Re: Attention-deficit/hyperactivity disorder: are we helping or harming?
Thomas and colleagues1 suggest that the recent rise in prevalence of ADHD may be caused by overdiagnosis or misdiagnosis and McClure and others 2.3. have highlighted the problems of subjectivity when the diagnosis depends on observational assessment.
NICE guidance states that the diagnosis of ADHD should be made following a full clinical and psychosocial assessment and not solely on the results of rating scales or observation and recommends that Trusts should form multi-disciplinary teams to oversee the implementation of the guideline4. In practice, rating scales are often regarded as providing objective evidence whilst they are in fact subjective depending on the opinion of the rater.
In Wolverhampton we have established a multi-agency group which includes education, social care, Child and Adolescent Mental Health Services,(CAMHS) and paediatrics and have developed an ADHD diagnostic pathway.
Children are referred from a variety of sources to specialist paediatric or CAMHS clinics.
An initial enquiry is made by the school’s educational psychologist (EP) to the class teacher. If there are concerns the EP will conduct a structured observation of the child comparing the time on task, distracted or impulsive compared with 2 reference children in the same class. This provides an efficient screening prior to more detailed assessment of those where there are concerns. Complex cases are discussed by the multi-agency group.
A recent evaluation of the pathway revealed that the school had no concerns in 65 of 137 initial enquiries (47%) Responses to the initial enquiry were usually received by the clinician within a few weeks enabling more appropriate referrals for behavioural and other support to be facilitated. Structured observation or assessment by the EP excluded ADHD in a further 7 children. Of the 45 children where concerns were raised by the EP, ADHD was confirmed in 19 (42%) and excluded in 9 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 developed by our multi-agency group has provided an efficient and effective diagnostic tool which has reduced the waiting list for the specialist ADHD clinic and allowed referral to more appropriate services for those without ADHD with minimal delay. angela.moore2@nhs.net
1. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172.
2. McClure I. Has NICE guidance unwittingly exposed a new challenge for assessing this condition? BMJ 2013;347:f6216
3. Timimi S. Over-prescribing methylphenidate won’t be cured by autism-style assessments BMJ 2013;347:f6622
4. Diagnosis and management of ADHD in children, young people and adults. Clinical guidelines, CG72 - Issued: September 2008 by NICE
Competing interests:
No competing interests
12 November 2013
Angela Moore
Consultant Paediatrician
Royal Wolverhampton NHS TRust
Gem centre, Neachells Lane, Wolverhampton WV11 3PG
Rapid Response:
Re: Attention-deficit/hyperactivity disorder: are we helping or harming?
Thomas and colleagues1 suggest that the recent rise in prevalence of ADHD may be caused by overdiagnosis or misdiagnosis and McClure and others 2.3. have highlighted the problems of subjectivity when the diagnosis depends on observational assessment.
NICE guidance states that the diagnosis of ADHD should be made following a full clinical and psychosocial assessment and not solely on the results of rating scales or observation and recommends that Trusts should form multi-disciplinary teams to oversee the implementation of the guideline4. In practice, rating scales are often regarded as providing objective evidence whilst they are in fact subjective depending on the opinion of the rater.
In Wolverhampton we have established a multi-agency group which includes education, social care, Child and Adolescent Mental Health Services,(CAMHS) and paediatrics and have developed an ADHD diagnostic pathway.
Children are referred from a variety of sources to specialist paediatric or CAMHS clinics.
An initial enquiry is made by the school’s educational psychologist (EP) to the class teacher. If there are concerns the EP will conduct a structured observation of the child comparing the time on task, distracted or impulsive compared with 2 reference children in the same class. This provides an efficient screening prior to more detailed assessment of those where there are concerns. Complex cases are discussed by the multi-agency group.
A recent evaluation of the pathway revealed that the school had no concerns in 65 of 137 initial enquiries (47%) Responses to the initial enquiry were usually received by the clinician within a few weeks enabling more appropriate referrals for behavioural and other support to be facilitated. Structured observation or assessment by the EP excluded ADHD in a further 7 children. Of the 45 children where concerns were raised by the EP, ADHD was confirmed in 19 (42%) and excluded in 9 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 developed by our multi-agency group has provided an efficient and effective diagnostic tool which has reduced the waiting list for the specialist ADHD clinic and allowed referral to more appropriate services for those without ADHD with minimal delay.
angela.moore2@nhs.net
1. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172.
2. McClure I. Has NICE guidance unwittingly exposed a new challenge for assessing this condition? BMJ 2013;347:f6216
3. Timimi S. Over-prescribing methylphenidate won’t be cured by autism-style assessments BMJ 2013;347:f6622
4. Diagnosis and management of ADHD in children, young people and adults. Clinical guidelines, CG72 - Issued: September 2008 by NICE
Competing interests: No competing interests