Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Abstract

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Keywords: Attention deficit hyperactivity disorder; Treatment engagement; Barriers; Interventions; Children; Adolescents

Core Tip: Assessment of families’ motivation for care at treatment initiation and recurrently over the course of treatment, especially during times of increasing stress and declining functioning, is essential to promote sustained engagement. Aspects of motivation that predict sustained engagement include desire and readiness for care, treatment preferences, self-efficacy to access and implement the selected treatment and perceived barriers to the treatment. Integrating services into trusted medical settings to reduce stigma, telehealth to reduce the burden of care, shared decision making to promote autonomy, psychoeducation about treatment options and how attention deficit hyperactivity disorder impacts current functioning and motivational interviewing can be employed to promote engagement.