Julie Proctor Psychological Therapies Lead Joint Clinical Team Lead Neurodevelopmental Pathway Team 2 Consultant Psychiatrists Specialist Trainee in Psychiatry FY1 and FY2 doctors Nurse Prescriber ID: 918633
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Slide1
Specialist CAMHS - ADHD
Neurodevelopmental Team, City and Hackney CAMHSJulie Proctor, Psychological Therapies Lead -Joint Clinical Team Lead
Slide2Neurodevelopmental Pathway Team
2 Consultant Psychiatrists *Specialist Trainee in PsychiatryFY1 and FY2 doctorsNurse Prescriber
Clinical Nurse Specialist
Consultant Clinical Psychologist
Principal Clinical PsychologistClinical PsychologistAssistant PsychologistFamily Therapist *Child and Adolescent Psychotherapist *
Slide3Referring into CAMHS -Where to refer?
? ADHD + Moderate – Severe LD – Refer to Hackney ARK CAMHS Disability
?ADHD +mild or no LD – refer to Specialist CAMHS at
Homerton
Row
Slide4DEMAND
Specialist CAMHS
CAMHS Disability
Monthly
Annually
Monthly
Annually
Number of new referrals
9
108
Number of ADHD assessments779220Number offered intervention563216Current caseload20040Current medication caseload15025Current wait for assessment9.6 weeks10 weeks
Childhood ADHD in City and Hackney
Estimate prevalence 1149 CYP (conservative ICD10
Dx
)
Slide5ADHD Diagnostic Assessment Process
Initial CAMHS Assessment in the Assessment Clinic – general overviewMDT Assessment Clinic discussion
Neurodevelopmental team MDT discussion
–
allocation to appropriate clinician(s) and professional discipline(s)Assessment – clinical interview, review of reports, school screening information. Plus if required - school observation, cognitive assessment, family functioning assessment, CSC referral/consultation, medical investigations, SLT/OT, genetic testing, attachment assessment etc.
Neurodevelopmental team MDT discussion
Assessment Feedback session and Care Planning
Slide6Service Developments
ADHD Quality Improvement Project All assessments completed within 12 weeks of referralNeurodevelopmental Pathway Patient Journey AnalysisCYP ADHD Primary Care Step Down
Stable cases for over 12 months, 11-18yolds that can be safely stepped down to Primary Care
Approx
60 cases in total – budget per patient for GPsStepped Down with direct support of ADHD Primary Care Liaison Nurse Prescriber
6 monthly reviews
–
20mins using EMIS template
Fast track referral back to CAMHS if required
–
all Diagnosis, Titration and Dose stabilisation remains in CAMHS Secondary Care
Slide7Referring to CAMHS – What do we need?
A copy of your report and summary of associated investigations (bloods, genetic testing etc)Other services involved e.g. social care
A detailed developmental history
Information about existing conditions e.g. ASD
If secondary ADHD – when was the TBI and what other services are involved?Information re current medications or treatmentsWhat other investigations are you completing, if any?Copies of additional reports you have e.g. SaLT
, OT, EP
Complete the specialist CAMHS referral form (it’s not too long)
Some examples of hyperactivity, inattention and impulsivity
across settings
(e.g. home, school, what did you observe in clinic?
If you’re not sure what to ask – complete a screening tool (SNAP IV 26 – its free and a PDF which can be accessed online) – attach this to your referralStill unsure? Ask our duty worker on 0203 222 5600
Slide8What is the definition of ADHD?
Primary ADHD is a neurodevelopmental disorder affecting both children and adults. It is described as a “persistent” or on-going pattern of inattention and/or hyperactivity-impulsivity that gets in the wayof daily life or typical development.
There are three presentations of
Primary ADHD
: Inattentive Hyperactive-impulsive Combined inattentive & hyperactive-impulsive (DSM V)
Slide9What diagnostic criteria do we use?
ICD-10Onset before age 7Cannot be diagnosed with a co-morbidity of ASD6 symptoms of inattention3 symptoms of hyperactivity
1 symptom of impulsivity
Seen in more than 1 setting
DSM-5
Onset before age 12
Different presentations (Inattentive, Hyperactive-impulsive and Combined type)
Can be diagnosed with ASD
Has six or more symptoms of the disorder
Seen in more than 1 setting
Slide10Inattention
Hyperactivity
Impulsivity
Slide11Impulsivity:
-Blurts things out
-Acts without thinking
-Interrupting
-Difficulty waiting or taking turns
-
Hyperactivity:
-
Always on the go
-Driven by a motor
-Fidgety-Restless-Running-Climbing-Talking ++Inattention:-Difficulty focussing-Disorganised-Losing things-Making accidental mistakes-Finding it hard to listen for long periods-Easily bored-Mind wandering / day dreamingExecutive function difficulties:-Difficulty with recall and working memory-Reduced problem solving skills-Emotional ups and downsSleep Disturbance:-Difficulty falling asleep-Restless sleep-Difficulty waking up and getting ready in the morning-Irritable and sleepy in the dayImpaired sense of time:-Difficult to predict how long tasks will take-Difficulty planning ahead-Losing track of time / lateness-Procrastination-Avoidant of long / boring tasksDifficulty learning from rewards and punishment:-Difficulty with motivation for long term rewards-Difficulty learning from past mistakesLearning problems:-Difficulty recalling information taught-Behind in class due to inattention-Difficulty structuring long pieces of workEmotional ups and downs:-Really excitable-Quick to anger / frustration-Perfectionism-Ripping things up-Low self esteemManaging co-morbidities:-DCD-Dyslexia-ASD-ODD-Anxiety-Low moodADHD Iceberg Stimulation:-Feeling over stimulated-Feeling under stimulated
Slide12Quick Humoured
Thinking outside the box
Great leaders
Creative thinkers
Generous
Loving
Hyper-focus!
Passionate
Resilience – picking yourself back up
Unique personalityStrong sense of fairnessWill take a risk – put themselves out thereSpontaneousStrengths
Slide13What are the causes of ADHD?
No definitive cause for ADHD has been identifiedInstead, there are a series of known risk factorsGeneticsExposure to environmental toxins during pregnancyExposure to toxins, such as high levels of lead at a young age
Low birth
weight
Premature birthLate birthBrain injurySmoking, drinking alcohol or substance misuse during pregnancy (NIMH, 2016)
Slide14Prevalence
ADHD affects approximately 5% of the school aged population Male to Female ratio in children is approximately 4:1 Girls more commonly have inattentive symptoms, whereas boys more hyperactive and impulsive (could account for skewed ratio’s)
Slide15Boys vs Girls
GIRLS
Often identified at older ages
Can present as more inattentive
Behaviours can be more internalised
Can be affected by hormones
Can have more difficulties with friendships
Can have more feelings of self-doubt
Higher rates of co-existing problems linked with mood or worries
Slide16How long does it last?
ADHD does persist into adulthood for approximately 60% of children / young people diagnosed (Targum & Adler, 2014)Hyperactivity and impulsivity symptoms can be seen to “decay” (reduce) as young people move into adulthood (
Wilen
, 2009)
Slide17Common Co-Occurring conditions
30-50% of Children diagnosed with ASD show symptoms of ADHD (Davis & Kollins, 2012)
Slide18What looks like ADHD?
PTSD (Post Traumatic Stress Disorder)
Attachment problems
Learning difficulties / disability
Chromosome deletions
FAS (Foetal Alcohol Syndrome)
Anxiety
ASD (Autism Spectrum Disorder)
Speech and Language needs
Slide19Interventions
Slide20What intervention is recommended and when? (NICE NG87)
Use of the NICE guidance (NG87)
Preschool children (under 5):
-Parent training / education programmes are the first line treatment
-Medication as a treatment is not recommended in preschool children
-Liaison with the school about the diagnosis
Slide21What intervention is recommended and when? (NICE NG87)
School Age Children and Young People (5 and above)Give information about ADHD
and
offer additional support to parents and carers of all children aged 5 years and over and young people with ADHD. The support should be ADHD focused, can be group based and as few as 1 or 2 sessions. It should include:
education and information on the causes and impact of ADHD advice on parenting strategies
with
consent, liaison with school, college or
university
both
parents and carers if
feasible
Slide22What intervention is recommended and when? (NICE NG87)
Medication as an interventionOffer medication for children aged 5 years and over and young people only if:
their
ADHD symptoms are still causing a persistent significant impairment in at least one domain after environmental modifications have been implemented and reviewed
they and their parents and carers have discussed information about ADHD
a
baseline assessment has been carried
out
Medication is not recommended in child under 5 years old
Slide23What intervention is recommended and when? (NICE NG87)
Consider a course of cognitive behavioural therapy (CBT) for young people with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain, addressing the following areas:social skills with
peers
problem-solving
self-controlactive listening skillsdealing with and expressing
feelings
Slide24Before medication…cover all bases
Should the child be wearing glasses whilst at school?Are they receiving appropriate support for co-morbid conditions? e.g. Speech and Language needs, learning difficulties, dyslexia, hypermobility, mental health needs etc.Are they being given the best opportunity to learn? e.g. where they’re sat in class, learning support in place if assessed as needed
Does the child have sensory needs and are these addressed? E.g. are they affected by bright lights, noise levels in the class
etc
Does everyone involved with supporting your child understand their needs?
Slide25Trialling medication
Slide26Pre-screening Physical Health Checks
Full CAMHS / Mental Health assessmentFull health history – including family health historyCardiac
Liver
Kidneys
DiabetesThyroidIron deficiencyPicaAsthmaEpilepsy
Tic disorder /
tourettes
Substance misuse / diversion risk
Allergies
Any current medications?
Any herbal remedies?
Slide27Pre-screening physical observations
Blood pressurePulseHeightWeightUse of centilesBaseline ECG if significant cardiac
hx
within the family
Slide28Concerta
XL – up to 12 hour preparation
22% and 78%
Medikinet XL –up to 8 hour preparation
50% and 50%
Immediate Release – up to 4 hours
Equasym
XL – up to 8 hour preparation
30% and 70%
Lisdexamfetamine –up to 13 hour preparation (peak 3.5-4.8hrs)
Dexamfetamine – peak at 1.5 hoursStimulant Medications54mg
Slide29Non Stimulant Medications
Atomoxetine
Clonidine (Alpha 2a agonist)
Guanfacine
–Alpha 2a agonist- 2
nd
line but not currently used in ELFT
Slide30Side effects
InsomniaReduced appetiteRaised Blood Pressure and Heart RateGrowth deceleration
Managed through monitoring and dose reduction if required
Atomoxetine
– side effects can include low mood + jaundicePotential increased cardiac risk when administered with salbutamol / beta2 agonists
Slide31Medication benefits
When dose is optimised, the following benefits are reported:
Improved concentration
Improved memory (due to improved focus)
Better problem solving skillsReduced emotional outburstsReduced restlessness / agitationEasier to engage in school which can improve outcomes
Easier peer relations as able to follow conversations
Slide32First line intervention when prescribing:
MethylphenidateCNS Stimulant medication (sympathomimetic – produces physiological characteristics of the sympathetic nervous system through stimulation of sympathetic nerves
)
Immediate release: lasts 3-4 hours (MPH IR; Ritalin)
Modified release: lasts 8-12 hours Medikinet XL – 8 hours 50/50
Equasym
XL – 8 hours 30 / 70
Concerta
XL – 12 hours 22 / 78%
Slide33I think my patient has ADHD………
What next?
Slide34Slide35Managing Adult ADHD in Hackney
Jide MorakinyoConsultant Psychiatrist City and Hackney Adult ADHD ClinicCity and Hackney Centre for Mental HealthEast London NHS Foundation Trust, Homerton Row, E9 6SR
Slide36Why bother about ADHD?
Neurodevelopmental disorder with childhood onset and often persisting into adulthood (Chronic)Common disorderSignificant functional impairment, personal distress and reduced quality of life. (education, work, family-life functioning, household economy, and social skills)Co-exist with many other psychiatric disorders and complicating matters.
Often unrecognised and with prejudiced and ill informed ideas about it.
Important to identify and treat
Often responds well to treatment/medication
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide37What is ADHD?
ADHD is a childhood onset neurodevelopmental condition which manifests as cognitive and behavioural deficits
.
May persist into adulthood
It is characterised by the core symptoms of persistent hyperactivity, impulsiveness and
inattention
.
As well as the presence of the core symptoms identified, there must be clear evidence of psychological, social and/or educational or occupational
impairment plus some impairment in two or more settings
(home, at work, social, occupational).
Thursday, 08 November 2018Jide Morakinyo/HackneyADHDClinic
Slide38Bibi:
‘
my brain is like pinball machine’.
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
People often say to her that their children have ADHD and she is like them.
Attentional deficits and being often restless all through her primary and secondary school years.
No longer as hyperactive or restless as she used to be.
She has trouble thinking.
Most difficult symptom now: problems with focusing and inability le to do things she enjoys because she can’t focus on them.
Finds it hard to stay on any task especially when she finds it boring and leaves it uncompleted. She feels frustrated that people can sit down and watch TV and movies, whereas she finds it difficult to relax and sit still to partake in these activities, therefore often she might leave her friends and walk away. She finds this upsetting and disruptive to her social life.
Slide39Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
School reports - inappropriate noises in class, talking when teachers were talking and arguing with teachers.
A teacher commented: ‘
Bibi finds it difficult to listen attentively and sustain concentration. Bibi has regularly failed to produce homework’
. Other teachers made similar comments: difficulties focusing on tasks, completing homework and not being able to participate meaningfully in class.
Couldn’t complete her GCSE and for most of her lessons she wasn’t let into the classes because of her restlessness. Later attended the local college for music productions; experienced same difficulties in the classes, completed the programme but with the lowest level of grades.
Currently, an IT engineer apprentice and works at multiple sites: starts some work and leaves and starts something else before one of the managers would point out that she is yet to complete the initial work she started.
Relationship problems: problems listening to people, saying there is a lot going on in her brain and not easy listening to people, and therefore she might easily misconstrue what people say to her. In addition, she is easily irritated and gets frustrated, which makes her relationship with her mother, friends and partner very difficult.
Slide40Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Avoids cooking, easily forgets and leaves that for hours unattended.
Mother advised her not to cook because of fear that she might inadvertently cause fire.
For this clinic, she was sent for ECG but she just remembered this in the course of our meeting that she didn’t go for it. She said this is often the pattern for her, as she would forget appointments and things to do. She says ‘
my brain is like pinball machine’.
Currently, she is on Fluoxetine and feels she was placed on it because she was feeling anxious and that sometimes she feels low in mood. She denies any ongoing psychotic experiences.
Slide41Genetics
Family/adoption/twin studies all support the view that genes contribute to the development of ADHD
Parents of an ADHD child ~ 5 times more likely to have ADHD
Siblings ~ 4 times more likely to have ADHD than the general population
Genetic causes of ADHD account for most of the variability in the presentation of the disorder,
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide42Biology
PET scan imaging indicates that methylphenidate acts to increase dopamineThe neurotransmitters dopamine and norepinephrine have been associated with ADHD.
The underlying brain regions predominantly thought to be involved are frontal and prefrontal.
Other studies have shown structural alterations in other parts of the brain
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide43Something different about the brain
Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis - Lancet
Volume 4, No. 4
, p310–319, April 2017
Neuroimaging studies have shown structural alterations in several brain regions in children and adults with attention deficit hyperactivity disorder (ADHD)
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide44Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis - Lancet
Volume 4, No. 4, p310–319, April 2017
Summary
Background
Neuroimaging studies have shown structural alterations in several brain regions in children and adults with attention deficit hyperactivity disorder (ADHD). Through the formation of the international ENIGMA ADHD Working Group, we aimed to address weaknesses of previous imaging studies and meta-analyses, namely inadequate sample size and methodological heterogeneity. We aimed to investigate whether there are structural differences in children and adults with ADHD compared with those without this diagnosis.
Methods
In this cross-sectional mega-analysis, we used the data from the international ENIGMA Working Group collaboration, which in the present analysis was frozen at Feb 8, 2015. Individual sites analysed structural T1-weighted MRI brain scans with harmonised protocols of individuals with ADHD compared with those who do not have this diagnosis. Our primary outcome was to assess case-control differences in subcortical structures and intracranial volume through pooling of all individual data from all cohorts in this collaboration. For this analysis, p values were significant at the false discovery rate corrected threshold of p=0·0156.
Findings
Our sample comprised 1713 participants with ADHD and 1529 controls from 23 sites with a median age of 14 years (range 4–63 years). The volumes of the
accumbens
(Cohen's d=−0·15), amygdala (d=−0·19), caudate (d=−0·11), hippocampus (d=−0·11), putamen (d=−0·14), and intracranial volume (d=−0·10) were smaller in individuals with ADHD compared with controls in the mega-analysis. There was no difference in volume size in the pallidum (p=0·95) and thalamus (p=0·39) between people with ADHD and controls. Exploratory lifespan modelling suggested a delay of maturation and a delay of degeneration, as effect sizes were highest in most subgroups of children (<15 years) versus adults (>21 years): in the accumbens (Cohen's d=−0·19 vs −0·10), amygdala (d=−0·18 vs −0·14), caudate (d=−0·13 vs −0·07), hippocampus (d=−0·12 vs −0·06), putamen (d=−0·18 vs −0·08), and intracranial volume (d=−0·14 vs 0·01). There was no difference between children and adults for the pallidum (p=0·79) or thalamus (p=0·89). Case-control differences in adults were non-significant (all p>0·03). Psychostimulant medication use (all p>0·15) or symptom scores (all p>0·02) did not influence results, nor did the presence of comorbid psychiatric disorders (all p>0·5).Thursday, 08 November 2018Jide Morakinyo/HackneyADHDClinic
Slide45How common is ADHD?
Viktória
Simon et al. BJP 2009;194:204-211
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide46NICE
multidisciplinary specialist ADHD teams and/or clinics expertise in the diagnosis and management of ADHDprovide diagnostic, treatment and consultation services for people with ADHDproduce local protocols for shared care arrangements with primary care providersensure age-appropriate psychological services are available
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide47Treatments
Comprehensive treatment programme that focuses on psychological, behavioural and educational or occupational needs. Medication Psychological interventions Social interventions
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide48Medication
Stimulants
Non-stimulants
Methylphenidate (Ritalin, Concerta XL, Equasym,
Medikinet
)
Atomoxetine
Dexamfetamine (Dexedrine)
Bupropion
Lis-Dexamfetamine (Elvanse)
DuloxetineModafinil GuanfacineMethylphenidate and dexamphetamine are schedule 2 controlled drugs (CD) thus are subject to prescription requirements. Thursday, 08 November 2018Jide Morakinyo/HackneyADHDClinic
Slide49NICE – Licensing arrangements
Methylphenidate, Dexamfetamine and atomoxetine do not have UK marketing authorisation for use in adults with ADHD. Atomoxetine is licensed for adults with ADHD when the drug has been started in childhood. Informed consent should be obtained and documented.
Drug treatment for adults with ADHD should be started only under the guidance of a psychiatrist, nurse prescriber specialising in ADHD, or other clinical prescriber with training in the diagnosis and management of ADHD
Good knowledge of the drugs used in the treatment of ADHD and their different preparations is essential (refer to the BNF and summaries of product characteristics).
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide50City and Hackney ADHD Team
Supernumerary Psychologist: 3hrs/Week
Clinical Psychologist (Band 7): 0.5 wte
Staff grade/SHO ~ 4 PA/week
SpR on special interest ~ 1PA/week
Consultant ~ 1.5 PA/week
Operational lead – Ms Maria Lee
Admin support
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide51Referrals and pathways
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide52Shared Care Protocol
Copy of this on CCG Website
An updated version should be available in coming weeks
This document defines the roles of each professional involved
Patients often get a copyHighlights for GP
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic
Slide53Conclusion
Adult ADHD is a valid diagnosis and a common and disabling disorderOften co-exists with other psychiatric disordersRequires a thorough assessment by professional with expertise in diagnosis and treatment ADHDMental health teams/services should provide clinics or MTD team providing diagnostic & treatmentTreatment encompasses medication and appropriate psychosocial interventions.
Good knowledge of drugs used to treat ADHD in very important
Thursday, 08 November 2018
Jide Morakinyo/HackneyADHDClinic