Adult ADHD - New Models of Care

Transcription

1 Adult ADHD - New Models of Care Mark Pitts Senior Clinical Nurse Specialist Adult ADHD Service, Maudsley Hospital & Lambeth Adult ADHD & Autism Service

2 What is needed? NICE (2008) guidance postulates 1) Diagnostic service* 2) Drug monitoring service 3) Psychological treatment service *Recommends full assessment even for transition cases, unless on stable medication

3 Attention deficit hyperactivity disorder Aetiology & prevalence Neurodevelopmental disorder 2-5% children in the UK, 2.5% adults 15-65% continue to have problems in adulthood Diagnostic challenge comorbidity and age Probable under diagnosis in adulthood

4 Diagnostic Service Should be made by a specialist psychiatrist or other appropriately qualified healthcare professional with training in diagnosis of ADHD (Rare!) Full developmental and psychiatric history We use DIVA diagnostic interview, plus neuropsychology where required Informant or other collateral information

5 Assessment outcome Diagnostic outcome Treatment recommendations Medication/Psychological/Comorbidity Who is going to look after comorbidity?? 5

6 Co-morbidity in Dutch series of 141 adult ADHD cases - 78% had one other disorder -Kooij JJ, PhD

7 Drug monitoring service Guidance during initiation/titration Prescribing by specialist or GP Depends on shared care agreements, may vary by drug In the longer term NICE recommend minimum annual review

8 Psychological treatment Best evidence for individual/group CBT based therapy 1. Residual impairment 2. No response to medication 3. Medication is not an option 4. Choose to avoid medication Can also can include psychoeducation?coaching?support groups How about anger, social skills?

9 Why is transition important in ADHD? Approximately 15% continue to meet full diagnostic criteria at age 25 years, Further 50% meeting criteria for ADHD in partial remission Faraone et al (2006) Psychological Medicine 36(2): Adult services are increasingly available, but vary in terms of availability and scope

10 Why is transition important? Young adults with ADHD have - higher risk of a range of additional psychiatric and developmental disorders increased criminal convictions, workplace and relationship problems Barkley et al, (2006) Journal of the American Academy of Child & Adolescent Psychiatry 45(2): ; Taylor et al (1996) Journal of the American Academy of Child & Adolescent Psychiatry 35(3): Successful transition can improve outcomes if clearly planned & including liaison between the young person/professionals/family Department of Health (2006) Transition: getting it right for young people.

11 NICE Transition Recommendations Transition to adult services should occur if the individual has significant symptoms of ADHD, or comorbid conditions that need treatment Reassessment by CAMHS/Paeds to consider need for transition Assessment by adult services to plan ongoing care inc assessment of comorbidities Services to meet/share information National Institute for Health and Clinical Excellence (2009) Attention Deficit Hyperactivity Disorder: Diagnosis and Management of ADHD in Children, Young People, and Adults. Clinical Guideline 72. NICE, London

12 Maudsley Adult ADHD Running since 1990s Pioneering service in the NHS Service offers assessment, second opinion, and treatment inc CBT & psychoeducational group workshops But not a good model 12

13 Satellite clinic model Pathway for transition and those presenting for the first time GPsi for prescribing where GP unable to No psychology No ASD

14 Satellite clinic - take 2 Local referrals via CMHT or CAMHS Transition pathway, inc care coordination, coaching, family work No ASD Time intensive

15 Lambeth model Neurodevelopmental clinic covers ADHD and ASD a one-stop shop inc Dx and CBT Based in GP practice, Easy access for those in transition and new/returning adult patients, with GP & CMHT referrals Supports local GPs with advice during titration, GPs prescribe Signpost to local services/national support organisations Close relationships with CMHTs for coordination of support

16 Psychological treatment of ADHD/ASD Evidence based short term psychological interventions 12 sessions of individual CBT Possibility of group psychoeducational workshops Cover core symptoms or comorbidities 16

17 Elsewhere? Huge variety No services Referral out of area Assessment only 1 person band /CMHT model model, lifespan clinics Services with psychiatry, nursing, psychology, O/T, good links with local CMHT and other providers, non- NHS services Full neurodevelopmental