Introduction

In the UK, ADHD has been shown to be the most common reason for follow-up appointments to be offered by CAMHS (Meltzer et al, 2000). Child and adolescent mental health services are regularly called upon to assess children who have problems with attention, concentration, distractibility, impulsivity, overactivity, regulatory difficulties, or a combination of these. These difficulties may be part of ADHD or may be symptoms of other disorders that mimic the clinical features of ADHD (Hill & Cameron, 1999). Attention-deficit hyperactivity disorder is a condition where the symptom profile and aetiology are regularly being redefined. Comprehensive guidelines from NICE (National Institute for Health and Clinical Excellence, 2006; National Collaborating Centre for Mental Health, 2008) and a large US study, with its recently published follow-up study (MTA Cooperative Group, 1999; Jensen et al, 2007) have also informed good practice. As additional resources have not often generally been forthcoming to support such good practice, existing services may restructure aspects of their functioning in order to form Tier 3 teams.

One way of rationalising resources effectively is to establish interagency links so that multidisciplinary working is not limited by professional boundaries. Some centres have done just this to meet the needs of children with complex problems, including ADHD complicated by comorbid difficulties (Williams et al, 1999). Where there is no coordinated approach to assessment and intervention for children who present with these difficulties, confusion may arise and contradictory advice may be given by different agencies. Parents and carers need to feel confident that professionals are working with them and with other agencies to provide a comprehensive assessment and treatment package for their children. A Tier 3 team within a CAMHS has the advantage of multidisciplinary working, and this facilitates the development of shared learning and understanding, and the evolution of clear protocols (Voeller, 1991). A specific attentional problems clinic can provide assessment, diagnosis, monitoring and a range of ongoing interventions.

The attentional problems team should ideally include a child psychiatrist, a clinical psychologist and a community psychiatric nurse.