6. Proposed Model of Care

Home ❭ HSE Model of Care for ADHD ❭ 6. Proposed Model of Care

6.1 Current Service Provision for ADHD

Children and Young People: Children and young people up to their 18th birthday are assessed and treated for ADHD within the Child and Adolescent Mental Health Services (CAMHS). The service is provided by a consultant led team responsible for a defined catchment area. Management of ADHD is an important part of the core work of teams and accounts for almost one third of all referrals to CAMHS (HSE 2012-2013).

Children and adults with intellectual disability and co-morbid ADHD: Those with moderate or greater degrees of intellectual disability (ID) are assessed and treated in age related Mental Health Intellectual Disability (MHID) services. This is also seen as part of core work of their teams. Up to one third of people with mild ID and comorbid ADHD may also attend these services if their needs indicate this is the more appropriate service (AVFC 2006). Generally, people (both adults and children) with mild ID attend the relevant CAMHS or General Adult psychiatry service (GAP). MHID is the subject of a HSE Service Improvement Project to ensure all geographic areas have such a service. Currently there are 16 teams for adults and 7 for children whereas there should be 29 and 17 respectively.

Adults without ID or mild ID: As previously stated, the only areas with a service are counties Sligo and Leitrim. A consultant with both an interest and an expertise in ADHD provides a small, mono-discipline (medical only) tertiary service in conjunction with the General Adult Psychiatry teams in Sligo and Leitrim. All referrals come from these teams and those referred remain under the care of their referring team.

6.2 Estimating Need

In devising this model of care the following were taken into account:

5% of children have ADHD with 65% continuing to be symptomatic but 15% meeting diagnostic criteria for ADHD at 18 years, i.e. 1.5% of young adults
A longitudinal population based register study on the annual incidence of diagnosed ADHD in adults indicate just under 1 (0.9) per 1,000 adults could be expected (Polyzoi 2018)
The known functional and psychological impact of these symptoms in adulthood
The lack of any public services in Ireland for adults with ADHD except for the research based service developed in Sligo / Leitrim
Evidence from the Sligo / Leitrim service that 135 of 600 current attenders of general adult psychiatry services in that area screened positive for ADHD i.e. over 20% (Adamis 2017). Similar evidence from an earlier study of current attenders in the North Dublin Mental Health Services (Syed 2010). Both are similar to international findings (Rao 2011, Deberdt 2013)
It is likely that one in four children with ADHD will have a parent with ADHD (Faraone 2001). In some parents, ADHD may not have been formally diagnosed
The positive evidence base for the use of medication in adults with ADHD (Nutt 2007) and its recommendation by NICE (2008, 2013, 2018)
Emerging non-pharmacological interventions for ADHD in adults (Weiss 2009; Knouse 2015).

6.3 Design of the Model of Care

In designing the Model of Care, a number of service models were considered (UKANN Annual Conference 2017).

These included:

Primary care service for adults with ADHD
Secondary care adult mental health service (General Adult Psychiatry)
A national ADHD service (tertiary level)
Tertiary level service for defined catchment area separate from local adult mental health service
Combined secondary care and tertiary care (ADHD Team) with close liaison and formal ways of working with adult mental health teams in their shared catchment area
Private adult ADHD service.

The National Clinical Programme is mandated to consider public service provision only.

Therefore service models 1 through 5 above were compared in Table 6.1 to assist in deciding the most effective, practical and viable model of care to recommend.

The development of services over time was presented at the 2018 UKAAN conference.

A common theme was that the standard direct referral ADHD service was not sustainable with waiting lists of up to 2 years described (North West Boroughs Service, UK).

It is now changing its service model with a shift to primary care but finding this difficult to achieve.

The Horsham service, also set up in 2008, had a waiting list of one and a half years and is now developing shared care protocols with AMHTs.

Further afield in Spain the approach is training AMHTs to diagnose and treat ADHD in adults with 300 teams trained to date. In one service in the Netherlands, a life-span approach (cradle to grave) has been implemented but only in one site.

In summary, there is no current widely used, stand alone model which is sustainable over time.

**Table 1: Comparison of Public Service Models**
Service	Primary Care	Tertiary Care National	Secondary Care Local	Combined (2&3)	General Adult Psychiatry
Domain
Quality of Assessment	High but no medical input	High	High	High	May be inconsistent
Quality of non-pharmacological Intervention	Limited	May be limited by distance	High	High	Inconsistent
Pharmacological Intervention	None	Available	Available	Available	Available
Referral Path	Direct	Direct or Secondary Care	Direct	Through local CMHT	Direct
Waiting List	Long	Long	Long	Can be managed effectively	Some as other referrals
Continuity of Care for ADHD	Fragmentation likely	Fragmentation likely	Fragmentation likely	Assured	Assured
Treatment of co-morbid mental illness including access to inpatient care	Limited	Limited	Limited	Assured	Assured
Monitoring of Medication	Medication not prescribed	May be limited by distance	Assured	Assured	May be inconsistent
Throughput	Backlog likely	Backlog likely	Backlog likely	Assured	Same as other patients
Training	For primary care level cases	Assured	Assured	Assured	Difficult unless special interest
Sustainable	Limited by demand	Not likely for reasons above	Not likely because of demand	Assured	Assured
Adapted from: Vaze A. update on the Leicestershire Adult ADHD Service presented at UKAAN Annual Conference 2017.

It is clear from the table that there is no gold standard service model. The best option appears to be the combined secondary and tertiary care model covering a defined catchment area based, as much as possible, on the secondary care mental health service structures. This model should provide:

High-quality ADHD specific assessment and treatment
Continuity of care for ADHD patients including annual review of ADHD specific medication
It's integrated working with the secondary care adult community mental health teams should ensure identification and treatment of co-morbid or separate mental illness both initially and subsequently
High-quality training for all professionals in the local mental health service in assessment and treatment of ADHD as required
Thereby assisting local teams to identify possible ADHD in patients currently attending or newly referred but not specifically for ADHD
It should be able to maintain throughput and, therefore, be sustainable
However, the overall effect on referrals to AMHTs is unclear and would need evaluation.

The model will operate as follows:

New referrals of people for assessment of possible ADHD will be seen by their local Adult Mental Health Team (AMHT). They will be fully assessed for co-morbid mental health illness or other mental illnesses. They will be screened using the ASRS (Kessler 2006) and WURS (Ward 1993).
Other new referrals or current attendees with symptoms suggestive of ADHD should also be screened.
Those screening positive on both will be referred to the ADHD Adult Clinic to be established in each mental health area for detailed assessment using the DIVA (Kooij 2019) followed by a feedback session to discuss the outcome of assessment, whether it confirms ADHD or not. The discussion with people confirmed to have ADHD will include outlining the recommended interventions. Those with significant mental illness, including significant co-morbid mental illness, will be treated by their AMHT. When improved they should be re-screened and, if they remain positive, be referred to the ADHD Clinic.
The interventions will be provided through the ADHD Clinic.

These will include:

Psychoeducation.
Medication (initiation and stabilisation).
ADHD specific Cognitive Behaviour Therapy (CBT) in group format.
OT input on practical techniques to manage symptoms and improve function.

As part of this the person will be advised as appropriate on:

Educational support available in 3rd level education
Coaching opportunities
Supports provided by ADHD Ireland
Employment supports.

All people attending the ADHD clinic will remain under the care of their AMHT.

Discharge from the ADHD Clinic will be to the person’s AMHT.

Where the person does not require follow up by the team, the person will be discharged to his / her GP with the AMHT copied on that letter.

Any re-referrals should be to the patient’s AMHT to determine whether the re-referral is ADHD related or not.

The respective tasks of AMHTs and ADHD Clinics are:

1. Adult Mental Health Teams

AMHTs will be expected to carry out the usual assessment, identify any mental illness and treat as required. They will also administer the two ADHD screening tools, which are straight-forward and completed by the person him/herself.
Online access to screening tools will be provided.
Each team should identify at least two people (of any discipline) to be trained in the administration of the screening tools.
The consultant will, as part of their usual practice with all referred patients, consider the screening outcome in conjunction with the rest of the person’s assessment and, if indicated, refer to the ADHD clinic.

2. Mental Health Service ADHD Clinic

Each Mental Health Service will be provided with additional resources to set up an ADHD Clinic. This is dependent on the Clinical Programme receiving the necessary funding for allocation to the local service.

When established, each clinic will be responsible for:

Completing an assessment on those screening positive based on the Diagnostic Interview for Adult ADHD (DIVA)
Delivering the interventions:
- Psycho-education
- Medication: initiate and stabilise dose and then refer back to GP / Adult Mental Health Team as indicated for continued prescribing
- Group Cognitive Behavioural Therapy (CBT) for ADHD
- Occupational Therapy (OT) intervention.

6.4 Young People Transitioning From CAMHS

A modified referral pathway is to be used for young people with ADHD who may need to transition to adult services on their 18th birthday.

Each such young person should have a formal re-evaluation of his / her ADHD status carried out by CAMHS one year prior to their 18th birthday to ensure diagnostic criteria for ADHD are met and/or an on-going need for ADHD specific medication established.
If being referred, a named CAMHS clinician should undertake the role of transition lead to ensure transition is smooth and provide support for the young person and their family during this time.
Transition is an elective process starting 6/12 months before it actually occurs. During this period the ADHD Clinic and relevant local AMHT will jointly consider the referral and make a decision on which service should see the young person first. The decision will be guided by and based on the following criteria:
- Where the young person meets diagnostic criteria for ADHD and/or needs to continue on ADHD specific medication and has no mental illness of moderate or greater severity (co-morbid with ADHD or otherwise) the ADHD Clinic will take the lead.
- Where the young person has significant mental illness/es as described above, the AMHT will take the lead.
- Where is it difficult to make a precise judgement despite the provision of all necessary information by the CAMHS Team, the two services will jointly agree which one will accept the lead role. This will be on the clear understanding that the accepting service can refer easily to the other, should this prove necessary or more appropriate.
A key factor in this modification of the referral process to facilitate access for young people transitioning to adult services is that both the AMHT and the ADHD Clinic are aware of the young person and will ensure easy cross-referral if clinically indicated.

6.5 Older Adults

Whilst most people requiring this service will be age 18 – 64 years old, people over 65 years who are cognitively intact and under the care of a psychiatry of old age team (POA) may be seen for assessment in the ADHD Clinic if screening positive for ADHD.

Where appropriate, access for interventions will be provided. Otherwise, the POA Team will be advised on possible interventions for it to coordinate or deliver.

6.6 Annual Review

All people on medication for ADHD whose dose has been stabilised will be followed up by their GP for prescribing purposes and monitoring of physical health. Each person still on medication will be recalled to the ADHD Clinic on an annual basis as recommended by NICE (2013).

This is to check whether the person continues to meet the diagnostic criteria for ADHD and hence requires medication for ADHD.

If they do, the GP will be advised to continue medication and the relevant Adult Mental Health Team copied on the letter.

This process of annual review will continue for so as long as the person meets the criteria for ADHD and is continuing to take medication for it.

6.7 Resource Implications

The functions of the ADHD clinic are additional and so will require additional resources as follows:

Consultant psychiatrist: 1 WTE for 300,000 – 400,000 working age adult population. Where there is 1 WTE consultant the team will require pro-rata:
Administration Support 1 WTE
Mental Health Nurse (Clinical Nurse Specialist) 1 WTE
Occupational Therapist (Senior) 1 WTE
Psychologist (Senior) 1 WTE

Team premises should be provided by the local mental health service.

The clinical components of the Model of Care are outlined in the next two chapters as key stages in the clinical pathway for adults with ADHD.

These include referral criteria; mode of referral; assessment process; outcome of assessment; treatment.

The clinical pathway is then shown diagrammatically to indicate the sequencing of the various components of assessment and treatment (Figure 1).

6.8 Summary on Model of Care

There is no gold standard service model that meets the needs of adults diagnosed with ADHD.

In this chapter a number of options have been considered and one service model recommended as closest to meeting the needs of patients i.e. the combined secondary and tertiary care model covering a shared catchment area.

The referral pathway for young people transitioning from CAMHS has been modified to ease the process for them.

It is proposed to set-up three demonstration sites to test the recommended model of care.

An Oversight, Support and Implementation Group (NOIG) will be established to monitor the operation of these services. Modifications to aspects of the model can be made if identified as necessary by this group.

This process will guide the setting up of other ADHD Clinics nationally.