While historically perceived as a childhood disorder, ADHD is now recognised as persisting into adulthood, with pooled prevalence estimates at approximately 2.5% (Simon et al., Reference Simon, Czobor, Balint, Meszaros and Bitter2009).

In Ireland, awareness of adult ADHD has grown in recent years, leading to the development of the National Clinical Programme for ADHD in Adults (NCPAA). However, service provision remains fragmented, with six of nine Community Health Organizations (CHOs) funded to provide specialised ADHD care (HSE National Clinical Programme, 2021). Recent popularisation in the media has further driven number of referrals to overburdened mental health services, increasing the gap between demand and capacity (Finn Reference Finn2023).

This audit evaluates and seeks to improve the efficiency of referral pathways for adult ADHD within a secondary care setting. Specifically, it examines the referral process from general practitioners (GPs) to secondary mental health services and onward to specialist ADHD services, comparing current referral practices with national standards.

This audit was conducted as a clinical audit within an Adult Mental Health Service (AMHS) in Sligo, Ireland. Evaluation of efficiency of referral pathways for adult ADHD was carried out by analysing referral patterns, adherence to national guidelines, and the impact of targeted interventions designed to improve service delivery. A two-cycle audit was employed over a period of six months, with each cycle spanning three months. Following initial cycle, targeted interventions were implemented in March 2023. This included clinician training emphasising the Diagnostic Interview for ADHD in Adults (DIVA) diagnostic criteria as per the NCPAA. Integration of the Autism Spectrum Disorder (ASD) screening tool, was done to inform assessment as it may present with similar symptoms and to increase awareness about ASD which could co-occur with ADHD.

The training intervention was provided to clinicians carrying out initial assessments in the AMHS. All members trained were also part of the Multidisciplinary Team (MDT) involved in the screening of referrals received from GPs, which included ADHD referrals. In this audit, a clinical nurse specialist (CNS) along with a psychiatric registrar were carrying out adult ADHD assessments.

Additional data on referral quality were collected during the second cycle, including the referrals returned to GPs for further information and the reasons for these returns. Following this, an opportunistic standardised template was introduced to ensure GPs provided essential details, including symptom descriptions and functional impairment in line with the referral criteria provided in the NCPAA.

A total of 36 referrals were received in both cycles (16 in the first, 20 in the second). The majority of referrals n = 23 (64%) was from individuals aged 18–34 years, with nearly equal distribution of male n = 19 (53%) and female n = 17 (47%) referrals (Table 1).

Table 1. Referral patterns and outcomes (first cycle: Dec 2022–Feb 2023)

Following the introduction of clinician training and pre-assessment screening review of referrals, referral patterns showed the following changes. A total of 20 referrals were received during this period, marking an increase in total referral volume. A total of n = 9 (45%) of referrals were returned to GPs for additional information, compared to none in the first cycle. (see Table 2). A total of n = 11 (55%) of referrals were accepted for initial assessment.

Table 2. Referrals returned to GPs and reasons following intervention in cycle 2

Referral outcomes for the repeat audit cycle are illustrated in Table 3.

Table 3. Referral patterns and outcomes (second cycle: Mar 2023–May 2023)

In this audit, interventions were carried out which are well supported by the literature. Primarily, a CNS along with a psychiatric registrar were carrying out assessments. The role of the CNS in the model of care has been supported in the Dundee study (Coghill et al., Reference Coghill, Seth and Crimlisk2015; Mangle et al., Reference Mangle, Phillips, Pitts and Laver-Bradbury2014).

A major part of the intervention was training of clinical staff involved in the assessment process. This also included a pre-assessment process, where referrals were reviewed. The NCPAA guidance states GPs should refer both adults with previous diagnosis of ADHD and without previous diagnosis of ADHD, who present with current symptoms contributing impairment of at least moderate severity (HSE National Clinical Programme, 2021). Clinical staff received training with the DIVA and were also familiarised with the referral criteria set by the NCPAA. The NCPAA tasks AMHS to assess and treat mental illness, as it may accompany or mimic ADHD symptoms. It further requires administration of ADHD screening tools, Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS). An overall clinical impression incorporating psychiatric assessment with possible ADHD and screening tool results is made by treating consultant prompting further referral if indicated (HSE National Clinical Programme, 2021). The literature has extensively highlighted the need for further training and increasing expertise and knowledge of staff with regard to ADHD assessments (Asherson et al., Reference Asherson, Leaver, Adamou, Arif, Askey and Butler2022; Kooij et al., Reference Kooij, Bijlenga, Salerno, Jaeschke, Bitter and Balázs2019).

It was observed that referrals returned to GPs increased from n = 0/16 (0%) in Cycle 1 to n = 9/20 (45%) in Cycle 2. To examine significance, data were analysed using Fisher’s exact test, as it is appropriate for small sample sizes with expected frequencies below five. This difference was found to be statistically significant, p = 0.002. However, the small sample size limits generalisability, and findings should be considered preliminary. This finding may also reflect an increase in the knowledge of staff contributing towards increased screening quality. Majority of referrals returned did not contain sufficient information. Some referrals were returned for further information regarding comorbidities and diagnostic clarity. A template letter requesting further information to process referral was sent, this included the core symptoms of adult ADHD, age of onset and impact on functionality, in line with the NCPAA. The rationale for this was to promote knowledge sharing among stakeholders, as GPs are primary gatekeepers for adult ADHD as well as to increase awareness regarding the referral criteria. No re-referral for any of the returned referrals were received during this audit cycle. Uncertainty among GPs as referrers and lack of familiarity regarding ADHD has been demonstrated in cross sectional study and case note reviews (Adamis et al., Reference Adamis, Tatlow-Golden, Gavin and McNicholas2019; Tatlow-Golden et al., Reference Tatlow-Golden, Prihodova, Gavin, Cullen and McNicholas2016).

In view of familiarising GPs with adult ADHD, as part of this intervention, a template including the referral criteria outlined by the NCPAA, was attached with a request for further information. It was hoped that this would encourage better assessments and promote training among GPs as primary gatekeepers in ADHD (Tatlow-Golden et al., Reference Tatlow-Golden, Prihodova, Gavin, Cullen and McNicholas2016). This may also enhance communication between services, as clarity regarding referral pathways as well as sharing of information in mental health services can affect efficiency (Hall et al., Reference Hall, Newell, Taylor, Sayal and Hollis2015).

There was a greater distribution of referrals in the second cycle, where there was only a total of n = 3 (27%) referrals to tertiary ADHD service. A total of n = 4 (37%) was accepted for non-ADHD mental health needs and a further n = 2 (18%) needed further assessment to ascertain outcome. This may reflect increased diligence among staff in completing assessments for possible ADHD.

It is noted that only n = 2 (13%) in the first cycle, and n = 4 (37%) in the second cycle were accepted by AMHS for non-ADHD mental health needs. This highlights a low rate as compared to a higher rate of comorbidity anticipated, prompting involvement of AMHS in the model of care as per the NCPAA. As this is a small sample, it requires further exploration in future studies.

This audit highlights the need for increased training among clinical staff involved in the pathway of care for adult ADHD, particularly GPs and AMHS. Given the small sample size in this audit, further audit of AMHS providing ADHD assessments is required to ascertain the quality of referrals received. The implementation of ASD screening tool was useful in formulating a comprehensive management plan for patients. By adopting evidence-based interventions and optimising care models, healthcare systems can ensure that individuals with ADHD receive timely, accurate, and effective care.