Perspectives of Rural Primary Care Clinicians on Pediatric Attention-Deficit/Hyperactivity Disorder Care

Abstract

Objective: Despite efficacious treatments, evidence-based guidelines, and increased availability of integrated behavioral health care, youth coping with attention-deficit/hyperactivity disorder (ADHD) receive suboptimal care. More research is needed to understand and address care gaps, particularly within rural health systems that face unique challenges. We conducted a qualitative study within a predominantly rural health system with a pediatric-integrated behavioral health care program to address research gaps and prepare for quality improvement initiatives, including primary care clinician (PCC) trainings and clinical decision support tools in the electronic health record (EHR). Method: Semistructured interviews were conducted with 26 PCCs representing clinics within the health system. Interview guides were based on the Practical Robust Implementation and Sustainability Model to elicit PCC views regarding determinants of current practices and suggestions to guide quality improvement efforts. We used thematic analysis to identify patterns of responding that were common across participants. Results: PCCs identified several internal and external contextual factors as determinants of current practices. Of note, PCCs recommended increased access to continuing education trainings held in clinic over lunch and delivered in less than 30 minutes. Suggested improvements to the EHR included incorporating parent and teacher versions of the Vanderbilt Rating Scale into the EHR, documentation templates aligned with evidence-based guidelines, and alerts and suggestions to aid medication management during appointments. Conclusion: Future research to identify implementation strategies to help rural PCCs adopt innovations are needed given the increased responsibility for managing ADHD care and intractable gaps in access to behavioral health care in rural regions.

Barriers and Enablers of Service Access and Utilization for Children and Adolescents With Attention Deficit Hyperactivity Disorder: A Systematic Review

“…Two studies used a quantitative longitudinal design ( Sayal et al, 2015 ; Zima et al, 2013 ); there were no randomized design studies. Thirteen studies used a qualitative design that included focus groups and interviews, analyzed through grounded theory, ethnography, and phenomenological approaches ( Araujo et al, 2017 ; Coletti et al, 2012 ; Flood et al, 2019 ; Graves, 2017 ; Laugesen et al, 2017 ; Lu et al, 2022 ; Moody, 2017 ; O’Dell et al, 2022 ; Paidipati et al, 2022 ; Rezel-Potts et al, 2021 ; Saulsberry et al, 2020 ; Shippen et al, 2022 ; Spencer et al, 2021 ). Two studies used a mixed method design consisting of both quantitative and qualitative methods ( Honorio Neto et al, 2021 ; Laugesen et al, 2020 ) ( Table 1 ).…”

“…Caregivers’ own poor awareness and acknowledgment of ADHD was also reported as a reason for delay in help-seeking or accessing services. These elements included caregivers not recognizing their child’s behavior as problematic, the belief that the child would recover, and parental attitude/misconceptions ( Al-Mohsin et al, 2020 ; Anand et al, 2018 ; Moody, 2017 ; O’Dell et al, 2022 ; Safavi et al, 2016 ). For example, common beliefs among caregivers of children screened at a pediatrics outpatient department of a hospital in India were that they thought the child was “just naughty” (reported by 84% of caregivers), that hyperactivity was a part of typical growth (64%) and/or that the child would improve with time (56%) ( Anand et al, 2018 ).…”

“…From the clinician’s perspective, primary care clinicians have reported that parental misconceptions and false expectations of children’s behavior can make it challenging to engage parents in treatment utilization for ADHD ( O’Dell et al, 2022 ). These barriers to diagnosis and treatment are driven by the beliefs of parents and the lack of understanding and awareness of the effects of ADHD on children.…”

“…Two studies identified a lack of understanding and expertise about ADHD among health providers as a negative influence on the process of diagnosis and treatment for children with ADHD ( Honorio Neto et al, 2021 ; O’Dell et al, 2022 ). Primary care clinicians reported a lack of knowledge and confidence to effectively manage and provide comprehensive care for children with ADHD ( O’Dell et al, 2022 ). While pediatricians were able to screen for ADHD, they often lacked the level of expertise necessary for diagnosing and treating children ( Honorio Neto et al, 2021 ).…”

“…Clinician Level of Expertise. Two studies identified a lack of understanding and expertise about ADHD among health providers as a negative influence on the process of diagnosis and treatment for children with ADHD (Honorio Neto et al, 2021;O'Dell et al, 2022). Primary care clinicians reported a lack of knowledge and confidence to effectively manage and provide comprehensive care for children with ADHD (O'Dell et al, 2022).…”