Service innovation: transitional attention-deficit hyperactivity disorder clinic

Attention-deficit hyperactivity disorder (ADHD) affects 3–7%of school-age children (Goldman et al, 1998) and causes symptomsof inattention, hyperactivity and impulsivity (DSM–IV;American Psychiatric Association, 1994). In the UK, many adolescentsare currently being treated for ADHD; the prevalence of treatedADHD among boys aged 5–14 years was estimated at 5.3per 1000 in 1999 (Jick et al, 2004). This means that over40 000 boys aged 5–14 years are currently treated inthe UK (2001 Census; http://www.Statistics.gov.uk/census2001/census2001.asp).

Although ADHD is primarily seen as a disorder in children, itis clear that symptoms continue into early adulthood (Gittleman et al, 1985;Weiss et al, 1985; Mannuzza et al, 1993). This was supportedby Faraone & Biederman (1998), who found up to 20% of parentsof children with ADHD also had the condition. Furthermore, ina more recent study, the prevalence of ADHD in adults was 2.5%,using a cut-off of four relevant DSM–IV symptoms (Kooij et al, 2005).

Hence young people currently treated for ADHD by child and adolescent mental health services (CAMHS) and paediatric services arelikely to require treatment beyond 16. However, when they reach16 (or 18 if they are continuing in education) these youngpeople will exceed the upper age limit for these services.

Need for transitional services

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Need for transitional services

It is unclear what happens to a patient with ADHD symptoms oncethey reach 16 or 18. In England, a mainly tertiary referralservice for adults with ADHD has been running at the MaudsleyHospital for some years. There is also a tertiary service atAddenbrooke’s Hospital in Cambridge. However, there islittle specialised provision to meet the needs of young peoplemoving on from child ADHD services.

In Rotherham, CAMHS are seeing patients beyond the upper agelimit. This not only increases pressure on existing services,but also raises the question of whether young adults shouldbe seen by a children’s service.

Is it possible that many patients are lost to follow-up owingto a lack of services to meet their needs? In this paper wedescribe a dedicated clinic that aids the smooth transitionof young people from child and adolescent mental health servicesto adult psychiatric services.

Assessment of local need

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Assessment of local need

An audit of cases of ADHD diagnosed in CAMHS between 1994 and2004, in Rotherham, found 88 confirmed cases of ADHD, 37 ofhyperkinetic conduct disorder and 3 of attention-deficit disorder.Of these, 27 patients were over the age of 16 but only 3 werebeing followed by general adult psychiatry services. Significantly,it was not known whether the other 24 individuals had beenlost to follow-up. A recent audit found 27 young people withADHD in the Rotherham CAMHS that were expected to reach theage of 16 between January 2005 and December 2006 (Verity et al, 2006).To meet this need, a transitional clinic for ADHD patients leavingthe service was proposed.

Transitional clinic

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Transitional clinic

History
In July 2004, South Yorkshire clinicians with an interest inADHD in adults and adolescents attended a meeting in Rotherhamwhich clarified two sources of ADHD referrals to general psychiatristsin the area: the first, from general practitioners for adultswith ADHD and the second from CAMHS for young people due tomove on from their service. It was agreed that R.V. should ascertain what was happening nationally to adult patients with ADHD,and report back in November 2004. At the November meeting itwas decided that efforts should initially be concentrated onthose transitional patients who were due to leave CAMHS, asthis represented the best use of limited resources.

In March 2005, a protocol for patients with ADHD at the upperage limit of CAMHS was agreed and in April 2005, the Rotherhampsychiatry consultant body approved its use (Box 1).

Aims
The aims of the transitional ADHD clinic were:

to be led by local need and ensure continuity of care
to providea supportive environment for the transition fromCAMHS to adult services
to promote a quality service through training, auditand research
to continue developing specialist expertise throughtraining,audit and research
to act as a role model for bestpractice.

Experience to date
At the first clinic appointment a current DSM–IV diagnosisof ADHD is confirmed and the degree to which symptoms affectthe individual’s life is assessed; thus the current needfor treatment is determined. All individuals are encouragedto attend the initial appointment with someone who knows themwell, and is able to give an informant history.

Box 1. Transitional protocol (April 2005)

Young person leavesthe CAMHS with a written doctor referral to transition service

Jointassessment with carer, CAMHS worker and R.V.

If continued treatmentis not appropriate, discharge, with letter informing that generalpractitioner can re-refer

If any comorbid psychiatric diagnosisis found, assessment and referral to appropriate service (e.g.drugs service)

If diagnosis and need to continue treatmentis confirmed, medication prescribing (e.g. methylphenidate)is continued, and general practitioner and CAMHS are informed

Six-monthassessment including blood pressure, weight, full blood count, urea and electrolytes and liver function tests

One-year assessmentincluding period off medication if applicable.

We have seen 11 patients so far, all moving on from the localCAMHS, and a diagnosis of ADHD has been made in each case.A further 16 patients will have been seen by February 2007.We are expecting more referrals in the near future.

In 9 out of 11 young people seen at the time of writing themedication regimen recommended by the CAMHS service was continued.One patient was recommended a higher dose of current medication,and for 1 patient medication was not recommended. No comorbidpsychiatric diagnoses have been made in the initial cohort.

Follow-up
If no changes are made to medication and the patient is stable,follow-up arrangements are for every 6 months. If medicationis changed, patients and/or their carers are asked to assessthe response to treatment over a period of 2 weeks for methylphenidate-basedmedications (there has been no experience so far with atomoxetine).Patients and carers then contact R.V. by telephone to discussthe outcome. The rationale behind this approach is that patientshave been treated usually for many years and know their ownreaction to stimulant medication. Prescriptions are given every6 weeks.

Full blood count, urea and electrolytes, liver function tests,weight and blood pressure are measured. The current plan for1-year follow-up is to advise the patient to consider a trialperiod without medication in order to reassess the need fortreatment.

Limitations
The following unmet needs have been highlighted in the clinic:

young people in need of educational or training opportunities
young people requiring help with housing
some young peopleand their families have chaotic lifestylesthat makes adherencedifficult
ADHD has caused difficulties in family relationships
we have no nursing, social work or psychology input into theteam which could help meet the above.

Furthermore, we only accept referrals from CAMHS, and currentlyoperate only within one locality of our NHS trust.

Future plans
In the near future we hope to become a trust-wide resource andlater aim to take referrals from the region. As the clinicexpands we aim to liaise with local general practitioners,facilitate shared care and offer a multidisciplinary serviceto counter the unmet needs.

Clinical implications

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Clinical implications

In our locality there is a clinical need for a service to enablethe transition of patients with ADHD from CAMHS to adult services (Verity et al, 2006). The Rotherham transitional ADHD clinicfacilitates this transfer, in accordance with the NationalService Framework for Children and Young People (Department of Health, 2004).

References

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