CLINICAL MANAGEMENT IN ADULT ADHD
Objective: To determine the effects of symptom profile, comorbid psychiatric problems, and the assessment and diagnostic processes in adult ADHD patients. Method: Adult ADHD patients, 89 service users (42= full and 47= transition), responded to questionnaires rating past and present symptoms of ADHD, comorbid conditions, treatment history, and work status and about ADHD service and assessment. For each service user, their patient care records were retrieved and they were sent a feedback questionnaire, of which 35 were returned. The GP and referring clinician (CAMHS/Paediatrician) where applicable, for each service user, were also sent a feedback questionnaire, of which 60 were returned. Results: The results indicate that the assessment and diagnostic processes undertaken by the service were compliant with the Guidelines and that all service users who wanted to trial a course of medication were prescribed drug treatment as the first-line treatment and this was commenced under the guidance of a psychiatrist. Prior to starting medication, the service was compliant with discussing potential side effects and ensuring anti- psychotics were not used in the treatment of ADHD. However, the service was only partially compliant with assessing cardiovascular symptoms prior to starting drug treatment. Conclusion: Early recognition and treatment of ADHD is a strong predictor of being in work as an adult, independently of comorbidity, substance abuse, and current treatment. Methylphenidate was the first-line drug treatment. All service users reported an improvement in their everyday functioning on the Recovery and Well-being Questionnaire since they are under treatment.
1.To identify potential areas for service development.
2.To identify potential areas of risk.
3.To ascertain whether service users and stakeholders are satisfied with the service they receive.
4.To ascertain whether service users who enrolled on the
Coping Skills Group found the programme useful.
5.To ascertain whether there has been an objective decrease in service users’ ADHD symptomatology (1) and an improvement in their everyday functioning (2) since being under the care of the Adult ADHD Service.
Examination of the data highlighted the following key findings:
-The service was compliant (≥80%) on 45 (46%) of the 96
standards assessing the safety of service delivery.
-There was minimal compliance (≤ 59%) with the
standard assessing and recording of service users’ blood pressure, pulse, weight, and family history of cardiac disease at both assessment and review. These areas were addressed by the service following the data collection and at re-study the compliance had improved considerably but there remains scope for further improvement with assessing and recording blood pressure and pulse.
-NICE Clinical Guideline 72 list (3) a number of specific side effects that should be documented as being discussed and monitored when prescribing atomoxetine. The
service were minimally compliant (≤ 59%) with reporting
these individual symptoms in the clinical reports.
-All service users and 77% of stakeholders said that overall they were happy with the service they received. Suggestions for further improvement included: shorter waiting list times, a smoother transition of service users between child and adult services, greater access to psychology and occupational therapy, and support for carers and family.
-The objective assessment of ADHD symptoms using the Barkley Current Self-Report Form (1) indicated that 80% of service users’ inattention difficulties and 65% of service users’ hyperactivity/impulsivity difficulties had improved following interventions at the Adult ADHD Service.
-All service users reported an improvement in their everyday functioning on the Recovery and Well-being Questionnaire since they are under treatment.
All service users who had undergone an assessment at the Adult ADHD Service, either as a new diagnosis (full) or a reassessment (transition), between March 2011 and October 2011, and were subsequently diagnosed with Adult ADHD or had their diagnosis re- confirmed were included in the study. Service users that did not meet, or who no longer met the criteria for adult ADHD following assessment were excluded from the sample. In total, 89 service users (42= full and 47= transition) were included in this study. For each service user, their patient care records were retrieved and they were sent a feedback questionnaire, of which 35 were r e t u r n e d . T h e G P a n d r e f e r r i n g c l i n i c i a n (CAMHS/Paediatrician) where applicable, for each service user, were also sent a feedback questionnaire, of which 60 were returned.
METHODOLOGY – including data collection methods
The list of potential service users to be included in the study was generated from the clinic sheets that detail the daily clinical activity. As detailed above, service users that did not meet, or who no longer met the criteria for adult ADHD following assessment were excluded from the sample. Each service user included in the sample was allocated an identification number to ensure all data was anonymous, yet allowing for cross-referencing with their stakeholder/s.
Whilst the study was being written up, new training and equipment was provided to all staff so that service users could have their blood pressure and pulse routinely checked and recorded as part of their assessment and follow up appointments (in cases where the service user was prescribed medication). It was also agreed that all service users would be asked about family history of cardiac disease at assessment. Consequently, it was felt appropriate to re-evaluate the Service’s compliance with these items through a re-study. In addition, the team compiled a resource folder containing information about relevant statuary and voluntary agencies in different geographical areas to which service users could be signposted when their needs were beyond the remit of the service, such as employment, counselling and parenting. It was also considered appropriate to determine how frequently this resource was being used.
The re-study was therefore carried out using 20 service users (nine full and 11 transition assessments) who were seen in clinic for the first time between September 2012 and December 2012.
Ongoing Service User Feedback
As part of ongoing service evaluation and feedback, service users were asked at their follow up appointments to repeat the standardised questionnaires administered at assessment, namely, the Barkley Current Self-Report scale (1) and Recovery and Well-Being Questionnaire (2) and comment on their satisfaction with their appointment. During the study time frame, 18 out of a potential 89 service users completed these questionnaires on two occasions and of these, 12 commented on their satisfaction with their appointment. All 12 respondents stated that they were happy with their appointment and six went on to expand on their answer. Their responses included: “it was nice to talk… about how I’m feeling and not be judged”, “I feel I am being catered (for) as an individual rather than being given ‘templated’ solution”, “the doctor (is) coming up with solutions for side effects” and “I am happy to be able to report that I’m making good progress”.
Service Effectiveness (Outcomes)
Barkley Scale Scores
Of all service users included in the study, 65 (73%) completed at least one copy of the Barkley Current Self- Report Form (1). Of those 65, 15 (17%) completed a subsequent form at follow up. When comparing the scores for those who had completed two forms (one at assessment and one at follow up), 80% of service users’ scores fell on the inattentive subscale, suggesting an overall improvement in self-rated inattention symptoms. On average the inattentive subscale scores fell by four points (range= 0–7).
On the hyperactivity/impulsivity subscale, 65% of service users’ scores fell, also suggesting an overall improvement in self-rated hyperactivity/impulsivity symptoms. Between assessment and follow up, scores fell by an average of three points (range= 0–8).
All service users who wanted to trial a course of medication were prescribed drug treatment as the first-line treatment and this was commenced under the guidance of a psychiatrist. Prior to starting medication, the service was compliant with discussing potential side effects and ensuring anti-psychotics were not used in the treatment of ADHD.
With regard to the monitoring and reviewing of medication, the service was minimally compliant with assessing and recording service users’ blood pressure, pulse, weight and family history of cardiac disease at both assessment and review. These areas were addressed by the service following the initial data collection and at re- study the compliance figures had improved considerably, but there remains the need for yet further compliance with assessing and recording blood pressure and pulse. The standard for recorded monitoring of symptoms and side effects was met (compliant) for service users on methylphenidate. This reduced to partial compliance for service users prescribed atomoxetine and dexamfetamine, but one should note the smaller sample size for these items. For atomoxetine specifically, there are standards related to warning service users below the age of 30 of the potential of atomoxetine increasing agitation, anxiety, suicidal thinking and self-harming behaviour, and the monitoring of these side effects at follow up appointments. The service complied with these items at a minimal or partial level. With regard to the initiation and titration of the medications, the service was compliant with methylphenidate (or atomoxetine if there was a concern about potential for drug misuse and diversion) being the first-line drug treatment. The service also reached full compliance by not completing routine blood tests, ECG, and liver function tests in service users prescribed atomoxetine.
During the initiation and titration of medication, the service was compliant with the items relating to the starting and maximum dose of methylphenidate. The compliance with the titration dose at four to six weeks was partial because some service users were recommended to trial an increase in dose of Concerta XL from 18mg daily to 36mg daily after two weeks, depending on the effectiveness and tolerance of the dose at 18mg daily. For dexamfetamine, there was compliance with the titration and division of doses. There was partial compliance for the starting dose and maximum dose of dexamphetamine and this was due to the limited effectiveness at a lower dose and a service user’s previous high level of illicit drugs use. The results for these items are affected by the small sample size.
Service Effectiveness (outcomes)
The Barkley Current Self-Report Form (1) is completed by service users at assessment and during follow up to objectively measure the frequency and intensity of ADHD symptoms. When comparing the scores for those who completed two forms, 80% of service users reported an improvement in their attention and 65% reported an improvement in their hyperactivity/impulsivity symptoms. With regard to everyday functioning, 100% of services users who completed the Recovery and Well- being questionnaire on two separate occasions reported fewer difficulties with the areas of life outlined in the questionnaire.
From the perspective of the stakeholders, 40% of GPs said their service users had made fewer demands on their service and 40% said their service users had made fewer appointments since being under the care of the Adult ADHD Service.
1.Barkley RA, Murphy KR. Attention-Deficit Hyperactivity Disorder:
A Clinical Workbook (3rd ed.). Guildford Press, 2006.
2.Adult ADHD Service. Recovery and Well-Being Questionnaire.
Unpublished scale, 2011.
3.National Institute for Health and Clinical Excellence (NICE). Clinical Guideline 72: Attention deficit hyperactivity disorder (ADHD): Study support (services for adults), 2008. Available via : http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Public ationsPolicyAndGuidance/DH_085825.
4.Darzi A. High Quality Care for All: NHS Next Stage Review (Final
Report). Department of Health London, 2008. Gateway reference
10106, available via: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Public ationsPolicyAndGuidance/DH_085825.