Care for children with ADHD — A collaborative approach between GPs and paediatricians

Jake is brought to his GP, Dr Jane, by his mother Sarah, following a discussion with his grade 2 teacher about his disruptive behaviour in class.  Apparently, he has difficulty concentrating on class activities, does not seem to listen to instructions and is upsetting classmates by always blurting out answers and being too “rough” in the group activities. The teacher has suggested that he gets checked for ADHD.

• ADHD is a condition often presenting to general practitioners by way of concerned parents, or at the request of a teacher.

• Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with an onset typically before 12 years of age. The symptoms include difficulties with attention and/or hyperactivity and impulsivity which are incongruent with a person’s age and interfere with activities and participation. 

Sarah reports that Jake lives with both his parents and an older sister (age 11). She and her husband report difficulties managing Jakes impulsive behaviour and maintaining consistent routines. Jake enjoys playing video games and sports but struggles with turn-taking and following rules.

Dr Jane considers that Jake could show symptoms of ADHD but that she would like to assess further.  She asks Sarah to fill in a Vanderbilt-Assessment-Scale and to ask Jakes teacher to fill in the teacher section. She then asks Sarah to make a long appointment for Jake to be assessed further.

• Diagnosis is usually made via clinical interview in association with screening tools or rating scales by a clinician experienced in the diagnosis of developmental or mental health disorders in children. Specific neuropsychological testing is not required for the diagnosis of ADHD but can be helpful in identifying specific strengths and difficulties that can guide treatment plans. [1]

At the next appointment Dr Jane reviews ADHD in Children and Youth - Community HealthPathways Brisbane South for help in assessing Jake. She reviews his Vanderbilt-Assessment-Scale and performs a physical exam, mental state exam and checks Jake’s hearing and vision.  She advises Sarah that she thinks that Jake does show symptoms of combined ADHD (i.e. > 6 symptoms in each category of Hyperactivity/impulsiveness and Inattention which have been present for > 6 months and occur in > 1 setting – home and school). Dr Jane advises that ADHD is likely and offers advice on non-pharmacological interventions. Dr Jane suggests that she likes to work in a collaborative model of care with a paediatrician in the management of her ADHD patients.

• Ideal models of care are integrated and transdisciplinary, whereby professionals from multiple agencies collaborate with each other, and the person and/or child and family with ADHD, to form a team. This care team should, from the beginning, allow sharing and integration of expertise into a single treatment plan.[2]

Jake is seen by the paediatrician who confirms the diagnosis, stabilises (or starts) Jake on medication and determines that he is suitable for collaborative care management.". Dr Jane receives a letter from the paediatrician outlining the diagnosis and suggested management plan. The letter confirms Jake is suitable for collaborative care and asks the GP to review Jake at regular intervals and to contact the OPD via request for advice in the event of concerns or queries.

Jake’s care is managed collaboratively between his General Practitioner (GP) and a paediatrician. His treatment plan includes:

• Medication: Methylphenidate (modified release), initiated by his paediatrician and monitored and titrated through regular reviews with his GP.

• Behavioural Strategies: Implemented at home and school, including structured routines, positive reinforcement, and sensory breaks.

• School Support: An Individualised Education Plan (IEP) with additional classroom support, including movement breaks and visual schedules.

• Paediatrician responsibilities:

o    Assessment and diagnosis of developmental conditions including co-morbidities

o    Initiation and stabilsation of medication as warranted for ADHD and comorbidities

o    Provide advice to GP on treatment plan and possible titration requirements

o    Evaluate progress via review or provide advice to GP as required

• GP responsibilities:

o    Conducts routine physical health checks (height, weight, blood pressure, heart rate) to monitor for medication side effects.

o    Provides ongoing support and advice to parents regarding behaviour management strategies.

o    Liaises with the paediatrician to notify concerns and request advice or review if required.

o    Review their local ADHD in Children and Youth - Community HealthPathways Brisbane South to aid their management of ADHD under collaborative care.

Conclusion:
Jake’s ADHD is being managed effectively through a collaborative approach between his GP, paediatrician, school, and family. Regular reviews ensure that his treatment remains appropriate, addressing both medical and behavioural needs to support his overall development.

[1] How should ADHD be assessed, diagnosed, and monitored

[2] ADHD treatment and support - Australian ADHD Clinical Practice Guideline