The multimodal assessment and management necessary for the individual with ADHD and his/her family is organised on a case management basis. However, the widespread effects of the persistence, co-morbidity and social dysfunction of ADHD on the individual, family and society require broader inter-agency collaboration. A wide variety of human service agencies, largely within the health, education, welfare and justice systems, provide assistance with management of the disorder and its effects.
While the majority of children and adolescents with ADHD and co-morbidity are managed in mainstream regular classrooms and within the child’s usual family environment, the co-morbidity and differential diagnosis, especially with cognitive learning disorders, demand services for assessment and treatment from community health and education service providers. This includes collaborative involvement of parent and patient treatment groups, occupational therapists, speech pathologists, pediatricians, child psychiatrists, psychologists, social workers, and educators.
The pressures faced by families affected by ADHD, sometimes over successive generations, can threaten family affection, cohesion and survival. The dissolution of families which can follow often finds a single parent struggling with a difficult child (or children), thereby creating an even greater burden both on the single parent and on welfare agencies.
For individuals, defiance or aggression in early childhood later increases the risk of Conduct Disorder, substance abuse and criminality (Satterfield, Swanson, Schell et al 1994). Large studies in the United Kingdom (Moffitt 1990), in New Zealand (Moffitt and Silva 1988; Moffitt and Harrington 1994) and in Canada (Offord and Bennett 1994) document the influence of early disruptive behavior, language learning disorders and family adversity on delinquency. The developmental trajectory of early disruptive behaviour, progressing through Conduct Disorder to antisocial personality disorder and chronic offending, predisposes to persistent offending, including perpetration of violent crime. A recent survey recorded ADHD in 25 per cent of male prisoners (Eyestone and Howell 1994). Legal precedent in the Supreme Court of Western Australia (1995) has recently recognized the impact of ADHD, associated learning disability and social compromise in the risk of delinquency. Needs are often unmet during juvenile incarceration, an opportunity that could have offered a chance for identification and intervention (Otnow, Yeager, Lovely et al 1994).
There are therefore major implications for management of ADHD and its co-morbidities in the justice and welfare systems. These systems must address appropriate management strategies including medication and behavioral, emotional and educational support. The collaboration between agencies present great challenges in treatment methods and professional practices, philosophies and training. However, the principles endorsed in The Health of Young Australians. A National Health Policy for Children and Young People (Australian Health Ministers’ Conference 1995) provides the basis and framework for this to occur.
Appropriate education within and between professions, collaborative management and sharing of resources, epidemiological data and scientific knowledge and evaluation of different treatment strategies are important because of the multimodal assessment and management necessary for ADHD. Modern information technology should assist greatly in matching demand to available services and aligning clinical practice with modern scientific and professional data.
Doctors, educators, other relevant professionals and parents should collaborate to ensure the optimum management of ADHD.
Further research is required regarding the impact of ADHD in the education, health, welfare and justice systems.
Access to community resources
Multidisciplinary services for comprehensive management are often scarce in any one locality. In addition, responsibility for case management may be determined by the presenting symptom or consequence of ADHD and by the most available, but not necessarily the most appropriate, service. Educational, behavioral and family support and counselling are all time consuming and likely to be needed long-term. Affected families need structure, energy, enthusiasm and continuity from their professionals (and agencies) who are at risk of overload with continuing and new cases. With a possible risk of up to 25 per cent of ADHD in close relatives, some families will have more than one child, and possibly a parent, with ADHD and associated disorders. The risk of siblings of children with ADHD for behavioral, academic and psychiatric disorders must be recognized and managed (Faraone, Biederman, Mennin et al 1996). All professionals involved need to manage combined consultations for several family members, who may have different types and severity of ADHD and co-morbidity. Shared management is essential.
In planning the extent and range of community resources required to manage children with ADHD it should be noted that not all children with ADHD present for professional management. Additional child and family factors may be associated with referral for clinical opinion. These include Conduct Disorder, school relationship problems, parents’ inappropriate discipline and parental depression. The severity of hyperactivity may be less significant. Though Woodward, Dowdney and Taylor (1997) only compared small numbers of clinically referred children, the influences they describe may be significant for service provision.
The time, complexity and continuity for consultation and management may only be available through private practitioners and agencies at great financial cost to the family and with less opportunity for multidisciplinary teamwork. Many children with ADHD are able to access appropriate management only because of financial assistance through the Child Disability Allowance (CDA), which currently is not widely available to children with ADHD. Future procedures for assessing eligibility for CDA based on functional disability rather than ‘manifest conditions’ may facilitate support for many more children with ADHD.
Monitoring and evaluation of the impact of ADHD in society
National databases currently being developed for community health, morbidity and mental health surveys should incorporate data related to with behavior and learning problems, including ADHD. Monitoring should also attempt to assess and compare resources consumed within the health, education and welfare systems.