1. Prescribing for ADHD in children, adolescents and adults
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 13b (re-audit)
Prescribing for ADHD in children, adolescents and adults
Coventry and Warwickshire Partnership Trust
© 2015 The Royal College of Psychiatrists

2. METHOD
POMH-UK invited all member NHS Trusts and relevant healthcare organisations to participate in re-audit of 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.
59 Trusts participated in this re-audit, submitting data for 6,109 patients from 359  clinical teams.  Demographic, clinical and service-related data were collected for each patient.
The Prescribing Observatory for Mental Health (POMH-UK) invited all member National Health Service (NHS) Trusts and relevant healthcare organisations in the United Kingdom providing specialist mental health services to participate in an audit-based quality improvement programme focussing on prescribing practice for ADHD in children, adolescents and adults. Staff from each organisation were invited to attend one of several regional workshops to discuss and review the aims, objectives and methodology of the proposed audit. Comment and discussion at the workshops led to refinements of the audit methodology and data collection tool. All Trusts and clinical teams were self-selected in that they chose to participate; paediatric services were recruited through secondary mental health care members. All participating Trust/healthcare organisations (hereafter referred to as ‘Trusts’) are listed in alphabetical order in Appendix C of the report.
A clinical records based audit of ADHD prescribing practice was conducted. A questionnaire/audit tool was sent to Trusts with instructions that copies should be made available to allow clinical teams to audit all current patients with a clinical diagnosis of ADHD, whether or not they were currently prescribed ADHD medication.
Demographic, clinical and service related data were collected for each eligible patient. A copy of the data collection tool can be found in Appendix D. The POMH-UK lead for each participating Trust will be sent an Excel dataset containing their Trust’s data. This allows Trusts to conduct further analyses on their own data should they wish.

3. PRACTICE STANDARDS FOR AUDIT: Initiating drug treatment for ADHD
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 & )
b. Height and weight (recorded on a growth chart in children) ( & )
c. Cardiovascular risk ( & )
d. Substance misuse risk ( & )
2.  Weight, heart rate and blood pressure should be measured within 3 months of starting treatment ( & ).
The standards are derived from NICE Guideline CG72. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Published September Updated March 2013
The audit data presented provide evidence of compliance for your Trust and the national sample with specific recommendations from this NICE guideline.

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

5. treatment targets
1. The diagnosis of ADHD is made by a specialist psychiatrist, paediatrician, or other appropriately qualified healthcare professional ( ). 2. For children and adolescents, parent training is offered to parents/guardians ( ). 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 ( ). 4. Antipsychotics are not prescribed for the treatment of ADHD in children, adolescents or adults ( ). 5. Shared care protocols with primary care are in place ( ).
In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers.

6. Three clinical sub-samples
RESULTS
Three clinical sub-samples
Baseline audit 2013
(n=5,479)
Re-audit 2015
(n=6,109)
Service
Number of patients
% of TNS
Paediatrics
429 8%
647
11%
CAMHS
3,737
68%
4,019
66%
Adult mental health
1,313
24%
1,443
Sample at re-audit prescribed ADHD medication: 5,275
Treated for less than one year: n= 1,236 - of whom 370 were treated for less than 3 months, while 866 were treated for 3 months or more.
Treated for one year or more: n= 4,039.
In order to facilitate navigation of this report, the colours above are used to identify the three clinical sub-samples throughout.

7. Type of ADHD medication currently prescribed in each of the three clinical sub-samples (n=6,109), at re-audit
Compared with children and adolescents, adults with ADHD are less likely to be prescribed stimulant medication.
Five thousand, two-hundred and seventy-five (86%) patients in the total sample were prescribed medication for ADHD, and 82% of these prescriptions were for a methylphenidate preparation. These proportions were very similar to baseline.
Of the 4,309 patients prescribed methylphenidate:
- 521 (12%) patients were prescribed an immediate release (IR) preparation only.
- 3,245 (75%) patients were prescribed a slow release (SR) preparation only.
- 543 (13%) patients were prescribed a combination of IR and SR.
The vast majority of patients prescribed medication (n=5,275) received monotherapy (87%). The most common combination was of IR and SR methylphenidate preparations

8. Antipsychotic and antidepressant medication prescribed concomitantly with ADHD medication (top graph, n=5,275) and in those patients NOT prescribed ADHD medication (bottom graph, n=834)
The dark zone of the bar represents ICD-10 co-morbidity: for antipsychotic medication these were schizophrenia or bipolar affective disorder; for antidepressant medication these were bipolar affective disorder or other mood disorder or neurotic, stress-related and somatoform disorders. Please note the vertical axes represent 0-30% only.
The figures on the following page show commonly prescribed psychotropic medication in the three clinical subsamples (separately for patients prescribed ADHD medication and those not) and allow comparison of prescribing prevalence at baseline and re-audit. Only a small proportion of these prescriptions were for identified co-morbid conditions, suggesting that their main use was for symptoms of ADHD, such as insomnia and irritability.
Antipsychotic and antidepressant medication was more commonly prescribed for those patients who were not receiving treatment with ADHD medication, particularly in adult services.

9. Diagnosis of ADHD: Documented sources of information/structured (n=1,236)
As would be expected, diagnosis in adult services tends to rest more on diagnostic assessment by a clinician along with completion by the patient of a standardised self-assessment than it does on reports from parents/guardians and teachers/school.
It is possible that the proportion of patients receiving a “diagnostic interview by a clinician” is an underestimate, as this question directed the data collector to identify a structured report to determine whether such a diagnostic interview had taken place.

10. % of patients diagnosed with ADHD in the last year with documented evidence that non-pharmacological interventions were offered (n=1,236)
Compliance with this treatment target requires the offering of parent training in every case. Given the overlap between parent training and behavioural management training, we have considered the proportion of cases where one or the other was offered. On this basis, the figure for paediatrics was 73%, while the respective figure for CAMHS was 63%.
In paediatric services, there has been an increased use of psychoeducation from one in ten children to one in four.
As at baseline, adults at re-audit were found to be less likely than children and adolescents to be offered non-pharmacological interventions. This may reflect in part the more limited evidence base for, and relevance of, many of the available interventions in adults.

11. Performance against the practice standards for audit
Tables on slides show compliance with the practice standards in each of the three clinical sub-samples at baseline and re-audit, nationally and in your Trust. The percentages shown in bold relate to evidence that the measure/assessment was documented in the clinical records. The percentages in brackets relate to the proportion of patients in the national clinical service sub-samples and your Trust for whom the relevant measure was documented on a centile or growth chart, as appropriate.
Note that data for all patients, irrespective of age, in each of the clinical sub-samples, are included in the percentages shown in bold, while the percentages in brackets only relate to data on those patients aged 16 years or younger.
PRACTICE STANDARDS FOR AUDIT
Initiating drug treatment for ADHD
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 & )
b. Height and weight (recorded on a growth chart in children) ( & )
c. Cardiovascular risk ( & )
d. Substance misuse risk ( & )
2.  Weight, heart rate and blood pressure should be measured within 3 months of starting treatment ( & ).
Maintenance treatment
3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales (derived from NICE CG72, recommendations ).
4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart ( ).
5. Weight should be recorded every 6 months in adults ( ).
6. Heart rate and BP should be measured every 3 months (recorded as a centile in children) ( ).
Treatment targets
1. The diagnosis of ADHD is made by a specialist psychiatrist, paediatrician, or other appropriately qualified healthcare professional ( ).
2. For children and adolescents, parent training is offered to parents/guardians ( ).
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 ( ).
4. Antipsychotics are not prescribed for the treatment of ADHD in children, adolescents or adults ( ).
5. Shared care protocols with primary care are in place ( ).

12. Compliance with the audit standards in paediatric services at baseline and re-audit, nationally and in your Trust
Between baseline and re-audit there have been marked improvements in the proportions of the national sample with pre-treatment and early on-treatment health checks. The recording of these measures on growth and centile charts has also markedly improved. The pre-treatment assessment of substance misuse risk has also improved. However no such improvements are seen in the physical health monitoring of those patients who have received treatment for a longer period. This remains an area for improvement.

13. Compliance with the audit standards in CAMHS at baseline and re-audit, nationally and in your Trust
Between baseline and re-audit, the proportions of the national sample with pre-treatment physical health checks have remained high and there has been a marked improvement in the recording of these measures on growth and centile charts. The pre-treatment assessment of cardiovascular risk has also modestly improved. However no such improvements are seen in the physical health monitoring of those patients on established treatment. This remains an area for improvement.

14. Compliance with the audit standards in adult mental health at baseline and re-audit, nationally and in your Trust
Between baseline and re-audit, there is no significant change in the proportions of patients who receive recommended physical health checks. Heart rate and blood pressure have been documented in around two-thirds of patients before starting treatment and at early on-treatment review, while weight has been less commonly recorded. Monitoring of established treatment remains poor.

15. Data from each Trust are presented by code.
Trust level findings
Analyses presented in this section were conducted for each Trust individually and for the total sample to allow benchmarking.
Data from each Trust are presented by code.
Your Trust code is 040
Sub-samples in your Trust:
In the figures that follow, “all 4 measures documented/recorded” refer to heart rate, blood pressure, height and weight. In the adult sub-samples, height is not expected to change, and so is excluded.
Note that, in the figures that follow, the data for CAMHS and paediatric services relating to standards 1a and 1b are restricted to patients aged 16 years of age or younger. It is therefore possible that some of the proportions may differ from those derived from non-age-restricted samples that are reported in the executive summary.
Paediatrics
CAMHS
Adult - 30 -

16. Before starting treatment: documented measures of height, weight, blood pressure and heart rate
Paediatrics (only patients ≤16 years of age)
Documenting measures before starting treatment, at re-audit (n=180)
Documenting and recording of measures on a centile/growth chart, at re-audit (n=180)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

17. CAMHS (only patients ≤16 years of age)
Before starting treatment: documented measures of height, weight, blood pressure and heart rate
CAMHS (only patients ≤16 years of age)
Documenting measures before starting treatment, at re-audit (n=680)
Documenting and recording of measures on a centile/growth chart, at re-audit (n=680)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

18. Before starting treatment: documented measures of height, weight, blood pressure and heart rate
Adult mental health
Documenting measures before starting treatment, at re-audit (n=304)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

19. Before starting treatment: documented cardiovascular risk assessment (CV) and ECG
Paediatrics (n=187)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

20. Before starting treatment: documented cardiovascular risk assessment (CV) and ECG
CAMHS (n=745)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

21. Adult mental health (n=304)
Before starting treatment: documented cardiovascular risk assessment (CV) and ECG
Adult mental health (n=304)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

22. Before starting treatment: documented assessment of the risk of substance diversion
Paediatrics (n=187)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

23. Before starting treatment: documented assessment of the risk of substance diversion
CAMHS (n=745)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

24. Adult mental health (n=304)
Before starting treatment: documented assessment of the risk of substance diversion
Adult mental health (n=304)
Initiating treatment for ADHD
Data in this section relate to the sub-sample of patients diagnosed with ADHD in the previous year (n=1,236)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

25. Within three months of starting treatment: documented measures of height, weight, blood pressure and heart rate
Paediatrics (only patients ≤16 years of age)
Documenting measures within 3 months of starting treatment, at re-audit (n=132)
Documenting and recording of measures on a centile/growth chart, at re-audit (n=132)
Early on-treatment assessment
The data presented in this section refer to the sub-sample of patients treated with ADHD medication for at least three months but not longer than a year (n=866)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

26. CAMHS (only patients ≤16 years of age)
Within three months of starting treatment: documented measures of height, weight, blood pressure and heart rate
CAMHS (only patients ≤16 years of age)
Documenting measures within 3 months of starting treatment, at re-audit (n=458)
Documenting and recording of measures on a centile/growth chart, at re-audit (n=458)
Early on-treatment assessment
The data presented in this section refer to the sub-sample of patients treated with ADHD medication for at least three months but not longer than a year (n=866)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

27. Within three months of starting treatment: documented measures of height, weight, blood pressure and heart rate
Adult mental health
Documenting measures within 3 months of starting treatment, at re-audit (n=219)
Early on-treatment assessment
The data presented in this section refer to the sub-sample of patients treated with ADHD medication for at least three months but not longer than a year (n=866)
PRACTICE STANDARD FOR AUDIT : Initiating drug treatment for ADHD
1. Before starting drug treatment, children, adolescents and adults with ADHD should
have a full pre-treatment assessment, including the following:
a. Heart rate and blood pressure (recorded as a centile in children)
b. Height and weight (recorded on a growth chart in children)

28. Within the last year: annual review using a standardised scale
Paediatrics (n=384)
Monitoring of continuing treatment
Data presented in this section relate to the sub-sample of patients diagnosed with ADHD more than one year ago (n=4,039)
PRACTICE STANDARDS FOR AUDIT: Maintenance treatment
3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales
4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart
5. Weight should be recorded every 6 months in adults
6. Heart rate and BP should be measured every 3 months (recorded as centile in children)

29. Within the last year: annual review using a standardised scale
CAMHS (n=2,825)
Monitoring of continuing treatment
Data presented in this section relate to the sub-sample of patients diagnosed with ADHD more than one year ago (n=4,039)
PRACTICE STANDARDS FOR AUDIT: Maintenance treatment
3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales
4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart
5. Weight should be recorded every 6 months in adults
6. Heart rate and BP should be measured every 3 months (recorded as centile in children)

30. Adult mental health (n=830)
Within the last year: annual review using a standardised scale
Adult mental health (n=830)
Monitoring of continuing treatment
Data presented in this section relate to the sub-sample of patients diagnosed with ADHD more than one year ago (n=4,039)
PRACTICE STANDARDS FOR AUDIT: Maintenance treatment
3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales
4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart
5. Weight should be recorded every 6 months in adults
6. Heart rate and BP should be measured every 3 months (recorded as centile in children)

31. Within the last year: documented measures of height, weight, blood pressure and heart rate
Paediatrics (only patients ≤16 years of age)
Documented measures within the last year, at re-audit (n=341)
Of the measures documented above, the proportion recorded on a centile/growth chart, at re-audit (n=341)
Monitoring of continuing treatment
Data presented in this section relate to the sub-sample of patients diagnosed with ADHD more than one year ago (n=4,039)
PRACTICE STANDARDS FOR AUDIT: Maintenance treatment
3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales
4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart
5. Weight should be recorded every 6 months in adults
6. Heart rate and BP should be measured every 3 months (recorded as centile in children)

32. Within the last year: documented measures of height, weight, blood pressure and heart rate
CAMHS (including only those who are ≤16 years of age)
Documented measures within the last year, at re-audit (n=2,280)
Of the measures documented above, the proportion recorded on a centile/growth chart, at re-audit (n=2,280)
Monitoring of continuing treatment
Data presented in this section relate to the sub-sample of patients diagnosed with ADHD more than one year ago (n=4,039)
PRACTICE STANDARDS FOR AUDIT: Maintenance treatment
3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales
4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart
5. Weight should be recorded every 6 months in adults
6. Heart rate and BP should be measured every 3 months (recorded as centile in children)

33. Within the last year: documented measures of height, weight, blood pressure and heart rate
Adult mental health   Documented measures within the last year, at re-audit (n=830)
Monitoring of continuing treatment
Data presented in this section relate to the sub-sample of patients diagnosed with ADHD more than one year ago (n=4,039)
PRACTICE STANDARDS FOR AUDIT: Maintenance treatment
3. In all patients, ADHD treatment should be reviewed at least annually, using standardised rating scales
4. Height and weight should be measured every 6 months in children and young people, and recorded on a growth chart
5. Weight should be recorded every 6 months in adults
6. Heart rate and BP should be measured every 3 months (recorded as centile in children)

34. Team-level findings
Analyses presented in this section were conducted for each clinical team from your Trust individually, for your total Trust sample and for the total national sample to allow benchmarking.
Data from each Trust clinical team are presented by code only.
Only the POMH-UK lead for your Trust or organisation has the key to team codes. You should contact this person if you need to identify data for your own particular team.

35. Documenting measures of height, weight, blood pressure and heart rate before starting treatment in your Trust and the national clinical sub-samples, at re-audit
Documenting measures before starting treatment, at re-audit (all patients, n=8)

36. Documenting measures of height, weight, blood pressure and heart rate before starting treatment in your Trust and the national clinical sub-samples, at re-audit
Documenting and recording of measures on a centile/growth chart before starting treatment, at re-audit (only patients ≤16 years of age, n=8)
This figure includes only those patients who are 16 years of age or younger. Older patients are not included. The number of patients in each clinical team included in each figure may therefore differ. Adult teams will not be shown in this figure.

37. Documenting assessment of cardiovascular risk measures before starting medication for ADHD in your Trust and the national clinical sub-samples, at re-audit (n=8)

38. Documenting assessment of the risk of substance diversion before starting medication for ADHD in your Trust and the national clinical sub-samples, at re-audit (n=8)

39. Documenting measures of height, weight, blood pressure and heart rate within three months of starting treatment in your Trust and the national clinical sub-samples, at re-audit
Documenting measures within three months of starting treatment, at re-audit (all patients, n=4)

40. Documenting measures of height, weight, blood pressure and heart rate within three months of starting treatment in your Trust and the national clinical sub-samples, at re-audit
Documenting and recording of measures on a centile/growth chart within three months of starting treatment, at re-audit (only patients ≤16 years of age, n=4)
This figure includes only those patients who are 16 years of age or younger. Older patients are not included. The number of patients in each clinical team included in each figure may therefore differ. Adult teams will not be shown in this figure.

41. Documenting measures of height, weight, blood pressure and heart rate within the last year in your Trust and the national clinical sub-samples (meeting the standard), at re-audit
Documenting measures within the last year, at re-audit (all patients, n=21)

42. Documenting measures of height, weight, blood pressure and heart rate within the last year in your Trust and the national clinical sub-samples (meeting the standard), at re-audit
Recording measures on a centile/growth chart within the last year, at re-audit (only patients ≤16 years of age, n=17)
This figure includes only those patients who are 16 years of age or younger. Older patients are not included. The number of patients in each clinical team included in each figure may therefore differ. Adult teams will not be shown in this figure.

43. Documenting measures of height, weight, blood pressure and heart rate within the last year in your Trust and the national clinical sub-samples (at least once), at re-audit
Documenting measures within the last year (at least once), at re-audit (all patients, n=21)

44. Documenting measures of height, weight, blood pressure and heart rate within the last year in your Trust and the national clinical sub-samples (at least once), at re-audit
Measures recorded on a centile/growth chart within the last year (at least once), at re-audit (only patients ≤16 years of age, n=17)
This figure includes only those patients who are 16 years of age or younger. Older patients are not included. The number of patients in each clinical team included in each figure may therefore differ. Adult teams will not be shown in this figure.

45. Broader observations of prescribing for ADHD
1. Although there have been marked improvements in the recording of heart rate, blood pressure, weight and height on centile and growth charts, this remains an area for improvement, particularly for longer-term monitoring. Use of such charts provides evidence for clinicians and parents as to whether the trajectory of growth and development is being adversely affected by stimulant medication. Trusts may wish to reflect on the availability of growth and centile charts, and how these are incorporated into the electronic patient record in a way that allows change over time to be easily accessed and displayed when a patient is seen for review.
2. While some key NICE recommendations depend on whether ADHD is mild, moderate or severe, such a classification of severity was not documented in over half of cases in all three clinical sub-samples.
3. The prescribing of antipsychotics is relatively common in adults with ADHD, the majority of which is not for a co-morbid mental illness. Antipsychotics were prescribed for 1 in 6 people prescribed ADHD medication and 1 in 4 of those not prescribed ADHD medication, suggesting that antipsychotics may be used to treat behavioural manifestations of ADHD as an alternative to stimulant medication.

46. Broader observations of prescribing for ADHD
4. Antidepressants were also relatively commonly prescribed for adults with ADHD but there is little difference in the prevalence of such prescribing in those who were prescribed ADHD medication and those who were not. In around half of such cases, the antidepressant was prescribed for a co-morbid mental illness. Where there was no co-morbid mental illness, the rationale for antidepressant prescribing may be that the pharmacological action of some of these medicines is similar to that of atomoxetine, a medicine licensed for the treatment of ADHD.
5. ECGs were almost always conducted in the context of a broader cardiovascular risk assessment. However, in nearly a quarter of the total sample, neither a cardiovascular risk assessment nor an ECG was conducted before ADHD medication was initiated. While the risk of serious cardiovascular events with ADHD medication is low, patients with existing cardiovascular problems or risk factors such as a family history require careful assessment and monitoring if ADHD medication is used.