This study provides insight into the pediatric practice and perceived challenges of ADHD management in Switzerland. In accordance with existing guidelines, the majority of participating pediatricians reported to perform a thorough and broad diagnostic procedure with valid diagnostic instruments and involvement of the parents and the child on a regular basis. Pharmacological therapy, psychotherapy, and multimodal therapy were the therapies about which pediatricians informed most often. Main reported challenges in the ADHD management were the subjectivity of diagnostic criteria, low availability of psychotherapy options due to a shortage of specialists, and a rather negative attitudes towards ADHD of parents, teachers and the public. Need for further education for all professionals involved, support for coordination with specialists, and schools and improvement of information on ADHD was expressed. In conclusion, we could not find any evidence for the assumption that participating office-based pediatricians prescribe MPH without embedding pharmacotherapy in a multimodal approach.
Acknowledged ADHD guidelines recommend that for the assessment of ADHD more than one visit is scheduled, which is technically difficult within primary care where time is often constrained (13,18). On average, pediatricians in this study arrange three meetings with parents for the diagnosis, of which two take place with the child concerned. To our knowledge, there is no published data from other countries for a comparison of how many meetings are in fact held. Parents and schools play the most important part with respect to initiating a diagnostic consultation, while the school psychological service or the children themselves play a less important role. Even though pediatricians report that they assign patients a central role in the diagnostic workup, the child apparently hardly ever initiates the consultation. The inclusion of parents, family members, and teachers in the assessment of ADHD, which has also been found in other studies, is in line with current guidelines (17,33).
Since the establishment of ADHD guidelines an increased use of screening instruments for the diagnosis has been described in the literature (33). In line with this, the majority of our participants reported that they use ADHD-specific screening tools. For differential diagnosis, half of our respondents used screening tools.
Pediatricians reported that they perceive the subjectivity of the ADHD diagnosis as challenging, which was also repeatedly reported in other studies (16,17,34). However, only few participants reported to refer children with suspected ADHD to a specialist for a further diagnostic workup. Similar, Gamma et al. observed that pediatricians more often diagnose patients with ADHD themselves compared to general practitioners (35). In our study, this finding might be accentuated by the fact that pediatricians, who consider themselves competent in this field and see patients with ADHD regularly predominantly participated in the survey. Nevertheless, some participants expressed the need for further training. Another reason for few referrals to specialists could be the shortage of child & adolescent psychiatrists, which was also expressed by our participants and is in line with research from other countries (24,34,36).
Once the diagnosis is established, the exchange with parents and children as well as the level of suffering of the child are reported to be central reasons in favoring or deciding against initiating a therapy. Next to drug therapy, pediatricians reported to inform about occupational therapy, educational counselling and patient organizations most frequently. Most probably, occupational therapy is favored when fine motor impairments are present, which have been described in up to 50% of ADHD patients (37–39).
In our study, involvement of the affected children or adolescents and parents in treatment decisions seems to be standard for many pediatricians and has been reported to be very important for the adherence to therapy (34). However, pediatricians described the families` therapeutic adherence and cooperation as a difficulty, they commonly face. This resonates with previous research where despite substantial evidence supporting the efficacy of stimulant medication for children with ADHD, adherence to stimulant treatment was often not optimal (40). The cause for low adherence was not assessed in the current study. However, proper involvement of the child and family in the therapy process is considered crucial for long-term compliance with therapy (34). With respect to involvement of the child there seems to be room for improvement.
According to the multimodal approach, the majority (80–90%) of pediatricians reported to always or often inform about multimodal therapy, pharmacological therapy and psychotherapy, and the majority (approx. 60%) stated that they always or often inform about education counselling and occupational therapy. This is comparable with the literature, although patients in the study by Venter et al. were more frequently (89%) referred to occupational therapy (35,37).
Even though pediatricians obviously inform about and apply multiple treatment options, the most frequent therapy still is pharmacological treatment, which corresponds with other findings (35,37). Although medication may be prescribed in combination with other therapies, the high use of medication may partly be explained by the reported poor availability of other treatment options such as psychotherapy and occupational therapy. Furthermore, monetary issues for other therapies seem to be a hurdle: for example, occupational therapy was described as problematic with respect to coverage by health insurance companies. An interesting aspect was reported by French et al. which found that physicians felt pressured by parents and teachers to prescribe medication (16).
Challenges in diagnosis and treatment of ADHD in pediatric practice
Pediatricians reported several challenges in the pediatric ADHD management which mostly correspond with other findings from Switzerland and international studies on ADHD management (16–18,34,35). In a systematic review, French et al. (16) identified four main issues in the management of ADHD in primary care: need for education on ADHD for primary care physicians, misconception and stigma towards ADHD among primary care physicians, constraints with recognition, management, and treatment such as limited time for gathering information from third parties, and issues with the multiprofessional approach, i.e. issues with communication between specialists, schools and parents. In our study, the same issues were found, however the need for specific education on ADHD and stigmata were only reported by a minority of participants. This might reflect the selection of participants, who predominantly see themselves as being competent. Interestingly, while French et al. found stigma and misconceptions among physicians (16), in the current study, participants were referring to stigma in the context of stigmatization of ADHD patients by their environment. However, more education and better information on ADHD for professionals and the public is a finding, which has already been identified in the literature, especially considering the perceived subjectivity of diagnostic criteria and vagueness of guidelines (16,17). In our study, pediatricians also suggested further education for school professionals (i.e. teachers and school social workers) and other specialists involved.
Another frequently mentioned issue in our study concerns the multi-professionality of ADHD management, coordination with specialists, schools/teachers and parents, which was described as time-consuming, complicated, and poorly reimbursed. Need for support for interprofessional exchange and case-specific discussions (“patient-centered round tables”) and improvements of reimbursement consequently was frequently stated by our sample and in the literature(16,17,33,37). Moreover, low availability of psychotherapy places is also a problem that is present not only in Switzerland, but internationally (24,34,36).