Introduction
Attention deficit hyperactivity disorder (ADHD) is a neurocognitive lifespan condition distinguished by persistent presentation of impulsivity, hyperactivity and/or inattentiveness, combined with functional impairments in at least two of the following domains: relationships, education, ability to carry out daily activities, and work (American Psychiatric Association, 2013; Sibley et al. Reference Sibley, Mitchell and Becker2016; Di Lorenzo et al. Reference Di Lorenzo, Balducci, Poppi, Arcolin, Cutino, Ferri, D.’Amico and Filippini2021). The estimated global prevalence of adult ADHD is 3% (Ayano et al. Reference Ayano, Tsegay, Gizachew, Necho, Yohannes, Abraha, Sileshi, Anbesaw and Alati2023), with approximately 150,000 adults likely meeting diagnostic criteria in Ireland (Seery & Bramham, Reference Seery and Bramham2024). Despite the growing recognition of adult ADHD, diagnosis and treatment rates across Europe remain low, highlighting the need for more effective service provision (Kooij et al. Reference Kooij, Bijlenga, Salerno, Jaeschke, Bitter, Balazs, Thome, Dom, Kasper, Filipe and Stes2019; Raaj et al. Reference Raaj, Wrigley and Farrelly2024).
The importance of efficient diagnostic and treatment pathways is emphasised by the personal and societal cost of adult ADHD (Doshi et al. Reference Doshi, Hodgkins, Kahle, Sikirica, Cangelosi, Setyawan, Erder and Neumann2012; Daley et al. Reference Daley, Jacobsen, Lange, Sørensen and Walldorf2019). Adults with ADHD face significant challenges in the areas of health, relationships, education, and employment (Shaw et al. Reference Shaw, Hodgkins, Caci, Young, Kahle, Woods and Arnold2012; Uchida et al. Reference Uchida, Spencer, Faraone and Biederman2018), with increased instances of homelessness, criminality, substance abuse, and mortality (Lee et al. Reference Lee, Humphreys, Flory, Liu and Glass2011; Dalsgaard et al. Reference Dalsgaard, Østergaard, Leckman, Mortensen and Pedersen2015; Young et al. Reference Young, Moss, Sedgwick, Fridman and Hodgkins2015; Garcia-Murillo et al. Reference Garcia-Murillo, Ramos-Olazagasti, Mannuzza, Castellanos and Klein2016). Similar to international findings (Babinski et al. Reference Babinski, Neely, Ba and Liu2020; Fuller-Thomson et al. Reference Fuller-Thomson, Rivière, Carrique and Agbeyaka2022), a survey of 136 Irish adults with ADHD suggested heightened risk of suicide, reporting that 20% previously attempted suicide, 61% experienced suicidal ideation, and 50% engaged in self-harm (Bramham et al. Reference Bramham, Seery, Murphy, Kilbride, O’Riordan and Wrigley2022). Untreated adult ADHD carries an estimated annual socio-economic cost of €1.8 billion in Ireland, with increased public expenditure in healthcare, social care, and unemployment benefits (Daley et al. Reference Daley, Jacobsen, Lange, Sørensen and Walldorf2014; Reference Daley, Jacobsen, Lange, Sørensen and Walldorf2019; HSE, 2021; Kilbride, Reference Kilbride2023). The positive impact of receiving a diagnosis on daily functioning, quality of life, and self-esteem combined with the socioeconomic cost of unrecognised ADHD highlights the importance of timely assessment (Young et al. Reference Young, Bramham, Gray and Rose2008; Agarwal et al. Reference Agarwal, Goldenberg, Perry and Ishak2012; Fleischmann & Fleischmann, Reference Fleischmann and Fleischmann2012; Matheson et al. Reference Matheson, Asherson, Wong, Hodgkins, Setyawan, Sasane and Clifford2013; Harpin et al. Reference Harpin, Mazzone, Raynaud, Kahle and Hodgkins2016).
Demand for adult ADHD services
There has been an unprecedented demand for adult ADHD assessment due to reduced stigma arising from the neurodiversity movement, social media, increased public awareness, decades of unmet need in the adult population arising from recent understanding of ADHD as a lifespan disorder, and COVID-19 related service disruptions (Dwyer, Reference Dwyer2022; Hartnett & Cummings, Reference Hartnett and Cummings2023; Rogers & McClean, Reference Rogers and MacLean2023). The UK ADHD Foundation has reported a 400% post-pandemic increase in adult help seeking (Topping, Reference Topping2023). Similarly, in Ireland, there has been increased reporting of adult ADHD within community mental health teams (CMHTs) (Adamis et al. Reference Adamis, Graffeo, Kumar, Meagher, O’Neill, Mulligan, Murthy, O’Mahony, McCarthy, Gavin and McNicholas2018; Gavin & McNicholas, Reference Gavin and McNicholas2018; Raaj et al. Reference Raaj, Wrigley and Farrelly2024).
Current Irish service provision
In response to increasing demand and lack of specialist public services, the National Clinical Programme for Adult ADHD (NCPAA) was established in Ireland in 2017 and formally launched in 2021 (HSE, 2021). The NCPAA recommends a model of care aligning with NICE (2018) evidence-based guidelines, proposing that assessment and treatment should be delivered by specialist services with ADHD-related expertise (NICE, 2018; Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022).
In 2022, €1.3 million was provided by the Department of Health to set up adult ADHD services in three pilot sites within HSE Community Healthcare Organisation (CHO) 1 which serves Sligo, Donegal, and Leitrim, CHO3 which serves Limerick, North Tipperary, and Clare, and CHO6 which serves Dublin South East, Dun Laoghaire, and Wicklow (HSE, 2021). Four additional ADHD teams were funded in 2022, with plans to allocate funding for the development of two further teams in 2024 (HSE, 2023). The NCPAA outlines a referral pathway to specialist adult ADHD teams for young adults transitioning from child and adolescent mental health services (CAMHS) requiring ongoing ADHD treatment, adults attending CMHTs for treatment of other mental health conditions where ADHD is also suspected, and adults with suspected ADHD referred by general practitioners (GPs) who are not receiving treatment for another condition (HSE, 2021). Given the rise in primary care referrals for adult ADHD (Raaj et al. Reference Raaj, Wrigley and Farrelly2024), this research will focus on the GP referral pathway whereby adults are referred by their GP to CMHTs for an initial ADHD screening and treatment for comorbid mental health conditions, before referral to specialist ADHD teams for assessment and treatment (HSE, 2021).
Barriers to effective service provision
Although progress has been made in Irish adult ADHD service provision, the current referral process is impeded by lengthy wait times, lack of nationwide availability and limited accessibility (Raaj et al. Reference Raaj, Wrigley and Farrelly2024). These barriers to treatment access highlight the need to evaluate current service provision. Supports provided by ADHD Ireland in collaboration with University College Dublin and the NCPAA, such as the Adult ADHD app and the Understanding and Managing Adult ADHD Programme (UMAAP) have helped provide information and low intensity interventions for ADHD (Raaj et al. Reference Raaj, Wrigley and Farrelly2024; Seery et al. Reference Seery, Leonard-Curtin, Naismith, King, Kilbride, Wrigley, Boyd, McHugh and Bramham2023). While they have provided psychoeducation and online group Acceptance and Commitment Therapy informed intervention (UMAAP) to service users (Raaj et al. Reference Raaj, Wrigley and Farrelly2024; Seery et al. Reference Seery, Leonard-Curtin, Naismith, King, Kilbride, Wrigley, Boyd, McHugh and Bramham2023), it is beyond their scope to provide diagnostic assessment or to address the needs of individuals with more severe functional impairment.
The GP referral pathway structure may also be a barrier for effective service provision. This referral pathway in which CMHTs screen for ADHD and comorbid mental illness was devised by the NCPAA and was informed by the high comorbidity rates in the research literature reporting up to 90% comorbidity between adult ADHD and mental health conditions such as anxiety, depression, bipolar disorder, substance abuse disorders, personality disorder, and autism (Charach et al. Reference Charach, Yeung, Climans and Lillie2011; Chen et al. Reference Chen, Hsu, Huang, Bai, Ko, Su, Li, Lin, Tsai, Pan and Chang2018; Hollingdale et al. Reference Hollingdale, Woodhouse, Young, Fridman and Mandy2020). However, there are concerns that this pathway structure is unduly impacting the workload of CMHTs, with anecdotal information from some CMHTs reporting that adults with suspected ADHD constitute up to one third of referrals received by CMHTs operating in regions with access to specialist adult ADHD teams. Despite high comorbidity, ADHD can be an independent diagnosis which suggests that the current pathway is not the most efficient structure for service provision (Katzman et al. Reference Katzman, Bilkey, Chokka, Fallu and Klassen2017). NICE (2018) guidelines recommend a shared care agreement to ease pressure on secondary and tertiary services, in which GPs take responsibility for the routine monitoring of adult ADHD. At present there is no statutory framework for shared care agreements between primary and secondary mental healthcare services in Ireland, although there are examples of shared care across other healthcare settings such as the Chronic Disease Management Programme (HSE, 2019). Despite the key role of GPs as gatekeepers referring individuals to CMHTs for initial ADHD screening, many GPs express reluctance in further involvement due to a reported lack of confidence in recognising ADHD and insufficient training in ADHD treatment. (French et al. Reference French, Perez Vallejos, Sayal and Daley2020). Lack of ADHD-related training can result in underdiagnosis or misdiagnosis, delaying the referral process and limiting treatment access (Sayal et al. Reference Sayal, Taylor, Beecham and Byrne2002; French et al. Reference French, Sayal and Daley2019).
Study aims and objectives
The NCPAA’s model of care recognises the importance of evaluating current referral pathways to ensure effective and efficient service provision (HSE, 2021).This study aims to evaluate the GP referral pathway for adult ADHD to improve understanding of the existing service model and determine the effectiveness and efficiency of this pathway, and workload for CMHTs. This research has three main objectives: (a) To quantify GP referrals to CMHTs for the screening of adult ADHD, (b) to measure the workload on CMHTs related to screening adult ADHD referrals without additional comorbid mental health problems, and (c) to quantify access to adult ADHD screening through CMHTs and subsequent access to assessment and treatment through the specialist adult ADHD teams.
Methods
Design
This study adopted an observational cohort design to retrospectively analyse referral data from January to December 2023.
Setting
Data collection occurred in hospital and clinic settings from which adult CMHTs and specialist ADHD teams operate across HSE Community Healthcare Organisations CHO1 (Sligo, Donegal/Leitrim/West Cavan), CHO3 (Limerick, Clare, North Tipperary), and CHO6 (Wicklow, Dun Laoghaire, Dublin South).
Participants
No participants were involved as the study was focussed on collecting referral frequency data. Referral data of 667 adults were collected from 11 CMHTs. Referral data from 1218 adults were collected from adult ADHD teams.
Materials
Digital data collection forms were created for CMHTs. This form required completion of the number of adult ADHD referrals received by the CMHT, the number of ADHD referrals seen by the CMHT, the number of referrals seen that required initial treatment for another mental health problem, and the number of direct referrals made to the specialist adult ADHD teams.
Data collection forms were also created for specialist adult ADHD teams. This form required completion of the number of referrals received from CMHTs, the number of referrals seen, and the number of referrals that fulfilled the diagnostic criteria for adult ADHD.
Procedure
Lead consultant psychiatrists of adult ADHD services in CHO1, CHO3, and CHO6 were contacted with an invitation to participate in this study. A presentation was delivered at weekly academic meetings of non-consultant hospital doctors (NCHDs) working with CMHTS to provide information about the study and encourage participation in data collection.
NCHDs who indicated interest were provided with data collection forms via email for completion with referral frequency data for the 12 month period from January to December 2023. NCHDs from 11 of 37 CMHTs participated in data collection; including one team in CHO1, four teams in CHO3, and six teams in CHO6 (see Table 1).
Table 1. CMHT information for CHO1, CHO3, and CHO6
CMHT, Community Mental Health Team; CHO, Community Healthcare Organisation.
The researcher liaised with NCHDs throughout data collection to limit bias and prevent misinterpretation of the data collection form. With support from CMHT administrators, NCHDs aggregated referral data in the form of frequency counts from existing records. Completed data collection forms were returned to the researcher by email.
Administrators from specialist adult ADHD teams in CHO1, CHO3, and CHO6 were contacted. Each administrator collated 2023 referral data using the data collection form provided, and returned the aggregated data to the researcher. All collected referral data were compiled in an excel spreadsheet and stored securely on a password protected Google Drive.
Analytic procedure
Data were analysed using IBM’s SPSS software, version 28. Descriptive statistics were produced to analyse the 2023 referral data for CMHTs and adult ADHD teams.
Results
Referral frequency data from January to December 2023 are outlined for involved CMHTs, followed by specialist ADHD teams. This data quantifies GP referrals received by CMHTs, measures workload placed on CMHTs by ADHD screening, and quantifies access to CMHTs and ADHD teams.
Adult CMHTs
11 of 37 CMHTs participated in the study. Table 2 displays ADHD-related clinical activity of the CMHTs for 2023.
Table 2. 2023 ADHD-related clinical activity for 11 CMHTs located across CHO1, CHO3, and CHO6
ADHD, Attention Deficit Hyperactivity Disorder; CMHT, Community Mental Health Team; CHO, Community Healthcare Organisation.
Direct referrals to ADHD teams were referrals with suspected ADHD who did not require CMHT input after initial screening.
The data in Table 2 quantifies GP referrals to CMHTs, showing high variability in the number of GP referrals for adult ADHD received by the CMHTs, range: 14–122.
There was high variability in the number of ADHD-related referrals seen by the CMHTs, range: 9–82. Due to differences between teams regarding staffing and catchment area size, it is not useful to provide means for referral rates and appointment frequencies. Statistical comparisons would not be meaningful.
Table 2 also addresses CMHT workload related to screening adult ADHD referrals without additional significant mental health conditions. Of 304 adult ADHD referrals seen, 77 (25.3%) required initial treatment for another mental health condition, meaning that 74.7% of the referrals seen only required initial screening from CMHTs without any other intervention.
Specialist adult ADHD teams
The adult ADHD teams in CHO1, CHO3, and CHO6 participated in the study. Table 3 displays the clinical activity of each team for the twelve month period from January to December 2023, providing information on access to specialist ADHD teams for assessment and treatment.
Table 3. Catchment area, NCPAA recommendations for clinical staffing, availability of clinical staff, and 2023 clinical activity for specialist adult ADHD teams in CHO1, CHO3, and CHO6
NCPAA, National Clinical Programme for ADHD in Adults; ADHD, Attention Deficit Hyperactivity Disorder; CHO, Community Healthcare Organisation; WTE, Whole Time Equivalent.
Referrals received include those from all 37 CMHTs. Referrals received include GP referrals and transition referrals from CAMHS.
Data in Table 3 displays the number of referrals received by each adult ADHD team which were between 3–4 times in excess of the numbers of referrals seen during the study’s 12-month timeframe.
Discussion
This study evaluated the NCPAA’s GP referral pathway via CMHTs to determine access to care and the pathway’s impact on CMHTs through the collection of ADHD-related clinical activity in 2023 from eleven CMHTS and three specialist adult ADHD teams.
GP referrals to CMHTs
The first objective of this study was to quantify GP referrals to CMHTs. The results revealed substantial differences in the number of GP referrals to CMHTs, ranging from 14 to 122. Some variability may be attributed to catchment area (Price et al. Reference Price, Ford, Janssens, Williams and Newlove-Delgado2020), and overall workload faced by GPs making it difficult to set time aside for screening and referral (Tatlow-Golden et al. Reference Tatlow-Golden, Prihodova, Gavin, Cullen and McNicholas2016). However, it is also important to consider variability in ADHD-specific training received by GPs (Tatlow-Golden et al. Reference Tatlow-Golden, Prihodova, Gavin, Cullen and McNicholas2016; French et al. Reference French, Sayal and Daley2019). French and colleagues (Reference French, Perez Vallejos, Sayal and Daley2020) reported a commonly experienced lack of confidence by GPs in recognising ADHD symptoms and explaining the referral pathway.
To address this variability and improve service user experience, expert advisor groups such as the UK Adult ADHD Network (Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022) have recommended the incorporation of more comprehensive neurodiversity training into medical training programmes and have proposed the establishment of training hubs to facilitate accredited training in adult ADHD assessment and management for clinicians to ensure a specialist level of knowledge is achieved. This could broaden the scope of clinical expertise in adult ADHD and lessen pressure on secondary mental health and specialist services. Provision of such training and adequate resourcing for both training and clinical delivery has applicability for GP-led ADHD medication prescribing and physical health monitoring supported by annual reviews by specialist ADHD teams. Since the beginning of this study in July 2023, a new project led by the NCPAA and ADHD Ireland has commenced to consider how a primary care component can be integrated into the current adult ADHD referral pathway to provide a more integrated, stepped approach to assessment and treatment (Niazi & Kilbride, Reference Niazi and Kilbride2023). Currently, the GP’s role is limited to initial referral to CMHTs (HSE, 2021) as well as prescribing maintenance ADHD medication supported by specialist service annual review. However, shared management of ADHD with increased primary care involvement in managing less complex cases, combined with additional resources and training, could be important in meeting the demand for adult ADHD services (NICE, 2018; Young et al. Reference Young, Asherson, Lloyd, Absoud, Arif and Colley2021; Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022; Smith et al. Reference Smith, Mukherjee, Müller-Sedgwick, Hank, Carpenter and Adamou2023). To facilitate this, additional resources are needed for clinical delivery and provision of training (in primary and secondary healthcare settings) in assessment of ADHD as well as prescribing and physical health monitoring of patients who are prescribed medication for ADHD. (French et al. Reference French, Perez Vallejos, Sayal and Daley2020; Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022).
Proposed service models by the Scottish National Autism Implementation Team (2021) and Johnson (Reference Johnson2024) stratify ADHD treatment according to different levels of need, with case complexity, risk and the degree of functional impairment being factors more likely to require specialist rather than primary care management, similar to service provision for common mental health disorders.
Additional CMHT workload
The second research objective was to measure CMHT workload related to screening adult ADHD referrals without comorbid illness. The current referral pathway involving initial CMHT screening was devised based on studies reporting high comorbidity rates of up to 90% between ADHD and other mental health conditions (Charach et al. Reference Charach, Yeung, Climans and Lillie2011; Chen et al. Reference Chen, Hsu, Huang, Bai, Ko, Su, Li, Lin, Tsai, Pan and Chang2018; Hollingdale et al. Reference Hollingdale, Woodhouse, Young, Fridman and Mandy2020; Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022). However, the results of this study indicated that 75% of ADHD referrals did not need initial treatment for a significant comorbid mental health condition, suggesting that CMHT involvement in the referral pathway may be less crucial than expected for non-complex cases. Adult ADHD can exist without comorbidities and cases are not always complex enough to warrant secondary mental health or specialist intervention (Katzman et al. Reference Katzman, Bilkey, Chokka, Fallu and Klassen2017; Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022). This study suggests that comorbidity between ADHD and other mental health problems may be at similar rates to those referenced in previous literature but may not meet the severity threshold for intervention by secondary mental health services (Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022). It is also possible that the lower comorbidity rate may reflect milder ADHD severity.
The outcome from this finding suggests that it is not appropriate for all GP referrals for ADHD to be seen initially by CMHTs. This finding suggests that it may be beneficial to consider revisions to the current model of care, such as implementing a direct referral pathway from GPs to specialist teams for cases meeting criteria for moderate to severe ADHD and significant functional impairment without evidence of moderate to severe mental illness. Further work is required in establishing clear triaging criteria based on functional impairment, and allocating resources to facilitate this. The time commitment and administrative demands posed by this referral pathway is an important consideration for GPs and specialist adult ADHD teams. Implementation of this referral pathway would need adequate training and resourcing for GPs and specialist services as otherwise it would risk further compounding the current high demand and waitlists for adult ADHD services currently in operation in Ireland. This referral pathway is currently being piloted in a recently developed regional specialist adult ADHD team and needs further time to evaluate its utility.
Access to CMHTs and adult ADHD teams
The final research objective was to quantify access to CMHTs for screening adult ADHD and access to specialist adult ADHD teams for assessment and treatment. The results found substantial variability in how CMHTs dealt with ADHD referrals, with referrals seen ranging from 9 to 82. While the reason behind this variability is not obvious from the data, various possibilities could be considered. Some CMHTs have had to limit the number of ADHD-related GP referrals they accept due to the volume of post-pandemic referrals (Griffin, Reference Griffin2024). Limited capacity to deal with ADHD referrals could potentially result in these referrals being declined by CMHTs, missing opportunity for assessment. Teams may be overwhelmed by referrals for other mental health conditions, which are not included in this data. The NCPAA was initially based on pre-pandemic demand (ISHA, 2021). When officially launched in 2021, CMHTs were dealing with back-logs created by service disruptions during COVID-19 and a surge of ADHD referrals which substantially surpassed pre-pandemic estimates (ISHA, 2021; Griffin, Reference Griffin2024). Staffing issues due to the HSE recruitment freeze have likely also contributed to the back-log of referrals (Griffin, Reference Griffin2024). The variability suggests that CMHT involvement in the GP referral pathway is not consistently improving service user experience, supporting the need to reconsider current pathway structure.
The findings revealed limited access to specialist ADHD teams, with teams receiving three times more referrals in 2023 than they were able to see. This can be explained by high demand for assessments and time spent by teams delivering assessments and managing complex cases (Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022). While specialist teams are important for appropriately targeting adult ADHD treatment, reliance on them as sole providers of public assessment and treatment can cause overwhelm and prohibit efficient service access (Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022). Based on these findings, it seems that adult ADHD teams are overwhelmed by demand, providing further support for reconsidering stakeholder roles within the referral pathway. NICE (2018) guidelines address the potential for GPs to support ADHD teams by undertaking routine medication prescription and physical check-ups, with sufficient training and resources.
Increased primary care involvement
Asherson and colleagues (Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022) suggest that increased GP involvement would help to facilitate national availability by increasing the capacity of ADHD teams to efficiently move through waitlists. In line with these recommendations, a Dutch collaborative programme for childhood ADHD was trialled in which trained GPs prescribed medication and monitored treatment (Hassink-Franke et al. Reference Hassink-Franke, Janssen, Oehlen, van Deurzen, Buitelaar, Wensing and Lucassen2016). GPs reported positive experiences, with greater confidence prescribing medication following training (Hassink-Franke et al. Reference Hassink-Franke, Janssen, Oehlen, van Deurzen, Buitelaar, Wensing and Lucassen2016). This highlights the potential for a more collaborative approach to adult ADHD service provision in Ireland. Similar to anxiety and depression management, Asherson and colleagues (Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022) propose mainstreaming adult ADHD into primary care services as a long-term treatment management, aligning with this study’s suggestions to include GPs in non-complex case management. Primary care services require additional resources to facilitate training, additional workload, and staffing required to assess and monitor ADHD (French et al. Reference French, Perez Vallejos, Sayal and Daley2020).
Integrated stepped care approach
While there may be no optimal solution for service provision, a more integrated stepped care approach with flow and flexibility between levels would support a more balanced workload between stakeholders and facilitate different levels of need. Appropriate training, resourcing, collaborative stakeholder relationships, and a clear service model are needed for this to be successful (French et al. Reference French, Perez Vallejos, Sayal and Daley2020).
Service augmentations remain important. Supports such as the Adult ADHD App and UMAAP, can be utilised to signpost adults to supports and provide psychoeducation for less complex cases of ADHD, easing pressure on primary, secondary and specialist services (Raaj et al. Reference Raaj, Wrigley and Farrelly2024; Seery et al. Reference Seery, Leonard-Curtin, Naismith, King, Kilbride, Wrigley, Boyd, McHugh and Bramham2023). Further resourcing for student health services would also allow students to access non-medical supports while waiting for an assessment to minimise the impact of ADHD-related challenges on educational performance (Asherson et al. Reference Asherson, Leaver, Adamou, Arif, Askey, Butler, Cubbin, Newlove-Delgado, Kustow, Lanham-Cook and Findlay2022).
The Darzi (Reference Darzi2024) report on the UK National Health Service reviews waiting times for specialist adult ADHD services, highlighting difficulties with increasing demand, lengthening wait times, and the cumulative impact on resources posed by annual review appointments. The report considers the challenges of identifying which groups should be prioritised by specialist adult ADHD services with limited resources. Delineation of priority groups is likely to be challenging in decision making around which groups are most likely to benefit from timely assessment and treatment. Suggested priority groups have included groups such as CAMHS transfers of care with ADHD to ensure continuing access to treatment, or young adults as they are at an important developmental life stage. Other suggested priority groups include women due to reported under recognition of ADHD (Boyd et al. Reference Boyd, Wrigley, Kilbride, Mulligan and Bramham2024; Young et al. Reference Young, Adamo, Ásgeirsdóttir, Branney, Beckett and Colley2020), or all referrals regardless of age/gender which are suggestive of significant functional impairment from ADHD. With current finite resources, pragmatic decisions may be needed around the remit of specialist services and the population most in need of such services.
Limitations
The limitations of this study are recognised. Referral data collected from the CMHTs and ADHD teams consisted of ADHD-related clinical activity for 2023 only. The limited scope of this data meant that the number of referrals received and seen did not necessarily map onto one another. For example, it was possible for a referral received in 2022 to be seen in 2023. As a recommendation for future research, a multi-year study may provide a more complete picture of an individual’s journey towards assessment. Data did not include referrals accepted by specialist teams, which can vary depending on the acceptance criteria of each service. Limiting the referral data collected to ADHD-related clinical activity made data collection more feasible and promoted data return. However, collecting information about CMHT staffing, waiting times, and clinical activity related to other mental health conditions would have been beneficial in further explaining the variability within CMHT data. It was not possible to collect referral data for all CMHTs due to limited resources within the services. While there is representation for each pilot area, lower representation from CMHTs in CHO1 and CHO3 is a limitation. Risk of unintentional bias during data collection was identified, given that the data were collected by different individuals and that different services store data electronically or using paper records. For quality control, standardised data collection forms were distributed and the researcher regularly liaised with data collectors to ensure consistency. There is variability in the number of CAMHS transfers seen by specialist ADHD teams, increasing the diagnostic rates in some cases. For future research, it would be beneficial to obtain access to data delineating the source of referrals.
Implications
This study makes a unique contribution to existing literature by presenting national level data about ADHD-related clinical activity, allowing for evaluation of the referral pathway for adult ADHD. This is the only study to date which formally evaluated the referral pathway proposed by the NCPAA and collected referral data to determine availability and efficiency of Irish public adult ADHD services. The findings have important clinical implications, highlighting the lack of service accessibility for adults seeking ADHD assessment, and current bottlenecks at the CMHTs and specialist services within the referral process. This research suggests improvements to service provision to increase efficiency for service users and clinicians, and cost-effectiveness for the HSE.
Financial support
This study was supported by Saint John of God Research Foundation (Seed Funding grant: ID-821).
Competing interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The study protocol was approved by the ethics committees of Saint John of God Hospitaller Services Group, Sligo University Hospital, University Hospital Limerick, and University College Dublin. Procedures contributing to this research comply with the ethical standards of these committees.
Open access
