What I wish my ADHD referral letter could say

4 minute read


I’m just a GP, so mandatory micro-credentialing is just one hurdle to providing safe and appropriate care for 5-10% of the community.


This is an example of the kind of referral letter I wish I could send.

Dear Doctor/Paediatrician/Psychiatrist.

Thank you for seeing Patient X

They are a 12-year-old child who I have been seeing essentially since prior to their mother’s preconception visit.

During antenatal care, mum had problems with hypertension and sugar. She has been added to our practice’s regular recall service and will be followed up with urine protein, blood pressure and blood glucose levels etc long term. The rest of the antenatal care was uneventful.

Then at six-week check I did pick up an innocent flow murmur and clicky hip which ultrasound showed had decreased acetabular coverage. Conservative therapy was unsuccessful, so our in-house physio fitted a Pavlik harness for me. Follow-up x-rays had shown an excellent outcome.

The child was reviewed regularly and met developmental milestones, as well as acceptable growth chart progression. They were fully immunised through the childhood National Immunisation Program, including us having access to some local funding to cover them for meningococcal B as well.

Preschool development was fairly uneventful apart from the trampoline incident – a nondisplaced radial fracture for which I applied a plaster cast and had to put a few sutures in a head wound at the same time.

We managed some early school bullying with focused psychological therapies and were assisted by in-house psychologist during a grief reaction with first grandparent’s death. I actually managed the grandmother for about 20 years with her chronic health issues including diabetes and congestive heart failure, which were interesting diseases considering the amount of new medications developing and changes in guidelines over the years – which I kept up with as part of regular professional development programs. The same issue we faced with her asthma – what’s indicated, contraindicated, indicated once again – from oral theophylline through to short-acting and long-acting medications and monoclonal antibodies in the development of therapies.

More recently though, there have been some issues with the 12-year-old’s behaviours. But all was well with some family-focused psychological input and support during a challenging time for mum and dad.

Weight gain became an issue in later childhood, but our in-house dietitian and exercise physiologists were of great assistance to them and their family with some lifestyle interventions and changes in behaviours which have hopefully made some long-term impact. Both for now and future.

With the upcoming entry into high school, there has been some feedback from teachers and school about distractibility and issues with concentration affecting performance at school. This was not relieved when we corrected their iron deficiency and excluded other pathologies.

A few sessions with our practice nurse and in-house psychologist has shown they fulfil requirements from DSM-5 for attention deficit hyperactivity disorder. I also sought some further review with our local neuropsychologist. It was confirmed with the diagnosis. After our practice multidisciplinary team meeting, it was thought they potentially could benefit from a trial of stimulant medication.

Hence following a six-month wait, they will be seeing you today for a short one-off consultation where your expertise will be able to diagnose ADHD and write a script for stimulant medication.

As you are aware despite ADHD diagnosis and treatment being included in my college’s fellowship curriculum, I remain just a GP so, pending mandated micro-credentialing or not, there is a regulatory barrier disenabling me from providing safe and appropriate care for 5-10% of the community.

It would be greatly appreciated if you could reconsider the fee structure today, as the gap will make a difference between accessing fresh fruit and vegetables or frozen preserved and takeaway food this month.

Also, it would be great for myself and the rest of the practise team to receive a reply letter to the referral, particularly one that would recommend that in your opinion it would be safe and appropriate for our practice to continue prescribing this child’s medication.

Yours, frustratingly,

Dr Kenneth McCroary

Dr Kenneth McCroary is a GP in Campbelltown, a lecturer at Western Sydney University and University of NSW, director and clinical co-chair of SWS PHN Aged Care & Mental Health, and chair of AMA NSW’s Council of General Practice.   

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