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ADHD Care Pathway for school age children

Checked: 27-06-2024 by Vicky Ryan Next Review: 26-06-2026

Overview

This page gives a summary for GPs on the referral pathway for children and young people for ADHD assessment in BNSSG. Referrals will usually be made through the school system and so GPs should not usually need to be involved unless this route is unavailable.

The ADHD pathway has been updated by Sirona care & health in June 2024 as part of the service process review.

Please see the Sirona care & health Community Paediatrics referral page for the care pathway for school aged children with impaired attention who may require an assessment for ADHD, and referral information for BNSSG. Please note that new referral questionnaires for assessments of ADHD for parents/schools and young people are now on the this page and can be accessed by schools making a referral.

Clinical Knowledge Summaries also has a summary of NICE guidelines for the diagnosis and management of ADHD. The guidelines cover diagnosis and management of attention deficit hyperactivity disorder (ADHD) in children and young people.

School Referral

Children with suspected ADHD should be referred by school Special Educational Needs Co-ordinators (SENCo) where possible rather than via a GP. They will be asked to complete the school questionnaire for assessment of ADHD.

This is preferable as

1.) Information from school is required as part of the assessment and is required before the assessment can begin.

2.) Schools need to be aware of the concerns and may be able to resolve some of issues with classroom intervention without the need for referral.

If a referral is received from a GP for a child who is in a school setting, without an explanation as to why a referral from school is not possible, the referral will be returned with the referrer directed to the school referral pathway.

Alternative Pathways

Age

Children under the age of five are not able to be assessed for ADHD through this service. Referrals of children younger than five will be returned with a request to resubmit when the child is over the age of five, if still required, with accurate supporting information for age.

Parents of pre-school children with challenging behaviour (including difficulties with hyperactivity and inattention) should be directed to resources - see ADHD - HappyMaps.

Professional support in managing these behaviours can also be accessed through parenting support courses (see resources section below).

Children over the age of 17 years and 6 months should be re-directed to adult ADHD services, as their assessment will not be completed before they turn 18 years old.

GP Referral (if school referral not available)

If the school referral route is not available, for example, if the child is home educated or outside of the educational system, a GP or other health care professional can make a referral to Community Paediatrics if criteria are met*, by following the steps below. Please note, this does not include children in alternative education settings such as Education First, who should be asked to make the referral themselves.

Before referral

Please ensure that parents have seen the information on ADHD resources available without a diagnosis on the advice and signposting page and direct them to local support services for children with challenging behaviour as appropriate.
Check that the child meets criteria for suspected ADHD*
Consider other options for support or referral if appropriate (see 'Other Scenarios' below)

Essential additional information - please include this information in a referral:

Involvement/previous involving of social care
Involvement of Youth Offending Team (YOT)
Chid attending/to be moved to an educational placement outside of mainstream setting.
Child not attending education.

Referral Forms - provide the following forms in order to complete the referral and email (or send) to SPE - sirch.singlepointofentry@nhs.net:

Parent ADHD referral questionnaire
SPE referral form (also available as as EMIS template)
Young person 11+ ADHD referral questionnaire (optional)
School ADHD questionnaire - only if child is in an educational setting

*Please note that in order to diagnose ADHD, the service require the following to be present:

The child has symptoms of inattention and/or hyperactivity which were present before the age of 12. Please note it is these symptoms, not other behaviours/conduct that are important here.
The inattention and hyperactivity must be abnormal compared with other children of a similar age and developmental level.
Inattention and hyperactivity must be present in at least two settings (most often home and school)
The inattention and hyperactivity symptoms must be impairing. For children with comorbid conduct or other difficulties, it must be the ADHD symptoms that are impairing and not symptoms from their other difficulties, as treatment for ADHD will not affect these other symptoms.
The features are not explained by an alternative medical, developmental condition or environmental source.

Other scenarios

Other Conditions

The following scenarios may present as suspected ADHD and should be considered - see the table below for details:

Area of difficulty	Recommendations
Sleep difficulties	Sleep difficulties are common in children. Sleep deprivation can also cause ADHD-like symptoms. The best way to manage sleep is through good sleep hygiene and routines. Good sleep hygiene is essential. One You and Happy Maps give information for improving sleep according to age group.
Sensory differences	Inattention can be due to sensory distraction, hyperactivity/fidgetiness may be sensory seeking behaviour. Information about sensory processing differences.
Difficulties in focusing if not an area of interest	We all find it easier to concentrate on things we are interested in. For some people it can be almost impossible to engage in areas outside their interest. Consider whether there are other neurodiversity differences such as those seen in autism.
Difficulties in a particular subject only	Some children may struggle more in one particular subject more than others, this might be down to the circumstances of that class or may be caused by a specific learning difficulty in that area such as dyslexia or dyscalculia. If you think this is the case, discuss this with school in the first instance.
High anxiety levels Low mood High stress levels (including past and present trauma)	It can be very difficult to concentrate when anxious, depressed or in a state of stress; and symptoms can sometimes look like ADHD. Support for child mental health.
Insufficient opportunities for exercise and activity	Children and Young People should exercise for a minimum of 60 minutes per day. There is good evidence that exercise is helpful for people with attention, hyperactivity and impulsivity needs whether they have ADHD or not. Physical activity guidelines for children and young people
Cognitive differences	If a child has low academic attainment, global developmental delay or learning disability, their needs around attention, hyperactivity and impulsivity should be considered in the context of their functional age and not their chronological age.
Difficulties with behaviour	It is important to recognise that children showing oppositional, defiant, aggressive and violent behaviour, although often seen with ADHD, are not ADHD symptoms. ADHD medication is often not helpful in these situations and sometimes makes the problem worse. Getting professional support is important in resolving these difficulties. Behavioural support is recommended at the educational setting as well as at home.
Young in school year	It is important to be aware that a child that is very young for the school year may appear to struggle more with attention compared to their older peers.

Co-morbid mental health issues

If, in addition to ADHD, you have concerns regarding complex mental health co-morbidities (i.e. anxiety, depression, self-harm or eating disorders) then a referral to CAMHS , or an appropriate service, should be made.

These conditions cannot be managed via Community Paediatric services, and it is important that patients are not spending time on a waiting list in the false expectation that they will be assessed or treated for these conditions. Please note that a cardiovascular examination is required prior to a CAMHS referral for ADHD assessment.

Private Assessments

If a private assessment has been completed and a diagnosis of ADHD has already been given, a request for ongoing NHS care can be submitted via the SPE form and will be triaged for assessment.

To complete this triage, the service need the original diagnostic report and details of the child or young person’s history and current medication.

If the ADHD assessment is not adequately robust at triage, a new referral from school will be requested where possible.

The following evidence is required to consider an assessment to be robust:

Completed by an appropriately qualified person (usually a consultant paediatrician or child psychiatrist).
Completed by an organisation registered within the Care Quality Commission (CQC).
Containing information provided by education, which can be in the format of psychometric questionnaires (i.e. Connor’s forms).

For children already on medication, the service require that their private provider has stabilised them on a medication for six months before they are able to take over medical oversight and see as follow up in clinic. Children who are not stabilised on medication, may need to be reviewed as new patients, which may take longer to be seen.

Right to Choose (update Oct 2024)

For patients wishing to choose a “Right to Choose” provider it is important they understand that the provider may not integrate with local BNSSG pathways and/or other services as the provider does not hold a contract directly with BNSSG ICB. It is advisable for the GP and patient to agree the most suitable provider as the referral must be “clinically appropriate” for the patient under choice framework.

The attached spreadsheet summarises the current services offered by RTC providers, including referral information and exclusions. See the relevant tab at the bottom of the page for ADHD/ASD Adults/Children.

Post diagnostic support - where a provider has indicated availability of post diagnostic support, referrers/patients should contact them directly to check what this includes before making a decision on this basis. Some post diagnostic support offers for ADHD and Autism may be limited to signposting to other organisations; so patient expectation around this should be managed at the outset.

Clinical Partners have paused offering CYP RTC assessment for ADHD

Evolve Psychology

Evolve Psychology offer ADHD assessment only for Children and Young People (5 years +).

Please see https://evolvepsychology.org/fees-and-funding/ for more information about referrals under NHS Right to Choose.

ADHD 360

ADHD 360 offer ADHD assessment for Children and Young People (14 years +) and will titrate and medicate where appropriate.

Link on website to referral documents, covering letter and referral form. This is then sent to the provider by the GP. Email address for referrals is: righttochoose@adhd-360.com

Psicon

Psicon offer ADHD assessments for Children and Young People (5 - 17 years) they will titrate and medicate where appropriate.

Healios

Healios is an organisation that is currently contracted by Sirona to carry out ADHD / ASD assessments to help them clear their backlog. GPs and school nurses cannot refer directly as they do not have a Right to Choose contract. Referrals need to go to the Sirona services who in turn may or may not send them on to Healios or they can go directly to a RTC provider as described above.

Resources

Support available without referral/diagnosis

Information about the non-medical management of inattention and hyperactivity is directly available on the advice and signposting page including a webinar, some resources and other support services. These can be accessed without a diagnosis or referral from a GP/school.

Information for schools can also be accessed on this page.

Please note that oppositional, defiant, violent and aggressive behaviours, although often seen with ADHD, are not ADHD symptoms. Children with these difficulties often do not respond to ADHD medication, and in fact medication may make some of these symptoms worse.

We would instead recommend behavioural support, the following services should be accessed, if appropriate, prior to referral. These services are free and can be accessed without medical or school referral, examples include:

The Incredible Years: for parents and carers of children aged 3 to 10 years with challenging behaviour.
Parents Plus Adolescents Programme: for parents and carers of children and teenagers aged 10 to 17 years.
Timid to Tiger: for parents and carers of children aged 3 to 12 years with anxiety.
Non-Violent Resistance or NVR: for parents or carers of children aged 8 to 17 years with violent, controlling or self-destructive behaviours.

A full list of available courses for each area can be found below:

Bristol: https://www.bristol.gov.uk/residents/social-care-and-health/children-and-families/support-for-parents-and-carers/parenting-courses-currently-running-in-bristol:

South Glos: Support with parenting | South Gloucestershire (southglos.gov.uk)

North Somerset: About parenting and family support | North Somerset Online Directory (n-somerset.gov.uk)

Happymaps

A locally developed website which includes information on ADHD, SEND and Autism in children. See the Happymaps Remedy page for more details.

Medication Shortages

ADHD Medicines Shortages – Advice for Primary Care on prescribing in Children(October 2023)

Patient information

Advice and signposting – Children and Young People’s Services (sirona-cic.org.uk)

Neurodiversity, autism and ADHD information for parents

Think ADHD Resource Hub

Provides useful resources for GPs and patients. It was developed by a GP to professionalise and streamline the data collection process for ADHD screening. Patients using Think ADHD can record their story at their own pace, and in their own time, without the pressure of short GP clinic appointment times.

Once complete, the validated ASRS score and comprehensive patient symptom history report can then easily be sent back to you via email, dedicated text message service or in printed form.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.