An Overview of the ADHD Pathway for Adults in Devon/Torbay

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1 An Overview of the ADHD Pathway for Adults in Devon/Torbay Andrew Blewett, also Charles Antwi, Mark Jay, Ruth Marlow, Rachel Pebworth, Abbie Turner, Rachel Webb January 2016

2 Resource/capacity 0.8 clinical psychologist 1.0 assistant psychologist 1.0 specialist prescribing nurse 0.3 consultant psychiatrist 1.0 clinical manager (shared with Autism Service) 0.6 administrative/secretarial support

3 Adult ADHD, ICD-10 Overview (summary) of the ICD-10 medical classification system for ADHD (Hyperkinetic Disorder, HKD) A combination of overactive, poorly modulated behaviour with marked inattention and lack of persistent task involvement Symptoms prior to six years of age and of long duration Impairment present in two or more settings Exclude diagnosis of anxiety disorders, mood affective disorders, pervasive developmental disorders and schizophrenia Diagnosis of HKD may also be made in adult life using the same criteria, however, attention and activity must be judged with reference to developmentally appropriate norms.

4 Adult ADHD, (DSM-5) DSM-5 Criteria for ADHD. People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: (lists nine symptoms) Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person s developmental level: (lists nine symptoms) In addition, the following conditions must be met: Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities). There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). (Combined Presentation, Predominantly Inattentive Presentation,Predominantly Hyperactive-Impulsive Presentation: if enough symptoms present for the past six months.

5 Key Documents NICE CG 72 Attention deficit hyperactivity disorder: diagnosis and management, [CG72] Published date: September 2008, specifically sections: 1.6 Transition to adult services, 1.7 Treatment of adults with ADHD, 1.8 How to use drugs for the treatment of ADHD Asherson, P. (2005) Clinical assessment and treatment of attention deficit hyperactivity disorder in adults. Expert Rev Neurother. Jul;5(4): Kooij, S. et al., (2010) European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BNF Chapter 4.4 CNS stimulants and drugs used for attention deficit hyperactivity disorder UKAAN, UK Adult ADHD Network, set up 2009, Devon and Torbay Service Specification for ADHD, updated January 2015 Operational Policy: Assessment & diagnosis of Attention Deficit Hyperactivity Disorder, The Devon Autism and ADHD Service, DANA, (current).

6 Exeter clinic pathway: Adult ADHD clinic Referral (GP; adult mental health, forensic, paediatric and CAMHS clinics) Triage - transition, previous diagnosis, possible new diagnosis & Waiting list including prioritisation criteria Initial assessment - NIP, Psychiatrist, (yes, no, grey area ; use of ASRS v1.1, DIVA (DSM 4)) (1) Explore diagnosis, decision making and preferences etc (2) medication, initiation, titration (current prescribing database) (3) information - written and verbal, assessment shared with GP, patient, involved clinicians (4) further assessment and MD discussion for grey area or otherwise relevant patients (5) psychological pathway for the patient and carer/partner (6) peer support/ information (7) Medication register, GP takeover of Rx with responsive advice/support and annual specialist review at the clinic, as per NICE Guide. (8) Ongoing MDT discussion, Full team planning meeting per 2 months, Pharmacy input.

7 Exeter Adult ADHD Clinic: Activity Cohort referred for assessment Q2, 2014: 37 offered assessment, 29 (annualised to 116) seen 24 had ADHD, other diagnoses included psychosis, personality disorders and ASD, (mood disorders) 2 were pregnant 20 medicated, either new or updated 2 lost, 1 chose to stop By Feb 15: 2 stopped by the clinic; 10 had Rx by GP; 5 still with the clinic. Increasing referral rate: currently 22 /month (annualised to 264) Recent 6 month referral rate to psychology input, 94

8 How effective is the clinic? All proxies really, although self rated ASRS scores show consistent mean decline Attendance rate is high, default is rare GP response to requests for sharing prescribing for stabilised patients is now over 95% positive (currently two declining) Feedback forms for general experience are strongly positive Complaints Feedback on psychological programmes is strongly positive The team appears to enjoy good morale Currently exploring factors associated with non-attendance, who and why? We think comorbidity may be an issue