1 What Is ADHD?
ADHD [Attention Deficit Hyperactivity or Hyperkinetic Disorder]
is a broad descriptive term that gets used for a large number
of children who are generally more overactive, inattentive and
impulsive, within which a small group of children merit a specific
diagnosis and treatment. Broadly, ADHD may be the child's response
to other stresses, disorders and learning difficulties which are
best identified and helped first. A few also need medication,
often Methylphenidate or "Ritalin".
2 Varying Definition
Lay and professional people use the term "ADHD" in such
a wide variety of ways that it would be best - in discussion and
referrals - to describe in straightforward language the problems
and concerns, and to consider what would help in ordinary ways.
This does not prevent a referral to specialist agencies made in
those ordinary terms.
3 A Four-Tiered Care Pathway
The help is delivered at four Tiers of multi-agency Child and
Adolescent Mental Health (CAMH) Services. These Guidelines outline
what to do at each Tier. There is a referral pathway between each
Tier. Figures are available to summarise this. A strengthened
working relationship is needed between Community Paediatricians
and Specialist CAMHS (Child and Family Clinic teams) in each area.
It is best to understand the Rationale behind the Guidelines (see
Appendix 1). You may wish to read that first. Most attentional
and/or hyperactivity difficulties will be managed at Tiers 1 and
2.
| 25% of all children exhibit hyperactive or attentional difficulties at some time | FAMILY | Most problems resolve using the family's own skills and resources |
| Some children require simple professional advice to help resolve problems | TIER ONE | Most problems resolve with professional advice about straightforward, common-sense measures |
| Some children have persistent problems requiring further assessment and help | TIER TWO | Many children have other reasons for their attentional and hyperactive problems family difficulties, communication disorders, mild learning difficulties etc |
| Some children have "Combined ADHD" (2% of all children) | TIER THREE | Almost all can be suitably treated by a comprehensive care programme which may include drug treatment |
| A very few children (say 1 in 1000) may have additional complex or special needs | TIER FOUR | These children need highly specialist assessment and management advice from a regional centre |
THE FAMILY
The parents and other immediate
carers for the children and young people are those who should
have the most contact, concern and responsibility for them. Some
have proposed the term 'Tier Zero' for them. They should be the
natural and best "keyworker" for their child's needs
and help. Easily available resources include support, help and
guidance from wider family and friends, and from the media and
internet. Unfortunately, these may also be a source of unhelpful
stress and misguidance, so making life for adults and parenting
difficult. Where there are extra problems and special needs which
go beyond the family's ability to cope alone, parents may need
professional help, as well as help with the complicated network
of agencies with which they may then come in contact.
TIER ONE
Tier One includes those services which have regular contact with
all children and their families. This includes General Practitioners,
Health Visitors, Nursery staff, Teachers, and School Nurses.
1 Point of First Contact - Normal Sensible
Help
When a parent or professional first thinks of "ADHD"
for a child or adolescent, they should not stop doing the sensible
things they would normally do. Even if a child does have ADHD,
sensible normal steps may be at least part of what may help. [See
for example Tips & Tactics
on this website]
2 Do Not Immediately Refer To Specialists
Do not refer immediately to specialist agencies. It is normal
for many pre-school children to be active, distractible and impulsive.
On grounds of ADHD by itself, few pre-school children need referral
for specialist help. Other family or life stresses should be attended
to anyway.
3 Provide Other Help Anyway - Be Constructive
The families of these and any other worrying children need advice
and support anyway, whatever the difficulty is called. At every
stage, professionals should adopt a constructive approach with
families. Refocusing the ADHD question should not turn worried
parents away, but engage with them helpfully over what may nevertheless
be a significant ADHD or other (CAMH) problem that could need
help.
4 Get To Know and Team Up With Other
Local Resources
It is the Tier One professional's responsibility to get and update
information about relevant local agencies and resources. Agencies
and managers should also make that information accessibly available,
especially across sectors (health, social and educational). Examples
of useful services at this level, for those who might otherwise
be thought of as ADHD, are Health Visitors, Nurseries, and Parent
Training and Support Groups.
5 Pre-School Help - Health Visitor, Nursery
Unit, PreSCAT
For preschool children, often the Health Visitor is the best person
to help. Health Visitors may also be the best keyworker for this
age group at Tier 1. Pre-school childrens or nursery units provide
opportunities to identify and assess problems before school entry,
as well as useful respite for stressed parents. It is not necessary
to have a firm diagnostic label to identify the need for special
support for learning or behaviour before or at school entry. The
focus for the further assessment of pre-school children who may
have special needs is the Pre-School Assessment Team (PreScAT)
in Tier 2.
6 Keep An Open Mind
It is important to keep an open mind, particularly initially,
about the cause of reported hyperactivity and inattention. It
is also important to find any learning or developmental difficulties
that can frustrate a child, and to identify other stresses around
the child's life at home (eg family stress or strife) or school
(eg bullying).
7 Contact Other Agencies Involved
It is best anyway, but especially before taking further steps
or referring onward, for professionals to ask families about any
significant involvement of other agencies, and to contact these
agencies to discuss and plan what to do. The assessment and treatment
of any CAMH problem (including ADHD) must be co-ordinated with
good inter-professional communication at every stage. For complex
situations, even at Tier 1, an identified key agency and key worker
can help support the family, advocate for them, and authoritatively
coordinate all the agencies involved. It is good to summarise
what is discussed and planned in a simple letter with copies to
other agencies involved and to the family.
8 One Step At A Time
It is not generally advisable to make several referrals at
once. Consider the next best step and follow it through. Don't
make the next referral before discussion with the agency involved
in the last one. Any further referral, is best made with the concurrence
of those already involved. This applies even when second opinions
are being proposed.
9 Referral To Tier 2
For attentional and/or hyperactivity difficulties where the
above steps have been followed but concern continues, Tier 1 agencies
will refer first to Community Paediatricians at Tier 2. Any Tier
1 professional may initiate this. This will be the best contact
where it is not clear which other agency is best involved. If
it is clearer, then other Tier 2 agencies can be referred to,
for example, school psychology (eg for assessment of school progress
and behaviour, or assessments of learning or developmental difficulties
like dyslexia), or speech and language therapists (eg for assessing
communication and language difficulties), or social work (eg for
family support). Tier 1 agencies can also benefit from a wide
range of indirect contact and guidance from Tiers 2 and 3 to guide
and improve services and promote mental health at Tier 1.
10 What To Tell Families
When referring families to Tier 2, it is helpful to explain to
families that in general
11 No Out Of Area Referrals
Referrals out of Lanarkshire from Tier 1 should be unnecessary
and are not advisable except when a family has been seen by local
services and asks a GP for a second opinion (see Tier 4 below).
Agencies outwith Lanarkshire should return direct referrals to
local services.
12 GPs and Prescription
The family's doctor, the general practitioner, has an important
role in prescribing and monitoring medication after specialist
assessment and treatment plans have been completed. Medication
started prematurely can set up an inappropriate way of thinking
that can be hard to reverse. It can obscure or invalidate other
important possible causes of an ADHD picture.
TIER TWO
Tier 2 includes those agencies who provide more specialist services
to some (ie not all) children and families, from a unidisciplinary
base and framework. In Lanarkshire, Tier 2 includes Community
and Hospital Paediatricians, Educational Psychologists, Area SWD
Child Care Social Workers, Speech and Language Therapists, and
Paediatric Occupational Therapists. Many of the principles summarised
above under Tier 1, apply at Tier 2 and 3 too.
1 The Community Paediatrician's Role
Where Tier 1 steps have been tried, but more seems to be needed,
referral to Tier 2 agencies is the next step. The task of the
Community Paediatricians is to integrate and ensure that all appropriate
measures have been undertaken, and to decide if onward referral
to specialist Tier 3 CAMHS is appropriate.
It is not generally the role or responsibility of Community Paediatricians or others at Tier 2 to undertake a full assessment (see Tier 3) and decide on a firm diagnosis of ADHD or prescription of Methylphenidate etc. However, further developments of joint case discussion, assessment, training and experience especially with Tier 3 (ie CFC teams) are expected to share skills and decision-making for CAMH problems, including those with attention and hyperactive difficulties.
2 Older Adolescents
Some teenagers with ADHD continue to have difficulties into adult
life. Like all young people with special needs, planning for future
support needs to be undertaken early and should involve all appropriate
agencies. There is no plan yet for the support and monitoring
of those few adults who continue with a diagnosis of ADHD and
longer-term medication.
3 Key Worker
A case co-ordinator or key worker should ensure good inter-professional
communication. Some agencies (eg educational psychologists, social
workers) are in a better position than others to take on this
role. A key-worker role includes:
4 Paediatric and Developmental Assessments
Developmental assessments may be indicated where the child has
a relevant problem (e.g. epilepsy, motor difficulties, developmental
delay, learning difficulties, genetic questions) or history (e.g.
significant antenatal or perinatal morbidity). Neuro-developmental
assessment may be done by Community or Hospital Paediatrician.
Contributory assessments may be done by Educational Psychologists,
Speech and Language Therapists, and Occupational Therapists. Schools
Psychology services may only accept referrals from Pre-SCAT or
schools. However liaison between disciplines, often by phone,
may help line up a complete assessment.
5 Family Stresses, Functioning and Child
Care Aspects
Workers at Tier 2 help to assess and support family stresses and
functioning. For these reasons, as for childcare and child protection
issues, liaison and case discussion with social workers may be
required.
6 The Fuller Criteria For ADHD
When all appropriate steps at Tier 1 and Tier 2 have been taken,
and concern still remains, it is appropriate to assess the fuller
criteria for "combined ADHD" or a "primary disorder
of hyperactivity". This is when a child's inattentive, impulsive
restlessness is:
These criteria for a "primary" disorder also, in general but not exclusively, indicate drug therapy.
7 Different Criteria For ADHD
Parents and others may have quite different criteria for their
child's ADHD, may be just as stressed anyway, and very much want
help as immediate as a pill. Indeed there are other criteria.
To understand enough to discuss these satisfactorily, please read
the Rationale (Appendix 1).
8 Referral For Full Assessement
A full specialist assessment is indicated on the grounds of a
probable Combined ADHD or primary disorder of hyperactivity.
As explained further in the Rationale, referrals of any CAMH problem are best made by simply describing the problem and family picture and without using the ADHD framework. Referrals from Tier 2 out of Lanarkshire should be unnecessary and are not advisable.
9 Collaboration Between Tier 2 (Community
Paediatricians), Tier 3 (CFC) and Families
A key relationship to be established and used in each area of
Lanarkshire is between the Community Paediatricians and the CFC
teams. To put these guidelines into operation, these two agencies
will need to collaborate in understanding and establishing good
practice about CAMH problems in general, about the principles
of ADHD services, and the needs of particular cases. This will
require routine liaison if not specific case-related meetings,
phone calls or other discussion.
This is also necessary to guide families being referred to Tier 3, who may already feel frustrated or defeated, but still need to be ready and able to engage reliably in what may be further sustained collaborative work. It is difficult to assess and diagnose ADHD properly, or to carry through care plans, or to prescribe and monitor medication without this teaming up of parent and professionals.
10 What To Tell Families
When referring families for fuller assessment at Tier 3, it is
helpful to explain to families that
11 Assessment Tools
Assessment tools such as Conners questionnaires should only
be used as part of an integrated assessment. A more useful preliminary
approach (than handing out Conners scales) for ADHD or any CAMH
problem is for parents and school (if possible) to keeping a full
and accurate "diary" account, for a couple of weeks,
of the "who, when, where, and why" of what happens in
the child's behaviour and life.
12 Do Not Pre-Empt Diagnosis
It is not appropriate to pre-empt, predict or promote ADHD or
other developmental disorder labels as if they are usually that
simple to identify or help. Do not prescirbe medication for ADHD
(or any CAMH problem) before multi-disciplinary liaison and full
assessment has been completed.
13 The Role Of Tier 3 Specialist CAMHS
At Tier 2
The multidisciplinary Child and Family Clinics teams provide direct
services to those referred, but also have an indirect role in
supporting professionals in Tier 2. They may be involved in liaison,
joint clinics, consultation, and training. The relationship with
Community Paediatricians will become more important in CAMH and
ADHD services. One of the most complex situations to review and
manage is of children and families who move into Lanarkshire having
been diagnosed and treated for ADHD elsewhere.
TIER THREE
Tier 3 for this purpose are Specialist Multi-Disciplinary CAMH
Teams. In Lanarkshire, these are the four Child and Family Clinic
teams covering Monklands-Cumbernauld, Motherwell, Hamilton-East
Kilbride and Clydesdale. However, for ADHD, other teamed up agencies
may be required to complete the full service.
1 Full Assessment
When and only when the preliminary stages at Tier 2 have been
carried through, and following the SIGN Guidelines, an assessment
should be carried out by an agency, that welcomes the remit with
the modern expectations of it, and are experienced and qualified
to provide an integrated full assessment. Awareness and skills
are required for this role in assessment, engagement, treatment
and management of:
2 Child and Family Clinics
At present, the key agency for this in Lanarkshire is the Child
and Family Clinic for that area, supplemented by other agencies
where necessary. Variations and developments will be guided by
an ADHD Steering Group. As described in the SIGN Guidelines, the
full assessment will include:
3 Responsibility For Prescribing
If medication is recommended as one component of treatment,
a qualified medical practitioner will be identified to take on
the role of prescribing and first line monitoring. GPs are well
placed to take on this role, guided by CFC staff involved, and
as part of a 'shared care' arrangement. So, generally the CFC
Psychiatrist recommends the prescription and the GP makes it alongside
other aspects of monitoring.
4 Medical Aspects of Medication
Before starting Methylphenidate or other medication, initial baseline
measures include history (to exclude epilepsy etc), pulse and
BP (to check heart and circulation), height and weight (to monitor
future growth) and full blood count and platelets (in case of
changes on medication). Once established, Methylphenidate is not
as dangerous a drug as once thought. Other drugs are used less
frequently.
5 Longer-Term Monitoring
Medication (and the diagnosis) may be needed for a relatively
long time, even into adulthood for some. Once the other kinds
of more active specialist help have progressed as far as possible,
the medication may be all that is needed. Monitoring should include
3-6 monthly check on BP, height and weight, and a yearly full
blood count and platelets. Informed and responsible parents may
understand the issues in long-term monitoring as well as many
professionals do. So they can take responsibility for ensuring
the medical and other monitoring required. It is best if 'holidays'
from the drug can be part of the regular pattern eg for weekends
or holidays. Especially if parents are not so able to take responsibility,
it is important for parent or professional (eg GP) to remember
to initiate a careful annual trial off the drug, and particularly
do so in adolescence when many young people grow out of ADHD.
How this is best done would be part of the 'shared care' planning
set up with them.
TIER FOUR
Tier 4 is the regional specialist service. For ADHD, an out-patient
clinic service is provided at RHSC Yorkhill Glasgow. In-patient
admission for complex cases to the child or adolescent psychiatric
wards at Yorkhill and Gartnavel may rarely be needed.
1 Access Via Tier 3
Only exceptionally would families require Tier 4 services. Access
to Tier 4 will be through or after Tier 3 involvement. Families
should now not need to go further afield or privately. The nature
of the integrated multiagency assessment and management means
that the quality of isolated involvement of distant agencies is
dubious to say the least. Inappropriate referrals initially made
to Tier 4 or others outside Lanarkshire will be channelled back
to Tier 2 or 3, as appropriate.
2 Role of Tier 4
Generally it is CFC at Tier 3 who may recommend that complex cases
be referred to Tier 4 for more specialist assessment and advice.
It can be helpful, and families have the right, to ask for second
opinions and these are provided by Tier 4.
3 Other Regional Services
Neurodevelopmental assessment of children with ADHD may be required
from regional paediatric services at Yorkhill, but referrals for
this reason do not have to follow this ADHD Guideline's referral
pathway. Children with autistic spectrum disorders have been served
at Yorkhill's Scottish Centre for Autism for additional assessment
at the request of local specialists, buit increasingly more local
services can provide this too.
GENERAL
1 Other Aspects Of Help
There are many other aspects to helping children with ADHD and
their families. All kinds of agencies need to play their part.
These are often at least as or more important than the medication,
but it is the medical steps of diagnosis and drug prescription
that require to be set out in a guideline like this. The main
danger of inappropriate drug prescription is the ignoring and
invalidation of potentially serious personal suffering of the
child as a contributing cause of the ADHD picture.
2 Networks and Information
As for all CAMH problems, agencies and managers should make information
about useful resources accessibly available, especially across
sectors (health, social and educational). Local ADHD or other
networks should develop this collective informing of agencies
to meet client needs better by teaming up resources together that
otherwise are badly used, stretched and scattered.
3 Training
A coordinated programme of informational and training events can
support the development of good practice and the understanding
of ADHD and this Guideline in Lanarkshire.
4 Feedback to Lanarkshire ADHD Steering
Group
In order to integrate and progress the ideas, structures and resources
throughout Lanarkshire there is a need for an ADHD Steering Group.
Since different districts of Lanarkshire may have different patterns,
there is a need to develop appropriate networks, provide information
and training, and to systematically monitor and audit the merits
and deficiencies of each in order to improve practice and integrate
this Guideline. The Steering Group therefore welcomes all feedback
and questions to inform future developments [contact: ADHD Steering
Group, c/o .... Telephone .... Email: ....]
5 Other ADHD Guidance
This Guideline is best read in conjunction with the Rationale
(see below) which further summarises the thinking behind it. Highly
summarised executive guidelines are available to focus each agency
and professional discipline on their key aspects of the Guidelines.
All of this is available on the internet at: .............
CONTEXT
1 ADHD [Attention Deficit Hyperactivity or Hyperkinetic Disorder] is a broad descriptive term that gets used for a large number of children who are generally more overactive, inattentive and impulsive, within which a much smaller group of children merit a specific diagnosis and treatment. Like many other childhood and family problems, ADHD is linked with a range of factors and stresses that may require careful and patient consideration and teamwork, with families, schools and between agencies.
2 Especially before the age of school entry, more serious attentional or hyperactive problems are difficult to recognise because of the wide normal variation. Like other child and adolescent mental health (CAMH) problems, ADHD may be associated with antisocial, aggressive or defiant behaviour. Learning disorders, clumsiness and specific delays in development occur with increased frequency. ADHD may result from or be hard to distinguish from other disorders, while mixed disorders are common.
3 Thanks to public information by media and the internet, and mobilised particularly by the fact that medication can sometimes help a lot, British services have been increasingly able and willing to respond to this task. Local services are usually best placed and sufficient.
4 All CAMH problems get labelled within a medical diagnostic system. But they are universally seen to be multi-factorial in cause. Therefore help is multi-disciplinary and multi-agency. The wide network of professional services is conceptualised in a pyramid of four Tiers from frontline Primary Care up to regional specialist CAMHS (HMSO 1995). Parents and other carers, of course, are the real frontline!
5 Representatives of relevant local agencies in Lanarkshire have met to discuss and plan how to work together effectively. This Guideline and Rationale are one result, complementing the "SIGN Guidelines on Attention Deficit and Hyperkinetic Disorders in Children and Young People" (2001). The Rationale summarises the background thinking to the Lanarkshire ADHD Guidelines. It is best to read both in conjunction. Any duplication that results helps to emphasise important points.
TERMINOLOGY
1 USA and UK
ADHD terminology is a very finicky and confusing business. Unfortunately
it is of key importance for all of us if we are to understand
any guideline intelligently. The term Attention Deficit Hyperactivity
Disorder (ADHD) is from the American Diagnostic and Statistical
Manual (DSM), not the UK's ICD (International Classification of
Diseases (10th Revision)). The equivalent to ADHD in the UK's
ICD is Hyperkinetic Disorder (HD). The SIGN Guideline title manages
to combine both!
2 Broad ADHD
The ADHD/HD symptom lists of DSM and ICD are very similar. But,
to enable the provision of help in the likes of the USA's non-welfare
state system, DSM gives looser criteria. Thus, for DSM, overactivity,
inattention and impulsivity do not all need to be present; and
the behaviour does not need to persist across settings (home,
school, clinic). We can call this Broad ADHD. Broad ADHD gets
even broader when the media describes it. Better still, to moderate
the inaccurate implications of the concrete medical terminology,
we suggest using non-specific words like "attentional"
and/or "hyperactive" "difficulties", avoiding
abbreviations if possible.
3 Combined ADHD
For the ICD diagnosis, all three key features of ADHD and persistence
across settings are required. This is equivalent to the Combined
ADHD category in DSM. We can use the term "Combined ADHD"
for the more tightly defined ADHD. Note that these categories
are still based on descriptive criteria.
The category Combined ADHD equates with what Hill and Cameron (1999) call a "primary disorder of hyperactivity". But they include other important criteria - more than descriptive, that is - when they define it. For detailed criteria, see Guideline section on Tier 2. These children with "primary disorders of hyperactivity" are also, in general but not exclusively, those that merit the prescription of drug therapy. But parents are likely to believe that Broad ADHD also merits a prescription.
4 Very Common or Quite Rare?
Broad ADHD applies to a quarter of all children. That is, lots
of children have attentional and/or hyperactive difficulties;
they are very common. Combined ADHD applies to about 2% of all
children; it is quite rare. A parent will bring a media-generated
confused view of Broad and Combined ADHD to a primary care setting
or school, eg that their child is very "hyper" at times
and so needs Methylphenidate. The confusion is unavoidable since
undefined "ADHD" is now lodged in our media, culture
and language. Professional services have to be able to think more
clearly.
There are other key points around terminology here.
5 Good Practice ADHD = Good Practice
CAMH
The only significant difference in the assessment and treatment
of a child with Combined ADHD (eg as outlined in the SIGN Guideline)
from the assessment and treatment of those with any CAMH problem,
is in the possible drug prescription and monitoring of Methylphenidate
etc. All the other aspects and methods recommended as good practice
for ADHD are also good practice for all specialist CAMH Services.
6 Labels Are Not Needed To Get Help
In the UK's welfare state and NHS, or at least in Lanarkshire,
all children with any worrying CAMH problem, however they are
labelled (or not), can and should be referred and receive help
from a network of agencies (including specialist CAMHS). Most
UK CAMH Services now do provide for ADHD what they once were not
so good at. So limiting which children are included under the
Combined ADHD definition does not exclude any child who needs
help from getting that help. Even if ADHD has not been mentioned
in advance, specialists nowadays anyway assess for ADHD and will
prescribe medication as appropriate.
7 Multifactorial Means Many Agencies
Help
Help for ADHD and other CAMH problems is, like it's causes, multifactorial.
Therefore many non-specialist CAMH disciplines and agencies provide
appropriate help. They are the "treatment of choice"
for attentional and/or hyperactive difficulties (Broad ADHD).
For Combined ADHD too, there will always be important and necessary
measures provided by other agencies. Sometimes these may replace
the need for those provided by a specialist CAMHS.
8 The Gatekeeping of Scarce Resources
As described above, the rationale here aims to promote a broad
multi-agency approach so that present resources of all kinds can
be integrated and usefully deployed. But a gatekeeping function
develops when there are scarce resources (eg Social Work) or a
need to control funds (eg DLA). If this happens, then the solution
is sometimes to require the family to obtain the approval of a
designated agency (eg by getting a diagnostic label) before the
resources are authorised. This ADHD Rationale and Guideline will
not work in the absence of broad multi-agency understanding and
services to go alongside the authority for ultimate diagnosis
and prescription of medication in one small agency (CFC) at Tier
3 level. It cannot be CFC's role to 'gatekeep' for other services
through its diagnositc authority. Services should generally be
based on assessed need not on labels.
9 Translate "ADHD" Into More
Ordinary Words
All of this confirms that it might now be more helpful in gaining
the best help for families and children of all kinds if referrers
translate any mention of "ADHD" as "CAMH problem"
or into ordinary descriptive English in their minds and referrals,
if not in their talk to families. It is best to assess and describe
the problem behaviour and concerns straightforwardly rather than
use the potentially very confusing premature diagnostic label.
If referrers do use the term ADHD, they should be aware of the
criteria above that Hill and Cameron (1999) give, to distinguish
attentional and/or hyperactive difficulties (Broad ADHD) from
Combined ADHD, and other "CAMH problems" from "primary
disorders of hyperactivity".
SERVICES
1 Coordinated Help At Each Of The Four
Tiers
Multi-agency help needs to be coordinated at each of the four
Tiers of service. This requires information and liaison about
services in general and in each particular case. Professionals
working with other members of a family may need to be involved
in the coordination of plans for that family's child.
2 Clear Referral Pathways Between Tiers
When help at one Tier is not sufficient or inappropriate, there
need to be transparent and clear referral pathways to the next.
These pathways should not become unnecessary hurdles that slow
down the delivery of services to children and families that need
it. The Guideline is organised to make this clear and achieve
more speed and less haste, without oversimplifying the much more
complex issues that simple labels obscure. The care pathway should
(a) help parents understand who and what step to expect next,
(b) facilitate adherence to best practice guidelines, and (c)
allow better measurement in due course of patient and professional
satisfaction.
3 Frontline (Tier 1) or Specialist Agencies
(Tier 3)?
Alongside a wide range of other CAMH disorders, it is the narrower
Combined ADHD that more specialist CAMHS (Tier 3) want to see.
At least, that is what they are resourced to see - there is no
way they can see a quarter of all children! The SIGN Guidelines
primarily describe specialist agencies' assessment and treatment
of Combined ADHD. Primary care and other frontline agencies (Tier
1) are therefore faced with a very difficult problem. They have
to sift out the rarer Combined ADHD from the very common attentional
and/or hyperactive difficulties (Broad ADHD), and to work out
how to guide families and refer to the appropriate agencies for
them at their own Tier and/or on to the next.
4 Developing The Role Of Community Paediatricians
(Tier 2)
To help sort this difficulty out, we have agreed a key role and
development of Tier 2 agencies, integrated by Community Paediatricians.
Integrating services for all CAMH in school age children may eventually
require the resourcing for a formal structure like the present
PreSCAT.
5 Planning For Future Special Needs Of
Young Adults
Similarly, older adolescents (with or without ADHD) may need coordinated
interagency planning for future needs.
6 The Role Of Specialist CAMHS (Tier
3)
Specialist CAMHS in Tier 3 are, in Lanarkshire, the multidisciplinary
Child and Family Clinics service. As well as providing direct
services to those referred, they can have an indirect role in
supporting services in Tiers 1 and 2 in a range of ways. They
are also the pathway for referral to Tier 4. The Guideline indicates
these roles too. Community Paediatricians and CFC Teams will need
to develop strong collaborative working relationships in providing
good services for CAMH problems in general and ADHD in particular.
7 Other Governmental Guidelines
The framework of this ADHD Protocol and Rationale includes the
SIGN (2001) and NICE (2000) Guidelines on ADHD and Methylphenidate
(respectively), as well as influential Government directives on
multi-agency 4-tier structure for CAMHS (HMSO 1995 and HAS 2000)
and documents on Social Inclusion, Early Intervention, Community
etc. For Scotland's Children: Better Integrated Services (2001)
also identifies the problem of limiting of multi-agency help that
the ADHD framework is seen to create.
8 Resourcing
Many of the measures outlined in this Guideline and Rationale
are already accepted good practice. The overall expectation is
that all services will be able to be more effective and efficient
given new guidance, concepts and clarity. That is, any inefficiently
used resources, time and energy will be freed up in the future.
However, collaboration of all kinds as well as some of the proposals
above, require further consideration, planning and extra resourcing.
This extra resourcing has not been discussed or secured in advance
of the publication of this Guideline and Rationale.
9 Added Value
The value and excitement in this process is to develop services,
not just for ADHD, but in a way that also improves integration
of services for all other kinds of CAMH and other needs and problems
of children and families in Lanarkshire. Children, families, professionals
and managers can expect greater satisfaction and efficacy across
a wide range of those services.
REFERENCES
1 Peter Hill and Mary Cameron (1999) Recognising Hyperactivity: A Guide for the Cautious Clinician. Child Psychology and Psychiatry Review, 4, pp 50-60
2 NHS Health Advisory Service (1995) Child and Adolescent Mental Health Services: Together We Stand. HMSO:London
3 Jenny Finch, Peter Hill and Carol Clegg (2000) Standards for Child and Adolescent Mental Health Services. Health Advisory Service (London) and Pavilion Publishing (Brighton).
4 SIGN (2001) SIGN Guidelines on Attention Deficit and Hyperkinetic Disorders in Children and Young People.
5 National Institue for Clinical Excellence (2000) Guidelines on the Use of Methylphenidate for AD/HD in Childhood. NICE, Technology Approcal Guidance, No 13, www.nice.org.uk
6 Scottish Executive (2001) For Scotland's Children: Better Integrated Services. The Stationery Office
nick.child@virgin.net