Dr S H Jawed Consultant General Adult Psychiatrist, Dorothy Pattison Hospital, Walsall Joint Lead Consultant for Adult Neurodevelopmental Service, DWMHP NHS Trust Regional Lead, UK Adult ADHD Network (UKAAN)
Disclosures Speakers and Consultancy fees from Lundbeck Janssen Eli Lilly
Brief Introduction Epidemiology Service Development Update
Introduction-1 What are Neurodevelopmental Disorders? Disorders of brain function Evident from an early age and impairments unfold as the individual grows NDD affect emotion, behaviour, motor functions, learning ability, self-control, memory, attention, imagination, social interactions and communication
Introduction-2 ADHD (Hyperkinetic Disorder) is a clinical Syndrome characterised by high levels of hyperactivity, impulsivity and inattention often in early childhood - that persist over time, pervade across situations and lead to notable impairments. Although traditionally considered as a childhood disorder, adults with ADHD features are increasingly presenting for evaluation and treatment.
Introduction-3 Inattention lack of attention to details, careless errors, difficulty sustaining attention, does not seem to listen, fails to follow through or finish, difficulty organising, avoids/dislikes tasks requiring sustained mental effort, loses things, easily distracted, forgetful Hyperactivity Fidgety, leaves seat, runs/climbs, difficulty playing quietly, on the go, talks excessively Impulsivity blurts out answers, difficulty awaiting turn, interrupts/intrudes on
Introduction 4 ASD (Autism Spectrum Disorder) is characterised by a triad of impairments in Social interaction Social communication Social imagination and fixed, repetitive behaviours Evident from early age and core impairments persist throughout the life affecting social, educational and occupational functioning
Introduction-5 National Autistic Society
Epidemiology-1 ADHD Follow up studies of children with ADHD find that 15% still have the full diagnosis at 25 years, and a further 50% are in partial remission, with some symptoms associated with clinical and psychosocial impairments persisting (Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006; 36:159-65.)
Epidemiology-2 Research suggests that 4-5% of adult population may have ADHD (Beiderman J, Faraone S, Mick E, Age dependant decline of ADHD symptoms revisited: impact of remission definition and symptom subtype. Am J Psychiatry 2000; 157(5): 816-817.) Recent studies indicate that the pooled prevalence of adult ADHD was 2.5% (95% CI 2.1 3.1) (Prevalence and correlates of adult attention-deficit hyperactivity disorder: metaanalysis Viktória Simon, Pál Czobor, Sára Bálint, Ágnes Mészáros, István Bitter. The British Journal of Psychiatry Feb 2009, 194 (3) 204-211; DOI: 10.1192/bjp.bp.107.048827)
Epidemiology-3 ASD Overall prevalence in UK 1.1% Prevalence higher in males than females (2% vs 0.3%) Prevalence in LD population around 33% Increased with increasing level of LD Increased with decreasing Verbal IQ Sex differences less marked (60% males vs 43% females) Brugha et al (2012)
Service Development-1 Adult Neurodevelopmental Service This is a national service and we welcome enquiries from a range of agencies. To refer an individual to either service we require a referral. Funding will need to be agreed by the relevant Clinical Commissioning Group before any work is undertaken, evidence of which should accompany the referral ASD Assessment Service We provide an Autism Spectrum Disorder assessment and diagnostic service for adults, using the latest assessment and diagnostic tools We accept referrals for individuals aged 16 and older. Please note we do not accept them for individuals, diagnosed with moderate to severe learning difficulties Referrals are accepted from a range of agencies. Typically referrals come from GPs; local authorities; other NHS providers or Clinical Commissioning Groups We do not manage any co-morbid conditions which should be managed by local adult psychiatric services.
Service Development-2 Adult Neurodevelopmental Service ADHD Assessment and Treatment We offer assessment and advice pharmacological treatments for patients suspected of or having a diagnosis of ADHD. This will be done through a shared care protocol with the patients GP. We accept referrals for individuals aged 16 and older. Please note we do not accept them for individuals, diagnosed with moderate to severe learning difficulties. Referrals are accepted from a range of agencies. Typically referrals come from GPs; local authorities; other NHS providers or Clinical Commissioning Groups. Funding must be agreed by the relevant CCG before any work is undertaken. We do not manage any co-morbid conditions which should be managed by local adult psychiatric services. We do not at this stage offer psycho-social intervention or support.
Service Development-3 Patients seeking ASD assessment and diagnosis We offer 2-3 60 minutes sessions of one of our Consultant Psychiatrists who, following assessment, will provide a comprehensive report Assessment includes History taking, mental state examination, risk assessment Interview the family, school reports, info from family, friends, employer Where appropriate, we can also offer a further assessment by one of our Psychologists in complex cases Diagnostic Interview of Social & Communication Disorders (DISCO)
Service Development-4 Patients seeking ADHD assessment and treatment Baseline Blood Investigation & ECG - GP 2-3 60 minutes assessments by one of the lead consultant psychiatrists History taking, mental state examination, risk assessment Interview the family, school reports, info from family, friends, employer DIVA-2,, Wender Utah Scale, ASRS, Weiss Functional Impairment Rating Scale Final report sent to the GP with a copy to the patient
Service Development-5 Patients seeking ADHD assessment and treatment- Contd. Up to 4 appointments for initiation and dose optimisation of medications -30 minutes each The above managed through a shared care protocol Annual Reviews One Hour
Update - 1 Referrals Spot Purchase Since we started the service we have received 191 ASD referrals and 120 ADHD Referrals. We have currently got approvals for 149 ASD referrals and 101 ADHD this includes the referrals that are pending funding (15 for ADHD and 6 for ASD) Referrals from Staffordshire, Telford and Wrekin, Shropshire, Dudley, Walsall, Coventry, Warwickshire, Sandwell and Wolverhampton Deaf CAMHS Transition for ADHD Annual Reviews
Update - 2 Protocols, Pathways & Contracts Shared Care Protocol for ADHD Prescribing Dudley CCG: ASD pathway established, developing ADHD pathway Preliminary discussions with Walsall CCG? Sandwell- referring all CAMHS ADHD graduates
Update - 3 Recruitment One WTE Secretary Appointed Two WTE Nurses Appointed Job Description for WTE Consultant Psychiatrist approved, in the process of advertisement, expected to join in August 2017
Update - 4 Education, Training & Research Local Educational Events for Nurses Local Educational Events for Trust Doctors and GP s in Walsall Clinical Supervision for Team Staff UKAAN Regional Educational Event Research Ideas/proposals including To look at comorbidities e.g. EUPD and ASD Do people labelled as EUPD get better with ADHD meds? Is it a comorbidity or misdiagnosis? Soft neurological signs in people diagnosed with ADHD Quality of life improvement among those who take ADHD medication
Update - 5 Fees ASD ASD assessment and diagnosis 795 ADHD ADHD new patient assessment 725 ADHD follow-up medication advice 163.48 per appointment Annual review for diagnosed and stable 285.69 patients ADHD - patient already diagnosed First appointment 480 ADHD follow-up medication advice if required (up to 5 appointments) 163.48 Annual review for diagnosed and stable patients per appointment 285.69