Adult ADHD -New Models of Care

Mark Pitts

Senior Clinical Nurse Specialist

Adult ADHD Service, Maudsley Hospital

& Lambeth Adult ADHD & Autism Service

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

Attention deficit hyperactivity disorder

• 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

Aetiology & prevalence

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

Assessment outcome

• Diagnostic outcome

• Treatment recommendations

• Medication/Psychological/Comorbidity

• Who is going to look after comorbidity??

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Co-morbidity in Dutch series of 141 adult ADHD cases- 78% had one other disorder -Kooij JJ, PhD 2006

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25

50

75

100

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

Psychological treatment

• Best evidence for individual/group CBT based therapy1. 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?

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): 159-165

• Adult services are increasingly available, but vary

in terms of availability and scope

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): 192-202; Taylor et al

(1996) Journal of the American Academy of Child & Adolescent Psychiatry 35(3): 1213-1226

•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.

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

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

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Satellite clinic model

• Pathway for “transition” and those presenting for the first time

• GPsi for prescribing where GP unable to

• No psychology

• No ASD

Satellite clinic - take 2

• Local referrals via CMHT or CAMHS

• Transition pathway, inc care coordination, coaching, family work

• No ASD

• Time intensive

‘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

Psychological treatment of ADHD/ASD

• Evidence based short term psychological interventions

• 12 sessions of individual CBT

• Possibility of group psychoeducationalworkshops

• Cover core symptoms or comorbidities

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Elsewhere?

• Huge variety –

– No services

– Referral out of area

– Assessment only

– “1 person band”/CMHT model

– 18-25 model, “lifespan clinics”

– Services with psychiatry, nursing, psychology, O/T, good links with local CMHT and other providers, non-NHS services

– Full neurodevelopmental