ADHD clinics in the Netherlands

Summary Attention Deficit Hyperactivity Disorder (ADHD) is a common psychiatric disorder, which is often associated with co-morbidity. Last century the number of diagnosed children, adolescents, and adults with ADHD has increased significantly. However, lack of clarity and many controversies about the disorder and how to treat and diagnose people with a presumption of ADHD occur. Moreover, it has been indicated that many ADHD patients are not treated by the most adequate practitioners. Research has shown that untreated and unrecognized ADHD has a major financial impact and may result in high economic cost. However, waiting times could be up to several months before a medical specialist sees a child. For these reasons, there is need for appropriate diagnostic process and clarity in the classification of children and adolescents with a presumption of ADHD. The development of ADHD clinics was one of the initiatives to reduce long waiting lists. The intention was to create a manner to include all the aspects of the diagnostic process in the shortest possible process, covering all relevant elements for the diagnosis. However, not much consistency between these ADHD clinics can be noticed since they all apply their own instruments, practitioners and techniques to achieve their goal. For that reason, an ADHD clinic in this research is described as an institution with a specific program or focus on the diagnosis and treatment of ADHD. Since not much is known about the phenomenon ADHD clinic, this research is the first attempt to provide more insight and information about this topic. The objective of this research is the provision of an overview of the characteristics of ADHD clinics in the Netherlands in terms of type of organization, involved practitioners, patient population and the treatment process. The future perspective for these ADHD clinics is evaluated related to the current changes in the health care system. Based on the obtained results and information, a systematic overview of the strengths, weaknesses, opportunities and treats is created through a SWOT analysis. The research design is descriptive in nature and consists of a qualitative research and a literature search. The literature search was focused on obtaining information about the characteristics of ADHD clinics, the current developments in mental health care and their relevance to the future impact on the ADHD clinics. The formulated characteristics of the ADHD clinics were the starting point of the semi-structured questionnaire, including 37 questions. The questions were divided into three parts: the organization, the ADHD clinic and the applied guideline and/or protocol. The qualitative search consists of interviews of about one hour with employees of the participating ADHD clinics. Several institutions were approached to obtain participants. In the end, ten different persons were willing to participate in the research. All interviews were recorded and the treatment process of each clinic was elaborated in a flowchart. To verify and adapt the obtained information, an E-mail and a letter were sent to all participants to exclude potential miscommunications. Further, participants were contacted in the final stage to obtain their opinion on the future perspective of AHD clinics. Also a care purchaser of an insurance company was contacted by phone to get information about his insight in the effects of the development in the health care system on ADHD clinics. The result of the research includes information about the four defined characteristics. First, three different types of organization exist, namely those related to hospitals, those related to mental health institutions (GGZ) and independent organizations (ZBC). The purpose of each ADHD clinic was to create more efficiency in the process of diagnosis and treatment. In nine out of the ten participating institutions, the multidisciplinary guideline for ADHD is applied. Almost all institutions use some kind of protocol, which they have developed based on the multidisciplinary guideline. Secondly, the team of involved practitioners in each clinic varies between the types of institutions and may include child-and youth psychiatrists, paediatricians, psychologists, nurses, secretaries, and/or other professionals. In the mental health institutions more psychiatrists are active, while in hospitals more paediatricians are employed. Thirdly, the target group of the ADHD clinics is about the same as the ADHD guideline, which is based on the DSM-IV criteria (4 to 18 years). Finally, the treatment process is based on four phases: identification (registration); diagnosis / classification (intake); indication; treatment (care allocation/develop treatment plan); and treatment (monitoring/adjusting treatment). Each client generally goes through a similar process; however, the content differs among the ADHD clinics, as do the waiting times. The secondary aim of the thesis was to discuss the future perspective of ADHD clinics. Recently, several changes have been implemented in the health care system, which have consequences for mental health care. Health insurance companies have generated more risk and will therefore contract health care providers based on strictly formulated requirements to stimulate efficiency and improve quality of provided mental health care. The set criteria can be seen as constraints for the diagnosis and treatment of ADHD in these clinics and are based on scientific research (Multidisciplinary guideline) and input of patient organizations. In general, most mental health institutions employ qualified professionals but the organizational process may be inefficient. The diagnosis and treatment process should therefore be more streamlined. However, specific ADHD clinics are in generally directed to clients with solely ADHD, while ADHD is often associated with co-morbidity. This means that more research and different kind of treatments are often necessary. Large mental health institutions are able to treat and diagnose patients with more complex problems. Patients should be treated in the right institution and unnecessary treatment should be prevented. Nevertheless such investments require time and adaption in the organization of mental health institutions. Currently, institutions are forced to provide the best attainable care for (ADHD) patients in the most efficient manner. Several clinics assume that they provide good care; however, these assumptions have not been investigated or confirmed yet. However, many clinics are currently not able to comply with the set criteria due to insufficiently available professionals according to health insurance companies. It seems that to develop a well running ADHD clinic, a clinic should act conform the set criteria of health care insurance companies since otherwise they probably will not be contracted. Concluded, self-regulation is developing in this market. Changes in the financial system of care for ADHD clinics may have significant impact on the characteristics and absolute number of ADHD clinics. Inefficient clinics are forced to stop since health insurers will no longer contract them. Mental health institutions are in general in the best position to comply with the set criteria of health insurance companies. However, outside the criteria of health insurers it is not clear whether these ADHD clinics are in fact the most effective and the most profitable. It is shown that hospitals or independent health centres with an ADHD clinic often refer complex patients to mental health institutions since they do not frequently have the suitable professionals to treat these patients. This method seems inefficient since many children with a presumption of ADHD are referred to a specific ADHD clinic, while in many of the cases other disorders occur also which may in general result in another referral to a mental health institution. For that reason, it may be recommended to study the effectiveness of ADHD care. To stimulate efficiency it seems important to define the right group and refer the patient to the right place, for example by the general practitioner. Training and education may be a manner to stimulate better coordination of ADHD patients.