Paediatricians' views on their role in the assessment and management of ADHD and autism.
ABSTRACT ADHD and Autistic Spectrum Disorders (ASD) are a core component of paediatricians case work in the U.K. and U.S., but the situation in Ireland is less clear. Due to significant underdevelopment of Child and Adolescent Mental Health Services in Ireland, long waiting lists may delay identification and treatment. The aim of our study was to explore the views of a group of paediatricians in relation to their current and future practice of assessing and managing ADHD and ASD. The outcome of our study indicated that more than half of the paediatricians surveyed are directly involved in the assessment or treatment of ADHD and ASD. Eighty five per cent (85%) of paediatricians believed that they should have a role in the assessment of ADHD and ASD and over half had thought that they should be involved in managing ADHD and ASD. These results suggest that there is potential to develop alternative specialist services in Ireland for the identification and treatment of children with ADHD and ASD. The development of a well coordinated integrated care pathway may reduce waiting times for families and lead to easier access to services.
Paediatricians??? Views on Their Role in the Assessment and
Management of ADHD and Autism
N O’Keeffe, F McNicholas
Department of Child and Adolescent Psychiatry, Our Lady???s Hospital for Sick Children, Crumlin, Dublin 12
ADHD and Autistic Spectrum Disorders (ASD) are a core component of paediatricians case work in the UK and US, but the
situation in Ireland is less clear. Due to significant underdevelopment of Child and Adolescent Mental Health Services
in Ireland, long waiting lists may delay identification and treatment. The aim of our study was to explore the views
of a group of paediatricians in relation to their current and future practice of assessing and managing ADHD and ASD.
The outcome of our study indicated that more than half of the paediatricians surveyed are directly involved in the
assessment or treatment of ADHD and ASD. Eighty five per cent (85%) of paediatricians believed that they should have a
role in the assessment of ADHD and ASD and over half had thought that they should be involved in managing ADHD and
ASD. These results suggest that there is potential to develop alternative specialist services in Ireland for the
identification and treatment of children with ADHD and ASD. The development of a well coordinated integrated care
pathway may reduce waiting times for families and lead to easier access to services.
Childhood mental illness represents a large proportion of the disease burden in young people globally
estimate that approximately one in ten children and adolescents suffer from mental health difficulties which cause
significant functional impairment and are in need of intervention
shown that the vast majority of children with mental health difficulties still do not receive appropriate services
Ireland, despite significant recent developments in child mental health, there are still difficulties in accessing
services with extensive waiting lists in many areas. The government???s mental health policy, A Vision for Change,
which outlined a number of targets and improvements, has been slow to materialise
the Child and Adolescent Mental Health Service Advisory Group looked at the activity within each CAMHS for a one month
period in 2008. It was found that there were a total of 3,117 children and adolescents waiting to be assessed.
Approximately 12% of the initial assessments which took place during that period had been on the waiting list for more
than a year
1. Recent studies
2. Despite increased public awareness, it has been
4. A national survey carried out by
In the current economic climate, understaffed teams are struggling to meet increasing demands with ever dwindling
resources and funding. New ways of working urgently need to be considered in order to prevent secondary morbidity and
associated increase in personal and financial implications for the child, family and society. In the national survey
2008, almost thirty percent of the case load seen in CAMHS was children presenting with ADHD and over 9% had
presentations consistent with ???Autistic Spectrum Disorders/Problems??? (ASD). In the UK, this is an area where the
community paediatrician plays a vital role. Given the shortage of resources in Ireland, the authors propose that there
may be scope to develop alternative multi agency care pathways for the identification and treatment of ADHD and ASD.
Paediatricians and child psychiatrists could develop a coordinated approach to the management of these children
subject to potential barriers being identified and remedied. The aim of our study was to explore the views of a group
of paediatricians in relation to their current practice and the possibilities of developing alternative specialist
services for the identification and treatment of children with ADHD and ASD.
A sample of 72 paediatricians, attending a national paediatric study day was asked to complete a study questionnaire
focussing on two main areas: paediatricians??? views on assessment and treatment of ASD and ADHD and their level of
training and practice in these areas.
The majority of respondents were general paediatricians (48, 67%), and 15% were community paediatricians. 22 practiced
in Dublin (30%). Nearly all treated children under 6 years (61, 98%) but a significant number treated older children;
89% (n=64) aged between 5-11; and 75% (n=54) up to age 18. With regard to ADHD, 85% of paediatricians believed they
should have a role in assessment and 76% thought they should be involved in treating ADHD. More than half (54%, n=38)
replied that this is their current practice. Almost half of the group, (19, 45%) reported that they provide treatment
other than medications. Many (46%, n=31), have had previous training in ADHD (8% in Ireland, 13% abroad, 7%
placement in specific ADHD CAMHS and 10% personal CPD attendance at conferences and day courses), but more than half
(56%, n=38) indicated an interest in additional training.
In relation to the ASD and related disorders, a similar number believed they should have a role in the assessment
(85%) and treatment (62%). Just over half of the group (53%) are directly involved in treatment or assessment of a
child with ASD, with 8 respondents (11%) having their own ASD specific team. Almost one quarter of this group (23%)
provide treatment other than medication. Over a third of the group (35%) have had specialised training in ASD, which
included part of their general training in Ireland (11%), abroad (4%), attendance at specialist ASD teams (8%); and
attendance at courses and conferences (6%). 28% had some training in behavioural management and 27% have had some
training in child psychiatric services. More than half of the paediatricians (55%) requested additional training or
more information on Autism.
The group was asked about the availability of other assessment and treatment services. Almost half (47%, n=33) had
ready availability of a dietician service. However only 11% (n=8) reported that speech and language or occupational
therapy was readily available to them. Other services perceived as difficult to access included psychometric
assessments, counselling services, and child psychiatry, with only 6 (8%) suggesting easy access to psychology, 11%
(n=8) to counselling services, and 16% (n=12) to child psychiatry.
Our findings suggest that currently more than half of the paediatricians surveyed are directly involved in the
assessment or treatment of both ADHD and ASD. Furthermore, there is a willingness and expectation from the vast
majority surveyed to become involved in managing both Autism and ADHD, and to receive additional training in these
areas. In the US, ADHD and ASD are routinely treated by paediatricians as well as primary care clinicians,
psychologists and psychiatrists. The American Association of Paediatrics has stipulated that paediatricians have a
responsibility to assess and treat ADHD and it has provided a comprehensive ???toolkit??? designed for paediatrics
which includes guidelines and protocols on assessment and treatment of ADHD and Autism
States have found that both child psychiatrists
psychiatric disorders, should be assessed and treated by paediatricians
American Academy of Paediatrics, it was found that 91% of primary care paediatricians agreed that paediatricians
should identify children with ADHD and 65% reported they usually manage ADHD. It was noted that those paediatricians
who perceived that they should be responsible for treating ADHD had twelve times the odds of reporting that they
manage ADHD themselves
6,7. Studies from the United
8 and paediatricians agree that ADHD, more so than managing other
9-11. In a national survey carried out by the
In the UK, the National Institute of Clinical Excellence recommends that children with suspected ADHD should be
referred to secondary care services including paediatrician as well as child psychiatrists
of child and adolescent mental health services, paediatricians play a front line role in terms of identifying and
managing certain neuropsychiatric conditions. In order to develop an integrated care pathway with our paediatric
colleagues, it is important to respond to their requests and provide regular training in these areas and to develop
well structured services with multiagency input. It is also important to develop with our primary care clinicians
shared care protocols in these areas, to disseminate clear practice guidelines and to develop national child mental
health policies in order to overcome barriers to appropriate care, and to allow ready transfer for such cases back to
child psychiatry when requested. It is imperative for families to have easy access to services and to improve practice
efficiency and standards. Pilot services should be developed and evaluated to look at the feasibility of such an
13. In view of the scarcity
Correspondence: F McNicholas
Department of Child and Adolescent Psychiatry, Our Lady???s Hospital for Sick Children, Crumlin, Dublin 12
Paediatricians??? Views on Their Role in the Assessment and Management of ADHD and Autism1
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Paediatricians??? Views on Their Role in the Assessment and Management of ADHD and Autism2