June 16, 2021

What are the barriers to understanding ADHD in primary care?

A newly-published systematic review by a British team identified48 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 229South 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 fewer developed countries. A 2001 U.K. survey of 150 general practitioners found that only 6percent of them had received formal ADHD training. In a 2002 study of 499Finnish PCPs, only half felt confident in their ability to diagnose ADHD. A2005 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 723U. S. PCPs found only 44 percent used DSM criteria. In a 2006 UK study of 40general 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 the use of APA (American Psychological Association) guidelines by PCPs had expanded markedly between1999 and 2005, from one in eight to one in two.

Given these facts, it is unsurprising that many PCPs expressed a 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 and138 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 on 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 of380 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 the consumption of sugary food and drink. Others reported a gender bias. A 2002 U.S. study of395 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 57French 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 2012study in the Netherlands found that 74 physicians and 154 non-medical professionals matched by age, sex, and education showed no differences in the 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's 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 the 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 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 the 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 the 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 the service providers and local authorities."

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

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Understanding Attention to Social Images in Children with ADHD and Autism

NEWS TUESDAY: Understanding Attention to Social Images in Children with ADHD and Autism

In the field of mental health, professionals often use a variety of tools to diagnose and understand neurodevelopmental disorders such as Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD). One such tool is the Autism Diagnostic Observation Schedule (ADOS), which is specifically designed to help diagnose autism. However, the ADOS wasn't originally intended for children who have both autism and ADHD, though this comorbidity is not uncommon.

A recent study aimed to explore how children with ADHD, autism, or both, pay attention to social images, such as faces. The study focused on using eye-tracking technology to measure where children direct their gaze when viewing pictures, and how long they look at certain parts of the image. This is important because differences in visual attention can provide insights into the nature of these disorders.

The researchers included 84 children in their study, categorized into four groups: those with ASD, those with ADHD, those with both ASD and ADHD, and neurotypical (NT) children without these conditions. During the study, children were shown social scenes from the ADOS, and their eye movements were recorded. The ADOS assessment was administered afterward. To ensure that the results were not influenced by medications, children who were on stimulant medications for ADHD were asked to pause their medication temporarily.

The results of the study showed that children with ASD, whether they also had ADHD or not, tended to spend less time looking at faces compared to children with just ADHD or NT children. The severity of autism symptoms, measured by the Social Communication Questionnaire (SCQ), was associated with reduced attention to faces. Interestingly, ADHD symptom severity, measured by Conners' Rating Scales (CRS-3), did not correlate with how children looked at faces.

These findings suggest that measuring visual attention might be a valuable addition to the assessment process for ASD, especially in cases where ADHD is also present. The study indicates that if a child with ADHD shows reduced attention to faces, it might point to additional challenges related to autism. The researchers noted that more studies with larger groups of children are needed to confirm these findings, but the results are promising. They hope that such measures could eventually enhance diagnostic processes and help in managing the complexities of cases involving comorbidity of ADHD and ASD.

This research opens up the possibility of using eye-tracking as a supplementary diagnostic tool in the assessment of autism, providing a more nuanced understanding of how attentional differences in social settings are linked to ASD and ADHD.

May 14, 2024

NEW STUDY: RASopathies Influences on Neuroanatomical Variation in Children

NEW STUDY: RASopathies Influences on Neuroanatomical Variation in Children

This study investigates how certain genetic disorders, called RASopathies, affect the structure of the brain in children. RASopathies are conditions caused by mutations in a specific signaling pathway in the body. Two common RASopathies are Noonan syndrome (NS) and neurofibromatosis type 1 (NF1), both of which are linked to a higher risk of autism spectrum disorder (ASD) and attention deficit and hyperactivity disorder (ADHD).

The researchers analyzed brain scans of children with RASopathies (91 participants) and compared them to typically developing children (74 participants). They focused on three aspects of brain structure: surface area (SA), cortical thickness (CT), and subcortical volumes.

The results showed that children with RASopathies had both similarities and differences in their brain structure compared to typically developing children. They had increased SA in certain areas of the brain, like the precentral gyrus, but decreased SA in other regions, such as the occipital regions. Additionally, they had thinner CT in the precentral gyrus. However, the effects on subcortical volumes varied between the two RASopathies: children with NS had decreased volumes in certain structures like the striatum and thalamus, while children with NF1 had increased volumes in areas like the hippocampus, amygdala, and thalamus.

Overall, this study highlights how RASopathies can impact the development of the brain in children. The shared effects on SA and CT suggest a common influence of RASopathies on brain development, which could be important for developing targeted treatments in the future.

In summary, understanding how these genetic disorders affect the brain's structure can help researchers and healthcare professionals develop better treatments for affected children.

April 30, 2024

News Tuesday: Integrating Cognition and Eye Movement

Integrating Cognitive Factors and Eye Movement Data in Reading Predictive Models for Children with Dyslexia and ADHD-I

In a recent study, researchers delved into the complex interplay of cognitive processes and eye movements in children with dyslexia and Attention-Deficit/Hyperactivity Disorder. Their findings shed light on predictive models for reading outcomes in these children compared to typical readers.

The study involved 59 children: 19 typical readers, 21 with ADHD, and 19 with developmental dyslexia (DD), all in the 4th grade and around 9 years old on average. Each group underwent thorough neuropsychological and linguistic assessments to understand their psycholinguistic profiles.

During the study, participants engaged in a silent reading task where the text underwent lexical manipulation. Researchers then analyzed eye movement data alongside cognitive factors like memory, attention, and visual processes.

Using multinomial logistic regression, the researchers evaluated predictive models based on three key measures: a linguistic model focusing on phonological awareness, rapid naming, and reading fluency; a cognitive neuropsychological model incorporating memory, attention, and visual processes; and an additive model combining lexical word properties with eye-tracking data, specifically examining word frequency and length effects.

By integrating eye movement data with cognitive factors, the researchers enhanced their ability to predict the development of dyslexia or ADHD, in comparison to typically developing readers. This approach significantly improved the accuracy of predicting reading outcomes in children with learning disabilities.

These findings have profound implications for understanding and addressing reading challenges in children. By considering both cognitive processes and eye movement patterns, educators and clinicians can develop more effective interventions tailored to the specific needs of children with dyslexia and ADHD.

April 30, 2024