Proposed Service Protocol for - PowerPoint Presentation

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Proposed Service Protocol for Children & Adolescents with ADHD at community based service settings Pilot Study of the ADHD+

Dr Chan Kwok Ling PhyllisChief of ServiceDepartment of PsychiatryQueen Mary Hospital

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Program objectivesEvaluate the logistics and treatment package for mild (+/- moderate) ADHD cases , PLUS other common psychological symptoms at

community based service settings2

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Referral sources10-15 schools participating in the programme(在各個醫管局聯網內所揀選的十至十五間學校就讀並患有輕度至中度專注力不足過度活躍症及合併症的學生。

(獲轉介的學生必需是未經醫管局兒童及青少年精神科服務、衞生署兒童體能智力測驗服務、

私人兒科醫生

、

私人精神科醫生或臨床心理學家的評估或診斷，亦未接受相應的介入和支援服務。

)

* By respective cluster’s C&A SOPCs (i.e. routine cases on waiting list)

Walk-in (outside participating schools)(非上述(一)所揀選的學校學生及青少年可從不同渠道轉介至先導計劃或自行前往參與。但他們必須是未經醫管局兒童及青少年精神科服務、衞生署兒童體能智力測驗服務、私人兒科醫生、私人精神科醫生或臨床心理學家的評估或診斷，亦未接受相應的介入和支援服務。)

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Role and Duty of Schools學校負責識別患有專注力不足過度活躍症及合併症但尚未被醫療機構評估或診斷，以及並未得到介入或支援服務的學生。轉介他們到相應的社區非政府機構服務平台。配合服務平台向被識別患有專注力不足過度活躍症的學生提供聯絡及支援服務。填寫評核表格及參與先導計劃的效益評估。

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5 clusters10-15 schools from corresponding cluster (non SMHSS

)

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community based platforms by NGO

Criteria

Not known to public / private medical doctor / school SEN service

DH / HA waitlisted cases not excluded*

Staff

Nurse (APN)

APN

OT

SW

CP

Total 200 cases / per year

Training of staff

Theoretical + Practicum

Ax tool / protocol

Training group

CP: PTSD

case manager

system

Proposed Service model (ADHD+)

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Assessment flow and treatment package Initial assessment: (trained AH staff/case manager) Standardized Assessment for syndromes and severityRisk assessment of urgent, early or routine levelMulti-Disciplinary Meeting

Management planreferral, and overall treatment package, follow up duration, liaison with schoolEXIT meeting at 6th

and 12

th

months , or HA first appointment

for

step up or down

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Assessment Screening Tools7Initial screening and risk assessment

ADHD+ psychological symptoms assessment

MD Meeting (4/52)

Beh

s/s, parenting Ax

exclude

include

subclinical cases

 refer for other needs

high risk case  refer to HA / AED

3. mild + moderate + severe case

(on WL)

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ADHD Screening/ Ax toolsStandard criteriaScreening :Risks and needsSDQ, modified HA triage form (child and adolescent /adult) General Behaviorial symptomsCBCL, TRF, YRF

Parenting and P-C relationsPPI, PCIADHD assessment toolsChild and adolescents: ADHDRS, SWAN

Adults

Adult

ADHD Clinical Diagnosis Scale (ACDS)

Adult ADHD rating scales

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ADHD and comorbidites: diagnostic toolsDISC-IV (ADHD and other comorbidities) If comorbid with ASD: Diagnostic tool: 3DiScreening tool : AQ

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Psychiatric Comorbidity10

Autism Spectrum Disorder

Dyslexia

Motor Co-ordination Problem

ODD / CD

Tics / Tourette Disorder

Depression

Anxiety DisorderStress related disorderSubstance Abuse

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Specify severity: mild, moderate, severe11New requirement to specify severityDSM-V also requires clinicians to specify the severity level of a client’s ADHD as either Mild, Moderate, or Severe.Mild is restricted to cases where there are few, if any, symptoms beyond those required to make the diagnosis and no more than minor impairment in functioning. In DSM-IV, where clinically significantly impairment was required, these individuals would not be diagnosed.

Moderate is simply defined as symptoms or functional impairment between ‘mild’ and ‘severe’. People in this category may not necessarily show clinically significant impairment and thus also would not have been diagnosed under DSM-IV.

Severe is reserved for cases with many symptoms in excess of those required for the diagnosis, or several symptoms that are especially severe, or marked impairment resulting from symptoms.

Specify current severity:

Mild:

Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in only minor functional impairments.

Moderate:

Symptoms or functional impairment between “mild” and “severe” are present.Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.40: 45: 15 %

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Preliminary screening toolsSDQ: preliminary screening toolScore <17 subclinical Modified Triage form (HA): risk assessment and urgency of needs Score : Refer HA as urgent cases/AED : ≥6, see in 2/52Refer HA as early cases: 4-5, see in 8/52

Refer HA as routine cases: ≤ 3 12

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ADHD Assessment /Screening ScalesChild and adolescentsDSMIV, 5 symptoms checklist: ADHS-RSSWAN 13

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Plus child and adolescent assessmentScreening toolsAnxiety (Spence Children’s Anxiety Scale SCAS preschool 2.5-6.5 children 8-15)Depression (CDI: Children Depression Inventory, 6-18)PTSD (Impact of Event-Scale Revised Child Version: IESC 8-17)

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Service Protocol15

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ADHD Management 16Online / self help / access to relevant information

ADHD s/s treatment group (manualized) – ESST, ET, transition, vocational APN / OT / SW

Carer

PMT group (

manualized)

(Child, Adolescent,

happy kids charter)

APN / CPCase management (case manager)SW/APN+/-OT, CPOther groups (manualized): heterosexual relation / SSTAPN / SW / OTIndividual vocational counselling OTIndividual psychotherapyCP

Medical consultations

Private Psychiatrists

/ Pediatricians

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Other needs

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Family and

carers

Management

Marital discord in parents

refer IFSC

Financial problem/ housing problem refer IFSCMental health symptoms

refer HA

psy

clinic, ICCMW

Child care/parenting

PMT, refer IFSC

Risk of child abuse or domestic violence

refer IFSC, FCPSU

Others

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Other needs

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Cases

Management

LD: dyslexia or IQ problem

refer EP, dyslexic group at NGO/school

IP/social skill issues

ADHD ESSTAggressive behavior or marked ODD or conduct symptoms

ADHD ESST, CP

Sexual or heterosexual relationship problems

heterosexual relation / SST

Parent child relationship problem: attachment/ post abuse, trauma

CP

Internet misuse and addiction

internet use / addiction group

Other major health issues

Refer FM/

paediatric

doctor

Others

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Mild casesDefinition: Low risk and minimal functional impairmentCriteria: by Ax/Dx tool, 1-2 area of deficits/needs, triage form score 2 or less

Moderate casesDefinition: Clear diagnosis, mild psychosocial functional impairment, low risks and probable need for medicationsCriteria: by Ax/Dx

tool , 2 to 3 major area of deficits/needs, comorbid symptoms are mild (subclinical), triage form score

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Severe cases

Definition : Clear diagnosis, moderate to severe psychosocial functional impairment, high risks, psychiatric comorbidity, forensic history, substance use and need for medication

Criteria: by Ax/

Dx tool , 4 or more major area of deficits/needs, with comorbid diagnosis, triage form score 4 or moreMild, Moderate and Severe – Definition and Criteria

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ADHD+: PTSDPost Traumatic Stress Disorder - CPProvide trauma informed care at schoolRefer to HA if high risk casesSuicidalSchool refusal DissociationComplex presentationChronic insomnia

Psychosis

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Plus Treatment: Child and adolescentOthers: subclinical treatment by ASWO/OT/APNSubclinical groupsAnxiety group CBT (Cool kids) Depression group CBT (Depression

group)Others: clinical treatment by CP CBT for anxietyCBT for depression

PTSD/ASR

group (7-17)

Cognitive

behavioural

therapy (CBT-T) (5-15 sessions)

Cognitive processing therapy (CPT)Narrative Exposure therapy (NET)21

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Support from PsychiatristsRefer to HA if necessarySupport from community medical charitable programs : Variety, Charity, NLPRA, CTF Hong Kong College of Psychiatrists : Care4ALL program : free psychiatric consultation for 4+4 sessions including medications related to mental health crisis22

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Review / Evaluation Repeated Ax tools: ½ yearly – yearly (by Case Manager)Evaluation/ Exit MD case conferenceExit criteria For child and adolescent cases:

ADHD symptoms, other comorbid /behaviorial symptoms Problem areas

Access of service at school or HA level

For adult ADHD:

ADHD

symptoms

Functional level: Global Assessment of Functioning (GAF), Work Performance Rating Scale, OT assessment tool

Access of service at school or HA level Carer stress rating scaleSatisfaction rating23

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Training24

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Training for professionals at community/NGO/ICCMWFirst week : theoretical module and clinical attachmentTheoretical module: similar to SMHSSPlus sessions on :How to provide trauma informed care at schoolPTSD assessment and treatment

Plus sessions on : Flow/service protocol of assessing ADHD cases at communityUse of ADHD related rating scales at community level

Specific training by qualified trainer on using structured diagnostic tools

Second

week :

Training for treatment of mild and moderate ADHD cases at

community:

running of manual based treatment groupsPracticum on treatment group training: observation and on the site support Ongoing technical support Plus25

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Overview

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ADHD – Plus / ADHD+Target:1) age 6-252) For ADHD cases, comorbidity and other related mental health symptomsWorkflow:Screening:

Age 6 – 15 / 17Age 16 / 19 - 25

ADHD

Others

ADHD

Others

ASD (3Di)

ASD + CMD

Anxiety (SCAS)

Depression (CDI)

PTSD (IESC 8-17)

+ CMD (CIS-R)

Anxiety

depression

PTSD (IESR >18)

ADHD treatment group

Child & Adolescent

Adult

+ others treatment

Others subclinical treatment

Individual CP NLPRA

- Low intensity treatment

eGPS

NHS IAPT, >18P

Treatment: Child

Anxiety group (CBT cool kids)

Depression group (CBT Depression group)

PTSD/ASR group (7-17)

Cognitive

behavioural

therapy (

CBT-T) (5-15 sessions)

Cognitive processing therapy (CPT)

Narrative Exposure therapy (NET)

Group

Treatment: Adult

Anxiety group CBT

Depression group CBT, ITP

PTSD/ASR group

CBT-T (8-12

sessions)

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Thank You!28