1. POMH-UK Topic 2e supplementary audit Screening for metabolic side effects of antipsychotic drugs in patients under the care of assertive outreach teams POMH-UK Quality Improvement Programme. Topic 13a (baseline audit) Prescribing for ADHD in children, adolescents and adults Coventry and Warwickshire Partnership Trust © 2013 The Royal College of Psychiatrists

2. CLINICAL BACKGROUND Attention Deficit Hyperactivity Disorder (ADHD) consists of maladaptive levels of inattentiveness, restless overactivity and impulsiveness. The prevalence in school children is about 5%. NICE has recommended a staged process to the recognition and treatment of ADHD. Before treatment begins, a medical history should be taken with particular reference to any cardiovascular problems or risk. Where these are identified, an ECG should be done, but blood pressure and pulse rate should always be recorded. In the short term, the great majority of children with ADHD should be markedly helped with treatment. In the longer term, however, ADHD may still constitute a disability. Accordingly, treatment should also be available for adults.

3. METHOD POMH-UK invited all member NHS Trusts and relevant healthcare organisations to participate in an audit-based quality improvement programme focussing on prescribing practice for ADHD in children, adolescents and adults. A questionnaire/audit tool was sent to Trusts for audit of current patients with a clinical diagnosis of ADHD, whether or not they were currently prescribed ADHD medication. 48 Trusts participated in this baseline audit, submitting data for 5,479 patients from 370 clinical teams. Demographic, clinical and service-related data were collected for each patient.

4. 1. Before starting drug treatment, children, adolescents and adults with ADHD should have a full assessment, including: a. Heart rate and blood pressure (recorded as a centile in children) (NICE CG72, recommendations 1.5.4.1 & 1.7.1.3) b. Height and weight (recorded on a growth chart in children) (1.5.4.1 & 1.7.1.3) c. Cardiovascular risk (1.5.4.1 & 1.7.1.3) d. Substance misuse risk (1.5.4.1 & 1.7.1.3) 2. Weight, heart rate and blood pressure should be measured within 3 months of starting treatment (1.8.4.2 & 1.8.4.6). AUDIT STANDARDS: Initiating drug treatment for ADHD

5. 3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales (derived from NICE CG72, recommendations 1.8.4.1). 4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart (1.8.4.2). 5. Weight should be recorded every 6 months in adults (1.8.4.2). 6. Heart rate and BP should be measured every 3 months (recorded as a centile in children) (1.8.4.6). AUDIT STANDARDS: Maintenance treatment

6. TREATMENT TARGETS 1. The diagnosis of ADHD is made by a specialist psychiatrist, paediatrician, or other appropriately qualified healthcare professional (1.1.1.1). 2. For children and adolescents, parent training is offered to parents/guardians (1.2.1.5). 3. Drug treatment for ADHD is started under the guidance of a psychiatrist, nurse prescriber specialising in ADHD, or other clinical prescriber with training in the diagnosis and management of ADHD (1.7.1.2). 4. Antipsychotics are not prescribed for the treatment of ADHD in children, adolescents or adults (1.5.5.7). 5. Shared care protocols with primary care are in place (1.8.1.4).

7. Three service sub-samples RESULTS Clinical subsamples Treated for less than one year: n= 1,078 - of whom 221 were treated for less than 3 months, while 857 were treated for 3 months or more. Treated for one year or more: n= 3,773.

8. Distribution of ADHD medication treated and not treated subsamples across services ADHD medication (n=4,851) No ADHD medication (n=628) Paediatric services8%6% CAMHS (including forensic CAMHS)67%54% CAMHS LD2%3% Early intervention services for psychosis<1% General adult psychiatry11%22% Specialist adult ADHD services8%7% Learning disabilities services (LD)2%4% Forensic psychiatry<1% Forensic psychiatry LD<1% Prison services<1% Other (including transition services)1% 2%

9. Type of ADHD medication currently prescribed in each of the three clinical sub-samples (n=4,851) The vast majority of patients (86%) received monotherapy. The most common combination was of IR and SR methylphenidate preparations

10. Other medication prescribed concomitantly with ADHD medication (top graph, n=4,851) and in those patients NOT prescribed ADHD medication (bottom graph, n=628)

11. Sources of information/structured reports used to inform the diagnosis of ADHD (n=1,078)

12. Documented assessment of 1. cardiovascular risk measures and 2. the risk of substance diversion before starting medication for ADHD (n=1,078)

13. % of patients diagnosed with ADHD in the last year with documented evidence that non-pharmacological interventions were offered (n=1,078)

14. Compliance with the audit standards in the paediatric clinical sub-sample, nationally and in your Trust

15. Compliance with the audit standards in the CAMHS clinical sub-sample, nationally and in your Trust

16. Compliance with the audit standards in the adult clinical sub-sample, nationally and in your Trust

17. Data from each Trust or organisation are presented by code. Your Trust code is 040 Charts in this section are ordered by performance against the standards, so the position of your Trust will vary in each figure according to your practice. PaediatricsCAMHSAdult 5461 Sub-samples in your Trust:

18. Documented evidence that the person with ADHD and/or parent/carer has been given information about ADHD Paediatrics (n=91)

19. CAMHS (n=653) Documented evidence that the person with ADHD and/or parent/carer has been given information about ADHD

20. Adult mental health (n=334) Documented evidence that the person with ADHD and/or parent/carer has been given information about ADHD

21. Before starting treatment: documented measures of height, weight, blood pressure and heart rate Documented measures (n=91) Measures recorded in a centile/growth chart (n=91) Paediatrics (including only those who are ≤16 years of age)

22. CAMHS ( including only those who are ≤16 years of age ) Documented measures (n=598) Measures recorded in a centile/growth chart (n=598) Before starting treatment: documented measures of height, weight, blood pressure and heart rate

23. Adult mental health (excluding height measurement) Documented measures before starting treatment (n=334) Before starting treatment: documented measures of height, weight, blood pressure and heart rate

24. Before starting treatment: documented cardiovascular risk assessment (CV) and ECG Paediatrics (n=91)

25. CAMHS (n=553) Before starting treatment: documented cardiovascular risk assessment (CV) and ECG

26. Adult mental health (n=334) Before starting treatment: documented cardiovascular risk assessment (CV) and ECG

27. Before starting treatment: documented assessment of the risk of substance diversion Paediatrics (n=91)

28. CAMHS (n=553) Before starting treatment: documented assessment of the risk of substance diversion

29. Adult mental health (n=334) Before starting treatment: documented assessment of the risk of substance diversion

30. Within three months of starting treatment: documented measures of height, weight, blood pressure and heart rate Documented measures (n=64) Measures recorded in a centile/growth chart (n=64) Paediatrics (including only those who are ≤16 years of age)

31. CAMHS (including only those who are ≤16 years of age) Documented measures (n=484) Measures recorded in a centile/growth chart (n=484) Within three months of starting treatment: documented measures of height, weight, blood pressure and heart rate

32. Adult mental health (excluding height measurement) Documented measures within 3 months of starting treatment (n=268) Within three months of starting treatment: documented measures of height, weight, blood pressure and heart rate

33. Paediatrics (n=301) Within the last year: annual review using a standardised scale

34. CAMHS (n=2,717) Within the last year: annual review using a standardised scale

35. Adult mental health (n=755) Within the last year: annual review using a standardised scale

36. Within the last year: documented measures of height, weight, blood pressure and heart rate Documented measures within the last year (n=265) Measures recorded in a centile/growth chart (n=265) Paediatrics (including only those who are ≤16 years of age)

37. Documented measures within the last year (n=2,219) Measures recorded in a centile/growth chart (n=2,219) CAMHS (including only those who are ≤16 years of age) Within the last year: documented measures of height, weight, blood pressure and heart rate

38. Adult mental health (excluding height measurement) Documented measures within the last year (n=755) Within the last year: documented measures of height, weight, blood pressure and heart rate

39. TEAM LEVEL GRAPHS Charts in this section are ordered by frequency of key results, so the position of teams in each figure will vary according to practice. Note that for the figures in this section, all data submitted by each clinical team are included, i.e. age restrictions are not applied.

40. Before starting treatment: documented measures of height, weight, blood pressure and heart rate in your Trust Documented measures (n=18) Measures recorded in a centile/growth chart (n=18)

41. Before starting treatment: documented assessment of cardiovascular risk measures (n=18)

42. Before starting treatment: documented assessment of the risk of substance diversion (n=18)

43. Within three months of starting treatment : documented measures of height, weight, blood pressure and heart rate Documented measures (n=15) Measures recorded in a centile/growth chart (n=15)

44. Within the last year: documented measures of height, weight, blood pressure and heart rate (meeting the standard) Documented measures (n=33) Measures recorded in a centile/growth chart (n=25)

45. Within the last year: documented measures of height, weight, blood pressure and heart rate (at least once) Documented measures (n=33) Measures recorded in a centile/growth chart (n=25)

46. What happens next? At your Trust Reflect on these benchmarked performance data, particularly where prescribing practice in your Trust falls short of the standards. Consider what actions could be taken locally to improve practice in key areas for your Trust, and, when implemented, monitor their impact. Consider adopting customised POMH-UK change interventions when these become available.

47. What happens next? At POMH-UK POMH-UK will discuss the audit findings with clinical experts and explore opportunities to provide customised change intervention tools in early 2014. Review data from Trust-level questionnaires on commissioning, service organisation and service delivery issues in relation to ADHD. A re-audit will be conducted in 2015.