Attending to Deficits in ADHD Clinic: Audit Cycle

Dr C Bellenis, Dr A Bachlani, Dr V R Badrakalimuthu

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is among the most commonly diagnosed behavioural disorders with 3-9% of school-aged children and young people affected in UK. Stimulants are a highly efficacious and safe treatment for ADHD with 75-90% of patients responding well (Plizka, 2003).  In 1998 there were about 220,000 prescriptions in England for stimulant drugs at a net cost of £5 million; in 2004 this number had almost doubled to 418,300 at a cost of almost £13 million. Not withstanding the large increase in rates of stimulant prescribing, the National Institute for Clinical Excellence (NICE), using a very conservative approach to treatment decision-making, reported that in England and Wales only 30% of those with Hyperkinetic Disorder, the most severe form of ADHD, were receiving stimulant medication (NICE, 2000).

Clinical audit should be used make the link between the implementation of clinical standards and real life improvements in patient care and/or outcomes (Palmer & Lelliot, 2000). There is a glaring paucity of published audits on current practice in ADHD Clinics in UK. Therefore, we present a completed an audit cycle based on the appraisal consultation document for ADHD, developed by NICE (NICE, 2005). 

Methodology

The ADHD Clinic in Eastleigh is run once a week by a doctor and a psychologist specialist in ADHD, as a part of the CAMHS in Eastleigh. There is a regularly updated computerised database on patients diagnosed with ADHD, including their demographic details, appointments and medications.  A randomised sample from the 105 and 108 patients registered in the database in May 2005 and August 2006 was selected. The information in the database was cross checked with the case notes. We went through the ADHD session sheets, correspondences and prescription copies.

The audit standards were set from the NICE Appraisal Consultation Document: ADHD- Methylphenidate, Atomoxetine and Dexamfetamine (2005). Additional guidelines and standards were set following discussion within the CAMHS team.

The guidelines are as follows:

For diagnosis

• Connor’s Questionnaire sent to school and parents
• Behavioural Therapy offered
• All measurements taken
• Treatment plan recorded

For Follow up

• Connor’s Q sent to school annually
• Medication with dose documented
• Documentation on information given to parents

The initial audit was presented in June 2005 at the Mid-Hants Academic Meeting. Following the recommendations, the ADHD session sheet (Appendix 1) was produced. A re-audit to complete the audit cycle was performed in August 2006 with particular reference to the standards on follow up. We have deliberately chosen not to re-audit the diagnostic guidelines and restrict to follow up as there have been very minimal new referrals to the ADHD Clinic between July 2005 and July 2006.

Results            

47 (2005) and 52 (2006) patients were randomly selected to be a representative sample from the total number of patients attending the ADHD Clinic.  The male to female ratio is 3:1. Table 1 gives a break-up of the age and table 2, medications. Table 3 and 4 compares the standards and achievements in the completed audit cycle.

Table 1 Age

Table 2 Medications

Table 3 Diagnosis

Table 4 Follow Up

Discussion

Our audit standards were part based on NICE consultation document and locally developed standards. This is in agreement with Geddes and Wessley’s (2000) opinion that clinical practice guidelines should be applied flexibly and tailored according to local circumstances and needs including patient preferences.

We have included the ADHD session sheet (appendix 1) designed based on the recommendations from the initial audit. This has helped in review, formulating treatment plan and documentation. In an era when those who are trying to monitor the quality of services are keen to get something tangible to measure, this tool also helps to monitor service quality.

This audit, apart from being quantitative, brings out certain qualitative issues in the successful set up of an ADHD Clinic.

Connors Questionnaire and Teachers

Teachers though have had positive experiences of CAMHS, many have complained about problems in communication (Ford & Nikapota, 2000). That 98% of those with an ADHD had Connors Questionnaire completed by parents and teachers during the initial assessment shows the improvement in communication between various agencies. During the follow-up, only about half had a short Connor’s Questionnaire completed by teachers twice a year. Pragmatically, once a year report from the school was found to feasible and there has been a considerable impetus towards this as evidenced by the figures in the table 4.

Medications

Polypharmacy is common practice in spite of little evidence of efficacy and safety from well-designed studies (Vitiello, 2005). In our audit, there has been an 8% decline in polypharmacy which is quiet heartening.

Feinberg (2005) notes that there is pressure to medicate any child or adolescent and atypical antipsychotics are being used at an increasing rate for nonpsychotic disorders. Though Risperidone is not licensed for use in children, 4% have been on Risperidone. Case note review showed that this group have been tried on stimulants and behavioural management before antipsychotic was started. Therefore there is evidence for prudent use of antipsychotics for controlling very difficult behaviour.  

Stimulants have been demonstrated to exert a positive effect on those biological and cognitive processes involved in the causation of ADHD. There is established importance in identification, assessment and accurate diagnosis of those with ADHD as untreated and severe symptoms are strong predictors of poor self esteem, academic achievement, occupational status, peer relationships, family functioning, antisocial behaviour, substance misuse and mood disorders (Coghill, 2005). Thus the 4% increase in prescribing rates in our audit, represents less of a worrying explosion than a move towards, but not yet to, the appropriate recognition and treatment of a serious childhood disorder. 

Behavioural Therapy and Information

When patients, parents, and teachers are well-educated about ADHD and use behavioural therapy along with medication, there were better outcomes (Friemoth, 2005). This audit shows that, there has been a gross under documentation of the discussion over behaviour therapy in the ADHD clinic. We have rectified this by using leaflets on behaviour therapy and having significant role for the psychologist in the ADHD clinic. Also, the new referrals are screened at the clinical meeting with a behavioural analyst to ascertain the form of behavioural interventuions.   The modified ADHD session sheet (appendix 1), requires documentation on behavioural therapy.

There has been very little increase in the documentation on information passed to the parents. However one should add that this is purely a documentation artefact as all the clinic letters are copied to the parent. This does not imply that one should shy away from the issue of documentation.

Recommendations

Initial screening of ADHD referrals in multi-disciplinary team meetings for assessing individual need and behavioural intervention

Standard assessment and monitoring sheets for meaningful follow up and documentation

Appropriate use of medications and very cautious polypharmacy or use of unlicensed medications

Documentation of information sharing with parents or carers

Educating parents and teachers on ADHD

Conclusion

The best way to tackle the public misgivings on ADHD is to provide quality service to the affected children and support to the carers. This audit report should help the development of evidence based standards in assessing and treating children with ADHD, as well as, encouraging the implementation in practice.

References

Coghill, D. (2005) Attention-deficit hyperactivity disorder: should we believe the mass media or peer-reviewed literature? Psychiatric Bulletin, 29, 288-291

Feinberg, T.D. (2005) Managed Care: Crossroads. Journal pf Child and Adolescent Psychopharmacology, 15, 3-4

Ford, T, Nikapota, A. (2000) Teachers’ attitudes towards child mental health services. Psychiatric Bulletin, 24, 457-461

Friemoth, J. (2005) What is the most effective treatment for ADHD in children? Journal of Family Practice, 54, 166-168

Geddes,J, Wessley, S. (2000) Clinical standards in Psychiatry. How much evidence is required and how good is the evidence base? Psychiatric Bulletin, 24, 83-84

www.nice.org.uk

Palmer, C, Lelliott, P. (2000), Encouraging the implementation of clinical standards into practice. Psychiatric Bulletin, 24, 90-93

Plizka, S. R. (2003) Non-stimulant treatment of attention deficit/ hyperactivity disorder. CNS Spectrums, 8, 253-258

Vitiello, B. (2005) Pharmacoepidemiology and Pediatric Psychopharmacology Research. Journal pf Child and Adolescent Psychopharmacology, 15, 10-11

Copyright Priory Lodge Education Limited 2007

First Published September 2007