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

2. 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

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

4. 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.

5. STANDARD

6. 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)

7. 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

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

9. 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

10. RESULTS Current Treatment
100% GP Prescribed
N = 24

11. 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)

12. 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

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

14. 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

15. 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 pts (0%)
HR measured within 3 months of initiation 1 pt (17%)
HR plotted pts (0%)
N = 6

16. 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)

17. 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

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

19. 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

20. 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

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

22. 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