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Program Committee: Stephen V. Faraone, PhD, Program Director;
Lenard Adler, MD, David Goodman, MD, Co-Chairs, APSARD Education Committee;
Jonathan Marx, MBA, Media and Marketing Director

What are the Barriers to Understanding ADHD in Primary Care?

A newly-published systematic review by a British team identified 48 qualitative and quantitative studies that explored “ADHD in primary care, including beliefs, understanding, attitudes, and experiences.” The studies described primary care experiences in the U.S., Canada, Europe, Australia, Singapore, Iran, Pakistan, Brazil, and South Africa.

More than three out of four studies identified deficits in education about ADHD. Of particular concern was the training of primary care providers (PCPs), most of whom received no specific training on ADHD. In most places, a quarter or less of PCPs received such training. Even when such training was provided, PCPs often rated it as inadequate, and said they did not feel they could adequately evaluate children with ADHD. There was even less training for adult ADHD.

A 2009 survey of 194 PCPs in Pakistan found that ADHD was not included at all in medical training there, and that most learned from colleagues. Half readily admitted to having no competence, and less than one in five were shown to have adequate knowledge about ADHD. In a 2009 survey of 229 South African PCPs, only 7 percent reported adequate training in childhood ADHD, and a scant one percent in adult ADHD.

These problems were by no means limited to less developed countries. A 2001 U.K. survey of 150 general practitioners found that only 6 percent of them had received formal ADHD training. In a 2002 study of 499 Finnish PCPs, only half felt confident in their ability to diagnose ADHD. A 2005 survey of 405 Canadian PCPs likewise found that only half reported skill and comfort in diagnosis. In a 2009 survey of 400 U.S. primary care physicians, only 13 percent said they had received adequate training. A 2017 study of Swiss PCPs found that only five of the 75 physicians in the sample expressed competence in diagnosis.

Eight studies explored knowledge of DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria and clinical guidelines among PCPs. Only a quarter of PCPs were using DSM criteria, and only one in five were using published guidelines. In a 1999 survey of 401 pediatricians in the U.S. and Canada, only 38 percent reported using DSM criteria. A 2004 survey of 723 U.S. PCPs found only 44 percent used DSM criteria. In a 2006 UK study of 40 general practitioners, only 22 percent were aware of ADHD criteria. In the same year, a survey of 235 U.S. physicians found that only 22 percent were familiar with ADHD guidelines, and 70 percent used child behavior in the office to make a diagnosis. More encouragingly, a 2010 U.S. study reported that use of APA (American Psychological Association) guidelines by PCPs had expanded markedly between 1999 and 2005, from one in eight to one in two.

Given these facts, it is unsurprising that many PCPs expressed lack of confidence in treating ADHD. In a 2003 survey of 143 South African general practitioners, two thirds thought it was difficult to diagnose ADHD in college students. A 2012 U.S. study of 1,216 PCPs found that roughly a third lacked confidence in diagnosis and treatment. More than a third said they did not know how to manage adult ADHD. In a 2015 survey of 59 physicians and 138 nurses in the U.S., half lacked confidence in their ability to recognize ADHD symptoms. This was especially pronounced among the nurses. A 2001 U.K. survey of 150 general practitioners found that nine out of ten wanted further training in drug treatment, and more than one out of ten were unwilling to prescribe due to insufficient knowledge.

Misconceptions about ADHD were widespread. In a survey of 380 U.S. PCPs, almost half thought ADHD medications were addictive, one in five thought ADHD was “caused by poor diet,” more than one in seven thought “the child does it on purpose,” and one in ten thought medications can cure ADHD. Some studies reported that many PCPs believed ADHD was related to consumption of sugary food and drink. Others reported a gender bias. A 2002 U.S. study of 395 PCPs found that when presented with boys and girls with parent reported problems, they were significantly more likely to diagnose ADHD in boys.

A 2010 Iranian study of 665 PCPs found that 82 percent believed children adopted ADHD behavior patterns as a strategy to avoid obeying rules and doing assignments. One third believed sugary food and drink contributed to ADHD. Only 6 percent believed it could be a lifelong condition. Half blamed dysfunctional families. The aforementioned large 2012 U.S. study similarly found that almost half of PCPs believed ADHD was caused by absent or bad parenting. More than half of 399 Australian PCPs surveyed in 2002 believed inadequate parenting played a key role. In a 2003 study of 48 general practitioners in Singapore, a quarter blamed sugar for ADHD. A 2014 survey of 57 French pediatricians found that a quarter thought ADHD was a foreign construct imported into France, and 15 percent attributed it to bad parenting.

In all, ten studies reported a widespread belief that ADHD was due to bad parenting, with ratios varying from over one in seven PCPs to more than half. They were particularly likely to attribute hyperactivity to dysfunctional families, and to dismiss parents’ views of hyperactivity as a medical problem as a way to deflect attention from inadequate parenting.

While a third of the studies reported on stigma, the surprise was that it did not seem to play as big a role as expected. A 2012 study in the Netherlands found that 74 physicians and 154 non-medical professionals matched by age, sex, and education showed no differences in level of stigmatization toward ADHD.

On the other hand, the studies identified significant resource constraints limiting more effective understanding, diagnosis, and treatment. Given the complex nature of ADHD, the time required to gain relevant information, especially in the context of competing demands on the attention of PCPs, was a limiting factor. Many studies identified a need for better assessment tools, especially for adults.

Another major constraint was PCP uneasiness about medication. Studies found a widespread lack of knowledge about treatment options, and more specifically the pros and cons of medication relative to other options. This often led to an unwillingness to prescribe.

Yet another limitation was difficulties PCPs had in communicating with mental health specialists. One study found that less than one in six PCPs received communications from psychiatrists. Much of this was ascribed to “system failure”: discontinuity of care, no central accountability, limited resources, buck passing. Many PCPs were unsure who to turn to.

Another problem is in often faulty interactions between schools, parents, children, and providers. Parents often fail to keep appointments. Schools and parents often are less than cooperative in providing information. In a 2004 survey of 786 U.S. school nurses, less than half reported good levels of communication between schools and physicians. Schools and parents often apply pressure on PCPs to issue a diagnosis. In a U.S. survey of 723 PCPs, more than half reported strong pressure from teachers to diagnose ADHD, and more than two-thirds said they were under pressure to prescribe medication.

The authors noted, “The need for education was the most highly endorsed factor overall, with PCPs reporting a general lack of education on ADHD. This need for education was observed on a worldwide scale; this factor was discussed in over 75% of our studies, in 12 different countries, suggesting that lack of education and inadequate education was the main barrier to understanding of ADHD in primary care.”

In addition, “time and financial constraints affect the opportunities for PCPs to seek extra training and education but also affect the communication with other professionals such as secondary care workers, teachers and parents.”

The authors cautioned that only eleven of the 48 studies were published since 2010. Also, because it was a systematic review and not a meta-analysis, there was no way to evaluate publication bias.

They concluded, “Better training of PCPs on ADHD is, therefore, necessary but to facilitate this, dedicated time and resources towards education needs to be put in place by service provider and local authorities.”

B. French, K. Sayal, D. Daley, “Barriers and facilitators to understanding of ADHD in primary care: a mixed‐method systematic review,” European Child & Adolescent Psychiatry (2018), https://doi.org/10.1007/s00787-018-1256-3.