Family Practice Vol. 20, No. 2, 129-134
© Oxford University Press 2003
Clinical Research |
A qualitative study of Australian GPs’ attitudes and practices in the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD)
Centre for General Practice,
b School of Population Health, University of Queensland and
a Child and Youth Mental Health Services, Royal Children’s Hospital, Herston 4006, Australia.
Correspondence to Kelly Shaw; E-mail: k.shaw{at}sph.uq.edu.au
Shaw K, Wagner I, Eastwood H and Mitchell G. A qualitative study of Australian GPs’ attitudes and practices in the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD). Family Practice 2003; 20: 129–134.
Received 13 March 2002; Revised 6 August 2002; Accepted 4 November 2002.
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Abstract |
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Background. The importance of general practice involvement in the care of attention-deficit/ hyperactivity disorder (ADHD) is increasing due to the rising numbers of patients who present with the disorder. It has been suggested by consensus bodies that GPs should be identifying and referring patients at the severe end of the ADHD spectrum and managing those with less severe symptoms. However, GPs’ views of their role in ADHD care are unknown.
Objective. Our aim was to explore the attitudes and practices of Australian GPs towards the diagnosis and management of ADHD.
Methods. We conducted a series of focus groups to explore GPs’ beliefs regarding the causes of ADHD, their perceived role in ADHD diagnosis and management and their views on the role of behaviour therapies and pharmacotherapies in ADHD management. The subjects were 28 GPs in six focus groups.
Results. GPs in this study did not want to be the primary providers of care for patients with ADHD. Participants indicated a preference to refer the patient to medical specialists for diagnosis and treatment of ADHD, and expressed low levels of interest in becoming highly involved in ADHD care. Concerns about overdiagnosis and misdiagnosis of the disorder, diagnostic complexity, time constraints, insufficient education and training about the disorder, and concerns regarding misuse and diversion of stimulant medications were the reasons cited for their lack of willingness.
Conclusions. The Australian GPs in this study identify a role for themselves in ADHD care which is largely supportive in nature, and involves close liaison with specialist services.
Keywords. Attention-deficit/hyperactivity disorder, general practice, qualitative.
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Introduction |
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Attention-deficit/hyperactivity disorder (ADHD) is a behavioural syndrome where inattention and/or hyperactivity impair social, academic or occupational function.1 Although the aetiology is still largely unknown, there is less evidence to support social and environmental causes than those that are neurobiological or neurodevelopmental in nature.2 Genetic factors, neurotransmitter abnormalities, cerebral glucose metabolism anomalies and frontal lobe abnormalities have all been implicated as possible causes of ADHD.3–5
Estimates of the prevalence of the disorder vary according to the sample population’s location, age and gender distribution, and the diagnostic criteria used to assess ADHD in different countries. Worldwide prevalence is estimated to be between 1.7 and 6.7%.6 The disorder is 4–9 times more common in boys than girls.7 Approximately 65.0% of these children will have one or more co-morbid psychiatric or disruptive behavioural disorder.8,9 If left untreated, the long-term prognosis is poor.10,11 Manuzza et al.12 described an 11-fold increase in ongoing ADHD symptoms, a 9-fold increase in antisocial personality disorder and criminal detention, and a 4-fold increase in the rate of drug abuse in unmedicated sufferers compared with medicated controls.
In many countries, the importance of primary care involvement with ADHD is increasing due to the rising numbers of patients who present with the disorder.1,13,14 A recent consensus statement of the American Academy of Pediatrics (AAP) recommends that primary care physicians should identify and refer patients at the severe end of the ADHD spectrum and reassure and manage those with less severe symptoms.6,15 Their argument is that primary care providers are strategically placed to fulfil this role. By offering continuity of care, primary care providers are able to identify the development of ADHD and provide counselling and support that is tailored to meet the needs of the child and family.1,15,16 However, the willingness of GPs to diagnose and manage ADHD is unknown.
There is little research on the current knowledge levels and attitudes of GPs towards ADHD. It is unknown whether they perceive ADHD to be a mental disorder, or use more normative explanatory models such as response to television violence or dietary deficiency.17,18 GPs are not trained generally in management strategies appropriate to ADHD care, such as family therapy, behavioural therapy or classroom management strategies.19 Demands on general practice also allow little time to explore the complex issues involved in diagnosing and managing childhood behavioural problems. Further, the willingness of GPs to prescribe stimulant medications is unknown, despite this being promoted by both the AAP (2000) and the NHMRC (1996) as first-line management of ADHD. Although the literature recognizes that GPs have a role to play in ADHD diagnosis and management, it is not clear whether this is reflected in the attitudes of GPs themselves.16 Therefore, the attitudes, training needs and information requirements of GPs must be assessed if they are to have a role in ADHD care.
The objectives of this study were to:
- investigate how GPs view their role in ADHD diagnosis and management
- explore GPs’ beliefs regarding the causes of ADHD
- explore which factors GPs identify as needing to be addressed to manage ADHD
- identify GPs’ views on the role of behavioural therapies and pharmacotherapies in ADHD management.
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Methods |
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Qualitative methods are useful in investigating complex health issues. Focus groups—a form of group interview —were chosen in this study because they generate data by capitalizing on communication between research participants. This process of encouraging participants to talk to one another about the topic allows exploration of people’s knowledge and experience. It is also a cost- and time-effective method for collecting data in a general practice setting.20
The principal investigator (KS), a GP, acted as the focus group moderator after receiving appropriate training. Six focus groups of up to 2 h duration were conducted with 4–5 GP participants per group (n = 28). A moderator guide, developed from a systematic review of the literature, was used thematically to guide and facilitate the unstructured group discussion. The themes included ADHD aetiology, diagnosis and management, as well as the participants’ perceived role, and areas of concern about ADHD care at the general practice level. Focus groups were conducted until content saturation was achieved.
To obtain a convenience sample, metropolitan GPs were selected at random from the RACGP (Royal Australian College of General Practitioners) Directory of Members (1999).21 To facilitate the attendance at the Brisbane Metropolitan interview site, study participants were drawn only from within this geographic region. Participants were allocated to each group according to which session they were able to attend, and reimbursed for their time. The response rate of those invited to participate was 97%.
Interviews were audiotaped and the content transcribed. All views were included in the coding process, which identified the major categories and concomitant themes.
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Results |
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The data were analysed and are presented below under three main categories: the causes of ADHD; issues relating to ADHD diagnosis; and issues relating to ADHD management.
Demographics of sample
Table 1
demonstrates the age and gender distribution of the focus group participants. There were approximately equal numbers of males and females. The majority of participants were aged between 31 and 50 years, suggesting that participants had varying degrees of clinical experience.
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The causes of ADHD
The analysis identified several important inter-related factors which were social, parental and environmental in nature.
GPs were asked to comment on what they considered to be the most frequent causes of ADHD. Some of the GPs ascribed the outcome of ADHD to normative factors related to the increasing stress of day-to-day life that contribute to difficulties in parenting, such as the breakdown of extended family and community support, and the pressure of life through workplace changes and technology.
"Most ADD is from ineffective discipline from infancy and the explosion of the problem has to do with breakdown of family and neighbourhood and friend support in our society."
"ADD is from lack of discipline, more stresses for parents with faster pace of life and more technology therefore more frustration."
Others indicated that attributing medical labels to social problems had led to the labelling of the outcome of ineffective parenting as ADHD. These informants felt strongly that parenting problems were at the core of childhood behavioural problems. While ineffective discipline in particular was felt to contribute to ADHD, another common view was that ADHD was a variation of normal behaviour, which had been turned into a medical diagnosis.
"The medical system finds it easier to label a child with ADHD than a parent as ineffective or poorly trained."
"There is very little appropriate discipline in evidence where I work. It is either over the top or non-existent especially in low socio-economic groups. And we call it ADD."
The findings also suggested that ADHD may be understood as a convenient label for childhood misbehaviour as distinct from a diagnostic category.
"I think people have forgotten what normal children are really like."
"People are so preoccupied with labelling normal variations of behaviour."
"Most kids whose parents think they have ADD are just normal kids with situational or parenting problems."
The GPs did not nominate other normative views of ADHD causality such as violence on television or dietary hypersensitivity. When these concrete environmental factors were raised in the focus groups, participants felt that they were not as important as the family unit and parenting style in influencing how a child behaves.
"Kids watch too much television but that doesn’t make them play up."
"Junk food doesn’t make kids ratty or bad."
"It’s not about diet it is about socio-economic stuff and parenting."
This section’s findings suggest that the distinction between ADHD as a diagnostic entity and ADHD as a common social label for childhood behavioural problems is relevant to understanding the GPs’ perceptions of the causes of ADHD. The GPs primarily attributed the cause of ADHD to external factors such as parent management, and social and environmental stressors that impact on the family.
Issues relating to ADHD diagnosis
Most informants believed ADHD was overdiagnosed. Some respondents considered that the consequence of overdiagnosis was the inappropriate use of medication.
"Many children are being medicated for normal behaviour."
"It is really overmedicated."
Other comments implied that the labelling of child misbehaviour as ADHD was a wider social phenomenon that contributed to overdiagnosis.
"At schools any child who does not fit in seems to be at risk of being ‘diagnosed’ or ‘offered therapy’."
"Behaviour problems are common and ADHD is much less common."
For others, the overdiagnosis of ADHD narrowed the focus to pharmaceutical interventions. This reduced the attention to other issues such as family dysfunction and inadequate parenting practices that would require interventions other than medication.
"Often overdiagnosed when family conflict, inconsistent parenting, parental drug abuse are more relevant."
"It is easy to overdiagnose it. It is also hard to ensure proper use of behaviour techniques."
The GPs’ responses suggest two main views regarding the diagnosis of ADHD. First, ADHD may be a misdiagnosis if it is labelling normal variants of behaviour. Secondly, ADHD may be overdiagnosed. As a consequence, medication may be used inappropriately, or used as the sole treatment rather than in conjunction with family interventions or behavioural therapy. Entwined with these themes is the GP perception of the specific meaning of ADHD as either a diagnostic category or a social label, as discussed in the previous section.
Issues relating to ADHD management
Participants showed little interest in being the primary care provider for children with ADHD. There was a strong consensus that involvement of specialists and multidisciplinary teams was necessary.
"I feel that unless a GP has a keen interest and access to a multidisciplinary team, they are best to stay clear of this and demand good child health services."
"It is misdiagnosed by GPs because it is complex and the issues are difficult. They should all be referred to specialists because they can unravel the issues."
Time constraints, training need and harm minimization through ensuring the appropriate use of stimulant medication were identified as interfering with the GPs’ capacity to manage ADHD.
"GPs don’t have time to deal with it adequately. It is too complicated and difficult."
"We haven’t got the training required and life is very busy to continually keep up-skilling in so many areas."
"Even if I could, I won’t prescribe drugs without a second opinion. We are dealing with a child’s health and future and that to me is very important."
"GPs are not sufficient to diagnose ADD and give out stimulants because of the problems with those things."
The GPs identified two preferred referral pathways, those of paediatrics and psychiatry, which are both medical. The primary determinant of the referral pathways between the two help sources was accessibility.
"There are so many more paediatricians than psychiatrists. They are easier to get into."
"The psychiatry wait is too long when you’ve got a kid who is out of control."
The concern about the use of stimulant medication was underscored by participants’ references to media representations and lay knowledge regarding inadequately supervised or uncontrolled use of prescription drugs.
"Recent newspaper stuff about kids selling their drugs rings alarm bells for me."
"They sell the drug at 727s and stuff for five dollars a tablet. It makes it hard to trust anybody with it."
"They crush them (the tablets) and shoot them up you know."
The GPs also indicated that their current level of knowledge and/or training was not adequate to diagnose and manage ADHD.
"It is difficult and important and should be managed and diagnosed in a multidisciplinary clinic with follow-up by GPs until GPs are better trained in the area."
"GPs shouldn’t be allowed to give out stimulant medications unless they have further qualifications like successful attendance at a seminar or graduate course."
The GPs indicated that they might be more willing to be involved in ADHD care if they received sufficient training and multidisciplinary support. In addition to increased drug education, GPs noted the value of a diagnostic tool to differentiate those who would benefit from pharmacological treatment from those who would not.
"I want to know about the drugs and have some guideline for when to use the drugs."
"A diagnostic tool which distinguished between kids who would benefit from drugs and those who don’t need them would be immensely helpful."
"I would diagnose and manage ADHD in general practice if I were given more tools to be able to do this."
The findings of this section suggest that, consistent with the themes of misdiagnosis and overdiagnosis, GPs perceive that complex and inter-related issues impact on the child’s behaviour. There is a sense of limited competence for assessing complex phenomena that is seen to require specialists or multidisciplinary teams. GPs did not want to use stimulant medications without specialist confirmation. Stimulants were perceived to be a negative treatment option for children.
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Discussion |
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The findings of this study suggest that GPs do not feel equipped to diagnose or manage ADHD even though the AAP (2000) states they should provide care for affected children. The GPs who participated in the focus groups emphasized social, family and environmental factors as important in the aetiology of ADHD. This understanding is at odds with the evidence base which emphasizes the neurobiological nature of the disorder.3–5 However, despite this lack of congruence with the evidence base and the emphasis on psychosocial factors, participants indicated a preference to refer the patient to medical specialists for diagnosis and treatment. They expressed low levels of interest in becoming highly involved in ADHD care.
Diagnostic complexity, time constraints, insufficient education and training about the disorder, and concerns regarding misuse and diversion of stimulant medications were the reasons cited for their unwillingness to be involved. Indeed, concerns about the illicit use of stimulant medication contribute to GPs’ reluctance to prescribe this medication. While educational strategies could redress the education and training issues, the diagnostic complexity of ADHD and time limitation for comprehensive assessment suggest that education and training, per se, may have limited impact on increasing GP involvement in management.
The participants of the focus groups voiced considerable concern regarding the overdiagnosis and misdiagnosis of ADHD. However, the evidence indicates that the majority of sufferers are unmedicated and, possibly, undiagnosed.22–24 The reason for the belief that ADHD is overdiagnosed or misdiagnosed has not been explored in the literature but may be related to GPs’ beliefs that children who behave badly are labelled inappropriately with ADHD and treated with stimulants. In this respect, differentiating between the GPs’ understanding of ADHD as a diagnostic category and as a social phenomenon is relevant. The themes that emerged from the focus groups, of ineffective parenting, family dysfunction and attributing medical labels to normal variations of behaviour, were entwined with issues of misdiagnosis and overdiagnosis. This suggests that GPs’ perceptions were located at a different point in the help-seeking encounter from that represented in evidence-based research.
The research of ADHD causality and best practice in treatment and management proceeds from the point where subjects have been positively identified as suffering from the disorder. The location of the GPs’ perceptions could be described as the social interface of the diagnostic process that precedes the identification of ADHD as a disorder. It is this point of the diagnostic process that the evidence base fails to address. Hence, there is little guidance for individual GPs in the determination of which symptoms are present or whether the symptoms cause ‘clinically significant’ impairment. The attribution of the overdiagnosis or misdiagnosis of ADHD to normative factors such as stress and coping, family dysfunction and parent disciplinary practices may reflect the difficult issues that predominate in the reality of the clinical interview. Evidence-based research and guidelines for best practice do not encompass the social context of the clinical interview where GPs’ decision-making processes are influenced by normative assumptions and values. The uncertainty that surrounds decision making in this context was reflected in the GPs’ positive views toward diagnostic assessment tools. Such tools enable a greater sense of certainty in an uncertain situation, and offer reassurance particularly if there is a parental expectation of a positive diagnosis of ADHD.
Although the GPs emphasized normative processes in ADHD aetiology, the identified referral pathways were medical. If ADHD is understood primarily as an outcome of normative social processes rather than as a pathological process, then it would seem reasonable for the referral pathways to include other primary care agents such as allied health professionals who offer parenting programmes and other family interventions. Despite attributing ADHD causation to normative social factors, such referral pathways were not identified by the GPs. This may imply that a primary concern of GPs is ensuring initially correct diagnosis. The GPs’ perceptions of their limited capacity to conduct the diagnostic assessment may underpin this concern. Alternatively, if referral is to medical specialists, the GP shares primary responsibility for the patient’s care, whereas if the referral is to allied health, the GP retains this responsibility, which is undesirable if they are not comfortable managing the condition.
However, if referral to medical specialists is the sole help-seeking response of the GPs, then this is of concern for the social well-being of the child. Long-term strategies that ameliorate some of the consequences of ADHD should involve the co-ordination of family- and school-based interventions, as well as the management of medication.1 It is unclear whether the GPs’ responses regarding referral reflect the initial step of management —the ascertainment of a definitive diagnosis of ADHD —or whether GPs tend to limit help seeking to medical pathways, despite their acknowledgement of broader issues.
Further research is required to confirm or refute the findings of the present study. Studies are required to assess GPs’ attitudes and practices in the diagnosis and management of ADHD. This will help to identify a model of ADHD primary care that facilitates effective involvement of GPs without further increasing their workload.
Our conclusions are necessarily tentative. The sample was a convenience sample rather than a random sample of GPs, which may have influenced our findings. The sample was small and the views and experiences of participants may not have been representative of those of the wider general practice community. For example, GPs who practice in provincial and rural areas were excluded from this sample and may have differing views of ADHD and its management.
Nevertheless, our findings suggest some specific factors which should be evaluated in subsequent studies. GPs who have no special interest in ADHD have concerns about its diagnosis and management at the general practice level. The reluctance to diagnose or treat ADHD has implications for the long-term prognosis of sufferers due to the negative long-term consequences of untreated ADHD. Early intervention for ADHD is effective in ameliorating the gradual accumulation of adverse processes and events that increase the risk of serious psychopathology later in life.25 In this regard, research that identifies both ADHD diagnostic and treatment barriers, and opportunities to facilitate management is salient. The attitudes of GPs towards the existence of ADHD and the underlying causes of the disorder have an obvious impact on their rates of diagnosis, and the type of treatment they offer the patient. This needs to be examined if GPs are to be encouraged to have more involvement in ADHD care. Also, the attitudes of the wider general practice population towards stimulant medication need to be explored. If GPs generally have concerns about the use of stimulant drugs, as was the case in these focus groups, their concerns will need to be addressed before they can be encouraged to prescribe them.
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