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      Practitioner Review: Pathways to care for ADHD – a systematic review of barriers and facilitators

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          Abstract

          Background

          Attention‐Deficit/Hyperactivity Disorder ( ADHD) is a common neurodevelopmental disorder starting in childhood that may persist into adulthood. It can be managed through carefully monitored medication and nonpharmacological interventions. Access to care for children at risk of ADHD varies both within and between countries. A systematic literature review was conducted to investigate the research evidence related to factors which influence children accessing services for ADHD.

          Method

          Studies investigating access to care for children at risk of ADHD were identified through electronic searches of the international peer‐reviewed and grey literature. Databases were searched from inception till 30th April 2012. This identified 23,156 articles which were subjected to three levels of screening (title, abstract and full text) by a minimum of two independent reviewers. Due to the heterogeneity in the study designs, a narrative approach was used to present the findings.

          Results

          Twenty‐seven papers met the inclusion criteria; these were grouped into four main themes, with some papers being included in more than one. These were wider determinants (10 papers); identification of need (9 papers); entry and continuity of care (13 papers) and interventions to improve access (4 papers). Barriers and facilitators to access were found to operate at the individual, organisational and societal level. Limited evidence of effective interventions to improve access was identified.

          Conclusion

          This review explored the multilayered obstacles in the pathway to care for children at risk of ADHD and the lack of evidence‐based interventions designed to address these issues, thereby indicating areas for service development and further evaluative research.

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          Most cited references27

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          The meaning of translational research and why it matters.

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            Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments.

            Nonpharmacological treatments are available for attention deficit hyperactivity disorder (ADHD), although their efficacy remains uncertain. The authors undertook meta-analyses of the efficacy of dietary (restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation) and psychological (cognitive training, neurofeedback, and behavioral interventions) ADHD treatments. Using a common systematic search and a rigorous coding and data extraction strategy across domains, the authors searched electronic databases to identify published randomized controlled trials that involved individuals who were diagnosed with ADHD (or who met a validated cutoff on a recognized rating scale) and that included an ADHD outcome. Fifty-four of the 2,904 nonduplicate screened records were included in the analyses. Two different analyses were performed. When the outcome measure was based on ADHD assessments by raters closest to the therapeutic setting, all dietary (standardized mean differences=0.21-0.48) and psychological (standardized mean differences=0.40-0.64) treatments produced statistically significant effects. However, when the best probably blinded assessment was employed, effects remained significant for free fatty acid supplementation (standardized mean difference=0.16) and artificial food color exclusion (standardized mean difference=0.42) but were substantially attenuated to nonsignificant levels for other treatments. Free fatty acid supplementation produced small but significant reductions in ADHD symptoms even with probably blinded assessments, although the clinical significance of these effects remains to be determined. Artificial food color exclusion produced larger effects but often in individuals selected for food sensitivities. Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms.
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              Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology.

              Part I of this paper traced the evolution of modern epidemiology in terms of three eras, each with its dominant paradigm, culminating in the present era of chronic disease epidemiology with its paradigm, the black box. This paper sees the close of the present era and foresees a new era of eco-epidemiology in which the deployment of a different paradigm will be crucial. Here a paradigm is advocated for the emergent era. Encompassing many levels of organization--molecular and societal as well as individual--this paradigm, termed Chinese boxes, aims to integrate more than a single level in design, analysis, and interpretation. Such a paradigm could sustain and refine a public health-oriented epidemiology. But preventing a decline of creative epidemiology in this new era will require more than a cogent scientific paradigm. Attention will have to be paid to the social processes that foster a cohesive and humane discipline.
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                Author and article information

                Journal
                J Child Psychol Psychiatry
                J Child Psychol Psychiatry
                10.1111/(ISSN)1469-7610
                JCPP
                Journal of Child Psychology and Psychiatry, and Allied Disciplines
                John Wiley and Sons Inc. (Hoboken )
                0021-9630
                1469-7610
                23 February 2015
                June 2015
                : 56
                : 6 ( doiID: 10.1111/jcpp.2015.56.issue-6 )
                : 598-617
                Affiliations
                [ 1 ] School of Health SciencesUniversity of Nottingham NottinghamUK
                [ 2 ] Specialist Services DirectorateNottinghamshire Healthcare NHS Trust NottinghamUK
                [ 3 ] School of Sociology and Social PolicyUniversity of Nottingham NottinghamUK
                [ 4 ] Division of PsychologyNottingham Trent University NottinghamUK
                [ 5 ] Division of Psychiatry and Applied PsychologySchool of Medicine University of Nottingham NottinghamUK
                [ 6 ] Child and Adolescent PsychiatryLincolnshire Partnership NHS Foundation Trust LincolnshireUK
                Author notes
                [*] [* ] Correspondence

                Nicola Wright, School of Health Sciences, Institute of Mental Health, University of Nottingham, Triumph Road, Nottingham NG7 2TU, UK; Email: nicola.wright@ 123456nottingham.ac.uk

                Article
                JCPP12398
                10.1111/jcpp.12398
                5008177
                25706049
                6b8f38c5-73dc-438e-baa3-468cdcdbdf6e
                © 2015 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

                This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Pages: 20
                Product
                Funding
                Funded by: National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Nottinghamshire
                Funded by: Derbyshire and Lincolnshire (NIHR CLAHRC‐NDL)
                Categories
                Practitioner Review
                Practitioner Review
                Custom metadata
                2.0
                jcpp12398
                June 2015
                Converter:WILEY_ML3GV2_TO_NLMPMC version:4.9.4 mode:remove_FC converted:01.09.2016

                Clinical Psychology & Psychiatry
                attention‐deficit disorder with hyperactivity,child,continuity of patient care,health service needs and demands,developmental disability

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