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.
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ABSTRACT: Many children who have a mental health disorder do not receive mental health services and are seen only in primary care settings. Perceptions of pediatricians and mental health specialists regarding the role that pediatricians should have in diagnosing and managing children's mental health problems have not been studied. To examine whether primary care pediatricians (PCPs) and child and adolescent psychiatrists (CAPs) agree about: (1) the pediatrician's role in identification, referral, and treatment of childhood mental health (MH) disorders; and (2) barriers to the identification, referral, and treatment of childhood MH disorders. Surveys were mailed in 2005 to 338 PCPs and 75 CAPs in 7 counties surrounding Cleveland, Ohio. Each group was asked whether they agreed that PCPs should be responsible for identifying, treating, or referring 7 prevalent childhood MH problems. Barriers that PCPs face in identification, referral, and treatment of MH problems were also assessed. Analyses were weighted for nonresponse; group differences were assessed via Rao-Scott chi test and weighted regression analyses. Approximately half of PCPs and CAPs returned the survey. With the exception of attention deficit hyperactivity disorder (ADHD), the majority of PCPs and CAPs agreed that pediatricians should be responsible for identifying and referring, but not treating child MH conditions. For ADHD, PCPs were more likely than CAPs to agree that pediatricians should identify and treat affected children. PCPs were more likely than CAPs to agree that pediatricians should be responsible for identifying child/adolescent depression and anxiety disorders; the majority of both groups agree that PCPs should be responsible for referring, but not treating these conditions. Both groups agree that lack of MH services is a barrier to identification, treatment, and referral of child MH problems for PCPs. CAPs were more likely to agree that pediatrician's lack of training in identifying child mental health problems was a barrier, whereas PCPs were more likely to endorse lack of confidence in their ability to treat child MH problems with counseling, long waiting periods to see MH providers, family failure to follow through on referrals, and billing/reimbursement issues as barriers. Most PCPs and CAPs believe it is pediatricians' responsibility to identify and refer, but not treat, the majority of children's mental health problems. Both groups agree that mental health services are not readily available. Future efforts are needed to support PCPs and CAPs in their combined effort to address the mental health needs of children.Journal of developmental and behavioral pediatrics: JDBP 09/2008; 29(4):262-9. · 2.27 Impact Factor
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ABSTRACT: Attention-deficit/hyperactivity disorder, the most common childhood behavioral condition, is one that pediatricians think they should identify and treat/manage. Our goals were to explore the relationships between pediatricians' self-reports of their practice behaviors concerning usually inquiring about and treating/managing attention-deficit/hyperactivity disorder and (1) attitudes regarding perceived responsibility for attention-deficit/hyperactivity disorder and (2) personal and practice characteristics. We analyzed data from the 59th Periodic Survey of the American Academy of Pediatrics for the 447 respondents who practice exclusively in general pediatrics. Bivariate and logistic regression analyses were used to identify attitudes and personal and practice characteristics associated with usually identifying and treating/managing attention-deficit/hyperactivity disorder. A total of 67% reported that they usually inquire about and 65% reported that they usually treat/manage attention-deficit/hyperactivity disorder. Factors positively associated with usually inquiring about attention-deficit/hyperactivity disorder in adjusted multivariable analyses include perceived high prevalence among current patients, attendance at a lecture/conference on child mental health in the past 2 years, having patients who are assigned or can select a specific pediatrician, practicing in suburban communities, practicing for > or =10 years, and being female. Pediatricians' attitudes about responsibility for identification of attention-deficit/hyperactivity disorder were not associated with usually inquiring about attention-deficit/hyperactivity disorder in either unadjusted or adjusted analyses. Attitudes about treating/managing attention-deficit/hyperactivity disorder were significantly associated with usually treating/managing attention-deficit/hyperactivity disorder in unadjusted and adjusted analyses. Those who perceived that pediatricians should be responsible for treating/managing had almost 12 times the odds of reporting treating/managing attention-deficit/hyperactivity disorder, whereas those who believe physicians should refer had threefold decreased odds of treating/managing. Other physician/practice characteristics significantly associated with the odds of usually treating/managing attention-deficit/hyperactivity disorder include belief that attention-deficit/hyperactivity disorder is very prevalent among current patients, seeing patients who are assigned or can select a specific pediatrician, and practice location. Taking responsibility for treating attention-deficit/hyperactivity disorder and practice characteristics seem to be important correlates of pediatrician self-reported behavior toward caring for children with attention-deficit/hyperactivity disorder.PEDIATRICS 02/2009; 123(1):248-55. · 4.47 Impact Factor
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ABSTRACT: This study was designed to investigate the perceptions of primary care providers about their roles and the challenges of managing attention-deficit/hyperactivity disorder and to evaluate differences between providers who serve families primarily from urban versus suburban settings. The ADHD Questionnaire was developed to assess primary care provider views about the extent to which clinical activities that are involved in the management of attention-deficit/hyperactivity disorder are appropriate and feasible in primary care. Participants were asked to rate each of 24 items of the questionnaire twice: first to indicate the appropriateness of the activity given sufficient time and resources and second to indicate feasibility in their actual practice. Informants used a 4-point scale to rate each item for appropriateness and feasibility. An exploratory factor analysis of primary care provider ratings of the appropriateness of clinical activities for managing attention-deficit/hyperactivity disorder identified 4 factors of clinical practice: factor 1, assessing attention-deficit/hyperactivity disorder; factor 2, providing mental health care; factor 3, recommending and monitoring approved medications; and factor 4, recommending nonapproved medications. On a 4-point scale (1 = not appropriate to 4 = very appropriate), mean ratings for items on factor 1, factor 2, and factor 3 were high, indicating that the corresponding domains of practice were viewed as highly appropriate. Feasibility challenges were identified on all factors, but particularly factors 1 and 2. A significant interaction effect, indicating differences between appropriateness and feasibility as a function of setting (urban versus suburban), was identified on factor 1. The challenges of assessing attention-deficit/hyperactivity disorder were greater for urban than for suburban primary care providers. Primary care providers believe that it is highly appropriate for them to have a role in the management of attention-deficit/hyperactivity disorder. Feasibility issues were particularly salient related to assessing attention-deficit/hyperactivity disorder and providing mental health care. The findings highlight the need not only for additional training of primary care providers but also for practice-based resources to assist with school communication and collaboration with mental health agencies, especially in urban practices.PEDIATRICS 02/2008; 121(1):e65-72. · 4.47 Impact Factor
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
1. World Health Organization. Caring for children and adolescents with mental disorders. Geneva: World Health
2. Green, H., McGinnity, A., Meltzer, H., Ford, T. & Goodman, R. (2005) A survey by the Office for National
Statistics. Hampshire: Palgrave MacMillan
3. Briggs-Gowan MJ, Horwitz SM, Schwab-Stone ME, Leventhal JM,Leaf PJ. Mental health in paediatric settings.
Distribution of disorders and factors related to service use. J Am Acad Child Adolesc Psychiatry.2000;39:841-849.
4. ???A Vision for Change??? Report of the Expert Group on Mental Health Policy, 2006
5. Child and Adolescent Mental Health Services Annual Report 2008,
6. American Academy of Pediatrics, University of North Carolina at Chapel Hill for its North Carolina Center for
Children???s Healthcare Improvement, National Initiative for Children???s Healthcare Quality. ADHD: Caring For
Children With ADHD: A Resource Toolkit for Clinicians. Elk Grove Village, IL: American Academy of Pediatrics; 2005
7. Autism: Caring for Children With Autism Spectrum Disorders: A Resource Toolkit for Clinicians , American Academy of
Pediatrics Autism Subcommittee
8. Heneghan A, Garner AS, Storfer-Isser A, Kortepeter K, Stein RE, Horwitz SM.
Pediatricians??? role in providing mental health care for children and adolescents: do pediatricians and child and
adolescent psychiatrists agree? J Dev Behav Pediatr 2008;29:262-269
9. Power TJ, Mautone JA, Manz PH, Frye L, Blum NJ. Managing attention-deficit/hyperactivity disorder in primary care:
a systematic analysis of roles and challenges. Paediatrics 2008; 121:e65-e72.
10. Kwasman A, Tinsley BJ , Lepper HS. Paediatricians??? knowledge and attitudes concerning diagnosis and treatment of
attention deficit and hyperactivity disorders. A national survey approach. Arch Pediatr Adolesc Med 1995; 149: 1211-6.
11. Stein, R. E. and Horwitz, S. M. and Storfer-Isser, A. and Heneghan, A. and Olson, L. and Hoagwood, K. E., Do
pediatricians think they are responsible for identification and management of child mental health problems? Results of
the AAP periodic survey. Ambul Pediatr 2008; 8: 11-7.
12. Stein RE, Horwitz SM, Storfer-Isser A, Heneghan AM, Hoagwood KE, Kelleher KJ, O’Connor KG, Olson L
Attention-deficit/hyperactivity disorder: how much responsibility are pediatricians taking? Paediatrics, 2009.
13. National Institute for Health and Clinical Excellence. Attention Deficit Hyperactivity Disorder: Diagnosis and
Management of ADHD in Children, Young People and Adults. NICE, 2008.
Paediatricians??? Views on Their Role in the Assessment and Management of ADHD and Autism2