Pathways to care in ADHD

J. Cribb

Young People's Service, 3 North Parade Buildings, Bath BA1 1NS, UK

I was interested to read Sayal et al's (2002) article on pathways to care for children at risk of attention-deficit hyperactivity disorder (ADHD). By using Goldberg & Huxley's (1980) pathway to care model I felt that the study oversimplified the complexity of professional input to this group of children, a point raised by the authors in their discussion. I think it is important, when considering improvements to services for children with ADHD, that the role of education is highlighted.

Teachers, as a profession, are well placed to observe children and are familiar with age-appropriate behavior. Indeed, Goodman et al (2000) found that teachers were more sensitive at identifying children with hyperactivity than were their parents. Although teachers' involvement in the assessment and monitoring of children with ADHD is well established (Dulcan et al, 1997), their role in identification is less clear. This is highlighted by the fact that only some child and adolescent mental health services (CAMHS) accept referrals directly from schools. By involving teachers in the identification of children with ADHD, access to children would improve from 74% seen in primary care to nearly 100%. This would significantly improve the sensitivity of any screening measure.

It is essential that CAMHS do not develop services for children in isolation, but instead utilise the skills of other professionals to improve care. If children with ADHD are to have their needs met, it is essential that we start to think outside of the medical model.

EDITED BY KHALIDA ISMAIL

REFERENCES

Dulcan, M. and the Work Group on Quality Issues, American Academy of Child and Adolescent Psychiatry (1997) Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit/hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 36 (suppl.), 855-1215.

Goldberg, D. & Huxley, P. (1980) Mental Illness in the Community: The Pathway to Psychiatric Care. London: Tavistock.

Goodman, R., Ford, T., Simmons, H., et al (2000) Using the Strengths and Difficulties Questionnaire (SDQ) to screen for psychiatric disorders in a community sample. British Journal of Psychiatry, 177, 534-539.[Abstract/Free Full Text]

Sayal, K., Taylor, E., Beecham, J., et al (2002) Pathways to care in children at risk of attention-deficit hyperactivity disorder. British Journal of Psychiatry, 181, 43-48.[Abstract/Free Full Text]


 

Authors' reply

K. Sayal, E. Taylor, J. Beecham and P. Byrne

Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK

EDITED BY KHALIDA ISMAIL

Dr Cribb's comments are welcomed. Our discussion (Sayal et al, 2002) also highlights the potential role of both parents and teachers in making referrals to child and adolescent mental health services (CAMHS). The paper is developing new methodology and we deliberately posed it on a simplified system, selecting an area where most referrals come from general practitioners (GPs). GPs are also the main referrers to CAMHS nationally and their role in primary care trusts will be of great importance in shaping specialist services. Nevertheless, this is only one component of tier 1 services and 48% of CAMHS referrals come from other sources (Audit Commission, 1999). We plan to widen our programme to examine the role of other sources of referral.

Restricting referrals to particular agencies imposes barriers to access, and the resulting delay in referrals might exacerbate severity or chronicity of problems. Kurtz et al (1996) described a service that only accepted GP referrals. It failed to reduce the number of referrals and generated resentment from other agencies. Comparisons of CAMHS with different referral systems will improve knowledge in quantifying the barriers to access to services. This could contribute to assisting the successful implementation of the National Service Framework for Children.

The role of teachers in the pathway to care merits particular comment. Relationship difficulties with teachers are a predictor of referral of hyperactive children to CAMHS (Woodward et al, 1997). Our study has demonstrated that selective targeting can lead to particularly high rates (98%) of teacher participation in research. This is likely to reflect their concern about behavioural and emotional difficulties in children. Teachers are a rich potential source of child mental health information for parents. However, in considering referrals from schools, it is imperative that teachers fully discuss their concerns with parents. Parents need to agree to any referral. For hyperactivity, in particular, it needs to be ascertained that the problems are pervasive. Unless this happens, there is a risk that learning difficulties are wrongly identified as hyperactivity. This also highlights the importance of adequately resourced educational psychology services to support schools, and health service input in the training of teachers.

REFERENCES

Audit Commission (1999) Children in Mind. Child and Adolescent Mental Health Services. London: Audit Commission.

Kurtz, Z., Thornes, R. & Wolkind, S. (1996) Services for the Mental Health of Children and Young People in England: Assessment of Needs and Unmet Need. Report to the Department of Health. London: South Thames Regional Health Authority.

Sayal, K., Taylor, E., Beecham, J., et al (2002) Pathways to care in children at risk of attention-deficit hyperactivity disorder. British Journal of Psychiatry, 181, 43-48.[Abstract/Free Full Text]

Woodward, L., Dowdney, L. & Taylor, E. (1997) Child and family factors influencing the clinical referral of children with hyperactivity: a research note. Journal of Child Psychology and Psychiatry, 38, 479-485.





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