ADHD is generally diagnosed and treated in the primary care setting; however, many general practitioners are not confident in recognising and managing the disorder (Wright et al. 2015; Tatlow-Golden et al. 2016), which can delay access to optimal care and potentially result in long-term impairment due to unmanaged ADHD (Shaw et al. 2012). With the aim of improving recognition of ADHD, this mixed-methods systematic review evaluated the barriers and facilitators influencing the understanding of ADHD in the primary care setting (French et al. 2018).
This systematic review included published and peer-reviewed qualitative and quantitative studies in primary care.*† Electronic searches of multiple databases identified 3898 articles, 48 of which met the inclusion criteria. Qualitative and quantitative data were then extracted from the included studies using standardised data extraction tools (JBI-QARI and JBI-MAS-tARI for qualitative and quantitative studies, respectively). Prior to the mixed-methods data synthesis, a segregated synthesis involving qualitative and quantitative evidence was conducted and combined by means of configuration. The results of these separate syntheses were combined in the form of qualitative themes, with all numerical results in the quantitative synthesis undergoing configurative conversion. Using the final aggregation of qualitative and quantitative findings as a basis, four themes were identified, and the barriers and facilitators for each are summarised below.
The need for education
Results from this systematic review identified 37 papers from 13 different countries that highlighted a lack of education on ADHD as a major barrier to recognition and treatment:
- Lack of initial training and inadequate training: A lack of training was reported by many studies, particularly at the undergraduate and postgraduate medical education level, with 1–28% of primary care health professionals (PCPs) receiving specific training about ADHD. Where PCPs did receive training, up to two-thirds felt inadequately trained to evaluate children with ADHD. This lack of education had a negative impact on multiple aspects of patient experience within the primary care setting, including referral and diagnosis, as well as management of ADHD.
- Lack of awareness, experience, understanding and knowledge of ADHD: Knowledge of guidelines and procedures for identification of ADHD was low, further highlighting the need for education. Inaccurate beliefs, such as believing that ADHD did not need to be treated or was not a medical problem, were also reported. Additionally, very few studies included in the systematic review reported a majority of PCPs in their sample being able to identify ADHD characteristics.
- Lack of confidence about ADHD: In addition to a general lack of confidence regarding ADHD, studies also reported low confidence and competence in the management and treatment of ADHD, with some PCPs reporting being uncomfortable with ADHD medication.
Although the need for education underpinned many barriers surrounding the overall understanding and knowledge of ADHD, a few positive outcomes were also reported in the systematic review. In fact, some studies (3/48) reported above-average ratings of confidence and high knowledge of ADHD. Furthermore, PCPs had a keen interest in gaining more knowledge about ADHD, with strategies such as asking colleagues, self-education and online enquiries being reported. Educational programmes also provided a benefit by further increasing knowledge.
Misconceptions and stigma
Results from this systematic review identified 17 studies from 9 different countries that highlighted misconceptions and stigma surrounding ADHD:
- General stigmas and misconception: Reported by most studies, including beliefs that ADHD is caused by a poor diet or high sugar levels, ADHD medication is addictive, and ADHD is only present in boys.
- Bad parenting: Reported by 10 studies, with approximately 15–50% of PCPs believing that dysfunctional families were the primary cause of ADHD symptoms.
- The role of the media and labels: Two studies suggested that the media had an influence on the general public’s perception of ADHD. Additionally, two studies reported that some parents felt PCPs were against labels, trying to normalise hyperactive behaviours.
Very few facilitators were observed within this theme; however, the authors noted that concepts regarding misconception and stigma were only evaluated in a third of the included studies, and thus patterns may not have emerged as expected.
Constraints with recognition, management and treatment
Results from this systematic review identified 20 studies from 7 different countries that discussed aspects related to recognition, management and treatment of ADHD.
- Time constraints and complexity of ADHD: Many studies reported that obtaining all of the relevant information regarding ADHD symptoms was often too time consuming. A number of studies also highlighted the need for better assessment tools, as well as the difficulties involved in assessing child behaviour across different settings.
- Treatment: A number of studies reported a general uneasiness around ADHD treatment, which sometimes led to resistance or refusal of PCPs to provide prescriptions. Studies also reported that PCPs had a limited knowledge of the available treatment options.
Despite the constraints reported in many of the included studies, attempts to address these issues were only reported in two studies; results demonstrated that strategies to improve education on the management and treatment of ADHD had a positive effect, increasing PCP confidence surrounding prescribing and monitoring medication, as well as increasing the rate of ADHD referrals.
This systematic review identified 22 studies from 5 countries that explored the concept of a multidisciplinary approach in ADHD management:
- The role of specialists and the importance of shared care: Many studies reported that communication between specialists, a key component in the multidisciplinary approach, was a major barrier to access to ADHD care. Furthermore, studies also highlighted confusion surrounding the role of different professionals.
- The role of school, parents and patients: Communication with schools, parents and people with ADHD was also identified as a barrier. Studies reported that missed appointments limited the opportunity for adequate assessment and treatment, and that PCPs had difficulty in getting the right information from parents and schools and felt ongoing pressure to provide a diagnosis.
Of the included studies, only one study demonstrated that the multidisciplinary approach employed in ADHD management was associated with a positive outcome. The authors suggested that an integrated pathway between primary and secondary care may provide an optimal solution for ADHD assessment.
This systematic review was associated with a number of limitations. First, there was considerable variability in the quality of the included studies, and as this was a systematic review rather than a meta-analysis, it was not possible to assess publication bias and its impact on study conclusions. Furthermore, only a small proportion of studies were published since 2010, which could limit their relevance compared with more recent studies. In some instances, the concept of ‘barriers’ and ‘facilitators’ was open to interpretation to the authors, as not all studies explicitly mentioned these terms. Finally, the majority of the studies included in the review originated from Western countries; therefore, further research from other regions is needed to draw conclusions that may be applicable on a global basis.
The authors concluded that a number of interacting factors may play a role in the recognition of ADHD by PCPs, with a strong recurring theme of a significant need for better education on ADHD. Therefore, educational strategies to enhance PCP knowledge and confidence could improve the recognition of ADHD in this setting.
*Qualitative studies were of any design exploring ADHD in primary care, including beliefs, understanding, attitudes and experiences; quantitative studies were of experimental and observational design (including, but not limited to, cohort studies, case-controlled studies and randomised controlled trials); mixed-methods studies were also included, and relevant quantitative and qualitative components extracted separately
†In the context of this study, the definition of primary care includes all public service health professionals that act as a first port of call for families and patients seeking medical advice (referred to as PCPs), and included professions such as physicians, family doctors, general practitioners, paediatricians, nurses and practitioners, depending on the country in which the study was conducted
French B, Sayal K, Daley D. Barriers and facilitators to understanding of ADHD in primary care: a mixed-method systematic review. Eur Child Adolesc Psychiatry 2018; Epub ahead of print.
Shaw M, Hodgkins P, Caci H, et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Med 2012; 10: 99.
Tatlow-Golden M, Prihodova L, Gavin B, et al. What do general practitioners know about ADHD? Attitudes and knowledge among first-contact gatekeepers: systematic review. BMC Fam Pract 2016; 17: 129.
Wright N, Moldavsky M, Schneider J, et al. Practitioner review: pathways to care for ADHD – a systematic review of barriers and facilitators. J Child Psychol Psychiatry 2015; 56: 598-617.