Demographics were similar between participants in the general outpatient setting and youth-ACT in terms of age (total mean [standard deviation (SD)] age, 11.2 [2.8] vs 12.3 [3.2] years; p = 0.08), gender (male, 65.4% vs 69.8%; p = 0.782), country of birth (the Netherlands, 100.0% vs 94.3%; p = 0.243), type of ADHD diagnosis (combined, 69.2% vs 79.2%; inattention, 30.8% vs 20.8%; p = 0.342) and living situation (single parent, 30.8% vs 35.8%; two parents, 69.2% vs 64.2%; p = 0.730). Participants in the general outpatient setting had significantly higher mean (SD) general functioning score compared with those in youth-ACT (54.7 [5.5] vs 46.5 [8.3]; p = 0.000).
Unmet care needs with a >8% frequency in the overall sample were as follows:
Physical and mental functions
- 61.9% for non-psychotic mental health problems (outpatient: 66.0%, youth-ACT: 57.7%; p = 0.497)
- 47.6% for information on diagnosis and treatment (outpatient: 60.4%; youth-ACT: 34.6%; p = 0.014)
- 18.1% for medication-related side effects (outpatient: 9.4%; youth-ACT: 26.9%; p = 0.038)
- 8.6% for quality and/or quantity of food (outpatient: 1.9%; youth-ACT: 15.4%; p = 0.016)
- 9.5% for danger to others (outpatient: 9.4%; youth-ACT: 9.6%; p = 1.000).
Performance of daily activities
- 17.1% for reading/writing skills (outpatient: 24.5%; youth-ACT: 9.6%; p = 0.077)
- 10.5% for handling money (outpatient: 11.3%; youth-ACT: 9.6%; p = 1.000)
- 8.6% for self-care abilities (outpatient: 1.9%; youth-ACT: 15.4%; p = 0.016).
Participation in the community
- 28.6% for future prospects (outpatient: 18.9%; youth-ACT: 38.5%; p = 0.045)
- 21.9% for making and/or keeping friends (outpatient: 13.2%; youth-ACT: 30.8%; p = 0.049)
- 20.0% for regular/suitable school or other daytime activities (outpatient: 9.4%; youth-ACT: 30.8%; p = 0.013).
In terms of the five most frequently reported unmet care needs in the overall sample (non-psychotic mental health problems, information on diagnosis and treatment, future prospects, making and/or keeping friends, and regular/suitable school or other daytime activities), there were no significant differences between primary-school children (aged 6‒12 years) and adolescents (aged 13‒17 years).
This is the first study to examine the self-reported perceived unmet care needs of children and adolescents with ADHD who have been referred to either a general outpatient clinic or youth-ACT. However, by using a cross-sectional study design, the causal explanations for the occurrences and persistence of unmet care needs could not be assessed.
In conclusion, the highest unmet care needs in the overall ADHD sample involved non-psychotic mental health problems, information on diagnosis and/or treatment and future prospects. There were several similarities and differences between unmet care needs in children and adolescents in the general outpatient clinic compared with youth-ACT. The authors suggested that focusing treatment of ADHD on unmet needs, and not just on ADHD symptoms, may help motivate children and adolescents, and reduce non-attendance, non-compliance and drop-out of specialised mental health care.
*Participants in the general outpatient population were randomly selected. All individuals who were referred to youth-ACT during the inclusion period were included in the sample; these participants had all previously received prior general outpatient treatment
†The CANSAS covers 24 items, each of which distinguishes between three levels of care need: (1) no (no problem); (2) met need (no or moderate problem because of help received); (3) unmet need (current serious problem, regardless of help received). Each item is categorised using the following health and health-related domains: (a) physical and mental functions; (b) performance of daily activities; (c) participation in the community; all according to the International Classification of Functioning, Disability and Health. The CANSAS was delivered via face-to-face interview with the individual during the intake procedure (on the day of the first appointment at the general outpatient clinic and after the first or second appointment in the youth-ACT setting). For children aged <12 years, interviews were conducted in the presence of a parent; parents were encouraged to support the child in answering questions if the child’s answer was unclear, or to help clarify the questions, but parents could not answer on behalf of the child
GGZ Nederland. Factsheet specialistische jeugd-GGZ. 2013. Available at: https://www.ggznederland.nl/uploads/publication/Factsheet%20specialistische%20jeugd-ggz.pdf. Accessed March 2020.
Vijverberg R, Ferdinand R, Beekman A, et al. Unmet care needs of children with ADHD. PLoS One 2020; 15: e0228049.