Attention-deficit hyperactivity disorder (ADHD): tackling health inequalities through inclusive pharmacy practice

As part of our ongoing series of articles focusing on equality, Aileen O’Hare and CPhO Clinical Fellow Amira Chaudry highlight the provision of pharmacy services to patients with ADHD, exploring its prevalence, the inequalities faced by patients when accessing services and treatments, the rise in adult diagnosis, ADHD medication shortages, and implications for pharmacy teams.

Edition
April 2024

What is ADHD? 

Attention-deficit hyperactivity disorder (ADHD) is a disorder marked by lifelong problems with inattention and/or hyperactivity-impulsivity, which can interfere with daily life, including impairing academic performance, work productivity, and relationships. Symptoms include impulsiveness, disorganisation, time management issues, difficulty focusing, and restlessness. Although these symptoms are often identified in childhood, there is a growing awareness that they can persist into adulthood and later life.

We engaged with ADHD UK to understand the challenges faced by people living with ADHD and in particular how pharmacy professionals could support patients with their medicines and pharmacy services.

Henry Shelford, Chief Executive of ADHD UK explains:

“Pharmacy teams can support people living with ADHD in several ways. 

“Individuals with ADHD are often very private about their, or their children’s condition. This can be to try to avoid being judged, stigmatised, or ostracised by those members of our community who don’t understand ADHD. Therefore, working to maintain confidentiality can be very important. Ensuring details of medication cannot be overheard and that medication is not visible to others can be very helpful.”

“People with ADHD can struggle with being still for queuing, planning their collection and organisation skills for any paperwork - which often goes unrecognised. Offering support around the collection – including reminders, longer appointments, and indications of likely shorter wait times, can be very helpful.”

Prevalence of ADHD

UK ADHD prevalence data from the Lancet and NICE give a childhood prevalence rate of 5% and an adult prevalence rate of 3-4%. That provides for a total estimate of 2.6 million people in the UK with ADHD (708,000 children and 1.9m adults). There is a male-to female ratio of approximately 3:1.

Among children, prevalence ratios are estimated at 2-5:1 with diagnosis being more common in boys. The gender gap may result from boys displaying disruptive behaviour more often, leading to referrals, while girls commonly display the inattentive subtype, possibly contributing to under-diagnosis. In adults, there is a male-to female ratio of approximately 3:1. 

See the NICE article on prevalence ratios

See the prevalence data from ADHD UK

Taking a multidisciplinary approach 

ADHD management requires a collaborative effort from healthcare professionals, including doctors, psychologists, and pharmacists. Pharmacists can contribute significantly to the care of ADHD patients by providing information, medicines counselling, and ensuring the safe and appropriate use of medications. 

See the the good practice guidelines from the Royal College of Psychiatrists

See how pharmacists can help as set out in this journal article

Equality guidance for pharmacies 

Our equality guidance for pharmacies promotes fairness and inclusivity in pharmacy services. This guidance emphasises the importance of delivering equitable care to all patients, irrespective of their background, ethnicity, gender, or socioeconomic status. Theme 2 of our EDI strategy supports the use of our standards to proactively help tackle discrimination and to make sure everyone can access person-centred care, fostering equality of health outcomes.

Equality guidance for pharmacies

GPhC EDI strategy

Health inequalities

Outcomes for individuals with ADHD are compromised by economic disadvantage, reduced family income and social class. In adults, it is more frequent in the unemployed and in people with disabilities. 

Health inequalities can impact ADHD patients' access to appropriate treatment and support. Individuals from disadvantaged backgrounds, traveller communities, or marginalised communities may face barriers in accessing healthcare services, including diagnosis, medication, and psychological interventions. 

It is crucial for pharmacies and healthcare providers to be aware of these disparities and proactively work towards reducing health inequalities by raising awareness and connecting with local community organisations. 

It is recognised in literature that there may be inequalities and challenges in the diagnosis and treatment of ADHD in ethnic minority populations. Factors such as cultural differences, language barriers and varying perceptions of mental health such as fear of social stigma, may contribute to these challenges. 

Children belonging to ethnic minority groups are less likely to receive diagnoses for ADHD and its co-morbid conditions such as learning disabilities and mental health issues. They are also less likely to be prescribed stimulant drug treatment and adhere to treatment compared to their non-minority peers. 

Research led by the University of Exeter, published in the British Journal of Psychiatry Open, has led to the first national map of ADHD service provision, based on responses to a survey completed by more than 2,600 respondents. The NIHR-funded research found huge variation in available care, patchy provision of dedicated ADHD services, and variation in the reports of services between people with ADHD, service users and health workers.

See the consensus statement on the failure of healthcare provision for ADHD in the UK

See the literature review of challenges in ADHD care for ethnic minority children

See the University of Exeter research and map

Diagnosis and self screening 

ADHD continues to be significantly under-diagnosed and under-treated in the UK. This hidden cost is then manifested in people being treated for anxiety and depression, eating disorders and even some with bipolar disorder, when in fact the underlying ADHD diagnosis is missed.

In response to the widely considered viewpoint that adult ADHD is under-diagnosed, meaning people with the condition are not getting the help they need, the World Health Organisation and the Workgroup on Adult ADHD have generated a screener survey.

The survey is designed to be completed by individuals on their own to give an indication of whether they might have ADHD and would therefore benefit from further clinical analysis. Only a clinician can accurately diagnose ADHD. Scoring 4 or above on this screening survey is a good indication that an individual would benefit from a clinical review.

You can also find information on diagnosis pathways for ADHD in children on the ADHD UK website.

Undiagnosed and unmanaged ADHD correlates with a range of poor health outcomes, such as high blood pressure, stroke, obesity, anxiety, depression, bipolar disorder, and addiction. Research cites significantly increased prevalence of self-harm and attempted suicide in the ADHD population.

Many individuals are now accessing private and independent healthcare services to avoid long wait times for an ADHD diagnosis. This potentially exacerbates healthcare disparities, especially considering the higher prevalence of ADHD in areas of deprivation. Those living in such areas might face financial barriers to accessing private healthcare, resulting in prolonged periods of undiagnosed and untreated ADHD symptoms. 

Research emphasises that individuals with ADHD, lacking the right treatment and support, are at a heightened risk of imprisonment. The estimated prevalence of ADHD among offenders is 25%, which is 5-10 times more common than in the general population. 

However, ADHD remains significantly under-diagnosed within prison settings. There is a highlighted need for increased efforts, particularly in the transition of care from the criminal justice system to the community to ensure ongoing access to treatment post-release.

See the article on underdiagnosis in the Pharmaceutical Journal (paywall)

Read how underdiagnosis leads to poor health outcomes

Read the research on ADHD and imprisonment

Pharmacy professionals’ roles and responsibilities in ADHD management 

Literature suggests that the management of ADHD aims to reduce the severity of symptoms and improve quality of life. The table below outlines pharmacy professionals’ roles in the management of ADHD patients, as set out in this article in the International Journal of Environmental Research and Public Health.

 

Communicate effectively

 

 
  • Raise awareness of ADHD with staff, patients and the wider public
  • Identify ADHD symptoms and signpost people to the ADHD self-reporting screening tool and local clinics. 
  • Advise on the appropriate use, dosage, and potential side effects of ADHD medications and conduct regular confidential medication reviews.
  • Adapt communication to meet the needs of people and consider patient’s privacy and dignity.
  • Safeguard people, particularly children and vulnerable adults.

 

Provide patient-centred care

 
  • Consider how accessible pharmacy services are to people with ADHD and their carers. 
  • Optimise the safe and effective use of ADHD medications.
  • Provide a calm, quiet and supportive environment for people with ADHD. 
  • Observe prescription frequency to assess medication adherence and provide repeat prescription reminder messaging.
  • Provide culturally competent care by considering ethnicity, disability, employment status, race, gender, and environment.

 

Patient monitoring

 

 
  • Encourage people taking medication for ADHD to monitor and record any adverse effects they experience. 
  • Ensure adherence to monitoring guidelines, including assessments for height, weight, baseline pulse, and blood pressure before commencing ADHD medications, followed by six-monthly monitoring of weight, blood pressure, and pulse.
  • Encourage feedback from service users and consider necessary adaptions to services.

 

Work in partnership with others

 
  • Refer patients back to their healthcare providers in light of shortages or any concerns regarding a person’s medicines.
  • Notify regular healthcare providers of any changes to ADHD medications or any new prescriptions for ADHD medications.
  • Enhance access to care by minimising waiting times or by streamlining ADHD clinical pathways. 
  • Signpost to relevant ADHD charities and resources

 

Maintain, develop knowledge and skills
  • Pharmacy professionals managing people with ADHD should consider changes in guidance and the impact of shortages on patients and their carers.
  • Encourage and support a multidisciplinary team approach to the management of people with ADHD.
  • Ensure pharmacy professionals have appropriate skills, qualifications and competence to manage people with ADHD.

Pharmacist independent prescribers 

Pharmacy professionals can help to improve the experience and healthcare outcomes of people with ADHD using their pharmacy’s services. An evaluation of a pharmacist-led ADHD clinic showed that pharmacists were able to manage ongoing caseloads and adjust medication, which included starting, stopping, and changing doses. In addition, pharmacists were able to monitor patient and drug parameters, and conduct necessary interventions either themselves or through referrals to other clinicians or services.

See the article about evaluation of the clinic in the Pharmaceutical Journal (paywall)

ADHD medicines shortages

We recognise the adverse impact that ADHD medicines shortages and supply chain issues can have on patients, the public and wider health and care teams.

It is vital that health and care professionals advise on, prescribe, supply, dispense or administer medicines within the limits of their training, competence and scope of practice, regulatory standards and guidance and the law. Alongside profession-specific codes of conduct, standards and guidance, health and care professionals are also expected to take account of relevant national policy and guidance.

You can find practical advice in response to the National Patient Safety Alert for Attention Deficit Hyperactivity Disorder (ADHD) medicines on the specialist pharmacy services website.

ADHD Resources

Published on
Last updated on