Table 1 Studies included in the review of gatekeeper GP attitudes and knowledge regarding ADHD

Sayal et al. (2002) [38]

UK - London

Hyperactivity in children: compare those who had passed through all service filters, with children in community who had not.

Quantitative – identify predictors of GP recognition

Strengths and Difficulties Questionnaire (SDQ) sent to 3218 parents of children 5–11 years in one London area to identify hyperactivity; n = 1194 completed

(40 % response; SDQ score 6+ n = 248, 21 %). 4 groups: No GP attendance; GP attender (referred); GP attender (recognised, not referred); GP attender (unrecognised).

Logistic regression; identify predictors of recognition

Only 12 % children with pervasive hyperactivity in community sample were in contact with CAMHS, though 74 % had seen GP in past year.

Parent perception of problem the only significantly predictor of GP attendance (hyperactivity, school burden not significant).

Non-recognition by GP was main barrier to specialist services.

Only comorbid conduct problem or parent referral request predicted GP recognition, after controlling for significant predictor variables.

As most high-risk children attend primary care, ADHD could be identified there, but GPs may not recognise it if parent is unaware or reticent.

Strong study design and excellent response rate for a community-based study

Ball (2001) [39]

UK - Wales

GPs’ views of ADHD management

Quantitative survey

150 GPs (68 % response)

Postal survey. GP experience, familiarity with ADHD, methylphenidate.

Views of professionals’ roles, prescribing practice, training needs.

Descriptive frequency analysis

85 % GPs had a child with ADHD in their practice, 89 % prescribed methylphenidate, 94 % with overview of child psychiatrist/paediatrician.

No GP thought GPs should initiate prescribing; 46 % prepared to repeat prescribe; 54 % said primary care could monitor physically; 64 % psychiatry should monitor clinically. 6 % formal ADHD training, 5 % conference/ course, 29 % journal article, 21 % media e.g., television, magazines.

84 % wanted further ADHD training (68 % preferred tutorial or lecture, 27 % written, 5 % phone).

GPs overloaded, reluctant to take on more. Study suggests CAMHS need to provide ADHD training ADHD for GPs and engage in discussions re shared care

Heikkinen et al. (2002)

Finland [45]

Primary care health centre GPs’ self-rated child psychiatric skills.

Quantitative survey

499 GPs (66 % response)

16-item postal questionnaire (5-point Likert scale) on self-rated ability regarding children’s mood, conduct and other disorders

Descriptive frequency analysis

Primary care health centre GPs rated their child psychiatric skills as inadequate in many domains.

41 % rated skill at identifying ADHD in school-aged children as adequate.

Medical training including CME appears to focus less on psychiatric than physical problems and GPs may not consider child psychiatry to be clearly within the primary health care remit

Self-report of diagnostic ability. Only 1 item regarding ADHD.

Shaw et al. (2002) [42]

Australia - Queensland

Assess GP ADHD knowledge, and actual and potential roles in ADHD management

Quantitative survey

399 GPs (76 % response)

Randomly selected from RACGP Directory

Survey piloted with GPs, parents, health sociologists & statistician.

Survey explored demographics & GP ADHD beliefs: existence; causes; diagnosis; practice, management; beliefs re GP role. Diagnostic criteria for ADHD, OCD, CD, anxiety & depression presented (n = 16); participants asked to assign each to a diagnosis.

Descriptive frequency analysis; internal consistency of relevant factors; chi-square tests compared GP age, gender, rural/urban

%s represent GP agreement with items

Aetiology: Family disruption 97 %; parenting 77 %; poor discipline 75 %; temperament 77 %; brain abnormality 70 %; food 12 %; TV 7 %; video games 5 % birth trauma 4 %; education 3 %.

Children with behaviour problems do not have ADHD 76 %; ADHD over-diagnosed 55 %. GPs lack knowledge of child behaviour problems 74 %; ODD/CD symptom mis-identified as ADHD 23–33 %.

1st line treatment: Behavioural 51 %, stimulants 43 %. Stimulants: 17 % always inappropriate, 86 % can be abused, 40 % addictive.

GPs identified their roles as provisional diagnosis, referral; monitoring assistance (height, weight, appetite, sleep); psycho-education; school liaison. GPs wanted greater knowledge. School input recommended for diagnosis but not sourced systematically. Most felt assessing children for ADHD best undertaken by specialists within MDT.

Barriers to greater GP involvement: resources; addiction concern; child behaviour problems complex; lack of ADHD training.

GPs diagnosed only 1–5 ADHD cases a year yet saw >550 children 4–16, so under-diagnosis likely. GP confusion about ADHD, mood disorders, disruptive behavioural disorders; weak knowledge of ADHD & comorbidities was weak; low confidence in diagnosing and managing.

Large-scale random sample; very high response rate.

Many T/F response options, so chance responding is high

Detailed and wide-ranging questionnaire

Miller et al. (2005) [44]

Canada – British Columbia

GP self-report of comfort, skill, care of children with behavioural, emotional problems

Quantitative survey, inferential analyses

405 GPs (64 % response) stratified by Health Board region.

Postal questionnaire; 22 items developed through consultation.

Principal Components Analysis (PCA) on comfort/skill items. Repeated measures ANOVAs; multiple linear regressions and logistic regressions

PCA: Comfort, skill not distinct – loaded onto single component for each type of problem

GP self-efficacy (comfort/skill ratings) for each problem related to CME as well as to belief that problems are significant and that GPs have a role in them.

Possible that CME effects may be due not only to knowledge acquisition but mediated through effects on attitudes and beliefs.

Need to bolster GP confidence, alter attitudes, especially re ADHD & behavioural difficulties

Large-scale study with stratified sample and excellent response rate, and inferential analyses.

Salt et al. (2005) [40]

UK - London

GP perceptions of ADHD and its management in primary care

Mixed methods: Quantitative survey and focus groups (see below)

93 GPs (52 % response) in one London Primary Care Trust

Questionnaire: 55 ADHD items: origins (16), symptoms (10), attitudes (9), treatments (9), all dichotomous; shared care (5 items; 7 response options), referral (6 response options).

Frequency analysis

Questionnaire

ADHD causes Most cited genetics, chemical imbalance, quality of parenting, family type; peers, environment chemicals, poverty, ethnicity, social class least cited.

Diagnostic criteria: most included inattention, hyperactivity, impulsivity, but > 75 % cited non-DSM ‘educational underachievement’, ‘antisocial behaviour’ and ‘sleep problems’ as symptoms.

Treatment: 92 % methylphenidate, followed by family & behaviour therapy. Specialist should be responsible, including monitoring.

Attitudes, knowledge: ADHD controversial 90 %; media influences attitudes 90 %; patients can be stigmatized, disadvantaged by ADHD diagnosis 79 %; parents invested in child ADHD diagnosis as it shifts blame 44 %.

ADHD exists after childhood 85 %

Small local sample, just one primary care trust.

Most items had T/F response options, so chance responding is high

Detailed questionnaire and associated qualitative section enables deeper interpretation

Ghanizadeh & Zarei (2010) [46]

Iran - Shiraz

GP ADHD knowledge

Quantitative survey

665 GPs; 74 % response.

Postal questionnaire, 20 items (dichotomous response), previously used to assess knowledge among teachers & pharmacists

Frequency analyses

ADHD causes: 37 % sugar, food additives, 53 % chaotic, dysfunctional family, 90 % parenting, spoiling, 83 % children with ADHD misbehave because they don’t want to obey rules, do assignments;

ADHD nature: 93 % ADHD is not lifelong; 20 % it is not serious; 75 % can be managed with medication; 71 % psychiatrist should manage; 21 % psychologist should manage; 97 % psychological support needed.

Treatment: half against methylphenidate use except if severe.

ADHD information: 10 % passed special courses on ADHD; 32 % info from medical journals, 25 % from media, magazines, 18 % from colleagues

All items had T/F response options, so chance responding is high. Excellent response rate from wide-ranging sample

Klasen & Goodman (2000) [47]

& Klasen (2000) [41]

UK - London

Examine attitudes of parents and GPs regarding hyperactivity including barriers to treatment

Qualitative design

10 GPs from central London, several with academic appointments or interest in children’s services.

Also with 29 parents of hyperactive children, selected purposively to achieve range of views.

Semi-structured interviews

3 clusters of GP attitudes to ADHD (1) ADHD labels, disempowers active children; reframe ADHD as poor parenting (2) Sceptical, confused by contradictory expert opinions; discourage medicalization, diagnosis is stigmatising; (3) Sceptical, diagnosis can be useful; aware of own limitations; sympathetic attitude to parents.

No GP had ever given a diagnosis; believed to be task of specialists. GPs’ decisions about referral were moral as well as medical, based on beliefs that diagnosis can stigmatise, and make children passive and dependent. They often failed to recognize that diagnosis can legitimate children’s and parents’ experience and reduce suffering. By emphasising parenting factors in ADHD, they confirmed parents’ fears of being blamed and alienated them.

Participants may have been better informed about ADHD & more interested in it than the average British GP

Shaw et al. (2003) [43]

Australia - Queensland

GP views: ADHD causes, role in diagnosis & management, behaviour therapy & medication

Qualitative, as part of mixed methods study (see Shaw et al. 2002 [42])

28 GPs in 6 focus groups

Random selection from RACGP Directory, (97 % response)

ADHD aetiology: Ineffective parenting, parent stress. Medicalisation of misbehaviour. Identified medical management (not parenting programmes, other family interventions). Little interest in management: time constraints, knowledge, training needs. Need diagnostic tool. Concern re media reports of diversion. Little guidance for GPs to determine symptoms or clinically significant impairment; research, guidelines do not encompass reality of GP clinical interview.

Random selection of GPs and excellent response allows high confidence in representativeness of findings

Salt et al. (2005) [40]

UK – London

GP perceptions of ADHD and its management in primary care

Mixed methods: Quantitative survey (see above) and focus groups

13 GPs (Focus groups)

Focus groups: GP ADHD knowledge, beliefs (incl. aetiology, treatment); ability to recognise, diagnose; practice re referral, training, management

Focus groups GPs unsure of ADHD causes; controversial; new diagnosis; many lack confidence. Most refer, but not clear what they should report. Most recommended combination of meds and behaviour; several said no side effects or could not remember. None had ADHD training in basic medical education.

Convenience sample of GPs from one locality only; however can be linked to quan study (see above)

Dennis et al. (2008) [48]

UK - London

Professionals’ and parents’ views of ADHD and service provision

Qualitative

5 GPs; purposive sampling from GP practices; other health professionals recruited via professional networks.

Purposive sampling of voluntary support groups for 49 parents.

Focus groups, and semi-structured and narrative interviews in 2 London boroughs with 29 professionals in total (42 % response)

Professionals more likely to see ADHD as medical; parents more likely to ascribe to socio-environmental causes, often battled with professionals to see their viewpoint. Parent dissatisfied due to delayed diagnosis, inadequate information and lack of co-ordinated care. Professionals emphasised the need for multidisciplinary ADHD management. Non-compliance when parents had different views from professionals.

Small sample from each individual profession; purposive sample of GPs; limited reporting of findings for GPs