Why do many Irish doctors have negative attitudes towards ADHD?

In 2016, in the journal Support for Learning, Irish researchers Michael Quinn and Andrea Lynch stated: "In many western countries, attention deficit hyperactivity disorder (ADHD) has achieved celebrity status, such that it probably no longer requires introduction."

It may not “require introduction”, but even with a definition – “a common disorder characterised by developmentally inappropriate hyperactivity, impulsivity, and inattention” – the condition is hotly debated.

Thus, Quinn and Lynch not only cite genetic and neurological studies supporting its qualification as a valid disorder, they note that “[S]ome critics of the ADHD construct question the possibility that ADHD is perhaps nothing more than an example of the ‘medicalisation’ of behaviours in children which are the most annoying and problematic for adults to control”.

Perhaps this tension between competing viewpoints helps explain why many GPs harbour negative attitudes towards ADHD.

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In a 2016 study published in BMC Family Practice, University College Dublin's Dr Mimi Tatlow-Golden and colleagues evaluated studies published worldwide, finding that "their geographic breadth indicates that mixed (and often unhelpful) attitudes regarding the construct of ADHD are internationally widespread, even among medically trained clinicians, in these gatekeeper settings".

Global phenomenon

Providing local focus to this global phenomenon, a recent study in the Irish Journal of Medical Science concludes: "Despite the high rates of ADHD among children, a slim majority of Irish GPs have positive attitudes towards ADHD. This could lead to undiagnosed or misdiagnosed cases." The researchers questioned 140 GPs of whom only "58.8 per cent expressed a positive attitude towards ADHD".

Lead author, consultant psychiatrist/researcher Dr Dimitrios Adamis of Sligo Mental Health Services and the University of Limerick, discussed his team's findings with The Irish Times.

"It is estimated that ADHD affects about 5 per cent of children and adolescents around the world," said Dr Adamis, "but a study of children in Ireland, aged 12 to 15 years old, reported that 3.7 per cent meet a diagnosis of ADHD. However, another study suggested that less than 1 per cent of children have received a diagnosis of ADHD in Ireland".

Dr Adamis believes there is either an under-detection and reluctance to refer children to child psychiatrists, or that ADHD is underdiagnosed in child and adolescent mental health services. He considers it is probably both.

Was Dr Adamis surprised to find a high prevalence of negative attitudes towards ADHD among GPs in Ireland? “Such unhelpful attitudes – that it is a fashionable disorder; an excuse for badly behaved children or bad parenting; or a means of obtaining Disability Access to Education or Domiciliary Care Allowance – was unsurprising because similar rates occur in other countries too,” said Dr Adamis.

“What was surprising, was the lack of association between GP training and knowledge and their attitudes, contradicting the assumption that being better informed about ADHD elicits a more ‘positive’ attitude towards it.”

Dr Adamis conferred with co-authors Prof Fiona McNicholas and Prof Blánaid Gavin to try to explain this: “We suggest two possibilities. First, it may be a statistical quirk because both groups – those with ‘positive’ and those with ‘negative’ attitudes – had little knowledge of ADHD. Second, attitudes and beliefs have an emotional component, and occasionally there is a disassociation between attitudes and knowledge. Despite adequate knowledge of a subject, individuals may hold negative views about it.”

Having identified this problem, how should it be addressed?

Support resources

Dr Adamis emphasises the importance of working with GPs, through conference presentations or other educational meetings; by collaboration at local level to raise awareness of the symptoms and treatment of ADHD; and providing appropriate support resources. “Equally important,” notes Dr Adamis, “is to inform not only GPs but teachers, psychiatrists and the public that ADHD is neither ‘bad behaviour’ nor a disability. Despite the difficulties associated with ADHD, equally there are strengths like creativity and persistence.

"There are many successful and famous people for whom ADHD has played a central part. However, to paraphrase the physicist Max Planck, it rarely happens that Saul becomes Paul on the road to Damascus: to change attitudes and beliefs and to enhance knowledge, much prolonged work is needed with continued effort and collaboration."

As for future research, Dr Adamis explains that although ADHD is not a new condition, globally it's only the last decade that has seen increased research and more publications, a trend that is reflected in Ireland. "ADHD research is growing here," observes Dr Adamis, "not only for children but for adults with ADHD. The research is multifaceted, investigating epidemiology, psychopathology, improved diagnosis, education, and service development. Currently a national clinical programme for ADHD in adults is developing with consultant psychiatrist Dr Margo Wrigley as a national clinical lead."

Similarly, explains Dr Adamis, scientific work is being undertaken by the charity HADD-ADHD Ireland: "Therefore," he adds, "we expect results over the coming years to enhance our understanding of ADHD and provide improved service and treatment. Of course, science evolves, and research is continuous, trying to address new questions arising from previous work. I hope this current momentum will continue into the future."

Interestingly, the role of parents in shaping the ADHD research agenda was recognised by a study undertaken by University College Cork researchers, who wrote in the journal Social Science & Medicine (2013) that with relationships between the medical profession and patients becoming increasingly complex and nuanced in the contemporary health arena, "parents' interventions have sought to expand the therapeutic domain of ADHD beyond the exclusive realm of biopsychiatry, and the dilemmas they face in making their experiences count . . ."