Attitudes of South Australian psychiatrists towards attention deficit hyperactivity disorder in adults

Abstract

Objective

A lack of access to psychiatric services for adult ADHD is a recognised issue in South Australia and nationally. This study aims to explore the practices of local psychiatrists and their attitudes towards adult ADHD, with a view to determining any barriers influencing accessibility to treatment.

Methods

We developed an online survey to examine the aims of the study. Free text boxes were included to obtain qualitative data. Quantitative data were tallied and presented as percentages. Qualitative data (free text responses) were analysed thematically.

Results

73 out of 322 psychiatrists responded (22.7%). The greatest barrier to seeing adult ADHD was the fear of being inundated with cases (68.5%), followed by lack of experience managing ADHD (32.9%), and potential drug-seeking behaviour of patients (31.5%). Two overarching qualitative themes were identified: practical barriers and attitudinal barriers.

Conclusion

ADHD service provision is complex and relates to many systemic factors such as public versus private, funding, and service organisation. More psychiatrists need to become involved in treating ADHD so that the work is more widely spread. Increased training in ADHD is also needed to increase confidence in managing the condition.

Keywords

attention deficit hyperactivity disorder psychiatrist attitude barrier treatment

Attention Deficit Hyperactivity Disorder (ADHD) is a recognised and treatable neurodevelopmental disorder characterised by persistent patterns of inattention and/or hyperactivity-impulsivity that interfere with functioning or development.¹ Studies show ADHD prevalence rates of about 2%–7% in children² and adults.³ The condition is associated with significant functional consequences, particularly if untreated. In childhood, this is evident through reduced academic performance and social rejection,⁴ which may manifest in adulthood as higher probability of unemployment,⁵ comorbid mood and substance use disorders,⁵ and higher rates of criminal activity.^5,6

Despite high estimated prevalence rates, lack of access to psychiatric services for the assessment and treatment of adult ADHD is a recognised local issue in South Australia.⁷ The models of care of most public adult community mental health services specifically exclude offering services for ADHD,⁸ and the numbers seeking treatment appear to far outweigh the available private psychiatrists. Lack of service availability not only creates frustration for those seeking treatment, but potentially contributes to societal illness burden due to the known functional consequences of untreated ADHD.⁹ Research has estimated the impact of untreated ADHD to cost the Australian economy over $20 billion each year.¹⁰

Difficulty accessing adult ADHD services is not limited to South Australia. The recently published ADHD Clinical Practice Guideline (AADPA) identified that existing services across Australia are difficult to access due to long waiting times and out-of-pocket costs, and that optimal care involving a multi-agency approach is rarely available.¹¹

Several overseas studies have surveyed healthcare providers to explore this matter^12–20 but we were unable to find a mixed methods study that explored attitudes of psychiatrists towards adult ADHD with an open-ended approach. As far as we are aware, there is no published research on this topic from Australia.

Aim

The aim of this study was to explore the attitudes and practices of South Australian psychiatrists towards adult ADHD, with a view to determining any local contextual factors influencing accessibility to treatment. We aimed to explore any barriers that may influence psychiatrists’ decisions to provide adult ADHD services.

Method

Survey development

We developed an online survey to explore the objectives of the project. The questions were based on the attitudes and barriers identified from our literature review and from our conversation with staff from the South Australian branch of the RANZCP (June 2019). The survey was organised into the following areas: four demographic questions about the participants’ practice; 10 questions about caseload, referral patterns and approaches to treatment; 16 questions on attitudes and opinions about ADHD and its treatment, presented as statements followed by a five-point Likert scale; multiple answer checkbox questions identifying barriers to seeing adult patients with ADHD (the specific options included were chosen from responses in overseas studies,^14–16 as well as anecdotally from RANZCP staff). Free text boxes were also included after each question where the participant could add their own comments about the statement proposed. This was included to obtain qualitative information to add a richer nuanced understanding, in addition to the quantitative information obtained from the Likert scales. Finally, there were two free text responses seeking additional comments and suggestions for change.

Ethics

Ethics approval was granted via the University of Adelaide Human Research Ethics Committee (HREC). Approval number H-2020-124.

Participants and recruitment

Permission was obtained from the RANZCP to use their email distribution list for South Australian psychiatrists. The first recruitment email was sent to all actively practising Fellows in South Australia on 30^th July 2020, followed by a reminder email on 17^th August 2020. Written consent was obtained online at the start of the survey.

All South Australian psychiatrists who were actively practising were eligible to participate. Participation in the survey was voluntary with no direct communication between researchers and participants. No identifying details were collected from participants. Completion of free text response boxes was voluntary; however, all other questions required a response before proceeding.

Data analysis

Quantitative data were descriptively analysed using percentages. The free text responses were analysed by separating these into themes. As many of the free text responses extended more broadly than the specific question asked, we chose to combine all the free text responses and analyse them together, rather than analysing the qualitative data for each question independently. The qualitative analysis of free text responses was informed by the six-stage process described by Braun and Clark,²¹ a widely used approach in qualitative research. In our study, investigators independently reviewed all the free text responses and organised them into codes and themes. Investigators then met to compare their individual analyses and through an iterative process reached a final consensus on the key themes and subthemes. The free text responses were reviewed again to ensure all responses were covered by one of the subthemes.

Results

Seventy-three responses were collected out of the cohort of 322 psychiatrists, totalling a response rate of 22.7%. Participant responses for demographic data, referrals and treatment, multiple choice questions and Likert scales are presented in Tables 1 to 6 and Figure 1. Through the process of analysis of themes, 10 themes were identified, which were then grouped into two overarching themes – practical barriers and attitudinal barriers to the treatment of adult ADHD (Tables 7 and 8).

Table 1.

Demographics of respondents.

Employment status			Setting of practice
	No.	%		No.	%
Public	27	37	Inpatient	8	11
Private	18	24.7	Outpatient	46	63
Both	28	38.4	Mixed	19	26

Location of training			Ages of patients seen
	No.	%		No.	%
South Australia	63	86.3	All children	2	2.7
Elsewhere in Australia	4	5.5	Mostly children	7	9.6
Overseas	6	8.2	Equal numbers of children and adults	6	8.2
			Mostly adults	27	37.0
			All adults	31	42.5

Table 2.

Caseload of respondents.

Number of total outpatients			Number of outpatients with adult ADHD
				Total		New in 1 year
	Number	%		Number	%	Number	%
0–10	9	12.3	0	28	38.4	32	43.8
11–50	18	24.7	1–5	17	23.3	20	27.4
51–100	16	21.9	6–10	7	9.6	7	9.6
101–200	14	19.2	11–20	8	11.0	9	12.3
>200	16	21.9	>20	13	17.8	5	6.6

Table 3.

Referrals acceptance and screening.

	Would you accept new patients for assessment and diagnosis of ADHD in an adult?		Would you accept referrals for continuing management of an adult who has an existing diagnosis of ADHD?		Do you routinely screen for adult ADHD in patients who present for other psychiatric issues?
	Number	%	Number	%	Number	%
Yes	30	41.10	37	50.68	24	32.88
No	43	58.90	36	49.32	49	67.12

Table 4.

Approaches to treatment.

	How many were treated for ADHD in childhood?		Do you initiate pharmacotherapy?		Do you recommend psychological treatment?
	Number	%	Number	%	Number	%
All/always	1	1.37	12	16.44	11	15.07
Most	11	15.07	19	26.03	13	17.81
Some	21	28.77	5	6.85	23	31.51
Few/rarely	14	19.18	7	9.59	2	2.74
None/never	3	4.11	3	4.11	1	1.37
N/A	23	31.51	27	36.99	23	31.51

Table 5.

Barriers to seeing more adult patients with ADHD.

Answer choices	Responses (%)
Fear that I may be inundated with cases if it became known I will see ADHD patients	68.5
Lack of experience	32.9
Drug-seeking behaviour of patients	31.5
The need to apply for Drugs of Dependence Unit approval	27.4
Potential for abuse of stimulant medications prescribed	27.4
Lack of interest	27.4
Model of care/service guidelines prevent it	17.8
Lack of confidence	17.8
Concern about potential damage to my profession and clinic reputation if I did	15.1
Risk to practitioner	13.7
Lack of evidence-base supporting treatment with stimulants	9.6
I disagree it’s a valid diagnosis	6.9
Other	35.6

Table 6.

Likert scale questions.

	Strongly disagree (%)	Disagree (%)	Neither agree nor disagree (%)	Agree (%)	Strongly agree (%)
ADHD is a valid psychiatric diagnosis in childhood	12.3	2.7	5.5	38.4	41.1
ADHD is a valid psychiatric diagnosis in adulthood	9.6	5.5	9.6	39.7	35.6
I feel confident diagnosing ADHD in adults	15.0	17.8	13.7	42.5	11.0
I feel confident treating ADHD in adults	13.7	15.1	19.2	43.8	8.2
I feel that I received adequate exposure to adult ADHD in my psychiatry training	42.5	32.9	8.2	13.7	2.7
In South Australia, ADHD is over-diagnosed in children	4.1	27.4	42.5	15.1	11.0
In South Australia, ADHD is over-diagnosed in adults	6.6	31.5	42.5	9.6	9.6
There is an adequate evidence base in the field of adult ADHD	8.2	9.6	35.6	42.5	4.1
Stimulant medications are overprescribed to children in South Australia	1.4	23.3	50.7	16.4	8.2
Stimulant medications are overprescribed to adults in South Australia	4.1	26.0	53.4	8.2	8.2
ADHD can be successfully treated with non-pharmacological strategies. Stimulant prescription is unnecessary	6.9	49.3	37.0	5.5	1.4
South Australia needs to improve access to ADHD treatments in South Australia	2.7	0	23.3	30.1	43.8
Adult ADHD services should be accessible in the public mental health system	11.0	11.0	13.7	31.5	32.9
Many adult patients who seek a diagnosis of ADHD are drug-seeking	9.6	38.4	27.4	23.3	1.4
I do not have any interest in seeing patients with ADHD.	21.9	27.4	15.1	20.6	15.1
I would be willing to be listed in a public directory of psychiatrists who are able to see adult ADHD	42.5	31.5	15.1	6.9	4.1

Figure 1.

Likert scale questions.

Table 7.

Practical barriers to treatment of ADHD.

Practical barriers to treatment of ADHD
Key themes	Subthemes
Lack of training and experience	• Lack of confidence/expertise
	• The need to improve training
	• Lack of adult ADHD cases in particular subspecialties, for example, psychiatry of old age, child and adolescent psychiatry
Too busy and lack of time	• Not accepting new referrals
	• Retiring
	• Fear of being overwhelmed with new cases
	• Would be more willing to accept ADHD patients if workload was shared
Lack of service availability	• Lack of psychiatric services
Lack of service availability	• Lack of other discipline availability, for example, psychology and GP
Prescribing barriers	• Prescribing too restricted
Prescribing barriers	• Drugs of Dependence Unit authority barriers

Table 8.

Attitudinal barriers to treatment of ADHD.

Attitudinal barriers to treatment of ADHD
Key themes	Sub-themes
Interest and sense of reward in the work	• Lack of interest vs strong interest
Interest and sense of reward in the work	• Rewarding work
Appropriateness of services for ADHD	• Public work vs private work
	• Perceived adverse consequences of lack of service availability including public health implications
	• Unethical for services not to be available
	• Psychiatrists’ duty to treat and ethical concerns around not providing service
ADHD as a diagnosis	• Under vs over diagnosis
	• Poor vs good evidence base
	• ADHD patients and psychiatrists are stigmatised
	• Aetiology: biological vs psychological
Stimulants as a treatment for ADHD	• Under vs over-use of stimulants
	• Scepticism vs advocacy for stimulants as treatment and their evidence base
	• Other interventions indicated rather than (or as well as) stimulants, including non-pharmacological
	• Rewarding to treat and stimulants are life-changing
ADHD patients and drug-seeking	• Fear that ADHD referrals would be drug-seekers vs those who had not seen this as a problem
Perceived complexity of management	• Straightforward vs complex
Perceived complexity of management	• Can lead to restrictions on who is accepted, for example, already diagnosed with ADHD, not GP referrals

Discussion

Despite the pivotal role psychiatrists play in managing ADHD, less than half of psychiatrists stated they would accept new referrals for ADHD patients and only 11% were willing to be listed in a public directory advertising this. Patients with adult ADHD will therefore find it challenging to access a psychiatrist to assess and manage their illness, which also raises ethical issues regarding psychiatrists’ duty of care and lack of access to a much-needed service. 64.5% felt that treatment should be provided by public mental health services as the associated complexities require a multidisciplinary approach.

The reluctance to join a public directory aligns with the biggest barrier to seeing more adult ADHD, namely, a fear of being inundated with new referrals. This then becomes a self-perpetuating problem as the lesser the psychiatrists there are available to treat ADHD, the more inundated the few who do make this known will be, perpetuating fear of work overload and maintaining access difficulties. This cycle can only be broken by a sufficient number of psychiatrists making it known that they will treat ADHD so the workload is redistributed.

Lack of training, experience, and confidence are key issues. This is concerning with ADHD being one of the disorders in which adult psychiatrists are expected (by the public and regulatory authorities) to have expertise. A concerning three-quarters of psychiatrists stated they did not receive adequate exposure to ADHD during their psychiatry training and may be reflected in the fact that only 32.88% of psychiatrists routinely screen for ADHD. One reason for this, in South Australia at least, is that almost all management of ADHD occurs in private practice, but almost all Fellowship training occurs in public practice, thus not allowing trainees any exposure. Most psychiatrists believed there should be more ADHD treatment available in the public system and this would help address the training shortfall. Also, developing more training opportunities in private practice could address this deficiency.

Challenges in accurately diagnosing ADHD and the complexities of management were also barriers. Certainly, this would be amplified by training gaps, which prevent these skills from being developed. However, these opinions were balanced by others who felt treatment is straightforward and rewarding. One explanation for these varying attitudes could be that ADHD cases encountered in the public system are comorbid and complex, thus giving public psychiatrists a skewed perception of the complexity.

The perceived inadequacy of evidence may reflect the wide heterogeneity of opinions regarding aetiology and diagnostic clarity, including whether ADHD is in fact a psychiatric issue. One-fifth did not feel that ADHD was a valid diagnosis in adulthood, increasing to one-quarter for childhood ADHD. There was consensus that as a neurodevelopmental disorder, ADHD does not arise de novo in adulthood and the symptoms should be present in childhood, even if not formally diagnosed.

A minority of psychiatrists believed ADHD was over-diagnosed, which was mirrored in attitudes to stimulant prescribing. Despite the evidence for stimulant treatment of ADHD being as robust as pharmacological treatment of most other common disorders in adults,^22,23 less than half felt there was an adequate evidence base. One explanation could be the gap in training. If trainees are not taught this evidence and have little incentive to study it, then they may conclude that the evidence does not exist.

Fears about drug-seeking by ADHD patients was a barrier for a minority of respondents, despite this being a common anecdotal concern. These fears and beliefs may be unfounded, as the comments made by other psychiatrists were that drug-seeking is not a common problem.

Limitations

The cross-sectional nature of the survey, conducted in 2020, does not account for changes in opinion over the past few years as a result of increased advocacy and awareness on this topic. The response rate of 22.7% is also quite low and the opt-in nature of the survey is subject to self-selection bias.

Conclusion and recommendations

There is a recognised lack of services for adults with ADHD in South Australia.⁷ Given the significant impact of untreated ADHD,^4–6 there is an imperative to increase access to appropriate assessment and management. Our study has examined the attitudes and practices of local psychiatrists to determine factors that may be contributing to the current situation. The most consistent themes were those of practical barriers to care. Attitudinal barriers, while heterogeneous, were surprisingly less prominent and perhaps stem from lack of experience working with this patient group.

More psychiatrists need to become involved in treating this cohort of patients, so that the fear of being inundated with ADHD referrals is eased by spreading the workload more widely. This study supports the contention that increased training in ADHD is an important strategy to allow more psychiatrists to feel comfortable managing this disorder. One recommendation is to provide access to more ADHD-focused professional development opportunities to upskill psychiatrists who would be willing to take a caseload of ADHD patients. Another recommendation is to increase training opportunities for registrars. A potential solution is to include public ADHD teaching clinics within established adult community mental health services, which would require services to embrace treatment of this patient population more than they do at present. Another option would be to create more training opportunities within private practice, especially with those psychiatrists who do already manage adults with ADHD.

Our findings also show that adult ADHD service provision is complex and relates to many systemic factors in terms of the segregation of public versus private sectors of care, health care funding and mental health service organisation. Further research to better understand the interplay of systemic factors may yield more solutions.

Footnotes

Acknowledgements

The authors would like to thank Ms Trudy Lisk (Branch Coordinator, RANZCP South Australian Branch) for her assistance in this project.

Disclosure

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

ORCID iD

Claudia Cao

References

American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5th ed. Arlington VA: American Psychiatric Association, 2013.

Sayal

Prasad

Daley

, et al. ADHD in children and young people: prevalence, care pathways, and service provision. Lancet Psychiatr 2018; 5: 175–186.

Song

Zha

Yang

, et al. The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. J Glob Health 2021; 11: 04009. DOI: 10.7189/jogh.11.04009.

Frazier

Youngstrom

Glutting

, et al. ADHD and achievement: meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students. J Learn Disabil 2007; 40: 49–65.

Erskine

Norman

Ferrari

, et al. Long-term outcomes of attention-deficit/hyperactivity disorder and conduct disorder: a systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry 2016; 55: 841–850.

Knecht

de Alvaro

Martinez-Raga

, et al. Attention-deficit hyperactivity disorder (ADHD), substance use disorders, and criminality: a difficult problem with complex solutions. Int J Adolesc Med Health 2015; 27: 163–175.

The Royal Australian & New Zealand College of Psychiatrist, South Australian Branch. SA State Parliament Budget Submission . Prioritising our investment in mental health. Fullarton, SA: The Royal Australian & New Zealand College of Psychiatrist, South Australian Branchm, (2020-21); 2020 Feb. 16 p. Report No: 1. Available from: https://www.ranzcp.org/files/resources/submissions/ranzcp-south-australian-state-budget-2020-21-march.aspx

Central Adelaide Local Health Network Mental Health Directorate . Community mental health model of care (ages 16–65 years). Glenside, SA: Mental Health Directorate, Glenside Health Services, 2019. . 22 p. Report No: 2. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/b8e64e3b-87ce-427d-9709-35baf9910283/CALHN+Community+Mental+Health+Model+of+Care+V2.0+June+2019_signed.pdf.

Sciberras

Streatfeild

Ceccato

, et al. Social and economic costs of attention deficit/hyperactivity disorder across the lifespan. J Atten Disord 2022; 26: 72–87.

10.

Deloitte Access Economics . The social and economic costs of ADHD in Australia. Sydney, NSW: Deloitte Access Economics, 2019, p. 53. Report No. 1.

11.

Australian ADHD Guideline Development Group . Australian evidence-based clinical practice guideline for Attention Deficit Hyperactivity. Melbourne: Australian ADHD Professionals Association, 2022.

12.

Matheson

Asherson

Wong

ICK

, et al. Adult ADHD patient experiences of impairment, service provision and clinical management in England: a qualitative study. BMC Health Ser Res 2013; 13: 184.

13.

Hall

Newell

Taylor

, et al. ‘Mind the gap’ - mapping services for young people with ADHD transitioning from child to adult mental health services. BMC Psychiatr 2013; 13: 186.

14.

Altin

Semerci

. An online survey of Turkish psychiatrists’ attitudes about and experiences of adult attention deficit hyperactivity disorder in clinical practice. Neuropsychiatr Dis Treat 2016; 12: 2455–2461.

15.

Beirne

McNamara

O’Keeffe

, et al. Survey examining the views of adult psychiatry consultants and senior registrars regarding ADHD. Ir J Psychol Med 2013; 30: 197–203.

16.

Aksoy

Baysal

ÖD

Aksoy

ŞG

, et al. Attitudes of psychiatrists towards the diagnosis and treatment of attention deficit and hyperactivity disorder in adults: A survey from Turkey. Nobel Med 2015; 11: 28–32.

17.

Faraone

Spencer

Montano

, et al. Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care. Arch Intern Med 2004; 164: 1221–1226.

18.

Adler

Farahbakhshian

Romero

, et al. Healthcare provider perspectives on diagnosing and treating adults with attention-deficit/hyperactivity disorder. Postgrad Med 2019; 131: 461–472.

19.

Mueller

Fuermaier

Koerts

, et al. Stigma in attention deficit hyperactivity disorder. Atten Defic Hyperact Disord 2012; 4: 101–114.

20.

Asherson

Buitelaar

Faraone

, et al. Adult attention-deficit hyperactivity disorder: key conceptual issues. Lancet Psychiatr 2016; 3: 568–578.

21.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101.

22.

Cortese

. Pharmacologic treatment of attention deficit-hyperactivity disorder. N Engl J Med 2020; 383: 1050–1056.

23.

Leucht

Hierl

Kissling

, et al. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry 2012; 200: 97–106.