In 2015, the Dutch government introduced a new Child and Youth Act, which instructed local governments in The Netherlands to take responsibility for the prevention, support and treatment of developmental and psychological conditions and disorders. The aim of the Child and Youth Act was to enable primary healthcare services to distinguish between those children with ADHD symptoms who require specialised mental healthcare and those who require supportive counselling only. Accurate diagnosis of ADHD is essential for the success of the Child and Youth Act, to avoid over- and under-diagnosis of ADHD and to allow adequate care to be matched to the needs of the child and their family. This study sought to gain insight into the characteristics of children with ADHD symptoms referred to a specialised care facility prior to initiation of the Child and Youth Act.
This study analysed data from a database of children attending the outpatient Medipsy ADHD clinic* between September 2011 and November 2015 who were assessed by a multidisciplinary team consisting of a psychologist, a nurse specialist, a staff member from the child psychiatric centre and a paediatrician. Prior to visiting the clinic, each child’s parents and teacher completed ADHD screening rating scales† and a demographic form, in addition to an open questionnaire which was completed by the teacher only. During the clinical visit, children underwent a medical history and complete physical examination, and children and their parents were interviewed by the psychologist to assess ADHD symptomatology and psychiatric comorbidities, and to establish who initiated referral to the clinic (e.g. parents, school, or both parents and school). A diagnosis was then made by the multidisciplinary team based on the above information in line with the Diagnostic and Statistical Manual of Mental Disorders – 4th Edition – Text Revision.
Data from 261 children were analysed (mean age ± standard deviation: 10.0±2.87 years; 72.8% male), with a clear indication of who initiated the referral to the ADHD clinic available for 258 children. Approximately half (50.8%) of children were referred to the clinic by both their parents and teacher, with significantly more boys than girls referred by teachers (p<0.05). Referral to specialised mental healthcare due to ADHD and/or other psychiatric symptoms causing serious impairment was deemed necessary for 31.4% (82/261) of children, whereas 33.3% (87/261) of children with ADHD without a psychiatric comorbidity were referred for supportive counselling, which was eventually to be combined with methylphenidate treatment in a primary care clinic. The remaining children (34.1% [89/261]) referred to the ADHD clinic were not diagnosed with ADHD but required primary care due to other problems. There was no significant association between who first initiated referral and the need for specialised mental healthcare, i.e. parents alone versus school alone (odds ratio [OR]=1.20; 95% confidence interval [CI] 0.55–2.63; p=0.64), or parents and school versus school alone (OR=1.58; 95% CI 0.81–3.01; p=0.17). There were no demographic differences between children with ADHD requiring specialised mental healthcare and those with ADHD referred instead for supportive counselling, except that children of divorced parents were more likely to be referred for specialised care (OR=2.35; 95% CI 1.15–4.80; p=0.02). Children with higher scores on the Child Behaviour Checklist (CBCL) and Teacher Report Form (TRF) were more likely to be referred to specialised care (CBCL: OR=2.10, 95% CI 1.14–3.80, p=0.02; TRF: OR=2.35, 95% CI 1.26–4.30, p=0.007). Scores on the ADHD-related symptoms, as reported by both parents and teachers via the ADHD Vragen Lijst (AVL) behavioural questionnaire, were higher in those diagnosed with ADHD in the absence of a psychiatric comorbidity.
Little is known about the regional differences regarding referral and use of different ADHD services, and since these results are based on data from one ADHD clinic in The Netherlands, assumptions about demographics and patient populations in other clinics cannot be made. Additionally, since there is no uniformity between ADHD diagnoses across different centres, this may also limit the generalisability of these results. Also, since the clinic studied here is located in a hospital, it is feasible that children with more psychiatric comorbidities and social problems could have been referred directly to specialised mental healthcare and did not register at this clinic, which may have introduced bias into the dataset.
In The Netherlands, the government are hoping to involve teachers and families in providing primary healthcare for children with ADHD, in addition to the current involvement of general practitioners, youth healthcare physicians, social workers, psychologists and coaches. In this study, the total scores of the CBCL and TRF were predictive of a need for specialised mental healthcare, but a clinical decision was only made by the multidisciplinary team. The authors concluded that by building relationships between primary and specialised healthcare, the Child and Youth Act will be successful in enabling a critical assessment of each child presenting with ADHD-like symptoms to be conducted.
*The Medipsy ADHD clinic is a collaboration between a primary mental healthcare clinic and a specialised child psychiatry institute for children aged 6–18 years. All children attending the clinic were referred by a general practitioner or their school doctor due to the presence of ADHD-like symptoms
†The Child Behaviour Checklist (CBCL), Teacher Report Form (TRF) and Youth Self-Report (YSR) form were used in this study to quantify behavioural problems, emotional problems and skills in children. Both attention and problem scores and total scores were used to evaluate the child, with total scores used to determine whether the child required specialised mental healthcare. T-scores between 65 and 70 were described as subclinical, whereas scores >70 were defined as clinical scores. The ADHD Vragen Lijst (AVL) is a Dutch behavioural questionnaire based on the DSM-IV, which was used to determine whether ADHD-specific healthcare symptoms existed, and if so the extent to which symptoms of inattention, hyperactivity and impulsivity contributed
Levelink B, Feron FJM, Dompeling E, et al. Children with ADHD symptoms: who can do without specialised mental health care? J Atten Disord 2018; Epub ahead of print.