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

Service components

The key components of a service for the diagnosis and management of attention deficit hyperactivity disorder (ADHD) in adults and young people in transition are:

• the transition of young people with ADHD into adult services
• appropriate referral, diagnosis and management of adults with ADHD
• developing a high-quality service for the diagnosis and management of ADHD in adults and young people in transition.
• the organisation and planning of services.

The transition of young people with ADHD into adult services

The NICE clinical guideline CG72 on ADHD states that young people with ADHD receiving treatment and care from child and adolescent mental health services (CAMHS) or paediatric services should normally be transferred to adult services if they continue to have significant symptoms of ADHD, or coexisting conditions that require treatment. Transition should be planned in advance by both referring and receiving services. An assessment at school-leaving age to establish the need for continuing treatment into adulthood should be carried out.

Flexibility in the timing of transition is important. The precise timing of arrangements may vary locally but should usually be completed by the time the young person is 18 years old.

Transition arrangements should normally include:

• details of the anticipated treatment and services that the young person will require
• consideration of a formal meeting involving CAMHS and/or paediatrics and adult psychiatric services, and provision of full information about adult services to the young person
• the use of the care programme approach as an aid to transfer between services for young people aged 16 years and older
• the involvement of the young person, and when appropriate the parent or carer, in the planning.

Transition: getting it right for young people describes best practice for the care of young people in transition between CAMHS or paediatric services and adult services. This guidance notes that well-planned transition improves clinical, educational and social outcomes and requires accountability, cooperation and partnership working across a wide range of professionals and organisations.

Appropriate referral, diagnosis and management of adults with ADHD

The diagnosis and general management of ADHD is described in detail in NICE clinical guideline CG72 on ADHD. It is important to ensure that people with symptoms suggestive of ADHD are referred for appropriate assessment, diagnosis and treatment in order to improve the recognition and management of ADHD in adults, and to reduce the risk of potentially vulnerable young people lacking access to appropriate treatment and services.

The NICE clinical guideline CG72 on ADHD recommends that:

• Adults presenting with symptoms of ADHD in primary care or general adult psychiatric services, who do not have a childhood diagnosis of ADHD, should be referred for assessment by a mental health specialist trained in the diagnosis and treatment of ADHD, where there is evidence of typical manifestations of ADHD (hyperactivity/impulsivity and/or inattention) that:
  - began during childhood and have persisted throughout life
  - are not explained by other psychiatric diagnoses (although there may be other coexisting psychiatric conditions)
  - have resulted in or are associated with moderate or severe psychological, social and/or educational or occupational impairment.
• Adults who have previously been treated for ADHD as children or young people and present with symptoms suggestive of continuing ADHD should be referred to general adult psychiatric services for assessment. The symptoms should be associated with at least moderate or severe psychological and/or social or educational or occupational impairment.
• A diagnosis of ADHD should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified health care professional with training and expertise in the diagnosis of ADHD.

The details of the diagnosis are described in the NICE clinical guideline CG72 on ADHD. This guideline also notes that drug treatment for adults should:

• be the first-line treatment unless the person prefers psychological treatment
• be started under the guidance of a psychiatrist, nurse prescriber specialising in ADHD or other clinical prescriber with training in ADHD diagnosis and management
• always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs
• be prescribed by an appropriately qualified healthcare professional with expertise in managing both ADHD and substance misuse for adults who also misuse substances.

Developing a high-quality service for the diagnosis and management of ADHD in adults and young people in transition

NICE clinical guideline CG72 on attention deficit hyperactivity disorder recommends that:

• trusts should ensure that specialist ADHD teams for children, young people and adults jointly develop age-appropriate training programmes for the diagnosis and management of ADHD for mental health, paediatric, social care, education, forensic and primary care providers and other professionals who have contact with people with ADHD
• child and adult psychiatrists, paediatricians, and other child and adult mental health professionals (including those working in forensic services) should undertake training so that they are able to diagnose ADHD and provide treatment and management.

The guideline states that people with ADHD would benefit from improved organisation of care and better integration of paediatric, CAMHS and adult mental health services.

The organisation and planning of services

NICE clinical guideline CG72 on ADHD recommends that multidisciplinary specialist ADHD teams and/or clinics for children and young people should be established, with separate teams and/or clinics for adults. Initially these could be provided by a specialist team, but over time should be integrated within generic mental health services.

The guideline also recommends that these teams and clinics should have expertise in the diagnosis and management of ADHD, and should:

• provide diagnostic, treatment and consultation services for people with ADHD who have complex needs, or where general psychiatric services are in doubt about the diagnosis and/or management of ADHD
• put in place systems of communication and protocols for information sharing among paediatric, child and adolescent, forensic, and adult mental health services for people with ADHD, including arrangements for transition between child and adult services
• produce local protocols for shared care arrangements with primary care providers, and ensure that clear lines of communication between primary care secondary care are maintained
• ensure age-appropriate psychological services are available for young people and adults with ADHD, and for parents or carers.

The size and commitment of these teams should depend on local circumstances (for example, the size of the trust, the population covered and the estimated referral rate for people with ADHD).

Every locality should develop a multi-agency group to oversee the implementation of the NICE clinical guideline CG72 on ADHD and to start and coordinate local training initiatives. This should include representatives from multidisciplinary specialist ADHD teams, paediatrics [if considered appropriate locally for adult services], mental health and learning disability trusts, forensic services, CAMHS, the Children and Young People's Directorate (including services for education and social services), parent support groups and others with a significant local involvement in ADHD services. It may also include the third sector, substance misuse services, youth justice, offender management and primary care.

Joint commissioning for mental health as a whole is still underdeveloped^[1] and the commissioning process should have full participation and ownership with health, social services and education^[2]. As the symptoms of ADHD are commonly found in people with learning difficulties and in offenders^[3], commissioners may need to carry out a joint health and social needs assessment and engage with a range of other partners. Commissioners may also need to consider these as potential sources of referrals to services for adults with ADHD. This may provide the opportunity to work with health and social care providers to develop local care pathways that support the integration of services across different sectors. In some areas the third sector is already bringing different agencies together and encouraging sharing of information on good practice.

A service model for the management of adults with ADHD might include a multidisciplinary specialist ADHD team and/or clinic for young people, with separate teams and/or clinics for adults. As generic mental health services develop competence in the management of adults with ADHD, the delivery of these services could be integrated between specialist and generic mental health teams. However, as there are currently no mechanisms in place for specialist tertiary mental health services to support general mental health teams, commissioners may wish to consider how this can be delivered across a geographical area. Generic mental health teams and/or primary care could provide a treatment monitoring service, which could include a nurse or other clinical prescriber and/or practitioner with a specialist interest.

Commissioners may wish to consider service models that include the NHS working with non-NHS providers and/or the third sector to stimulate the market. As service models may need to take into account patients with a dual diagnosis, it may be appropriate for generic adult mental health services to provide an overall coordinated package of care, with advice from specialist clinicians for the management of ADHD. Some patients may need support over a significant period of time, so service models may need to consider current levels of provision, clinical skills and competence, and how best to provide the level of service capacity required in the local area (see also the commissioning and benchmarking tool).

Local stakeholders, including service users, should be involved in determining what is needed from a service for the diagnosis and management of adults with ADHD and young people in transition in order to meet local needs. The service should be centred on the person with ADHD and integrated with other elements of care for people with ADHD.

The service specification needs to consider:

• The required competencies of, and training for, staff responsible for providing the service. This may need to focus on the competencies and skills required by individuals involved at various stages of the care pathway, rather than which specific professionals should be involved^[4].
• The expected number of patients. This should take into account how quickly any changes in service provision are likely to take place.
• Ease of access and service location. Commissioners should engage with service users and other relevant individuals and organisations locally.
• Referral and care pathways should support the integration of services across different sectors.
• Information and audit requirements, including IT support and infrastructure.
• Planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks.
• Service monitoring criteria.

Useful sources of information may include:

• The NHS Purchasing and Supply Agency's Mental health roadmap is an online resource pack for commissioners of mental health services for people of all ages. The pack contains practical tools, guidance, case studies and templates, and integrates commercial and procurement elements with clinical aspects to help commissioners get the most from the provider market, enabling quality and value for money in delivering improved outcomes
• Delivering the 18 week patient pathway: 18 week commissioning pathways
• Implementation advice for NICE clinical guideline CG72 on ADHD.

References

1. 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.

2. Department of Health (2004) 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. London: Department of Health.

3. 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.

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