Opinion
The answer to psychiatric and child development waitlists
Allowing trained GPs to initiate stimulant prescriptions for ADHD would help families and clinicians, writes Dr Andrew Leech.
Many patients cannot access paediatric care due to extensive waitlists.
As I reflect on another week of seeing families stuck in a circle of trying to find a paediatrician or psychiatrist to help their child, only to end up on a waitlist or be told to call back in a year, I now realise one key element in this giant puzzle that would potentially improve the entire health system.
We urgently need to de-regulate stimulant prescribing for GPs and provide a clear, consistent guideline nationwide for the treatment of ADHD.
It’s confusing – I can easily prescribe morphine and all of its various substitutes, medicinal cannabis, benzodiazepines and other highly addictive medications, with little to no training. But after years as a GP working with families in child and adolescent health, I’m unable to prescribe medication that we know from research is at least 70% effective for children with diagnosed ADHD.
With the advances in technology and the inception of ‘safe script’, we’re far better off than we have ever been in making sure both GPs and patients are acting safely with medications that could be potentially at risk of abuse.
It’s appalling to think that we’re delaying a diagnosis and treatment purely because only two types of medical specialists can do it. How is this fair to families?
We already have a workforce of GPs interested in neurodevelopment, child development and mental health, potentially in the thousands across Australia, ready and able to support families.
Recent child health webinars hosted by RACGP Specific Interests have had around 1000 GPs attending, which demonstrates considerable interest in wanting to be supported and trained.
Many who have reached out to our ADHD working group are willing to be involved in any way possible but are limited by the rigid state prescribing rules.
I propose that the RACGP be funded to provide training and accreditation to GPs under the guidance of primary health alliances around the country.
This should not be a ‘free for all’ process and GPs would need similar approvals to other potentially risky medications such as methadone, Yellow Fever vaccination and hepatitis C treatments.
But what doesn’t seem to be acknowledged is that this seemingly cheap, accessible, ready-to-go-now option continues to be delayed.
Anecdotally, I’ve heard these barriers are in place due to the risk of over-prescribing and over-diagnosing, the lack of knowledge and training that GPs might have, and the fact that ADHD is far more complex than what it may seem on the surface.
I don’t dispute any of these concerns. ADHD never exists on its own, and there are usually precipitants such as mental health or trauma, genetic elements, and other comorbid conditions.
But I have to ask – who is better placed to help these patients than a GP?
We see the whole family.
We understand the impact of disease on the child and the siblings and parents, and we see children over a lifespan.
We’re also trained to recognise disease patterns early on and have a long-term relationship that gives us a unique lens into what might be happening.
Whether it’s ADHD, bullying, anxiety, or, more importantly, whether we are missing a health condition such as obstructive sleep apnoea, epilepsy (which was a cause in one of my paediatric patients), endocrine disorders, malnutrition and iron deficiency or hearing deficits to name a few, GPs can look at all possible causes of the child’s symptoms and broadly consider why there are difficulties with learning or development.
Even after an ADHD diagnosis and treatment initiation, most paediatricians send children back to the GP for monitoring of side effects. We are well equipped to do this; it’s not hard work.
It’s also revealing to hear from parents that diagnosis and treatment consultations are often quick due to how busy the paediatrician is, to the point where they didn’t know how the medication worked and what to look out for. While the above may not be true for all paediatric specialists, the pressure on them to see patients is so high right now that there’s less time than ever for education or follow-up.
This is not to say paediatricians and psychiatrists don’t do this work. They do and are necessary in caring for children with neurodevelopmental or complex health needs.
The problem is many patients can no longer access paediatric care because unnecessary regulatory rules disempower primary healthcare providers from providing a diagnosis and treatment of what is an increasingly common concern for parents.
Dr Andrew Leech has proposed that the RACGP be funded to provide training and accreditation that would allow GPs to initiate stimulant prescriptions for children with ADHD.
Rather than overwhelming paediatricians and psychiatrists with patients who could be safely managed in general practice, we need them to be more available for those with concerns beyond our scope.
I’d like to finish with an example of this. I’ve been helping a 15-year-old girl, Charlotte*, whose mental health has been deteriorating, with severe symptoms of OCD, body dysmorphia and depression with anxiety.
I needed secondary support, but the six referrals sent to private psychiatrists were all rejected as Charlotte sits in the difficult category of being too old for a paediatric psychiatrist and too young for adult psychiatry, where many won’t start seeing patients until 17 or 18.
In the time since those referrals were rejected, Charlotte’s condition has deteriorated to the point where she is now self-harming and having suicidal thoughts. She fears needing to go to the emergency department, but we have spoken about this possibility and emphasised that if she is in acute crisis, she does need to go.
Her family even increased her insurance coverage to allow private admission, but despite my phone calls, no private hospital could admit this age group.
Charlotte is fortunate enough to have family support, but is still isolated and cannot leave her home or go to school. I’m not skilled enough to handle her complex mental health on my own, but I can’t access psychiatric care for her.
How is this happening in a country with so many resources and dedicated health workers?
My theory is in addition to Charlotte’s age, psychiatrists and paediatricians are so inundated with referrals for ADHD and autism they can no longer deal with other mental health issues, which further backs my argument and solution: empower GPs to help with ADHD.
Ironically, allowing GPs to prescribe stimulants will make us also less busy.
The repercussions and repeated attendances of non-diagnosed children and teenagers currently occupy a significant amount of my time. Presentations are all too common now and range from non-school attendance, defiance, bullying, being misunderstood in the classroom, and lack of engagement with psychology or OT as they cannot sit or focus on therapy, through to family dysfunction from a child who is emotionally dysregulated and challenging to deal with.
What about those minors in detention or prison who have untreated ADHD? Could this have been prevented? I’m currently treating adolescents post-incarceration who clearly have untreated ADHD, and the impulsiveness of their condition has contributed to them making poor decisions and imprisonment.
I’m not exaggerating, just passing on what I see.
ADHD treatment is effective and evidence based. Whether we like it or not, the rates of diagnosis are rising.
A consequence of our current generation or an increase in awareness? More research is still needed.
But knowing that we have medication which does help children and improves lives should be enough to at least get started.
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