Response of The Royal College of Psychiatrists (Irish Division) Child and Adolescent Section to: Report on Attention Deficit Disorder in Ireland Prepared by the Joint Committee on Health and Children, 1999. Introduction: We welcome this timely report and agree broadly with its recommendations. We regret that the consultation process involved in the preparation of the report was not wider. The views of the Royal College of Psychiatrists (Irish Division)- Child and Adolescent Section were not sought, nor were the views of the majority of Consultant Psychiatrists working in the Health Board Child and Adolescent Psychiatric Services throughout the country, despite the fact that service provision to young people with Attention Deficit Disorder and their families constitutes a large part of the workload of these services. We particularly support the recommendations that multidisciplinary diagnostic and treatment teams should be developed throughout the country to help address the problems of ADHD. We believe that these multidisciplinary teams should develop as specialist teams within the Child and Adolescent Psychiatric Services where the majority of children with ADHD are already being seen. We believe the proposed multidisciplinary teams should not be developed in isolation from these services. Young people with ADHD tend to have significant co-morbidity (oppositional and conduct disorders, depressive disorders, anxiety disorders, specific learning difficulties, speech and language disorders). Considerable expertise exists within the Child and Adolescent Psychiatric Services in the management of these disorders, and it makes little sense to consider developing a separate service for children with ADHD and their families. The development of the ADHD Clinics in Our Lady s Hospital, Crumlin and The Children s Hospital, Temple Street, should be facilitated to provide a tertiary referral service for the most difficult cases, and to enable research to be carried out. We agree that the needs of most young people with ADHD are not being met within the Educational Services. Considerable more training needs to be made available to teachers, and the resources necessary to support children with ADHD within the mainstream school system need to be provided. These resources include educational psychologists, remedial teachers and classroom assistants. A proportion of children with severe ADHD and its co-morbid conditions will continue to need special school provision. The recommendation to set up a school especially for young 1
people with ADHD is interesting. One school would do little to address a country-wide problem, but it might foster the development of expertise in teaching and classroom management of children with ADHD which could be used in other schools. Attention Deficit Disorder 1. Estimated Prevalence: The estimated prevalence of this disorder is somewhere between 1% and 5 % of school age children (i.e. aged 5-15 years). If one takes a population unit of 100,000 people, each population unit in this country would have approximately 25,000 children aged 5-15 years. This means that between 250 and 1,250 school aged children per population unit will have ADHD at any one time and 25-125 new cases of children aged five will arise each year. At present the Child and Adolescent Psychiatry Services in Ireland receive a total of approximately 150-200 referrals per year per population unit of 100,000. Currently only a small proportion of school age children with Attention Deficit Hyperactivity Disorder are referred to the specialist Child and Adolescent Psychiatric Service for assessment and treatment. With increasing recognition of this condition in the community the number of children referred will increase substantially with serious resource implications for the Child and Adolescent Psychiatry Service. It would be reasonable to assume that the lower prevalence figures refer to the more severe cases necessitating referral to Child and Adolescent Psychiatric Services. 2. Input required per child. a. Assessment Procedure: ADHD is a clinical diagnosis, there is no diagnostic test available to confirm it. Assessment therefore means considering whether there are alternative causes of inattentive, impulsive, restless behaviour as well as a full appraisal of the child in order to detect associated (co-morbid) conditions or problems. Considerable care and expertise are essential in assessing children s emotional disorders and co-morbid problems in order to ensure a correct diagnosis. Assessment includes: Detailed psychiatric evaluation of the child, interview with parents and information from the school setting. Medical history and examination. Completion of behaviour rating scales (e.g. Connors questionnaire both from parents and teachers) which assist diagnostic interview and in monitoring response to treatment. Referral for paediatric examination / neurological evaluation may be deemed necessary as a result of this assessment. Investigations (e.g. blood tests, EEG as indicated clinically). Family Assessment to include family dynamics, parent management techniques and identification of other stressors within the family. Psychometric testing - Due to the high rates of co-morbid, cognitive and academic problems and educational under-achievement psychometric testing is frequently indicated. 2
This may identify the need for further specialist neuro-psychological testing or specific educational requirements. Speech and Language Assessment where clinically indicated, with a possible need for a therapeutic intervention. Occupational Therapy evaluation,where clinically indicated which may lead to a recommendation for special sensory integration therapy. Direct observation in the classroom setting may be helpful as part of the overall assessment. This detailed assessment is required to establish a diagnosis and rule out underlying conditions which may mimic Attention Deficit Hyperactive Disorders and to establish the presence or absence of other co-morbid conditions. Recognition of co-morbid conditions and difficulties enables the child to be treated in a more holistic fashion. ADHD is in itself associated with the development of conduct disorder. At least 1/3 of children with ADHD will have a diagnosis of Conduct Disorder by current criteria though this figure may be higher in older age groups. The co-morbid rates of emotional disorders are also raised, increasingly so by age. b. Treatment / Management Plan. The evaluation and management of the treatments used for ADHD require input and co-operation from the patient, the parents and the school, making the clinicians role as co-ordinator or case manager vital to the treatment. ADHD has an extended course requiring continuous treatment / planning to evaluate the effectiveness of current treatment and the emergence of new problems. Education of Child, Family and Teachers about ADHD. Pharmachotherapy. The decision to medicate is based on the presence of a diagnosis of ADHD and persistent target symptoms that are sufficiently severe to cause function impairment at school and usually also at home and with peers. In most cases a stimulant is the first choice medication e.g. Ritalin (Methylphenidate) or Dexedrine (Dexamphetamine). Stimulant drugs are clearly effective from a large number of research studies and many years of clinical experience in large numbers of patients. These are controlled drugs which require a gradual dose titration and careful monitoring of the child s response and detection of any unwanted side effects. The majority of children, approximately 90%, respond to stimulant medication. However a small proportion require alternative treatments e.g. Tricyclic Anti- Depressant or combinations of medications. Such children may be referred to a specialist centre for evaluation. Instruction or teaching of parents the strategies to handle their children s behaviour taking into account identified difficulties. This work is lengthy and labour intensive and may require several sessions. Family Intervention, Family therapy if the family dysfunction is present. Individual work with the child. Some of this may take the form of addressing target symptoms such as anger management or impulse control. Alternatively treatment of comorbid conditions. Specific educational remedial education. Many children with ADHD also have co- existing specific learning difficulties which require specific remedial intervention. These can only be provided in the educational system by specially appointed remedial and resource teachers. Ongoing consultation and 3
collaboration with teachers and other school personnel providing information about ADHD, educational techniques and behavioural management. Issue of Behavioural Difficulties in the class room. Teachers and class room assistants are in regular daily contact with children with ADHD and often require specific instruction in the handling of these children s difficult behaviours. Specific behaviour modification programmes may be indicated and in this we see a role for co-operative working with the educational psychology service. Social Skills therapy for children and adolescents with peer relationship difficulties. Auxiliary treatments including speech and language therapy, occupational therapy as indicated clinically. c. Review: Once diagnosis of ADHD has been established and a treatment plan initiated, it is vital to maintain a long-term supportive contact with the patient, family and school to ensure compliance with the treatment and to address problems at new developmental stages or in response to family or environment changes. This will require regular reviews. For children whose condition improves and stabilises regular review by a Child and Adolescent Psychiatrist is required. A multi-disciplinary review which addresses both educational attainments and family functioning is advisable on an annual basis. Many children have co morbid conditions which require additional input both at an individual, family and school level (e.g. oppositional defiant disorder or an emotional disorder). d. Pharmacotherapy. Children who are receiving medication require regular careful monitoring of response, onset of side effects (which can usually be improved by altering the dosage of medication). An annual review of the child s need for pharmacotherapy is recommended. This involves withdrawal of the medication for a number of weeks in order to establish whether the need for pharmachotherapy exists any longer. Children at the severe end of the spectrum (0.5 to 1% of school going population ) may need to continue medication for an extended number of years. Recommended Action - Resource Provision. At present only a small proportion of children and adolescents with Attention Deficit Hyperactive Disorder are referred to Child and Adolescent Psychiatry Services for assessment and treatment. With increasing awareness of this problem which affects 1% - 5% of school going children in the community, referrals will undoubtedly increase dramatically. Taking into account the process of assessment and management of Attention Deficit Hyperactive Disorder it is obvious that this is a need which cannot be adequately addressed within the existing Child and Adolescent Psychiatry Service as it is presently resourced. 4
We recommend that the Department of Health plan to put in place one whole time equivalent Consultant Child and Adolescent Psychiatrist, per 200,000 of the population in addition to existing services (i.e. where there are two Child Psychiatry teams this would increase to three). With this additional resource a reasonable expectation could be that each of the three teams in each area could devote three sessions per week to Attention Deficit Hyperactive Disorder (i.e. one session per new assessment and two sessions for follow up assessment and treatment). Educational Interventions. The Department of Education should be pressed immediately to augment the Educational Psychology services and to provide remedial and resource teachers where necessary as the majority of treatment plans require the provision of appropriate educational services. Suitable educational services should be made available for children with learning disability who also have Attention Deficit Hyperactive Disorder. ADHD In Adults Prospective longitudinal studies of hyperactive children have revealed that approximately 50% function well as adults, whereas the remainder suffer from some degree of impairment affecting attention, impulse control, problem solving strategies, school performance, self esteem, peer relations, academic attainment and work record. The provision of a treatment for those adults who were initially diagnosed and treated in childhood and adolescence and continue to have symptoms and those adults who have the diagnosis made in adulthood (this often occurs when their child has been diagnosed with Attention Deficit Hyperactive Disorder and the parent recognises some of their own symptoms) within the adult psychiatry service is a matter that needs serious consideration. Conclusion. We hope that this report will lead to increased mental health and educational resources for children with Attention Deficit Hyperactive Disorder and their families. Increases communication between the Departments of Health and Children and of Education and Science to facilitate co-ordinated service development. References. 1. The Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention-Deficit /Hyperactivity Disorder (J.Am.Acad Child & Adolescent Psychiatry 36:10 supplement, October 1997). 2. Commissioned Review: Recognising Hyperactivity. (Child Psychology and Psychiatry Review, Volume 4 no 2 1999). 3. FOCUS on The use of stimulus in Children with Attention Deficit Hyperactivity Disorder ( College Research Unit, The Royal College of Psychiatrists, London 1999). 4. Fourteen Month Randomised Clinical Trial of Treatment Strategies for ADHD 5
( Archives of General Psychiatry 1999 56:1073-86). 5. Moderators and Mediators of Treatment Response for Children with ADHD (Archives of General Psychiatry 1999 56:1088-96). 6. Development of Clinical Service for ADHD. (Archives of General Psychiatry 1999 56: 1097-99). This report was prepared for the Child & Adolescent Section of the Royal College of Psychiatrists (Irish Division) by: Professor Carol Fitzpatrick. Dr Colette Halpin. Dr. Brendan Doody. July 2000 child/adhdresp.doc/18.7.00 6