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Should ADHD, ASD & related services be delivered in an integrated way?BACCH Conference Workshop Sept 10th 2018FACILITATORS: DR IAN MALE (CONSULTANT PAEDIATRICIAN, MID SUSSEX CHILD DEVELOPMENT CENTRE) DR VENKAT REDDY (LEAD CLINICIAN, COMMUNITY PAEDIATRIC SERVICE, PETERBOROUGH)

Synopsis With separate NICE guidelines and a perception of ADHD as a

mental health disorder, and ASD as neurodevelopmental, service provision in many parts of the UK has been dividedbetween Child Development Teams and CAMHS, who often sit in different organisations. This can often result in inefficientservice delivery and long waits for families to reach final diagnostic conclusions as well as doubling up of assessments across teams. Using costings methodology from “Cost of Autism” study, and the presenters experiences, one working in an established integrated service, the other working towards this we aim to explore the arguments for and against integrated and non-integrated approaches, as well as some of the challenges and advice for those wishing to move to an integrated approach

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Some Questions Do you assess children for ASD? ADHD?

Do you have access within your team to: Speech Therapist Clinical Psychologist Nurse Specialist Family Support Worker ADHD Nurse Child Psychiatrist Occupational Therapist

Do you work in a joined up CAMHS/CDC service?

Can you easily access CAMHS eg for ADHD assessment, management of anxiety in ASD?

Do you diagnose ASD as single practitioner-or always as part multidisciplinary assessment

More Questions In a child referred with possible ASD, how confident would you be

that your available multidisciplinary team could assess/manage that child for: Impact of Early Life Trauma / Attachment Disorder Comorbid ADHD Anxiety/Anxiety Disorder Foetal Alcohol Syndrome Eating disorders including limited diets/sensory Demand avoidant behaviours Comorbid learning difficulties or learning difficulties as cause social

communication difficulties Comorbid language difficulties ASD in under 5s, 5-11yrs, 11-19yrs Comorbid depression/suicidal ideation

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Costs of Autism Study

Aim 20 CDCs and 5 tertiary centres Each centre collect data on 20 “consecutive” children referred for

ASD / social communication assessment Retrospective from case notes For each child complete proforma:

Who involved at each stage and for how long

Additional time spent gathering information eg school observation

Includes clinical admin and travel, and admin staff input

Diagnostic outcomes, investigation, referrals eg for support

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Calculate costings Calculate hours of each professional in

completing process for each child Calculate means of above for each centre Multiply by Unit Hourly costings taken from: Curtis, L. & Burns, A. (2017) Unit Costs of Health

and Social Care 2017, Personal Social Services Research Unit, University of Kent, Canterbury.

Based on salary + salary on costs (14% of salary) + trust overheads + management (20%) + non-staff costs (50%) + capital overheads + travel + training costs.

Hourly Costings Consultant £106 Reg/spec doc £53 Band 8a £62 Band 7 £53 Band 6 £44 Band 5 £36 Band 4 £28 Band 3 £24

Time from referral to diagnostic clinicMean 426 days (292-554)

416

554

542

387

508

292

349

433

356

0 100 200 300 400 500 600

1

2

3

4

5

6

7

8

9

Time from referral to diagnostic clinic

Mean 426 days (CI 366-486)

0

100

200

300

400

500

600

1 2 3 4 5 6 7 8 9

referral to diagnosis stage 0ne to diagnosis

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Professional Time taken by centreMean 16.6hrs (13-24hrs)

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9

Time take by centre

hours of assessment additional hours for full diagnostic assessments only

mean time 16.6hrs (CI 14.2-19.2)mean diagnostic 17.6hrs (14.6-20.6)

Cost of assessment by centreMean £1026 (£713-1638)

0

200

400

600

800

1000

1200

1400

1600

1800

1 2 3 4 5 6 7 8 9

Cost of assessment by centre

Cost all cases additional Cost diagnostic pathway cases only

mean cost £1026 (CI 863-1189)diagnostic £1086 (905-1267)

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Integrated ASD/ADHD Pathway?

National Picture Big increase ASD-now 1 in 50 (US CDC 2018, N Ireland 2018, S Korea

1 in 30), and ADHD 1-5% or more Comorbidity ASD and ADHD 20-40%, ADHD on differential diagnosis for ASD and vice versa Mental health or developmental disorder? Is it CAMHS or CDC? At what age? Or should it be both? What competencies do you need in team to diagnose and

manage both conditions and related developmental and mental health comorbidities and differential diagnosis

Underlying conditions-genetic, chromosomal, FASD Attachment Disorder etc Anxiety, Catatonia, conduct disorder

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NICE ASD Guidleines

assessment should be able to consider neurodevelopmental disorders (e.g. developmental coordination disorder), mental and behavioural disorders (e.g. ADHD, mood disorder), developmental regression (e.g. Rett’s syndrome), “maltreatment”, and visual, or hearing impairment. In addition to a core team, advise access to other disciplines e.g. occupational therapy, to“construct a profile for each child or young person, for example (their) intellectual ability…speech, language and communication, fine and gross motor skills, and mental and emotional health including self- esteem.”

ASD/ADHD pathway-applying costs methodology

Typical non integrated approach took 17.5 hours, cost £1340

Integrated pathway (based on Peterborough) took 10.3 hours, cost £740

If add in initial filter, A+C and travel times would take longer and cost more hence differences with costs data

 

 

CDT Initial Developmental Assessment 

Consultant Paediatrician 1.5 hrs including admin= 1.5 x £106=£159 

Referred into Social Communication Assessment Pathway 

Referred to CAMHS for possible ADHD 

Referral rejected, passed to Early Help for 

Parenting Course

CDT Social Communication Assessment Information Gathering 

ADOS by band 8a Psychologist 2 hours= 2x62 =£124                      

Psychometric testing by Band 8a Psychologist 1.5 hours = 1.5 x62 =£93 

School Observation by Band 7 SALT 2 hours= 2x53 =£106 

CDT Social Communication Diagnostic Clinic 

ADI by consultant paediatrician 1 hour 1x£106 = £106                  

Feedback by Paediatrician and Psychologist 1 hour 1x(106+62) =£168 

Report writing 0.5x168= £84

Rereferred CAMHS: Choice (triage) appointment

Band 6 Nurse 2 hours = 2x43= £86

CAMHS ADHD Diagnostic Clinic

Band 6 Nurse school observation 2 hours 2x43= £86                

Consultant Psychiatrist 1.5 hours 1.5x108= £162

CDT Review for possible ASD diagnosis in light response ADHD medication

Consultant Paediatrician 1.5 hours=1.5x£106= £159 

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W Sussex and Brighton experience

Context

•Increasing referrals, No increase in capacity•Small teams, wide geographic patch•Already efficient diagnostic service eg Fast Track, questionnaires from settings, Multidis,•ASD under CDC, ADHD 6+ under CAMHS but only after Early Help

Mechanisms

•Demand outstripping capacity•difficult to fill vacancies/cover absence•Parents unhappy at waiting times•Other services also struggling eg CAMHS, minimal EP service

Outcome

•Complaints to trust and commissioners•Commissioners want service redesign with integrated ASD/ADHD pathway•Steering group clinicians, commissioners, parents, voluntary agencies, council•Commissioners keen single provider, trusts wary of this and risks•A long journey ahead!!!!!!

Peterborough Experience - Single Integrated Team

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Peterborough - Why new pathway ?High number of referrals for suspected ADHD/ASD Limited information Lengthy waitsUnstructured and inconsistent assessments Low diagnostic yieldNo support while waiting or if not diagnosedNo time for evidence based interventions

High Level Pathway

Referral

Community Paediatrics and or CAMH

General Developmental Assessment

Specialist assessment and Interventions

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Longest wait for first assessment in weeks

0

20

40

60

80

100

120

140

ASD ADHD

Dec-15May-18

Why Integrate, tips and warningsFor

Competency based-range of skills, egcan include FASD, attachment

ASD and ADHD often overlap-seeing in one service more efficient

Allows expertise eg complex psychopharmacology

Single trust vs shared ownership? Reduced complaints and timely

assessment Economies of scale Attractive to trainees and permanent

staff Get a good project manager Build in strong clinical leadership Link to Early Help-does this need unitary

authority to succeed

Against If shared ownership across trusts will all

partners commit once money provided

Balancing commercial risk for trust with clinical risk

Balancing other priorities eg complex neurodisability, anorexia

Ensuring commissioners fund at level to allow success or accept limit to numbers if under funded. This is where commercial wing of trust really important

Potential loss of local service if centralise

Will it work in all settings or is this Peterborough specific

Lack trust between CAMHS and CDCs