The role of General Practitioners in ADHD diagnosis and management

7. Pathway to diagnosis and treatment

Here's a diagram detailing the patient’s journey to diagnosis and access to care. This is a broad representation about the ADHD journey. Referral and treatment pathways for ADHD are complex and not the same within every Clinical Commissioning Groups(CCG). Specific secondary care services will differ widely from one area to another. In some areas, child diagnoses are the sole responsibility of community paediatricians or CAMHS, in other areas this responsibility is shared. Specific waiting times will also widely differ, often reaching months before a diagnosis.

Whilst clinical services for children with ADHD are commonly available in the UK, adult service provision is more patchy. This is particularly problematic for children approaching the age of 18 in areas where there are no adult services. These need commissioning.

(As services vary so widely across the UK), it is not possible for us to be able to inform you about each local structure of care provision for ADHD. It is therefore important for each GP to know and understand local referral and management procedures.

The diagram details the patient’s journey to diagnosis and access to care and both videos explain in detail what happens in secondary care once the referral is sent.

Adult services

Child services

Dr Alinda Gillott

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If you suspect an adult may have ADHD a referral to secondary adult mental health services should be made in the first instance. There a clinician trained in the assessment of ADHD in adults such as a psychiatrist, clinical psychologist or nurse will carry out the assessment. If there is complexity such as additional mental health or neuro developmental issues a referral to a specialist adult ADHD clinic may be sought. The process can be lengthy and involve multiple appointments. Once diagnosis is established a treatment plan can be made. This may involve a combination of pharmacological and non-pharmacological treatment options. The clinician will make this plan with the patient and report back to you.

Nurse Joe Kilgariff

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Following on from ADHD symptoms being identified a referral will usually be made into secondary services and from there somebody will take some initial information and then decide whether the child should be seen in community paediatrics or child and adolescent mental health services, this is usually to do with complexity, co morbidity or difficulty to diagnose because of family situations. An initial appointment is then likely to be undertaken in one of those services where the history of the child will be taken from the parent and the child themselves and hopefully information from the school will also be collated. There will then be questionnaires given to the parent to give to school. They’ll then be a gap of time while those questionnaire are given to the school and handed back in to the service usually about 3 to 6 months and the paediatrician of CAMHS worker may suggest some strategies to try in the meantime to see if some of the symptoms can be reduced such as sleep hygiene or diet changes.

A second appointment after that 3 or 6 months will then be undertaken where the questionnaires will be reviewed and the history looked at and if a diagnosis is appropriate it will be made in that appointment. Following on from that there will then be a discussion about treatment and this may include medications or school liaison or parenting courses. If medication is appropriate it will be initiated in either that appointment or the next one titrated, stabilised and then the child is likely to return back to primary care for repeat prescribing under shared care, as with children there is a local shared care protocol. There may be regular follow ups in the secondary care organisation and hopefully there will be letters sent to you in your primary care service to keep you informed of what’s going on. The child may stay on medication until they are 18 or until they feel it’s no longer needed or they transition into adult mental health services.