Awareness of ADHD in primary care

Despite ADHD impacting around 5% of children in the UK, GPs are ill-equipped to deal with this disorder. Over half of children with ADHD will continue experiencing symptoms into adulthood, and untreated and undiagnosed ADHD can strongly impact individuals throughout their lifetime. It is therefore vital that individuals access treatment and diagnosis at an early stage. The diagnosis pathway for ADHD is very complex. Specialist services in secondary care are responsible for ADHD diagnosis, most often following a referral from the patient’s GP. Without such referral, access to diagnosis and, in turn, access to care is often impossible. GPs' accurate understanding and awareness of ADHD is therefore primordial. Studies investigating GPs’ awareness of ADHD have found that GPs are ill-equipped to deal with individuals with ADHD, demonstrating a lack of knowledge and training, the presence of stigmas and misconceptions and a lack of clarity about their role. These barriers impact GPs’ ability to recognise ADHD in their patients and therefore referring to specialist services for assessment and treatment. To address some of these issues, these doctoral studies aim to raise GPs’ awareness and knowledge of ADHD through a targeted online training resource. In the first instance, this thesis sought to investigate the gaps and barriers in GPs’ understanding of ADHD. These findings facilitated the development of an online psycho-education programme tailored for GPs. The second aim was to evaluate the efficiency and usability of this programme. This thesis included three phases using mixed-methodologies: - A systematic review and qualitative interviews with GP trainees, GPs, patients and healthcare professionals were conducted to investigates barriers in GPs’ understanding of ADHD. - These findings informed the development of a 45-minute online psycho-education programme. This programme was co-produced with GPs, and a usability study was conducted to assess the accessibility of the programme. - A pilot Randomised Control Trial (RCT) and interviews were then conducted with GPs to assess the program's efficiency. A brief evaluation of long-term impacts and implementation was also conducted. The development of an online intervention was informed by evidence from a literature review, and Chapter one provides an overview of GPs’ role and pathway to care in the UK. Through a systematic review, the first study explores the barriers and facilitators of GPs' understanding of ADHD. To further investigate the gaps in GPs’ understanding, the second study explores interviews with key stakeholders in the ADHD in primary care - patients, secondary care professionals, GP trainees and GPs. Findings from the first two studies were inputted into the development of the online resource for GPs. The usability of this co-produced resource was assessed through a usability and feasibility study. This led to the final and primary study, which explores an online psycho-education resource's efficiency through a pilot RCT. Preliminary findings on long-term implementation and impact of the research were also collated. This thesis demonstrates the many gaps in primary care understanding of ADHD and evaluates the use of a psycho-educational programme in addressing these gaps. The contribution of the studies and the implication of the findings are discussed. Considerations over the development process, the impact on primary care and implications for future research are also presented. GPs’ knowledge of ADHD was improved by developing an online psycho-education programme resulting in increased understanding of the pathways to care and reduced stigma. Lack of identification and recognition of ADHD in GPs can be remediated by GPs completing a short 45-minute online course, in turn improving patients’ access to care

Awareness of ADHD in primary care

Despite ADHD impacting around 5% of children in the UK, GPs are ill-equipped to deal with this disorder. Over half of children with ADHD will continue experiencing symptoms into adulthood, and untreated and undiagnosed ADHD can strongly impact individuals throughout their lifetime. It is therefore vital that individuals access treatment and diagnosis at an early stage. The diagnosis pathway for ADHD is very complex. Specialist services in secondary care are responsible for ADHD diagnosis, most often following a referral from the patient’s GP. Without such referral, access to diagnosis and, in turn, access to care is often impossible. GPs' accurate understanding and awareness of ADHD is therefore primordial. Studies investigating GPs’ awareness of ADHD have found that GPs are ill-equipped to deal with individuals with ADHD, demonstrating a lack of knowledge and training, the presence of stigmas and misconceptions and a lack of clarity about their role. These barriers impact GPs’ ability to recognise ADHD in their patients and therefore referring to specialist services for assessment and treatment. To address some of these issues, these doctoral studies aim to raise GPs’ awareness and knowledge of ADHD through a targeted online training resource. In the first instance, this thesis sought to investigate the gaps and barriers in GPs’ understanding of ADHD. These findings facilitated the development of an online psycho-education programme tailored for GPs. The second aim was to evaluate the efficiency and usability of this programme. This thesis included three phases using mixed-methodologies: - A systematic review and qualitative interviews with GP trainees, GPs, patients and healthcare professionals were conducted to investigates barriers in GPs’ understanding of ADHD. - These findings informed the development of a 45-minute online psycho-education programme. This programme was co-produced with GPs, and a usability study was conducted to assess the accessibility of the programme. - A pilot Randomised Control Trial (RCT) and interviews were then conducted with GPs to assess the program's efficiency. A brief evaluation of long-term impacts and implementation was also conducted. The development of an online intervention was informed by evidence from a literature review, and Chapter one provides an overview of GPs’ role and pathway to care in the UK. Through a systematic review, the first study explores the barriers and facilitators of GPs' understanding of ADHD. To further investigate the gaps in GPs’ understanding, the second study explores interviews with key stakeholders in the ADHD in primary care - patients, secondary care professionals, GP trainees and GPs. Findings from the first two studies were inputted into the development of the online resource for GPs. The usability of this co-produced resource was assessed through a usability and feasibility study. This led to the final and primary study, which explores an online psycho-education resource's efficiency through a pilot RCT. Preliminary findings on long-term implementation and impact of the research were also collated. This thesis demonstrates the many gaps in primary care understanding of ADHD and evaluates the use of a psycho-educational programme in addressing these gaps. The contribution of the studies and the implication of the findings are discussed. Considerations over the development process, the impact on primary care and implications for future research are also presented. GPs’ knowledge of ADHD was improved by developing an online psycho-education programme resulting in increased understanding of the pathways to care and reduced stigma. Lack of identification and recognition of ADHD in GPs can be remediated by GPs completing a short 45-minute online course, in turn improving patients’ access to care

Barriers and facilitators to understanding of ADHD in primary care: a mixed-methods systematic review

Attention Deficit Hyperactivity Disorder (ADHD) is a developmental disorder affecting up to 5% of children and adults and is underdiagnosed in many European countries. The process of access to care for this disorder is complex and variable across countries. In general, those affected, or their caregiver, will seek help through their primary care practitioners who are then often responsible for referral to other professionals for diagnosis and provision of treatment. Previous studies have highlighted that many barriers to recognition exist in primary care settings (such as misconceptions, lack of education or lack of resources), preventing access to care for this population and potentially affecting diagnosis rate. This systematic review aims to establish the barriers and facilitators with regard to attitudes, beliefs and experiences of ADHD within primary care. Electronic searches of multiple databases identified 3898 articles of which 48 met our inclusion criteria – primary care professionals from any country, understanding, knowledge, awareness, attitude and recognition of ADHD. Four main themes were identified, 1) need for education, 2) misconceptions and stigma, 3) constraints with recognition, management and treatment, 4) multidisciplinary approach. The findings suggest many interacting factors are at play in the recognition of ADHD by primary care practitioners with a strong recurring theme of a significant need for better education on ADHD. Implications for research and practice are discussed, suggesting that educational interventions for primary care practitioners could improve the recognition of ADHD in this setting

Pet ownership and grief - Exploring how pet ownership effects owners' mental wellbeing during times of grief, a qualitative pilot study

Animal-assisted interventions (AAIs) have exhibited encouraging outcomes in enhancing human mental health. However, research has investigated the potential benefits of untrained pets for human mental wellbeing, as training animals for AAI can be costly and time-consuming. However, despite times of grief representing a significant risk factor for poor mental wellbeing, to date few studies have explored how pets may protect owner mental wellbeing during this period. This qualitative study explored how pet ownership impacts owner's mental wellbeing during times of grief, and through what mechanisms. This study used semi-structured interviews to interview pet owners who had lost a loved one (human) in the last 2 years. Twelve participants took part in the interviews which were analysed with thematic analysis. The analysis determined three key themes: hedonic wellbeing, feeling connected, and emotion regulation. The mechanisms that lead to owners' mental wellbeing during times of grief were varied, including things like cuddling and walking pets, as well as just being in their presence. The key benefits owners derived from these activities and interactions are discussed. The findings of this study highlights how different owner-pet activities and interactions bring differing benefits. While further studies are necessary, these preliminary findings can help inform current guidelines on pet ownership, and further understanding how these key relationships in times of grief. Future research should explore further the mechanisms related to pet ownership and grief

Hand posture, but not vision of the hand, affects tactile spatial resolution in the grating orientation discrimination task

The grating orientation discrimination task (GOT) is a sensitive and reliable measure of tactile spatial resolution, or acuity. We used the GOT in three experiments to investigate the effects of hand posture and hand visibility on spatial acuity. Participant sex and experimental design were also manipulated. Healthy adult participants received brief touches to their index fingertips of grated, domed objects. Their task was to decide whether the gratings ran 'along' or 'across' their finger. Measures of the smallest grating width for which participants could reliably discriminate between orientations were recorded as threshold. Experiment 1 evaluated the effect of two- versus one-interval discrimination, hand used and participant sex. Experiments 2 and 3 evaluated the effects of hand visibility (visible or covered) and hand posture (in front or to the side). Females were better than males; the two-interval task resulted in lower thresholds than the one-interval task; and left and right hand thresholds were not significantly different. Most importantly, while hand visibility did not have a significant effect on the task, thresholds were affected by hand posture—worse when the hand was oriented to the side of the body than in front. These results replicate previously reported effects of sex (or finger size), but failed to replicate the so-called ‘visual enhancement of touch’ (VET) effect. We also report a meta-analysis of 27 VET studies, finding a significant effect of ‘non-informative’ vision on tactile perception. Our novel finding is that hand posture affects tactile acuity

Nutrition, growth, and other factors associated with early cognitive and motor development in Sub-Saharan Africa: a scoping review

© 2020 The British Dietetic Association Ltd. Background: Food insecurity, poverty and exposure to infectious disease are well-established drivers of malnutrition in children in Sub-Saharan Africa. Early development of cognitive and motor skills – the foundations for learning – may also be compromised by the same or additional factors that restrict physical growth. However, little is known about factors associated with early child development in this region, which limits the scope to intervene effectively. To address this knowledge gap, we compared studies that have examined factors associated with early cognitive and/or motor development within this population. Methods: Predetermined criteria were used to examine four publication databases (PsycInfo, Embase, Web of Science and Medline) and identify studies considering the determinants of cognitive and motor development in children aged 0–8years in Sub-Saharan Africa. Results: In total, 51 quantitative studies met the inclusion criteria, reporting on 30% of countries across the region. Within these papers, factors associated with early child development were grouped into five themes: Nutrition, Growth and Anthropometry, Maternal Health, Malaria and HIV, and Household. Food security and dietary diversity were associated with positive developmental outcomes, whereas exposure to HIV, malaria, poor maternal mental health, poor sanitation, maternal alcohol abuse and stunting were indicators of poor cognitive and motor development. Discussion: In this synthesis of research findings obtained across Sub-Saharan Africa, factors that restrict physical growth are also shown to hinder the development of early cognitive and motor skills, although additional factors also influence early developmental outcomes. The study also reviews the methodological limitations of conducting research using Western methods in sub-Saharan Africa

Ceiling effects in the Movement Assessment Battery for Children-2 (MABC-2) suggest that non-parametric scoring methods are required

Initially designed to identify children's movement impairments in clinical settings, the Movement Assessment Battery for Children-2 (MABC-2) is also widely used to evaluate children's movement in research. Standardised scores on the test are calculated using parametric methods under the assumption of normally-distributed data. In a pilot study with thirty five 8-10 year old children (i.e., in Age Band 2 of the MABC-2), we found that maximal performance was often reached. These ‘ceiling effects’ created distributions of scores that may violate parametric assumptions. Tests of normality, skew, and goodness-of-fit revealed this violation, most clearly on three of the eight sub-tests. A strong deviation from normality was again observed in a sample of 161 children (8-10 years, Experiment 1), however ceiling effects were reduced by modifying the scoring methods, and administering items designed for older children when maximal performance was reached. Experiment 2 (n=81, 7-10 years) further refined the administration and scoring methods, and again improved the distributions of scores. Despite reducing ceiling effects, scores remained non-parametrically distributed, justifying non-parametric analytic approaches. By randomly and repeatedly resampling from the raw data, we generated non-parametric reference distributions for assigning percentiles to each child's performance, and compared the results with the standardised scores. Distributions of scores obtained with both parametric and non-parametric methods were skewed, and the methods resulted in different rankings of the same data. Overall, we demonstrate that some MABC-2 item scores are not normally-distributed, and violate parametric assumptions. Changes in administering and scoring may partially address these issues. We propose that resampling or other non-parametric methods are required to create new reference distributions to which an individual child's performance can be referred. The modifications we propose are preliminary, but the implication is that a new standardisation is required to deal with the non-parametric data acquired with the MABC-2 performance test

Improvement in children’s fine motor skills following a computerized typing intervention

Children spend a large proportion of their school day engaged in tasks that require manual dexterity. If children experience difficulties with their manual dexterity skills it can have a consequential effect on their academic achievement. The first aim of this paper was to explore whether an online interactive typing intervention could improve children’s scores on a standardised measure of manual dexterity. The second aim was to implement a serial reaction time tapping task as an index of children's finger movement learning, and to see whether performance on this task would improve after the intervention. Seventy-eight typically developing children aged between 8 and 10 were tested at their school on the pre-intervention Movement Assessment Battery for Children (2 nd edition; MABC-2) and tapping tasks. Twenty-eight of these children volunteered to be randomly allocated to the intervention or control group. Children in the intervention group had a choice of two online games to play at home over a period of four weeks, while the children in the control group were not given these games to play. The intervention and control groups were then re-tested on the MABC-2 manual dexterity and the tapping task. Children in the intervention group significantly improved their manual dexterity scores in the MABC-2 compared to the control group. On average, all children learnt the tapping sequence, however, there were no group differences and no effect of the intervention on the tapping task. These results have important implications for implementing a freely available, easy to administer, fun and interactive intervention to help children improve their manual dexterity skills

Involving psychological therapy stakeholders in responsible research to develop an automated feedback tool: Learnings from the ExTRAPPOLATE project

Understanding stakeholders’ views on novel autonomous systems in healthcare is essential to ensure these are not abandoned after substantial investment has been made. The ExTRAPPOLATE project applied the principles of Responsible Research and Innovation (RRI) in the development of an automated feedback system for psychological therapists, ‘AutoCICS’. A Patient and Practitioner Reference Group (PPRG) was convened over three online workshops to inform the system's development. Iterative workshops allowed proposed changes to the system (based on stakeholder comments) to be scrutinized. The PPRG reference group provided valuable insights, differentiated by role, including concerns and suggestions related to the applicability and acceptability of the system to different patients, as well as ethical considerations. The RRI approach enabled the anticipation of barriers to use, reflection on stakeholders’ views, effective engagement with stakeholders, and action to revise the design and proposed use of the system prior to testing in future planned feasibility and effectiveness studies. Many best practices and learnings can be taken from the application of RRI in the development of the AutoCICS system