Attention-deficit/hyperactivity disorder (ADHD) affects around 5 percent of children and 2-3 percent of adults.1,2 Although the population level of ADHD has not changed over time, its definition has evolved. Also, public and professional awareness of ADHD has increased. These factors, coupled with historical underrecognition, mean that many countries are witnessing huge increases in referral rates for ADHD assessment and treatment.3,4 This is unsurprising given the greater scientific understanding of ADHD and its risks and the availability of highly effective treatments.5

This increase in ADHD referrals, however, means that where there is publicly funded health care provision, service capacity has not been able to match population need. This has led to deepening inequalities as those who can afford to do so will seek private health care.

Some countries (e.g., Australia) are beginning to shift to greater primary care involvement such that some specialist primary care staff now are trained to take on assessment and treatment. Other countries (e.g., United Kingdom) still rely on specialist care. Given how prevalent ADHD is, an exclusively secondary care, specialist service for ADHD is unsustainable.6 Primary care already plays a leading role in mental health care for common mental health conditions (e.g., anxiety and depression) in many countries. Also, primary care physicians are especially skilled at providing care across the lifespan and in managing physical as well as mental health. So, what are some of the barriers to greater primary care involvement for ADHD?

Key Barriers to Primary Care Involvement in ADHD Diagnosis and Management

A major concern is inadequate funding for primary care to take on a greater role. Also, staff may not be fully trained about ADHD or are left with the responsibility of highly complex individuals and encounter delays in accessing specialist support. This includes those who develop psychiatric comorbidities or are exposed to complex social adversities.

A second concern is that ADHD lies on a dimension, and to make a diagnosis currently requires a lengthy, detailed assessment that would not be feasible typically in routine primary care appointments.

Another concern is that stimulants are first-line medications for ADHD. Whilst highly effective, they are subject to misuse and diversion, which has been the experience in some countries. Guarding against this may be more challenging in primary care.

These challenges are not insurmountable, but they do require political and professional will to change. This includes prioritising funding and training in primary care for an enhanced role. Also, primary and specialist care services need to be well linked and seamless to allow rapid secondary assessment and consultation when needed. Furthermore, primary care needs to include a range of professionals beyond physicians alone (e.g., nurses, pharmacists, and nonpharmacological support such as psychology).

Research Priorities for Optimizing ADHD Care Pathways

Future research needs to examine how best to identify those most suitable for primary versus secondary care. Those with major comorbidities, who are suicidal, exposed to social adversities, or at high familial risk for severe mental illness (e.g., psychosis) are known to have worse outcomes, so they would likely be greater priorities for specialist services.

Other research, some of which is in progress, needs to evaluate the effectiveness of nonstimulants as first- rather than second-line treatment in primary care, as this would reduce risks of diversion in less supervised contexts.

Regardless, across nations, we need to shift our thinking around ADHD as a specialist condition that is rare and move to a model that is more accessible and sustainable but safe.