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Lucena Clinic, 59 Orwell Road, Rathgar, Dublin 6, Ireland and Centre of Disability Studies, University College Dublin, Belfield, Dublin 4, Ireland, e-mail: sarahbuckley{at}o2.ie
St Michael’s House, Dublin and Centre of Disability Studies, University College, Dublin
Child and Family Guidance Centre, Roscommon
Department of Psychology and Centre of Disability Studies, University College Dublin
Centre of Disability Studies, University College Dublin and School of Nursing, Health Studies and Allied Sciences, Dundalk Institute of Technology, Dundalk
Centre of Disability Studies, University College Dublin and Stewart’s Hospital Services, Palmerstown, Dublin 20, Ireland
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionConclusionReferences |
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Anecdotal evidence suggests that attention-deficit hyperactivity disorder (ADHD) is underdiagnosed in adults and people of all ages with learning disability. This study examines the clinical practice of Irish consultant psychiatrists when assessing and treating symptoms of ADHD in children and adults with and without a learning disability. A postal questionnaire was sent to 302 consultant psychiatrists working in Ireland.
RESULTS
Ninety-seven consultants (32%) responded, 62 working in general adult psychiatry, 23 in child and adolescent psychiatry and 12 in learning disability. Overall, respondents were more confident about making a diagnosis of ADHD in people without a learning disability. Those working with children were significantly more confident in diagnosing and treating ADHD than those working with adults, irrespective of whether the patient had a learning disability.
CLINICAL IMPLICATIONS
There is general agreement that symptoms of ADHD exist in children and adults both with and without a learning disability. It is likely that ADHD may be undertreated in patients with learning disability, especially in the adult population.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Although the prevalence of ADHD in adults is not known (Schaffer, 1994) there is a growing consensus that ADHD continues into adulthood (Barkley, 1990; Toone et al, 1999; Fitzgerald, 2001; Willoughby, 2003). It seems logical that this disorder would present in adults with a learning disability, and possibly to a greater extent than in adults without such disability (Fox & Wade, 1998), but there are diagnostic difficulties with the current classification system, particularly in making the diagnosis in adults and those with learning disability (Murphy & Barkley, 1996; Seager & O’Brien, 2003).
The literature has shown that treatment of ADHD not only improves abnormal behaviour but also self-esteem, cognition, and social and family function, and that response can vary in different age-groups and with certain comorbid conditions (Wender, 1995; Findling et al, 1996; Wilens et al, 1996). However, studies indicate that less than half of those with the disorder are receiving treatment (Barkley et al, 2002; Dekker & Koot, 2003).
This study was carried out to assess the practice of Irish psychiatrists in relation to the diagnosis of ADHD. We postulated that the diagnosis of ADHD is generally overlooked in adults and in patients with learning disabilities.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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An anonymous postal questionnaire was prepared specifically for this survey. An explanatory letter, a questionnaire relating to either children or adults and a prepaid envelope were sent to all 302 consultant psychiatrists listed in the Irish Medical Directory (Irish Medical Services, 2003). Of these, 250 worked with adults, 36 with children and adolescents, and 16 with patients with a learning disability. Four weeks later a reminder letter was sent with further copies of the same questionnaires.
The questionnaire was designed to establish whether consultant psychiatrists believe that ADHD exists, what assessment methods they use and what treatments they use when working with children and adults both with and without learning disability. The questionnaire also requested demographics and examined levels of confidence in making the diagnosis of ADHD using a visual analogue scale; respondents were asked to indicate the frequency with which they included symptoms taken from DSM-IV criteria (American Psychiatric Association, 1994) using the following options: ‘never’, ‘sometimes’, ‘often’, ‘always’. They were also asked to rank these symptoms in the order they considered the most important for making a diagnosis of ADHD. The questionnaire also included general questions concerning the respondents’ understanding of ADHD and its assessment and treatment. Finally, participants were asked to add any other symptoms which they regarded as important for the diagnosis of ADHD.
The Statistical Package for the Social Sciences version 10.1 for Windows was used for data analysis.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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All respondents were asked whether ADHD ‘occurred’ in children, adults and in those with learning disability (Table 1).
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Ranking and presentation
Ranking of symptoms of ADHD in children and adults both with and without
learning disability was also examined using a Mann-Whitney analysis. Only one
symptom ‘Often fidgets with hands or feet’ was ranked as
significant only in patients without learning disability. Consultants in adult
psychiatry considered fidgeting less important for a diagnosis in those
without learning disability than consultants in child psychiatry.
2 analysis revealed that the following six symptoms were
seen significantly more often by those working with children without learning
disabilities than by consultants working with adults: ‘often fidgets
with hands or feet’; ‘has difficulties engaging in leisure
activities quietly’; ‘is often on the go or acts as if driven by a
motor’; ‘blurts out answers before questions are completed’;
‘often interrupts or intrudes on others’; ‘doesn’t
seem to listen when spoken to directly’.
Confidence in making a diagnosis
A two-way analysis of variance (ANOVA) was used to assess
consultants’ confidence in making a diagnosis of ADHD in adults and
children with and without learning disability. The dependent variable was
self-rated confidence (possible range 0–100). The independent variables
were children/adults (non-repeated) and with/without intellectual disability
(repeated). Groups were defined as adults and children and our population as
with and without learning disability. No interaction was found between group
and population. However, the main effect for group was significant
(Fobs=18.732, d.f.=1, 57, P<0.05).
Examinaiton of the means suggested that consultants working with children were more confident at making a diagnosis in patients with and without learning disability than the consultants working with adults. The main effect for population was also significant (Fobs=32.661, d.f.=1, 57, P<0.05), with the mean scores suggesting that consultants were more confident about making a diagnosis of ADHD in patients without learning disability.
Methods of diagnosis
Respondents were asked in an open-ended question to specify which methods
they used for diagnosing ADHD. The most common answers were:
Treatments
The most frequently used medications were methylphenidate and
dexamphetamine. Other medication included carbamezepine, mood stabilisers,
clomipramine, venlafaxine, psychotropics, imipramine and zopiclone. Other
treatments included psychoeducation, cognitive-behavioural therapy, social
skills training and occupational therapy. A combination of stimulant
medication and behaviour management and Parents Plus programmes was also
reported to be effective.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Consultants might be more confident about making a diagnosis of ADHD in patients without learning disability because of ‘diagnostic overshadowing’ in the latter group (Reiss & Szyszko, 1983; White et al, 1995; Jopp & Keys, 2001; Mason & Scior, 2004). This is a well-described problem in the diagnosis of psychiatric conditions in people with learning disabilities. It is of concern that despite indications that ADHD is more common in people with learning disabilities (Seagar & O’Brien, 2003) the diagnosis was not generally considered in this group by those we surveyed.
It is interesting that the child psychiatrists were significantly more confident in diagnosing ADHD in patients with and without learning disability than those working with adults; this may reflect the historical emphasis on this condition as being a diagnosis of childhood and suggests the need for training of general psychiatrists (Royal College of Psychiatrists, 1998, 2004).
A limitation of this study is the poor response rate from certain groups. Only 25% (n=80) of general adult psychiatrists completed the questionnaire compared with 64% (n=23) of child and adolescent psychiatrists and 75% (n=12) of consultants working with learning disability. The overall response rate was 32% (n=97). This study reflects only the practice of one discipline; the practices of other disciplines (e.g. psychology) were not examined. However, in Ireland the assessment and treatment of ADHD is usually carried out by multidisciplinary teams led by a consultant psychiatrist and we believe that our results are a fair representation of current practice in Ireland.
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Conclusion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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We believe that it would be useful to produce two consensus statements regarding the assessment and treatment of ADHD: one in relation to adults and one in relation to patients of all ages with learning disabilities. We will be recommending to the relevant faculties of our College that groups be established to produce such consensus statements.
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References |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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BARKLEY, R. A. (1990) Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
