Clinical Studies in ADMIRE
Sleep plays an important role in child development and inadequate sleep leads to serious deterioration in social and academic functioning. Children with ADHD already face significant challenges in their attention, concentration, impulsivity, behaviour and academic achievements (Mindell et al, 1999). Interest in research on sleep in ADHD is increasing with sleep problems reported to occur in 50-70% of ADHD patients (Turan & Pekcanlar Akay, 2020).
Sleep disturbances in children with ADHD are likely to be multi-factorial in origin, ranging from psychostimulant mediated sleep-onset delay in some children to bedtime resistance related to a co-morbid anxiety disorder in others (Owens et al. 2000).
The purpose of this study is to examine the presence of sleep disturbances in children with ADHD using a valid and comprehensive sleep questionnaire, and to investigate the relationships between sleep disturbance and a number of factors including ADHD severity, presence of other comorbid diagnoses (e.g. anxiety / autism spectrum disorder / mood disorders) and ADHD medication. A greater understanding of sleep disturbances in ADHD will help us to improve our approach to the overall management of ADHD in ADMiRE.
This study will be an online survey. Parents of all young people attending ADMiRE will be invited to participate in the survey.
Researchers: Dr Jennifer Keane, Dr Maeve Haran, Dr Niamh Crowley, Dr Liliana Marques, Barbara Cawley, ADMiRE team, Prof Jane McGrath
This study is designed to assess the effectiveness of ADMiRE, Ireland’s first early access specialist service for children and adolescents with ADHD. Over the past four years, Prof Jane McGrath and the ADMiRE clinical team have conducted detailed reviews of the files of all young people attending the service. This study will examine service adherence to international best-practice guidelines for assessment and treatment of ADHD, and will examine how changes in processes have benefitted service provision for young people with ADHD.
Background / Objective
Set up in 2018, ADMiRE is the first public specialist service for young people (YP) with Attention Deficit Hyperactivity Disorder (ADHD) in Ireland (McGrath, 2020: https://doi.org/10.1017/ipm.2020.53; McGrath et al, 2022: https:// 10.1017/ipm.2022.15).
The ADMiRE model of care involves a standardised assessment/intervention protocol similar to the Dundee Clinical Care Pathway (Coghill&Seth, 2015:https://doi.org/10.1186/s13034-015-0083-2). The research objective was to complete a five-year audit in ADMiRE to determine adherence to international standards and ensure provision of high-quality ADHD care.
Methods
Files of all young people attending ADMiRE have been audited annually over a five-year period in January (2019, 2020, 2021, 2022 and 2023). The audit questionnaire investigated adherence to standards obtained from NICE guidelines for diagnosis/management of ADHD (NG87), andincluded additional information about demographics, diagnosis (including comorbidities), assessment, ADHD severity and pharmacological treatment. The audit data will be analysed to investigate adherence to NG87 standards, and to compare progress and trends between 2018 and 2022.
Results
196 YP currently attend ADMiRE (male-female ratio 3:1, age-range: 6.5-18). 87% have confirmed ADHD diagnosis (13% undergoing assessment). Key initial findings from this study:
- Excellent adherence to NG87 guidelines with significant improvement in care-planning, interagency communication and physical-health monitoring,
- Increased recognition of ADHD in females,
- Increased recognition of comorbidity (86%),
- Prescribing-shift from Lisdexamphetamine/Atomoxetine to Methylphenidate/Guanfacine XR in 2022.
- The ADMiRE model-of-care led to effective, efficient ADHD assessment and intervention (50% caseload optimised between Jan-Dec 2022).
- Detailed data analysis is ongoing.
Conclusions
Over the past 5 years, ADMiRE has pioneered the development of effective, efficient, safe and scalable ADHD service provision in the public health service in Ireland. This audit demonstrates ongoing optimisation of the ADMiRE model of care. Planned digital transformation of the ADMiRE model will increase accessibility and scalability.
This study will investigate the barriers and enablers for smooth and effective transition from child to adult services for young adults with ADHD.
Researchers: Dr Liliana Marques, Prof Jane McGrath
Oppositional defiant disorder (ODD) and Conduct Disorder( CD) commonly co-occurs in young people (YP) with Attention Deficit Hyperactivity Disorder (ADHD) (Eskander et al,2020). There is limited understanding about the factors that influence the development of behavioural disorders in YP with ADHD (Azeredoa et al,2018).
This study aims 1) to determine the prevalence of ODD and CD in YP with ADHD in ADMiRE, the first public-healthcare specialist ADHD service in Ireland and 2) to investigate factors that influence diagnostic status.
In the first part of this study, a retrospective file review of all open cases in an ADHD specialist service was carried out in November 2022. Of those children and adolescents attending the service who had a formal diagnosis of ADHD, 67% had significant traits of ODD (n=74), and 40% of the YP with ODD traits (n=44) also presented with significant traits of Conduct Disorder.
The influence of various factors on presence / absence of behavioural difficulties in children with ADHD are poorly understood. Data analysis is ongoing to determine if specific factors increase the risk of developing ODD / CD with ADHD. In the second phase of this study, we will investigate whether optimal treatment of ADHD is associated with a significant reduction in ODD / CD symptoms.
Researchers: Dr Sinead Killeen, Dr Karen Conlan, ADMiRE team, Prof Jane McGrath
Approximately 37% of young people (YP) with Attention Deficit Hyperactivity Disorder (ADHD) have co-existing autism spectrum disorder (ASD) (Berenguer-Forner et al, 2015). When both disorders co-occur, they cause greater morbidity and create more complicated clinical challenges. Previous research in ADMiRE, the first public ADHD-specialist service in Ireland, reported ASD prevalence of 39%. This study aims to investigate overall prevalence of ASD (diagnosed or suspected) in all YP attending ADMiRE in January 2023, and to determine the prevalence of ASD symptoms specifically over the past year (January 2022 – January 2023).
In this study, a retrospective review of the files of all young people attending ADMiRE in January 2023 will be carried out. We will collect the following data: 1) whether the YP had an existing formal diagnosis of ASD, 2) their T-scores on Parent and Teacher Social Responsiveness Scale (Constantino & Gruber, 2005), 3) Parent-reported scores on the Social Communication Questionnaire (Rutter et al, 2003) and 4) whether clinicians suspected ASD following comprehensive ADHD assessment. Following this we will determine overall prevalence of formally diagnosed ASD and suspected ASD. We will further analyse the prevalence of ASD/ suspected ASD in those who attended ADMiRE for initial assessment over the past year (January 2022 to January 2023).
There are currently 196 YP attending ADMiRE, and 23% have an existing formal diagnosis of ASD. Following clinician assessment and review of quantitative rating scales a further 25% have a suspected diagnosis of ASD. Data analysis of ASD prevalence over the past year is ongoing.
This study highlights the high prevalence of ASD in YP with ADHD. A clear pathway for ASD assessment in Ireland is urgently needed in order to optimise management for YP with ADHD and comorbid ASD.
Researchers: Dr Louise O’Rourke, Barbara Cawley, Dr Margaret Grace, Dr Jennifer Keane, Louise Creed, Dr Daniel Leahy, Kathryn Hallahan, Prof Jane McGrath
Until recently it has not been possible to use online prescribing for ‘Controlled drugs’ - those subject to control under the Misuse of Drugs Acts 1977 – 2016. Stimulant medications used in the treatment of ADHD are listed as controlled drugs, and historically all stimulant prescriptions had to be handwritten in a specific format, which was time-consuming and prone to error. In the first phase of the Covid-19 outbreak, to assist the public and prescribers, amendments were made to the Medicinal Products Regulations 2003 and the Misuse of Drugs Regulations 2017 to allow prescribers to send electronic prescriptions, including controlled drugs, to pharmacy health-mail accounts. There are significant benefits to online prescribing including increased safety and efficiency.
In the first phase of this study, a protocol outlining the mechanism for online Controlled drug prescribing was established in collaboration with a HSE Primary Care Pharmacist in Cork. This protocol was then implemented in early adopter centres in Cork and Dublin. Initial clinician user-experience has been overwhelmingly positive.
In the second phase of this study, we will be investigating clinician knowledge and experience of online prescribing and determine if users feel the process has a positive effect on quality and safety of care for children and their parents. We also plan to survey pharmacists and general practitioners as to their experience of the process and their experience of the increased communication and collaboration between key services.