Commissioning a service for the diagnosis and management of ADHD in adults

Attention deficit hyperactivity disorder (ADHD) is a heterogeneous behavioural syndrome characterised by the core symptoms of hyperactivity, impulsivity and inattention. Common co-existing conditions in adults include personality disorders, bipolar disorder, obsessive-compulsive disorder and substance misuse. Young people with ADHD are also likely to have higher rates of both specific and generalised learning disabilities^[1]. Based on the criteria in the Diagnostic and statistical manual, 4^th edition, ADHD is thought to affect about 2% of adults worldwide. See the Determining local service levels section for further information.

ADHD has been increasingly recognised in the UK over recent years, but the provision of treatment for young people has been variable^[1],^[2]. The identification of ADHD in adults in the UK is uncommon. There are very few specialist or generic mental health services in the NHS for adults with ADHD^[1], despite evidence of effectiveness; in addition, clinicians often feel ill equipped to treat adults with ADHD^[3]. Young people often leave children's services with no readily identifiable adult service to support them^[4], even though most young people with a sustained diagnosis will go on to have significant difficulties in adulthood. These, may include continuing ADHD, comorbid psychiatric disorders, emotional and social difficulties, substance misuse, unemployment and involvement in crime. This also means that there is a pool of adult patients in whom the diagnosis of ADHD has been unidentified and where ineffective treatments have been put in place for alternative diagnoses, which may account for the high rates of contact reported with mental health services for adults with ADHD and in turn the associated cost implications^[1]. In addition, many people with ADHD, and their parents or carers, experience stigma and other difficulties because of the symptoms and impairment associated with ADHD and current practice within healthcare and education.

Transition from children's to adult services remains a major concern in young people with mental health problems^[5], particularly those with ADHD who are vulnerable^[6] and require continuing care into adulthood. Currently there is a lack of experience and training in the care of young adults with ADHD within adult mental health services, primary healthcare and psychology services^[6]. It has also been identified that some clinicians may be reluctant to prescribe psychostimulants^[7], as methylphenidate is not licensed for use in adults. Therefore the full implementation of the NICE clinical guideline CG72 on ADHD may require significant effort and partnership working.

The NICE clinical guideline CG72 on ADHD makes recommendations for the diagnosis and management of ADHD. This includes drug treatment for adults, which should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs. The guideline also notes that people with ADHD require integrated care, that addresses a wide range of personal, social, educational and occupational needs.

Benefits

The potential benefits of robustly commissioning an effective service for the diagnosis and management of ADHD in adults include:

• better care of young people with ADHD during the transition between child and adolescent mental health services (CAMHS) or paediatric services, and adult mental health services, which improves clinical, educational and social outcomes^[8]
• decreasing the number of people who disengage from services at a time when they are most vulnerable, and reducing the likelihood of them re-presenting in crisis in the future
• improving the recognition, diagnosis and treatment of ADHD in adults and reducing the risk of misdiagnosis, which can improve the quality of care and may reduce the number of mental health contacts, with the associated costs
• reducing the distress from the symptoms of ADHD in young people and adults and their parents and/or carers
• improving clinical and social care outcomes
• reducing inequalities by improving access to adult psychiatric services for ADHD and addressing differences in referral rates for different ethnic groups^[9]
• increasing patient choice, and improving partnership working, patient experience and engagement
• better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Drug treatment for adults should be the first-line treatment for ADHD unless the person prefers psychological treatment. There is the potential for substance misuse and diversion (where the prescribed medication is forwarded on to others for non-prescription use) in adults with ADHD, especially in some settings, such as prison. However there is no strong evidence that this is a significant problem and the appropriate treatment of ADHD is associated with a reduction in substance misuse^[1].

Key clinical issues

Key clinical issues in providing an effective service for the diagnosis and management of ADHD in adults are:

• accurately identifying and diagnosing all adults with ADHD
• ensuring that appropriate referral pathways are in place for young people to support a smooth transition between CAMHS or paediatric services, and adult services (including adult mental health services, substance misuse services and primary care)
• ensuring offender management services have appropriate referral pathways for young people and adults
• providing effective and efficient clinical care in line with NICE clinical guideline CG72 on ADHD, and ensuring appropriate treatment of comorbid psychiatric disorders including personality disorders, bipolar disorder, obsessive-compulsive disorder and substance misuse, and specific and generalised learning disabilities
• ensuring that the service is integrated with other health and social services for young people and adults with ADHD
• ensuring responsive engagement with the third sector
• providing the best possible outcomes for individual people/patients, their carers and local communities
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a service for the diagnosis and management of ADHD in adults include:

• High quality care for all: NHS next stage review final report identifies the need for locally-led, patient-centred and clinically driven change, including the work stream on children's health.
• World class commissioning.
• The NHS in England: The operating framework for 2009/10 identifies the national priorities for children in 2009/10 including reviewing the effectiveness of CAMHS and ensuring that vulnerable children have access to services. Locally determined priorities include providing services relative to need, to support vulnerable people, and improving the overall quality of healthcare for people with a learning disability.
• National service framework for children, young people and maternity services and in particular standard 9: The mental health and psychological well-being of children and young people, which identifies markers of good practice for transfer from child to adult services, and National service framework for mental health: modern standards and service models.
• Promoting mental health for children held in secure settings: a framework for commissioning services.
• Commissioning IAPT for the whole community: improving access to psychological therapies.
• Joint planning and commissioning framework for children, young people and maternity services sets out the overarching framework for local partners to use in the commissioning of services for young people.
• Delivering the 18 week patient treatment pathway.
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Commissioning framework for health and well-being.
• Considering the impact of patient choice.
• The Expert patients programme.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with Standards for better health.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. National Collaborating Centre for Mental Health (2008) Diagnosis and management of ADHD in children, young people and adults. London: Royal College of Psychiatrists.

2. Department of Health (2004) National service framework for children, young people and maternity services. The mental health and psychological well-being of children and young people. London: Department of Health.

3. Young S, Bramham J (2007) ADHD in adults: a psychological guide to practice. Chichester: J Wiley and Sons Ltd.

4. Nutt D, Fone K, Asherson P et al (2007) Evidence-based guidelines for management of attention deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 21 (1): 10-41.

5. Healthcare Commission (2008) State of healthcare 2008. London: The Stationery Office.

6. Department for Children, Schools and Families (2008) Children and young people in mind: the final report of the national CAMHS review. London: Department for Children, Schools and Families.

7. Thompson A (2008) Commentary: controversies in NICE guidance on attention-deficit/hyperactivity disorder. BMJ 337: a1466.

8. Department of Health, Department for Education and Skills (2006) Transition: getting it right for young people. Improving the transition of young people with long term conditions from children's to adult health services. London: Department of Health.

9. Moosa F, Lohawala A (2007) ADHD - do guidelines translate into service? Child and Adolescent Mental Health 12 (2):73-5.