Table 1.
Included study characteristics
| Reference | Measure | Population of interest and sample size | Quality rating | Synopsis of findings | Themes |
|---|---|---|---|---|---|
| Qualitative studies | |||||
| Fiks et al. (2011b) US | Semi-structured interviews | 30 paediatricians and 60 parents | High |
Shared decision-making (SDM) GPs think SDM is more about convincing parents to follow their lead. Difficulty in determining how much involvement families should have Clinicians reported importance of involvement of other stakeholders, psychiatrists, schools in decision-making Half mentioned difficulty communicating with other specialists |
Constraints with recognition, management and treatment Multidisciplinary approach |
| Guevara et al. (2005) US | Focus groups | 3–4 focus groups of 19 family physicians | High |
Highlighted breakdown of communication between parents, schools, physicians, not from a lack of will or desire. “System failure”—lack of accountability, discontinuity of care, lack of support, limited knowledge and resources and finger pointing Issues with treatment options available Limitation in training provided, even with previous knowledge, finding the constant change difficult to keep up with Lack of support from administration and lack of time to communicate with other schools |
Need for education Constraints with recognition, management and treatment Multidisciplinary approach |
| Hassink-Franke et al. (2016) Netherlands | Interviews | 15 GPs | High |
Most GPs did not see a role for them in the diagnosis process Barriers: lack of knowledge and experience Too little time to get all information Resistance towards prescribing medication Importance of long-lasting relationships Felt more confident and competent after an online course on ADHD medication |
Need for education Constraints with recognition, management and treatment Multidisciplinary approach |
| Klasen and Goodman (2000) UK | Semi-structured interviews on hyperactivity (not ADHD per se) | 10 GPs and 37 parents | Moderate |
Parents felt that GPs did not believe hyperactivity as a medical problem, most were unsure about boundaries between normality and abnormality Parents felt that professionals were against labels, that GPs were often badly informed and that it was a matter of chance whether they received useful help and information GPs felt that labelling did more harm than good Many GPs felt that parents’ views of hyperactivity as a medical problem were an attempt to avoid dealing with shortcomings in their parenting and an effect of dysfunctional families GPs were not aware of specialist help available in their area and not certain of whom to refer to Parents and GPs felt that information on hyperactivity was often conflicting and ambiguous GPs also felt they had not had sufficient training in assessment and treatment of hyperactivity |
Need for education Misconceptions and stigmas Constraints with recognition, management and treatment Multidisciplinary approach |
| Klasen (2000) UK | Semi-structured interviews on hyperactivity | 10 GPs and 37 parents | Moderate |
Only 2 out of 10 GPs had diagnosed children with hyperactivity 2 felt labelling ADHD was not useful Uneasiness around medication |
Need for education Misconceptions and stigmas Constraints with recognition, management and treatment |
| Shaw et al. (2003) Australia | Focus groups | 28 GPs in 4 groups | High |
GPs believed the main causal factor of ADHD was increased stress in daily life, contributing to difficulties in parenting. The use of labels has led to labelling bad parenting as ADHD Importance of involvement of specialists Time, training needs and medication management identified as constraints in ADHD management Lack of knowledge and training, need for more multidisciplinary support Negative media representation of medication |
Need for education Misconceptions and stigmas Constraints with recognition, management and treatment Multidisciplinary approach |
| Mixed methods studies | |||||
| Leslie, et al. (2006) US | Vanderbilt rating scale. Likert scale interviews | 16 paediatricians | Moderate |
Need for better tools and training to identify discrepancies between parents and teachers’ reports Material accessible for families from different background and in different languages |
Constraints with recognition, management and treatment |
| Salt et al. (2005) UK | Questionnaire survey and interviews | GPs. 93 surveys and 13 interviews | High |
Mixed results on factors believed to influence ADHD, causes and diagnosis procedures Some thought quality of parenting was relevant 75% thought some non-ADHD symptoms were ADHD symptoms, despite non-inclusion in DSM criteria Only 3 GPs in surveys restricted themselves to the three main symptoms GPs agreed of the strong stigmatisation and controversial nature of ADHD; importance of the media in attitude towards ADHD All GPs were uncertain about prevalence rates in UK Lack of adequate training on ADHD |
Need for education Misconceptions and stigmas Multidisciplinary approach |
| Quantitative studies | |||||
| Alder et al. (2009) US | Survey on adult ADHD. Likert scale | 400 primary care physicians | High |
Only 13% reported that they had received good training 77% believe adult ADHD is not well understood 72% agree that it is more difficult to diagnose in adulthood than in childhood 48% reported lack of confidence in diagnosing adult ADHD and 44% believe that there are no clear criteria 75% reported poor quality of assessment tools with 85% indicating they would take a more active role if a reliable tool existed |
Need for education Constraints with recognition, management and treatment |
| Ayyash et al. (2013) UK | Delphi methodology from consensus statement to questionnaire. Level of agreement on a scale of 1–4 of 40 statements | 122 specialist of which 6 trainee doctors | Moderate |
Variation in scoring on ADHD consensus between subgroups, trainee doctors had the lowest agreement scores The variation in scoring across each of the subgroups of respondents may prove useful in understanding the different perspectives offered by each sub-group Shared cared, integrated pathways between primary and secondary care Need to raise awareness in primary care regarding ADHD, especially with GPs. Commissioning may be developed collaboratively across multiple GP consortia. Failure to treat ADHD effectively has significant social and economic impacts Primary care clinicians need to be educated to recognise the diagnostic signs of ADHD |
Need for education Multidisciplinary approach |
| Ball (2001) UK | Questionnaire on attitudes and use of methylphenidate | 150 GPs | Moderate |
Only 6% had received formal ADHD training 28% gained information from articles and 21% from the media 11% do not prescribe ADHD medication due to lack of knowledge Complex views on the role of different professionals Over 60% felt they would change their view with clearer advice from specialists and clear protocol on monitoring 80% wanted further training and 88% specifically on medication |
Need for education Constraints with recognition, management and treatment |
| Baverstock et al. (2003) UK | Questionnaire with 11 open-ended questions | 45 GPs in university and college settings. | Low |
Transitional care for university students 39 GPs had not attended any courses on ADHD GPs commented that it is likely to be an underestimate (due to complexity and inaccuracy in the way ADHD is recorded) and that most students with a diagnosis are from the US. Some surgeries said that they had no awareness of university students with ADHD, unless student were on medication Patient fail to attend follow-up |
Need for education Multidisciplinary approach |
| Chan et al. (2005) US | Survey with 53 Likert scale questions | 861 paediatricians and family physicians | High |
Variation in time and number of visit to gain evaluation, getting teacher information is difficult Only 57% use formal criteria to make a diagnosis, of which only 27% used DSM. Most do not follow AAP guidelines Increased volume of ADHD evaluation associated with increased use of formal criteria and increased used of teacher/school information Decreased volume of ADHD evaluation associated with increased likelihood of using laboratory test (lead level, thyroid) and more likely to feel inadequately trained 36% felt inadequately trained and 66% inadequately trained with comorbid |
Need for education Constraints with recognition, management and treatment Multidisciplinary approach |
| Clements et al. (2008) US | Survey with Likert scale | 35 paediatricians and family physicians with ADHD patients | Moderate |
80% used parent and teacher information for diagnosis 74% reported getting information on ADHD through self-training, 80% on continuing medical education and 45% from medical school |
Need for education |
| Copeland et al. (1987) US | Survey, 21 multiple-choice questions | 290 paediatricians | High |
Only 20% based their definition of ADHD on DSM Majority identified main symptoms, 35% said social difficulties and anger where also symptoms 79% said increased activity in GP office contributed to diagnosis and 20% dysmorphic features Over 60% used parents and teachers scales |
Need for education |
| Daly et al.(2006) US | Survey of 18 questions | 303 family physicians | High |
54% were not aware of AAP guidelines 90% used DSM diagnostic criteria 77% used lab test (lead, EEG, etc.) Barriers to diagnosis included, lack of training and education, time constraints and complexity |
Need for education Constraints with recognition, management and treatment |
| Dryer et al. (2006) Australia | 117 items questionnaire, Likert scale | 670 medical professionals of which 82 GPs | High |
GPs thought that behaviour and concentration were characteristics of ADHD as well as low self-esteem and adjustment problems For causal factors, GPs agreed that it was mainly due to brain function as opposed to home, school or toxins |
Need for education |
| Evink et al. (2008) US | Questionnaire and vignettes | 66 physicians | High |
Comparison between different types of physicians 55% of family physicians vs 100% of paediatricians use DSM criteria 100% will seek specialist input when presented with complicated cases Main difference in treatment and assessment is in medical specialty Pressure from parents and schools |
Multidisciplinary approach |
| Fiks et al. (2011a) US | Free listing and interviews of word related to ADHD | 30 paediatricians and 60 parents | High |
ADHD was linked to the words school, impulsive, hyperactive and focus Clinicians associated help with medication, time (negative), side effect, psychologist and frustration Talking to families was associated with time, learning and explaining |
Need for education Constraints with recognition, management and treatment |
| Fuermaier et al. (2012) Netherlands | Stigma questionnaire on adult ADHD | 228 professionals of which 74 physicians | High |
Shows that a control group (matched in age, sex and education) and physicians do not differ in level of stigmatisation towards ADHD The only subscale where they showed lower stigmatisation is misuse of medication Reflect different training and experience and different dimensions of stigmatisation |
Need for education Misconceptions and stigmas |
| Gamma et al. (2017) Switzerland | Survey on ADHD | 75 physicians | Moderate |
44% of presenting cases were diagnosed by PCPs Difference in diagnosis and management between GP and paediatricians Only 7% of PCPs felt competent in diagnosing ADHD, lack of competence the primary reason for not diagnosis GPs felt less competent than paediatricians |
Need for education |
| Gardner et al. (2002) US | Survey on mental health with small elements of ADHD | 395 primary care clinicians | High |
Physicians were more likely to find ADHD in boys when presented with boys and girls with similar levels of parent reported problems Therefore, bias of treatment for different genders |
Misconceptions and stigmas |
| Ghanizadeh and Zarei (2010) Iran | Self-reported questionnaire to assess knowledge and attitude | 665 GPs | Moderate |
20% reported ADHD is not a serious problem, 1/3 believed sugar is a cause Nearly all reported higher risk of delinquency, 80% believe it is a risk factor for truancy Different beliefs on IQ and educational levels Half believed it is due to dysfunctional families, only 6% believed it can be lifelong Not sufficient information about ADHD |
Need for education Misconceptions and stigmas |
| Gomes et al. (2007) Brazil | Interviews | 2117 professionals of which 128 general practitioners | High |
7% of GPs did not know of ADHD even after reading a definition GPs expressed the least agreement with the statement “ADHD must be treated with medical products” 5% believed it is not a disease 19% believed you can leave without treatment |
Need for education Misconceptions and stigmas Constraints with recognition, management and treatment |
| Goodman et al. (2012) US | Survey with clinical vignette on adult ADHD | 1924 professionals of which 1216 primary care physicians | High |
30% reported being not confident in diagnosis, 38% in treatment, 35% in managing adult ADHD Greatest barrier was limited experience Reported difficulty distinguishing ADHD from other things Main barrier: complexity of disorder, stigma, concerns around meds and adherence to therapy Gap in communication between specialists Almost 50% believed ADHD is caused by absent parent or bad parenting |
Need for education Misconceptions and stigmas Constraints with recognition, management and treatment Multidisciplinary approach |
| Heikkinen et al. (2002) Finland | Questionnaire, 16 items, not just about ADHD | 499 physicians | High | 44% of male and 60% of female physician felt confident in their skills in assessing ADHD | Need for education |
| Jawaid et al. (2009) Pakistan | Questionnaire | 194 primary paediatric care providers | High |
Colleagues were reported as the main source of information Only 13% of GPs and 21% of paediatricians were shown to have sufficient knowledge 50% showed inadequate knowledge No training for GPs in ADHD in Pakistan |
Need for education |
| Kwasman et al. (1995) US | A 48-item survey Likert scale | 380 paediatricians | High |
8% reported being “burned out” by ADHD children 39% reported barriers in time required Want more interdisciplinary contact, Only 8% follow-up Misconceptions about ADHD including poor dieting, child does it on purpose, medication can cure ADHD and children outgrow ADHD 44% believe ADHD medication is addictive |
Misconceptions and stigmas Constraints with recognition, management and treatment Multidisciplinary approach |
| Kwasman et al. (2004) US | 51-Item survey | 786 school nurses | High |
89% attended presentation on ADHD Most agree that they tried to get written report from school to physician Most disagree of integration of communication between school and physician Most disagreed that physicians did a good job at educating parents and children about ADHD Higher estimate of boys vs girls |
Need for education Misconceptions and stigmas Multidisciplinary approach |
| Lanham (2006) US | 55-Item survey | 235 physicians | High |
Only 22% are familiar with guidelines 70% use child behaviour in office to make an official diagnosis |
Constraints with recognition, management and treatment |
| Lian et al. (2003) Singapore | Cohort study on developmental disorders—4 questions on ADHD | 48 GPs | Moderate |
31% agreed that children may show all signs at home but not in school 25% believed sugar to be the cause 73% agreed that it improved in adolescence 85% believe that medication alone is sufficient |
Need for education Misconceptions and stigmas |
| Louw et al. (2009) South Africa | Surveys 22-item multiple-choice questions | 229 GPs | High |
57% reported average to good knowledge of ADHD in children. Only 10% in adults 7% felt they had adequate training in children and 1% in adult Self-study most prominent education tool, lack of training at university level Most felt the need to know more about ADHD, in adults 89% and children 81% Need for appropriate screening tools Main barriers in management are uninformed parents, limited funds, time and difficult parents |
Need for education Constraints with recognition, management and treatment Multidisciplinary approach |
| Miller et al. (2005) Canada | Questionnaires | 405 GPs and FPs | High |
47% reported low comfort with diagnosis, 52% high 51% low skill in diagnosis, 48% high 51% low comfort with management, 48% high 50% low effectiveness in management, 49% high Comfort skills are a predictor of GPs’ tendency to take responsibility and are related to previous educational exposure |
Need for education |
| Morley (2010) US | Case studies vignettes with a survey | 187 primary care physicians | High |
Race and insurance status do not have an effect on diagnosis Respondent effective at discriminating between ADHD cases or not |
|
| Murray et al. (2006) UK | Questionnaires | 40 GPs | Low |
Only 22% were aware of the three diagnosis criteria Almost half identified the need for more information 7 thought causes of ADHD were due to family management approaches |
Need for education Misconceptions and stigmas |
| Power et al. (2008) US | Questionnaire of 24 items with Likert scale | 121 primary care providers | High |
PCP believe assessing ADHD is within their scope of practice as well as prescribing medication Issues with initiating communication with school professionals Additional training related to assessment, school collaboration, family education and collaboration with mental health providers |
Need for education Multidisciplinary approach |
| Quiviger and Caci (2014) France | Questionnaire of 23 items | 57 paediatricians | High |
13 out of 49 did not know what TDAH (Trouble Déficit de l’Attention/Hyperactivité—ADHD) stood for 72% responded having insufficient training on ADHD Education on ADHD is mainly self-taught from articles, colleague or internet 24% thought it was a disorder constructed abroad and imported to France, 36% thought it was societal, 15% believed it is due to bad parenting 77% believed mothers worry too much about hyperactivity 62% based their decision on the child’s behaviour in the practice |
Need for education Misconceptions and stigmas Constraints with recognition, management and treatment |
| Ross et al. (2011) US | 38-Item cross-sectional survey | 100 primary care paediatricians | High |
Communication with psychiatrist is low and changeable, would prefer closer collaboration 15% reported receiving communication with psychiatrist Depend on parents to provide information |
Multidisciplinary approach |
| Rushton et al. (2004) US | 37-Item survey about diagnosis and treatment measures | 723 paediatricians and family physicians | High |
77% familiar with AAP guidelines and incorporated them in their practice Laboratory test still conducted by up to 39% (lead, iron) 20% believe parents are reluctant to accept diagnosis 55% believe teachers pressurise them to get diagnosis and 70% to prescribe meds 43% believed of misuse of meds which was associated with less prescription Most did not believe stigma was a barrier to access to care Lack of awareness of guidelines, only 44% used DSM criteria |
Need for education Constraints with recognition, management and treatment Multidisciplinary approach |
| Sayal et al. (2002) UK | Questionnaire | 16 GPs | High | GP were less likely to agree that children could managed solely with primary care | Multidisciplinary approach |
| Shaw et al. (2002) Australia | Questionnaires | 399 GPs | High |
A majority believed inadequate parenting was influential Importance of multimodal assessment Variation in DSM knowledge of features of ADHD, lack of confidence 17% believed stimulant is an inappropriate treatment Most GPs were unhappy managing respondents in general practice as it is too difficult and time consuming |
Need for education Misconceptions and stigmas Constraints with recognition, management and treatment Multidisciplinary approach |
| Stein et al. (2009) US | 8-Page survey with fixed responses | 745 paediatricians | High |
12% reported they neither treat nor report ADHD 53% responded that paediatricians should not be responsible for referring ADHD Continuity of care associated with enquiring and treating ADHD Debate over whether prevalence in practice and higher level of attendance at lectures/conferences are causes or consequences of inquiring and treating/managing. Once paediatricians are more aware of a problem, it is likely that they will pay more attention to it |
Need for education Multidisciplinary approach |
| Thomas et al. (2015) US | 37-Item survey with closed responses | 298 professionals of which 59 physicians and 138 nurses | High |
Only 38% believed ADHD to be a problem Half of respondents felt comfortable in their ability to recognise ADHD symptoms, nurses least comfortable Over 85% stated the need for more research in college students and ADHD |
Need for education Constraints with recognition, management and treatment Multidisciplinary approach |
| Venter et al. (2003) South Africa | 51-Item survey | 143 GPs | Moderate |
Problems area identified were coordination of intervention and liaising with schools 45% found parents difficult Management of ADHD could be improved by teacher education, parent education, interdisciplinary contact and improved training of medical professional The majority believed chaotic home situation and bad parenting were strong influences 68 and 67% of GP and nurses thought it was difficult to diagnose ADHD in college student |
Need for education Misconceptions and stigmas Multidisciplinary approach |
| Ward et al. (1999) Canada | One-day course. Three part needs assessment: 42-item survey |
100 family physicians 34 provided data before and after |
High |
An educational program showed significant difference about ADHD knowledge pre- and post-tests, and altered management of ADHD Pre-course, 17% referred for diagnosis with a minimum of history taking, 4% post-course |
Need for education |
| Wasserman et al. (1999) US, Puerto Rico and Canada | Questionnaire | 401 paediatricians | High |
AHP (attentional and hyperactivity problems) rather than ADHD DSM criteria used in only 38% and school report in only 53%. Lack of standardisation in primary care assessment Children 7–10 years old, twice as likely to be diagnosed to those older with higher scores No evidence of used of labels by clinicians to children with family or social issues, racial or ethnic status. Gender bias |
Misconceptions and stigmas |
| Williams et al. (2004) US | Interviews on behavioural health diagnosis | 47 paediatricians | High |
High level of comfort in making ADHD diagnosis and prescribing meds 48% spend time focused on ADHD, information about cause of the disorder, school modification, organisation skills, parenting Great interest in future training for update on ADHD, not so much basic information |
Need for education |
| Wolraich et al. (2010) US | Surveys in 1999 and in 2005 | 551 paediatricians in 2005, 452 in 1999 | High |
Increase in use of APA guidelines over the two surveys More used diagnostic criteria More used both teacher and parent rating scales Large proportion in both surveys felt training in treatment and evaluation was inadequate |
Need for education |