ADHD: A Survey of Psychiatric and Paediatric Practice
Most child and adolescent psychiatrists and community paediatricians have a heavy commitment to the assessment and management of children with ADHD. The paediatric approach is heavily biased toward clinical investigation and psychostimulant treatment. Child and adolescent psychiatrists prioritise mental health assessment and have access to a wider range of treatment options. This survey clearly suggests the need for joint working between the two disciplines to provide a holistic approach to the condition to exclude and manage coexisting mental health, physical and developmental problems.
Anecdotally, child and adolescent psychiatrists and paediatricians throughout the UK are reporting that increasing numbers of children are being referred to them for the assessment and treatment of suspected attention deficit hyperactivity disorder (ADHD). Indeed, research from the USA indicates that as many as 30–50% of referrals to child and adolescent mental health services are specifically for this problem (Popper, 1988; Barkley, 1996). An additional difficulty occurs when, despite recent recommendations, general practitioners in some areas are reluctant to take on routine monitoring of stimulant medication and repeat prescribing (Taylor et al., 1998; Overmeyer & Taylor, 1999; Ball, 2001; NICE, 2000).
The pressure of the large numbers of children involved has been coupled with an increase in expectations: parents have formed special interest groups and have much more knowledge about biological causes and treatments (Overmeyer & Taylor, 1999). Our education system promotes the integration of all children in the state school system. Children are educated in the large class setting, which is often a challenging environment for the young child with ADHD. Teachers are increasingly recognising pupils with possible ADHD, seeing the benefits of treatment, and are recommending that even more children be referred for assessment. The media hosts an ongoing debate about the very existence of this condition, its cause and the efficacy and acceptability of medication.
Much has been published in recent years on the assessment and treatment of children with suspected ADHD and although most clinicians who are involved will have a fairly good idea of what constitutes ideal practice, wide variations have been found (Sloan, Jensen, & Kettle, 1999). Much of the advice published to date comes out of specialist ADHD clinics and is not always practical for the average paediatrician or child and adolescent psychiatrist who may not have the benefit of being part of a specialist multi-disciplinary team. This has largely been redressed and standardised with the publication of the National Institute for Clinical Excellence (NICE) guidance on the use of methylphenidate (NICE, 2000). This document supports the use of stimulant medication in ADHD. However, there is currently considerable variation in what happens in practice, both between countries and within the UK (BAP Consensus Statement, 1997).
The management of ADHD requires a seamless approach from primary and secondary professionals and educationalists. There has been a long standing debate as to which professionals should take the lead responsibility for managing children with ADHD, fuelled by the fact that both the International Classification of Disorders, 10th version (ICD-10) (World Health Organisation, 1992) and the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) (DSM-IV) (American Psychiatric Association, 1994) classify the problem as a mental health disorder.
The recently published NICE guidelines recommend that assessment and management of children with ADHD be led by a child/adolescent psychiatrist or paediatrician with experience in the field. There is little research, however, that shows the extent of variation between the psychiatric and the paediatric approach to the condition. A questionnaire survey of 100 British child psychiatrists on their use and views concerning psychostimulant medication showed wide variations in prescribing practice (Bramble, 1997). This was thought to be the first survey of clinical activity in this field and was answered by nearly a quarter of Britain's child psychiatrists. Of the 200 questionnaires circulated, 50% yielded analysable data. Of these respondents 52% reported current use of psychostimulant medication, almost double that obtained in James' survey of the prescribing practices of child and adolescent psychiatrists one year earlier (1996). This study may well have documented the start of the rapid rise in prescription rate of methylphenidate in the UK. The range for new annual prescription rates varied greatly between prescribers, emphasising the inconsistency in clinical activity. Even when psychostimulants were prescribed, there was wide variability in the extent and form the treatment took.
In the absence of any specific diagnostic tests, a multi-method assessment approach is recommended for the diagnosis and treatment of ADHD (Barkley, 1990; Schaughency & Rothlind, 1991; NICE, 2000). Details of recommended assessment procedures are given by Cameron and Hill (1996) and Hill and Cameron (1999), Baumgaertel and Woolraich (1998) and in the American Academy of Child and Adolescent Psychiatrists Practice Parameters (1997). The use of multiple assessment techniques allows for the presence and severity of symptoms in more than one setting to be determined and other conditions that may account for the child's inattention to be excluded (DuPaul et al., 1992).
Once a diagnosis has been established, a treatment programme combining psychosocial, medical and educational interventions is recommended. This requires a joint approach between child psychiatry, paediatrics, psychology and education providers and has the greatest chance of alleviating the multiple symptoms and domains of dysfunction with which these children present (Cantwell, 1996; Taylor et al., 1998; Overmeyer & Taylor, 1999). Treatment approaches include: education and information for the child and parents, family support and parent training, behavioural management approaches including school-based programmes, individual cognitive approaches, social skills training and medication (Sandberg, 1996; Overmeyer & Taylor, 1999). The results of the recent MTA study (The MTA Cooperative Group, 1999) may now encourage practitioners to turn to the use of stimulant medication at an earlier stage following a sub-optimal response to behaviour management. Protocols have recently been drawn up for giving children a trial of stimulant medication where this is thought appropriate (Hill & Taylor, 1999). Once a satisfactory dose has been established, 3–6 monthly follow-ups with height, weight and blood pressure monitoring are recommended.
In the context of the recent NICE recommendation and with the hypothesis that both specialities adopt a different approach, we have attempted to identify the differences between the child and adolescent mental health service (CAMHS) and the paediatric approaches to the assessment and management of ADHD. Additionally, we aimed to look at the consistency of approaches throughout Wales and the modalities of assessment measurements and treatment available to children. One of us (GS) undertook a survey of child and adolescent psychiatrists and paediatricians throughout Wales on their current practice in the assessment, treatment and follow-up of children referred with this problem. We are aware that current practice does not necessarily equate to what colleagues consider to be ideal practice but could simply be a reflection of what individual services were actually able to provide.
A list of components that might be included in an assessment, treatment and follow-up package for ADHD was drawn up following a review of the literature. The list was deliberately over inclusive and was not meant to represent `gold standard' practice. Questionnaires were circulated to all consultant child and adolescent psychiatrists currently in practice and registered with the Faculty of the Royal College of Child and Adolescent Psychiatrists in Wales and Specialist Registrars (SpR) on the South Wales Child and Adolescent Psychiatry training rotation (eligible n=33). The questionnaire was also circulated to all consultant hospital and community paediatricians in Wales listed in The Royal College of Paediatrics and Child Health (RCPCH) handbook (eligible n=72). A second questionnaire was sent after 5 weeks to all those who failed to respond, and a reminder was sent 5 weeks later. Recipients were invited either to complete and return the questionnaire if they were involved in the assessment, treatment or follow-up of children with ADHD or to return the front sheet only, indicating that they were not.
In order to look at current practice, responses from the questionnaire were coded into `item used' (incorporating the options `currently use/provide', `always use' and `use occasionally'), `item not used' (incorporating the options `would like to use/provide' and `think is unnecessary), or `missing data' (where the response was left blank) and entered into an SPSS data set (SPSS version 9, SPSS Inc., Chicago, USA). Frequency distributions were used to obtain the percentage of doctors using each of the questionnaire items. The practice of psychiatrists and paediatricians was compared using the Chi-squared test or Fisher's Exact test where appropriate. Additionally, the number of items each practitioner used in their general and physical assessments was recorded as well as the number of treatments their service offered and the number of components to their monitoring process. The means for each speciality were compared by one way analysis of variance. All statistical tests were considered significant at p <.05. Two sided p values and 95% confidence intervals are quoted.
Of the 33 questionnaires sent out to 26 consultants, 1 associate specialist and 6 specialist registrars in child and adolescent psychiatry, 29 responded (88% response rate). Of these respondents, 24 (82.8%) were actively involved in the assessment, treatment and follow up of children with ADHD and completed the questionnaire. The questionnaire was also circulated to 72 consultant paediatricians in Wales, of whom 47 were working in hospitals and 25 in the community. Sixty-nine of these (44 hospital paediatricians and 25 community paediatricians) responded (95.8% response rate). Thirty of the respondents (43.5%) had some involvement in the assessment and/or treatment and/or follow-up of children with ADHD (8 hospital paediatricians, 18.2%, and 22 community paediatricians, 88%) and completed the questionnaire. All of the child and adolescent psychiatrists completing the questionnaire were involved in all aspects of the ADHD package, whilst 8 paediatricians (26.6%) of the 30 who completed the questionnaire did not offer the complete package. This difference was statistically significant (see Table 1).
Table 1. .
Degree of involvement of practitioners in the aspects of assessment, treatment and monitoring of ADHD
In the general assessment of children for ADHD, the majority of assessors use a multi-modal approach combining use of clinical interview and observation with collection of information from various sources by questionnaire as well as by telephone call or correspondence. Statistically significant differences are seen in the use of the mental state examination (used by 100% of child and adolescent psychiatrists and 59.1% of paediatricians), psychometric tests by psychologists (used by 29.2% of child and adolescent psychiatrists and 65.2% of paediatricians), and a speech and language assessment (used by 22.7% of child and adolescent psychiatrists and 65.2% of paediatricians) (see Table 2).
Table 2. .
General assessment, treatment and monitoring (% of those responding to question who use each item)
In the physical assessment of children with ADHD there is a high usage of baseline measures of height, weight and blood pressure by both specialities. There was a significant difference in the use of the cardiovascular system examination, measurement of head circumference, neurological/neuro-developmental examination, assessment for stigmata of congenital disease, sight test, hearing test, fragile-X test, use of CT/MRI scan and neurological consultation. In each case the item was more likely to be carried out by a paediatrician than a child and adolescent psychiatrist. Paediatricians were also more likely to carry out full blood counts and EEGs, although the difference was not statistically significant (see Table 2).
When it came to treatments on offer, more child and adolescent psychiatrists than paediatricians had access to parent training, behaviour modification and social skills training although the differences in percentages were only statistically significant for parent training in this small sample (see Table 2). One hundred percent of practitioners in both speciality offering treatment for ADHD would advise the use of medication where appropriate. Comparing the mean number of items used by each speciality in each part of the ADHD package, there was no significant difference in the general assessment or the monitoring of children on medication between the specialities. In the physical assessment, paediatricians offered a significantly more comprehensive package than child and adolescent psychiatrists with child and adolescent psychiatrists having a significantly higher mean number of treatments on offer (see Table 3).
Table 3. .
Comparison of mean numbers of items used in general and physical assessment, treatments on offer and components to monitoring between child and adolescent psychiatrists and paediatricians
The findings of this survey are based on a significant response rate. We confirm that whilst the recognition and management of ADHD is still a relatively new phenomenon in the UK, it is clearly making huge and increasing demands on the majority of community child health consultants and children's mental health services in Wales. It is likely that this survey is illustrative of practice throughout the UK.
The majority of practitioners in Wales appear to be providing comprehensive and multi-dimensional assessment and management of children with ADHD. The general assessment provided by both specialities has a reasonably high level of consistency. Paediatricians do not offer mental state examination to the same extent as psychiatrists and have a higher level of referral to psychologists for psychometric testing. This is clearly indicative of the lack of expertise in this field. Paediatricians do not have the resources to offer parenting interventions, cognitive behaviour therapy or social skills training in their treatment programme. They offer a significantly more rigorous physical assessment and traditionally have more opportunity for school liaison and joint work with education departments. They also have the capacity to work within a child development team and directly access physiotherapy and occupational therapy.
The greatest area of discrepancy overall is the extent of physical assessment undertaken. Child and adolescent psychiatrists rarely conduct comprehensive physical examinations on children except where there is a specific indication and run the risk of missing associated physical or developmental disorders. The physical examination is not generally part of a routine child mental health assessment; indeed many child psychiatry clinics are ill-equipped for this job with no designated examination areas and a lack of equipment or interpretative skills for clinical investigations performed. In view of recent recommendations that hearing loss should be screened for and investigated if necessary (Taylor et al., 1998; Hill & Cameron, 1999), it is particularly worrying that so few child and adolescent psychiatrists include a hearing screen or test as part of their physical assessment. The child and adolescent psychiatrist, however, undertakes a more standardised mental health assessment and may be more likely to detect psychiatric co-morbidity. They also have the advantage of more treatment options open to them through multi-disciplinary CAMHS teams.
The differences in assessment between the two specialities may reflect a different subset of children with ADHD being referred to each service. Paediatricians may see more children with other developmental or learning difficulties and child and adolescent psychiatrists see children with psychiatric co-morbidity. The difficulties presented by the former group of children will justify a clinical examination and the greater use of speech and language assessments by paediatricians. They may already be known to educational psychologists and have received psychometric assessments.
Practitioners in either speciality should consider the place of further investigations to complement their assessment of suspected ADHD when there is a clinical indication. Such investigations might include a full blood count, thyroid function or chromosomes/DNA for Fragile X or more complex investigations such as an EEG or brain scan. Although an EEG is a helpful test in determining the presence of epilepsy as a cause of sudden spells of inattention, most children with ADHD symptoms do not have clinical features suggestive of this. A CT or MRI scan is indicated for a child with ADHD symptoms only when other signs or symptoms are present to suggest a condition that would call for such diagnostic studies in children without inattention and hyperactive symptoms. An ECG is advised as a baseline before starting imipramine or clonidine (especially when used in combination with methylphenidate) but not as a routine investigation. A specialist neurological consultation may be indicated in the presence of focal neurological signs or clinical suggestions of seizure disorder or degenerative condition. Neuropsychological tests are useful to evaluate specific deficits suggested by history, physical examination or basic psychological testing but are not sufficiently helpful for the diagnosis of ADHD to be carried out routinely.
The results of the study suggest that the child and adolescent psychiatrist and the paediatrician offer different skills in the overall management. These largely reflect the training and different clinical approach of each discipline and also highlight the fact that ADHD has both physical and mental health dimensions that need to be considered. Some of the differences in approach could be overcome by joint training. Community paediatricians receive negligible training in child mental health and CAMHS practitioners do little clinical child health in their post graduate years. Clinical training programmes in each other's discipline would benefit the child with ADHD and other related conditions.
This study supports collaborative work between CAMHS and paediatricians in the management of ADHD in the future. NICE identifies 48,000 children in England and Wales who have yet to be assessed and treated for this condition, with a huge financial cost of £44 million per year to assess, manage and monitor them. Joint working practices will therefore need to be carefully designed to avoid duplication of work and optimise scarce resources. It is clear that either discipline can treat a child with uncomplicated ADHD. Triage of patients at the point of referral should channel children with comorbid mental health problems (conduct disorder, oppositional defiant disorder, anxiety, obsessive compulsive disorder or depression) to the CAMHS and those with developmental disorders and milder emotional or behavioural problems to the paediatricians. In this way each child will have an individual assessment and management package tailored to his/her needs. Good communication pathways need to be maintained to ensure appropriate referral pathways and consistency of approach. Joint CAMHS/paediatric clinics could then address the more complex cases that will include the children at the severe end of the ADHD spectrum, young children and those with poor treatment responses or atypical clinical presentation. Full consideration will need to be given to follow up and management of this client group into adulthood, where there is currently little service provision.
An approach offering multimodal treatment might meet the needs of the patients. However, it is hard to achieve in a climate where social work and educational resources have increasingly been drawn away from CAMHS and where child health services do not often have direct access to forms of treatment other than medication. It is likely that purchasers will need to review their provision and commission additional services to meet the need.
The lack of primary care involvement in the monitoring of increasing number of children on stimulant medication was evident from comments made on the questionnaires. Many of these children who are symptomatically stable may need to remain on treatment for a considerable length of time. Child health and child psychiatry clinics are becoming swamped with follow-up appointments for treatment monitoring and repeat prescriptions. There are opportunities for the management of children and adolescents on stimulant medication in the community through shared care and in accordance with NICE guidelines and we need to develop packages with general practitioners that will also increase their understanding and recognition of the condition over time.
It is hoped that, through dissemination of these results to child and adolescent psychiatrists and paediatricians, a protocol for seamless joint assessment and care packages can be encouraged. We suggest that the most popular assessment, treatment and monitoring modalities used by child health professionals in Wales may usefully be incorporated into protocols for the joint management of children with ADHD by a combined team of community paediatricians and child and adolescent psychiatrists.
The authors wish to thank Hollie Thomas, Lecturer in Epidemiology, University of Wales, College of Medicine, Psychological Medicine Academic Unit, Cardiff, for her help and advice on statistical elements of the paper.