Evaluation of a diagnostic ADHD pathway in a community child mental health service in South London
| Published date | 14 March 2020 |
| DOI | https://doi.org/10.1108/MHRJ-10-2019-0035 |
| Pages | 1-19 |
| Date | 14 March 2020 |
| Author | Georgina L. Barnes,Alexandra Eleanor Wretham,Rosemary Sedgwick,Georgina Boon,Katie Cheesman,Omer Moghraby |
| Subject Matter | Health & social care,Mental health |
Evaluation of a diagnostic ADHD pathway
in a community child mental health
service in South London
Georgina L. Barnes, Alexandra Eleanor Wretham, Rosemary Sedgwick, Georgina Boon,
Katie Cheesman and Omer Moghraby
Abstract
Purpose –Clinicians working in UK child mental health services are faced with several challenges in
providing accurateassessment and diagnosis of attention deficit hyperactivity disorder (ADHD). Within
the South London& Maudsley (SLaM) NHS Trust,community Child & AdolescentMental Health Services
(CAMHS) are developing structuredpathways for assessing and diagnosing ADHD in youngpeople. To
date,these pathways have notbeen formally evaluated.The main aims of this evaluationare to evaluate all
ADHD referrals made to the service in an 18-month period, including the number of completed
assessmentsand proportion of childrendiagnosed with ADHD; and investigateadherence to the National
Institutefor Clinical Excellence(NICE) guideline fordiagnosing ADHD in childrenand young people.
Design/methodology/approach –Retrospectivedata analysis was performed using servicedatabases
and electronic patient records. Adherence to the clinical guideline was measured usingthe NICE data
collection tool for diagnosing ADHD in children and young people. All completed ADHD assessments
were comparedto four key recommendation points in the guideline.
Findings –Within the timeframe, 146 children aged 4-17 years were referredand accepted for an ADHD
assessment. Of these, 92 families opted in and were seen for an initial appointment. In total,36 ADHD
assessmentswere completed, of which 19 children received a diagnosis of ADHDand 17 did not. Aside
from structuredrecording of ADHD symptoms based on ICD-10 criteria(69%) and reporting of functional
impairment (75%),adherence to all guidance points was above90%. The study also found that although
a greater proportion of children referred to the service were male and identified as White, these
differencesnarrowed upon receipt of ADHD diagnosis.
Research limitations/implications –Relationshipto the existing literature is discussed in relationto the
assessmentprocess, demographic characteristicsand rates of co-occurrence.
Practical implications –The findings demonstrate that in child mental healthservices, gold standard
practice for diagnosing ADHD should be the adoption of clear, protocol-driven pathways to support
appropriateaccess and treatment for youngpeople and their families.
Originality/value –This article is unique in that it is, to the best of the authors’ knowledge, the first to
describe and report clinician-adherence to a structured pathway for diagnosingADHD in young people
withina community CAMHS service in South London.
Keywords Childhood, ADHD, Child neurodevelopment, Clinical recommendations,
Hyperkinetic disorder
Paper type Research paper
Background
Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed
disorders of childhood; the worldwide prevalence rate for children aged 6-18years is
estimated to be 3.4 per cent (Polanczyk et al., 2015) and between 2-5 per cent in the UK
(Murphy et al.,2014). The core features of ADHD are persistent and developmentally
inappropriate levels of inattention, hyperactivity and impulsivity, with an onset before the
Georgina L. Barnes is
based at the Department of
Psychology, Institute of
Psychiatry, Psychology and
Neuroscience, King’s
College London, London,
UK. Alexandra Eleanor
Wretham is based at the
South London and
Maudsley NHS Foundation
Trust, London, UK.
Rosemary Sedgwick is
based at the Department of
Psychological Medicine,
Institute of Psychiatry,
Psychology and
Neuroscience, King’s
College London, London,
UK. Georgina Boon,
Katie Cheesman, and
Omer Moghraby are all
based at the South London
and Maudsley NHS
Foundation Trust, London,
UK.
Received 18 October 2019
Revised 2 February 2020
Accepted 3 February 2020
DOI 10.1108/MHRJ-10-2019-0035 VOL. 25 NO. 1 2020, pp. 1-19, ©Emerald Publishing Limited, ISSN 1361-9322 jMENTAL HEALTH REVIEW JOURNAL jPAGE 1
age of 6 years and associated functional impairment. In the UK, clinicians typically
diagnose hyperkinetic disorder (HKD) rather than ADHD, based on descriptions provided
by the International Classification of Diseases -10th edition (ICD-10, World Health
Organization, 1992). Generally, HKD is conceptualised as a more “severe” form of ADHD,
characterised by significant psychosocial impairment in more than one domain (Singh,
2017). However, UK national guidelines continue to use the term “ADHD” in their clinical
recommendations, and this will be the term usedthroughout this study.
Epidemiological studies have demonstrated a sharp rise in the number of children
diagnosed with ADHD over the past three decades (Webberet al.,2018). Many hypotheses
have been put forward to explain this increase, including shifts to public and mental health
policy (Hinshaw and Scheffler, 2014) and changes to conceptualisations of normative child
behaviours over time (Miller and Leger, 2003;Timimi and Taylor, 2004). Clinicians therefore
face many challenges in providing accurate assessment and diagnosis of ADHD in
practice. For example, there is considerable overlap between ADHD symptoms and those
of other conditions; inattention and restlessness may be observed in depression
(Delavarian et al., 2012), anxiety disorders (Connolly and Bernstein, 2007), specific
language disorders (Pham and Riviere, 2015) and intellectual disabilities (Simonoff et al.,
2007;McClain et al.,2017). Results from national surveys also indicate that over half of
children with ADHD have at least one additional neurodevelopmental or psychiatric
condition, with the most common being specific learning difficulties, anxiety disorders and
oppositional defiant disorder (Reale et al.,2017;Zablotsky et al.,2018). This can lead to
misdiagnosis and underdiagnosis of ADHD, which has been associated with several
adverse outcomes for young people and their families, including higher emotional
problems, peer relationship difficulties and impaired family functioning (Okumura et al.,
2019).
Another challenge relates to the accurateidentification of ADHD symptoms in the context of
diverse behavioural profiles. For example, community prevalence studies highlight
considerable variation in rates of ADHD diagnosis according to gender; and there appears
to be a relative under-recognition of ADHD symptoms in females compared to males
(Erskine et al.,2013;O’Leary et al.,2014). Population-based studies have found that males
are more likely to be referred to clinical services for externalising behaviours (Gershon,
2002;Mowlem et al., 2018), which may have an indirect effect on the threshold for
acceptance into clinical services, leading to an under-identification of ADHD in females. At
a diagnostic level, gender differences may reflect a wider discrepancy between the two
major classification symptoms used to diagnose ADHD in children and young people.
Although ADHD/HKD behavioural symptomology is similar in the DSM-IV (American
Psychiatric Association, 1994) and ICD-10, there are differences in how the two systems
combine symptoms across the three core domains of inattention, hyperactivity and
impulsivity and how pervasiveness is defined for ADHD diagnostic criteria to be met.
Empirical evidence suggests that females are more likely to present with predominantly
inattentive symptoms (Greven et al.,2018) and this sub-type of ADHD is not included in the
ICD-10 for HKD. Female gender has also been found to predict ADHD diagnosis based on
DSM-IV symptom criteria and controlling for symptom severity (Sayal et al.,2008), which
highlights potential inconsistencies in symptom measurement and the application of
diagnostic criteria across differentgroups.
Recent prevalence studies have identified associations between race/ethnicity and ADHD,
with some research indicating that children from non-White and non-English speaking
households may have lower rates of diagnosis (Coker et al.,2016;Morgan et al., 2013).
Similarly, research describing associations between sociodemographic variables (e.g.
parental income, education and marital status) and ADHD prevalence has found higher
rates of ADHD in low-income children (Russell et al., 2015). It is hypothesised that these
differences may reflect culturally contextualised parental explanatory models of ADHD
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