Opinion

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ADHD diagnosis and management in children: something needs to change

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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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