Letters Attention-deficit/hyperactivity disorder

Results from multiagency ADHD pathway in Wolverhampton

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f7069 (Published 27 November 2013) Cite this as: BMJ 2013;347:f7069
  1. Angela Moore, consultant paediatrician1
  1. 1Gem Centre, Royal Wolverhampton NHS Trust, Wolverhampton WV11 3PG, UK
  1. angela.moore2{at}nhs.net

Thomas and colleagues suggest that the recent rise in prevalence of attention-deficit/hyperactivity disorder (ADHD) may be caused by overdiagnosis or misdiagnosis,1 and McClure and others have highlighted the problems of subjectivity when the diagnosis depends on observational assessment.2 3

The National Institute for Health and Care Excellence recommends that the diagnosis should be made after a full clinical and psychosocial assessment and not solely on the results of rating scales or observation. It also recommends that trusts form multidisciplinary teams to oversee the implementation of the guidance.4 Although rating scales are often thought to provide objective evidence, they depend on the rater’s opinion and are therefore subjective.

In Wolverhampton we have established a multiagency group that includes education, social care, child and adolescent mental health services, and paediatrics and have developed an ADHD diagnostic pathway.

Children are referred from a variety of sources to specialist paediatric or child and adolescent mental health services.

The school’s educational psychologist initially asks the class teacher about the child. If there are concerns, the psychologist conducts a structured observation of the child, comparing the time on task, distracted, or impulsive compared with two reference children in the same class. This provides an efficient screening before more detailed assessment of children for whom there are concerns. Complex cases are discussed by the multiagency group.

A recent evaluation of the pathway showed that the school had no concerns in 65 of 137 initial inquiries (47%). The clinician usually received a response to the initial inquiry within a few weeks, enabling the facilitation of more appropriate referrals for behavioural and other support. Structured observation or assessment by the educational psychologist excluded ADHD in a further seven children. Of the 45 children where concerns were raised by the educational psychologist, ADHD was confirmed in 19 (42%) and excluded in nine in favour of alternative diagnoses: epilepsy (3), learning difficulties (3), dyspraxia (1), auditory processing disorder and dyspraxia (1), and constipation (1).

More than half the children referred for possible ADHD did not have the condition (72/137; 52%). The ADHD pathway that we have developed provides an efficient and effective diagnostic tool that has reduced the waiting list for the specialist ADHD clinic and allowed referral to more appropriate services for those without ADHD with minimal delay.


Cite this as: BMJ 2013;347:f7069


  • Competing interests: None declared.


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