How Do General Practitioners Identify Autism and ADHD in Children?

What you need to know

• General practitioners (GPs) use both explicit information like behavioral markers and parental reports, as well as tacit knowledge like clinical intuition when identifying autism and ADHD in children.
• Changes to referral pathways in some areas mean GPs are no longer the main gatekeepers for autism and ADHD assessments, with mixed views on this change among GPs and specialists.
• Better communication and information sharing between GPs, schools, and specialist services could improve the identification process for neurodevelopmental conditions.

How GPs Identify Autism and ADHD

General practitioners (GPs) are often the first point of contact for parents concerned about their child’s development. This study explored how GPs go about identifying autism spectrum disorders (autism) and attention deficit hyperactivity disorder (ADHD) in children. The researchers conducted in-depth interviews with GPs and specialists to understand their approaches and perspectives.

Explicit Information Sources

When assessing a child for possible autism or ADHD, GPs rely on several explicit sources of information:

• Behavioral markers: GPs look for specific signs associated with each condition. For autism, this might include atypical eye contact, delayed language development, fixed interests, repetitive behaviors, or sensory sensitivities. For ADHD, GPs watch for inattention, concentration problems, impulsivity, and difficulties with social interactions or academic performance.

• Parental reports: Most GPs considered parental concerns to be extremely important. As one GP noted, “Nine-tenths is the story you’re given by the parents. Because they are the…as I say to parents, you know your son or daughter better than anybody in the world.” However, many GPs felt that parental reports alone were not sufficient for a referral and should be corroborated with other observations.

• Professional resources: Some GPs mentioned looking up information in medical reference sources or even general websites like Google or Wikipedia to refresh their knowledge of specific symptoms or criteria.

Tacit Knowledge and Clinical Intuition

In addition to explicit information, GPs also draw on more subtle forms of knowledge when assessing children:

• Clinical intuition: Many GPs described developing a “feel” for what is typical or atypical in child development through their experiences. As one GP explained, “As a GP you get a subconscious idea of the spectrum of the range with children - from the kid who’ll sit there like butter wouldn’t melt in their mouth, like a bit oddly so, to the kid who’s climbing up your curtains.”

• Prior knowledge of families: GPs often have longstanding relationships with families, giving them valuable context about a child’s development and family history. This background knowledge can inform their assessments.

• Socioenvironmental factors: GPs consider how a child’s home environment, parenting, or recent life events might be contributing to their symptoms.

Changes to Referral Pathways

A key focus of this study was exploring recent changes to referral pathways for autism and ADHD assessments in some areas of the UK. Traditionally, GPs have acted as “gatekeepers,” deciding whether to refer children for specialist assessment. However, in the area studied, referrals now primarily come through schools or health visitors rather than GPs.

Mixed Views Among GPs

GPs had varying opinions on these changes:

• Accepting: Some GPs felt the new system made sense, as teachers and other professionals who interact with children regularly might be better positioned to identify developmental concerns.

• Ambivalent: Other GPs saw both pros and cons to the changes. They recognized that schools might have valuable insights, but worried about their diminished role in the process.

• Critical: A few GPs strongly disagreed with the new system, feeling it undermined their professional role and created difficulties for families trying to access assessments.

Specialist Perspectives

Professionals working in specialist neurodevelopmental services generally viewed the pathway changes positively. They reported that the new system had helped reduce waiting times for assessments. However, many specialists still felt that GPs had an important role to play in identifying autism and ADHD, albeit with some caveats:

• Time constraints: Specialists recognized that the short duration of GP appointments (often just 10 minutes) made it challenging to thoroughly assess developmental concerns.

• Training needs: Many specialists felt that GPs would benefit from more specific training on neurodevelopmental conditions.

Barriers and Opportunities for Improvement

The study identified several challenges in the current system for identifying autism and ADHD, as well as potential areas for improvement:

Information Sharing

A recurring theme was the difficulty of sharing information between different services involved in a child’s care. GPs often lacked easy access to observations from schools or updates from specialist services. Improving communication channels between GPs, schools, and specialist teams could lead to more comprehensive assessments.

Professional Networks

GPs valued both internal networks (colleagues within their practice) and external networks (educational professionals, specialists) for gathering information and seeking advice. However, recent changes to primary care organization have disrupted some of these connections, particularly with health visitors who previously worked more closely with GP practices.

Training and Resources

While some calls for more GP training on neurodevelopmental conditions emerged from the study, the researchers caution against viewing this as a simple solution. They note that framing the issue solely as a “lack of training” risks oversimplifying the complex nature of identifying these conditions and ignoring broader systemic challenges.

Conclusions

• GPs use a combination of explicit information sources and tacit knowledge when identifying potential autism or ADHD in children.
• Changes to referral pathways that reduce the gatekeeper role of GPs have been met with mixed reactions from both GPs and specialists.
• Improving communication and information sharing between GPs, schools, and specialist services could enhance the identification process for neurodevelopmental conditions.

This study highlights the complex nature of identifying autism and ADHD in primary care settings. While recent changes aim to improve the efficiency of the referral process, they also raise questions about the evolving role of GPs in supporting children with neurodevelopmental differences. Further research is needed to evaluate the impact of these pathway changes on families’ experiences and outcomes.