CLINICAL AUDIT Drug Prescribing for ADHD in Children Dr S McVea (ST2 Paediatrics) Dr A Armstrong (Consultant Paediatrician)

INTRODUCTION Attention Deficit Hyperactivity Disorder A heterogeneous behavioural syndrome characterised by Hyperactivity Impulsivity Inattention Prevalence ≈ 3-5% M:F 2-4:1 Clinical diagnosis based on standardised questionnaires Management involves a combination of pharmacological and non pharmacological interventions Oxford Specialist Handbook: Community Paediatrics. Gada. 2012

AIM To identify areas of good practice and areas for improvement when prescribing medications to treat ADHD.

METHODOLOGY All children attending ADHD clinics in Holywood Arches during March 2013 were identified from clinic lists. Patient notes, PARIS entries & letters on Patient Centre were reviewed retrospectively. Standardized proforma used to collect data RCPsych POMH-UK Topic 13a: Prescribing for ADHD in children adolescence and adults.

STANDARD

STANDARD Prescribing Observatory for Mental Health (POMH-UK) Initiating drug treatment for ADHD (<1 year subgroup) Before starting drug treatment, children, adolescents and adults with ADHD should have a full pre- treatment assessment, including the following: heart rate and blood pressure (recorded as centile in children), height and weight (recorded on a growth chart in children), cardiovascular risk, substance misuse risk and Weight, heart rate and blood pressure measured within 3 months of starting treatment. Maintenance treatment (>1 year subgroup) In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart Heart rate and BP should be measured every 3 months (recorded as centile in children)

RESULTS 38 patients attended ADHD clinic in March 2013 8 children excluded Notes unavailable / Insufficient detail on PARIS / Patient Centre (n=3) Non ADHD attendances (n=5) 30 patients included in audit

RESULTS Gender & Age Distribution M:F 2.75:1 Mean Age: 10y Median Age: 10y

RESULTS 24 (80%) had a diagnosis of ADHD Normal Connors 2 pts ADD diagnosed 2 pts Connors +ve in single setting 1 pt Awaiting result of Connors 1 pt N = 30

RESULTS Current Treatment 100% GP Prescribed N = 24

STANDARD Prescribing Observatory for Mental Health (POMH-UK) Initiating drug treatment for ADHD (<1 year subgroup) Before starting drug treatment, children, adolescents and adults with ADHD should have a full pre- treatment assessment, including the following: heart rate and blood pressure (recorded as centile in children), height and weight (recorded on a growth chart in children), cardiovascular risk, substance misuse risk and Weight, heart rate and blood pressure measured within 3 months of starting treatment. Maintenance treatment (>1 year subgroup) In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart Heart rate and BP should be measured every 3 months (recorded as centile in children)

RESULTS Initiating Drug Treatment 7 patients identified had been started on treatment within 1 year Diagnosis made by Paediatrician in all cases All diagnoses were based on standardized rating scales Connors Rating Scale in all cases Input from parents and school in all cases. Treatment initiated by Paediatician in all cases N = 7

RESULTS Pre-Treatment Risk Assessment Growth Pre-treatment height and weight recorded 7 pts 100% Both plotted 6 pts 86% CVS Risk Assessment Pre-treatment BP recorded 6 pts 86% BP plotted 0 pts 0% Pre-treatment HR recorded 1 pt 14% HR plotted 0 pts 0% Cardiac examination 7 pts 100% Cardiac history 2 pts 29% Substance misuse risk assessment 0% 0% N = 7

RESULTS Non-Pharmacological Therapies Documented non pharmacological therapies offered to 6pts (86%) Parent training books Local parent training classes Anger management books Information leaflets given and documented in 4pts (57%) N = 7

RESULTS Post Initiation Monitoring 6 children initiated on Rx were started 3-12 months prior to audit. Height plotted within 3 months of initiation 3pts (50%) Weight plotted within 3 months of initiation 4pts (67%) BP measured within 3 months of initiation 5pts (83%) BP plotted 0 pts (0%) HR measured within 3 months of initiation 1 pt (17%) HR plotted 0 pts (0%) N = 6

Initiating drug treatment for ADHD Maintenance treatment STANDARD Initiating drug treatment for ADHD (<1 year subgroup) Before starting drug treatment, children, adolescents and adults with ADHD should have a full pre- treatment assessment, including the following: heart rate and blood pressure (recorded as centile in children), height and weight (recorded on a growth chart in children), cardiovascular risk, substance misuse risk and Weight, heart rate and blood pressure measured within 3 months of starting treatment. Maintenance treatment (>1 year subgroup) In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart Heart rate and BP should be measured every 3 months (recorded as centile in children)

RESULTS Maintenance Treatment 15 patients identified had been on treatment for >1year Medication review within the preceding year 13pts 87% DNA appropriate review appointments 2pts 13% Standardized rating scale utilized to guide Rx 1pt 7% This was a r/v from another trust where Parents asked for 2nd opinion These 3 patients were excluded from further analysis

RESULTS Number of Reviews in 12 months Prior to Audit Number of Patients Number of Reviews N = 12

RESULTS Maintenance Therapy Height measured ≤6 monthly 6pts 50% Height plotted ≤6 monthly 2pts 17% Weight measured ≤6 monthly 6pts 50% Weight plotted ≤6 monthly 3pts 25% N = 12

RESULTS Maintenance Therapy BP measured ≤3 monthly 2pts 17% BP plotted ≤3 monthly 0pts 0% BP measured ≤6 monthly 6pts 50% BP plotted ≤6 monthly 0pts 0% HR was recorded in only one review N = 12

LIMITATIONS Retrospective Single center audited Results strongly influenced by standard of documentation Single center audited Limited subpopulation sizes

RECOMMENDATIONS Update current new patient proforma Formal CVS risk assessment section in PMH / FH Specific weight, height, BP and HR spaces in examination section with associated centile entry spaces Make BP and HR centiles easily accessible in clinic Specific substance misuse risk assessment section Update review proforma Make standard ADHD review more <yearly Workforce limitations GP to check parameters and send to lead paediatrician ? Issue annual repeat standardized questionnaires with appointment letter Staff education to increase awareness of current standards