1. ADHD occurs in 5-7% of children. It is also known that approximately 15% of these young people continue to have the full syndrome in adulthood, i.e. 1-1.5% of adult population.
2. The full syndrome consists of the core symptoms of ADHD together with impairment in at least two functional domains (work or education, managing money, relationships, social interaction, driving and offending behaviour).
3. Co-morbid mental health problems, especially anxiety and depression, are common with up to 15% of those without psychoses attending adult services having unrecognised ADHD.
4. Drug and alcohol misuse and anti-social behaviour are also more common.
5. The key features of the recommended response are:
   • working in partnership with people with or thought to have ADHD
   • comprehensive and skilled assessment
   • evidenced based multi-modal treatment aligned to the principal of altered ability rather than disability.
6. The service model is based on the lack of public services for adults with ADHD in Ireland. This includes:
   • those diagnosed with ADHD as children and requiring on-going treatment as adults
   • those attending mental health services in whom ADHD has not been recognised
   • adults suspected as having ADHD for whom assessment is required.
7. The model of care recommends a combined secondary/tertiary service approach based on close collaboration with adult and child mental health services. A key feature is integrated working with general practitioners and primary care teams.
8. The referral process consists of referral to adult community mental health teams (ACMHTs) where screening for possible ADHD is completed as part of an overall mental health assessment. Those screening positive are then seen by the ADHD Clinic Team. This process includes current attendees of AMHTs thought to have ADHD.
9. A modified pathway for adolescents with ADHD attending child and adolescent community mental health teams (CAMHS) is outlined. This will smooth the transition process to the ADHD Clinic for those whose primary problem is ADHD for which they continue to require mental health intervention.
10. A comprehensive and skilled assessment is carried out at the ADHD Clinic. The Diagnostic Interview for Adult ADHD (DIVA) is recommended to ensure all relevant symptoms are explored. This must include identification of co- morbidities.
11. An integral part of the assessment is the post assessment discussion, whether the outcome confirms ADHD or not. This is to agree a comprehensive individual care plan to which the person commits. It also ensures appropriate signposting for those found not to have ADHD.
12. Treatment includes:
    • ADHD specific medication in the ADHD Clinic
    • Treatment of co-morbidities – those with severer co-morbidities to be treated by their Adult Community Mental Health Teams before ADHD specific interventions are considered
    • Non-pharmacological interventions delivered through the ADHD Clinics
    • ADHD specific cognitive behaviour therapy
    • Occupational therapy interventions which are task focused
    • Other important interventions recommended and available outside the HSE
    • ADHD Ireland for information and support
    • ADHD specific coaching
    • General wellbeing advice
    • EmployAbility service to assist those with difficulties in finding and/or keeping a job.
13. The clinical pathway for adults with ADHD is shown in figure 1. It includes referral routes, screening, assessment, treatment and eventual discharge.
14. The model of care is in line with A Vision for Change and Sharing the Vision and based on local service delivery in defined mental health catchment areas, in line with the CHO structure (figure 2) with one ADHD clinic team recommended for 250,000 - 400,000 working age adults. The current population indicates 11 such teams will be required, together with an additional team to work in tandem with the Forensic Psychiatry Teams serving the Dublin prisons.
15. Each team will be multidisciplinary to ensure the provision of comprehensive assessment and multimodal treatment. A full team will consist of:
    • Consultant General Adult Psychiatrist – 1.0 WTE
    • Administrator (Grade IV) – 1.0 WTE
    • Clinical Nurse Specialist (mental health) – 1.0 WTE
    • Psychologist (senior) – 1.0 WTE
    • Occupational Therapist (senior) – 1.0 WTE
16. Each local mental health area must provide appropriate outpatient clinic facilities and one site for the team. Rooms required are:
    • Waiting area with administrator adjacent
    • Group/ meeting room
    • 4 Offices for patient contacts.
17. It is envisaged there will be two stages of development of the Model of Care. The first phase will focus on all assessments being carried out by the ADHD Clinic as well as multi-modal interventions, together with the provision of training in the assessment of ADHD for all current adult psychiatrists, if required, and higher specialist trainees in psychiatry. In the second phase, it is envisaged that only more complex cases will be referred to the ADHD Clinic for assessment. Multi-modal interventions will continue to be delivered through the ADHD Clinic.
18. The Adult ADHD National Clinical Programme will be implemented to operate within the established governance structures for mental health services.
19. Implementation will be supported and over-seen by a National Oversight Implementation Group led by the Clinical Lead and supported by the Programme Manager.
20. Collection of activity and outcome data will be co-ordinated by the Programme Manager working with the local ADHD Clinic Team. This will guide future development and inform the implementation process.
21. On-going training and education for the Adult ADHD Clinic Teams and the wider mental health service will be part of the role of the National Group working closely with the relevant training bodies and professional groups.
22. These recommendations and specifically their implementation are entirely dependent on the provision of the additional funding required to establish the Adult ADHD Teams. 

Home ❭ HSE Model of Care for ADHD ❭ Summary of Key Recommendations

NEXT: 1. INTRODUCTION