ADHD diagnosis and management in children: something needs to change

Andrew Leech

25/01/2022 4:09:14 PM

When it comes to ADHD in children, there is an emerging concern that support and treatment is becoming increasingly inaccessible.

GP speaking to a young child and their parent.
GPs have a unique skillset and can contribute much to the lives of families living with neurodiversity, writes Dr Andrew Leech.

I am hearing almost daily now of parents unable to access paediatricians or psychiatrists for diagnosis or support of attention deficit hyperactivity disorder (ADHD).
It is not unusual to hear of parents ringing 30 or more specialist phone numbers seeking an appointment. Waiting times in the public system have blown out beyond two years in WA and some services do not accept referrals when ‘ADHD’ is mentioned.
Many paediatricians have closed their books until further notice. They are at their capacity and a crisis is emerging.
Allied health services are also experiencing similar levels of delay. One local private occupational therapy group I contacted the other day reported a waitlist of over 200 children. My experience is not in isolation and it is commonly discussed amongst GPs that this is now the norm.
ADHD is an important neurodevelopmental disorder that affects one in 20 children. I find the children I see who have ADHD to be fun, interactive, bubbly and busy children who have so much potential. I tell them it is their ‘superpower’. 
There is plenty to understand below the surface of this positive exterior.
Children with ADHD either have hyperactivity – cannot sit still and are always squirming – or inattentiveness – where they daydream and tune-out – or a mixture of both.
Some are labelled as ‘naughty’ and end up repeatedly getting in trouble. They inadvertently become the centre of attention in schools. Some also lack positive reinforcement and have reduced self-esteem.
The truth is, children with ADHD have so much potential and energy that time left untreated puts them at risk of harm. The condition is also associated with an increased risk of other conditions such as anxiety, depression and conduct disorders.
It is time for general practice to step up and fill the gap
GPs have such a unique set of skills and can contribute so much to the lives of families living with neurodiversity and learning difficulty.
We can:

  • build rapport and trust with children and their families, creating a long-lasting therapeutic relationship
  • involve the whole family, seeing siblings, parents and even grandparents
  • think holistically and broadly about the ‘bio-psycho-social’ issues facing that child
  • set up and create a multi-disciplinary team to work with that child (including allied health and paediatricians)
  • follow up regularly over a long period of time to ensure those goals are being met.
These are our core values and exist across all conditions, not just ADHD.
Unfortunately, GPs are not recognised as specialists who can either diagnose or prescribe for treatment of ADHD.
I have spent the past 12 months campaigning at state level for change. A change that would allow GPs with a special interest in paediatrics to have the ability to embark on accreditation and skills to achieve these outcomes.
Even if we could initiate a starting dose of medication, imagine how that would allow families to get started while getting onto a waitlist somehow. Integrating the use of telehealth services could make this option a reality, with time-poor paediatricians able to meet families and their GP virtually, create a plan and initiate treatment together.
Medication treatment for ADHD can change the trajectory of that child’s life for the better. However, it is not the whole story when it comes to treatment.
The benefits of allied health input is also evidence-based and important to implement as early as possible – in particular psychology, occupational therapy or both.
So, if encounter families stuck in what feels like a never-ending system, I encourage to stick with me for the journey, and I implement a few early interventions:
  • The SNAP, Conors or Vanderbelt screening questionnaires offer some insight into the function and difficulties that child is facing (all accessible online for free)
  • Offer a mental health care plan if the diagnosis of ADHD is highly likely, or even more commonly, comorbid anxiety disorder exists
  • Refer under this plan, to a mental health OT or psychologist with special interest in ADHD and learning difficulties
  • Screen for medical causes of behaviour changes. This might include regular physical examination such as BMI, BP and ENT checks, joint examination (consider hypermobility), blood testing for iron and thyroid, sleep studies if sleep disorder such as obstructive sleep apnoea is possible (or ENT referral), audiology and optometry referrals, and consideration of neurological conditions such as epilepsy
  • Consider the home environment. Is the child safe at home and school? Has there been any trauma or trigger?
  • Sleep hygiene education and advice, treating any sleeping issues with melatonin if required
  • Involving a tutor, educational assistant and communicating with the school about the areas of need
  • Providing a handout on ‘strategies for learning’ which focuses on limiting distractions, breaking tasks down, sitting towards the front of the classroom, fidget toy use and allowing extra breaks to step outside
  • Encourage parents to enrol their child in a positive activity that they enjoy such as a sport or club. The benefits of doing this can be huge for social skills, self-esteem and burning the extra energy that kids with ADHD seem to have
  • Regular review (initially monthly, then in school holidays) of mental health and physical health
  • Offer to become a co-prescriber of stimulant medication depending on the state law that exists
This list is not everything we can do, but it is a start.
GPs are uniquely positioned to give families hope, and sometimes hope is what they are seeking from us rather than more dead ends.
We can all help the strained system and save these families from added stress. Likewise, remember to consider ADHD in children who are struggling at school.
Hopefully one day we will have a more seamless support service in place which enables these children to thrive.
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AHDD attention deficit hyperactivity disorder paediatrics

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Dr Henry Arthur Berenson   26/01/2022 10:05:11 AM

The DSM prevalence of ADHD is 6% of the community. This group has issues that they bring to general practice. The prevalence inside a general practice would be 2 to 3 times higher than outside. The RACGP and the college of psychiatry have handled patient management over to the regulators by allowing them control of dopamine agonists medication. Where is the evidence that GPs cannot prescribe these drugs responsibly?

Dr Peter James Strickland   26/01/2022 11:56:26 AM

Many GPs are very cognizant of how to diagnose ADHD, and in fact often better, and simply because they have contact with the child, parents, teachers etc more often than any paediatrician or psychiatrist who works off a standard list of diagnostic parameters. Sometimes ADHD is harder to diagnose, and simply because the child has reached a stage of depression due to rejection by teachers, parents and school colleagues ---those need to go onto anti depressives, and here the older tricyclics can be of a benefit. It is really in the almost medically incompetent (and unethical) bracket that a child cannot be treated for known ADHD by their GP until seen by a psychiatrist or paediatrician for up to 2 years plus. The RACGP should lobby very hard on this matter --it has everything to do with dollars from advice by public servants, and is a constant thorn in the side of pragmatic, ethical and quality medicine in being able to treat something by their GP that is often quite obvious.

Dr Fiona Jane Henneuse-Blunt   26/01/2022 1:29:42 PM

I also know the NDIS will not fund therapies once children are over 8 years old for ADHD/ADD as a sole diagnosis , and neither will they fund the diagnosis of ADHD with a Clinical Psychologist , which costs more than $1000. The waiting times for Allied health in my own experience are ridiculous. We moved house last year and my own son, who is on the NDIS for ADHD And ASD had to wait over 4 months to get any appointment with an OT/Speech pathologist/Psychologist. And those were very inconvenient appointment times during the middle of the school day. Thankfully my husband works from home and could drive to collect my son from school, and take him to therapy. There is insufficient support for families in this situation.

A.Prof John William Kramer, OAM   26/01/2022 8:30:13 PM

There is a huge backlog of unaddressed or undiagnosed ADHD in this country. A recent Deloitte's study has the annual cost of ADHD to Australia at $20 billion.
Draft National Guidelines for ADHD Management in Australia will be released for public comment in February, 2022.

Dr Paul Michael Coughlan   27/01/2022 7:55:32 AM

Prescribing is merely an end-point.This is a major isue in rural.
The problem being that these neurodiversity syndromes are complex and require an assessment process that is not readily available in the fifteen minute window of a general practice consultation .Neither is the Allied Health support readily available or affordable to the client.
Much like Chronic pain and indeed RACF behavioural disturbance , prescribing is only the tip of the problem iceberg.
Without the Specialist status of a GP Fellow being recognised outside of the National ie in the public mind and that of Ministers ,and without the appropriate resources of funding for long Consultations and access to Allied Health support at an affordable rate for the patients -a focus on prescribing will simply expose us to the beady eye of regulation.
Meaningful reform starts with recognition of the Specialist status of a Fellow ,and parity with Consultant MBS rebates for the same work.

A.Prof John William Kramer, OAM   27/01/2022 6:26:44 PM

Just a reminder that the RACGP Faculty of Special Interests has a newly formed group, "ADHD, ASD and Neurodiversity". Get involved, join us in addressing this important clinical issue!