Clinical Studies in ADMIRE
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.
Researchers: Dr Sonita Sharma, Professor Jane Mc Grath, Dr Sharon Ryan
Attention Deficit Hyperactivity Disorder (ADHD) is a common disorder with a conservative prevalence estimate of approximately 5.29% worldwide 1. ADHD has many co-morbidities such as anxiety, depression and obsessive compulsive disorder2. There is a growing body of evidence that sleep disorders are also commonly co-morbid2. Some researchers suggest this is a co-morbidity, however, others, suggest it may be part of ADHD symptomology, results of stimulant medication or brain maturation processes 3.
ADHD is characterised by inattention, hyperactivity, and impulsivity and is often associated with behavioural difficulties and functional impairment. Sleep disorders can also result in aforementioned symptoms and impact on functioning. The presence of sleep disorders in addition to ADHD may result in further impact on functioning2. We believe it is important to assess if sleep disorders are present in patients attending the clinic in order to improve assessment, diagnosis and management and ultimately improve patient care and the quality of care provided by the service.
This study aims to calculate the prevalence, severity and nature of sleep difficulties in a sample of young people who attended the ADHD clinic for initial assessment in 2022. The study aims to investigate the relationship between ADHD subtype, severity and co-morbid conditions on sleep disorders. The study also aims to assess if the presence of sleep disorders in addition to ADHD impacts on functional impairment and if so what domain.
The researchers have conducted a retrospective chart review of parent rated Children’s Sleep Habits Questionnaire (CSHQ), Conners questionnaires and Weiss Functional Impairment Rating Scale (WFIRS) collected historically at baseline initial assessment. The research team are currently analysing the data and are exploring the relationship between sleep disorders and ADHD and the subsequent impact on functioning. Results will be reported in due course and our aim is to publish our findings and implement service improvements.
References:
1 . Polanczyk G, Silva de Lima M, Horta B, Biederman J, Rhode L. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. AM J Psychoatry. 2007; 164(6):942-948.
This study will investigate the barriers and enablers for smooth and effective transition from child to adult services for young adults with ADHD.
Team: PI Dr Marie Boilson, Consultant psychiatrist, adult ADHD Team, South Central Dublin, Denise Connolly, Senior occupational therapist, adult ADHD Team, South Central Dublin
Two workshops were held in October and December 2023 using a “Design Thinking” process to construct a pathway for young people with ADHD from child and Adolescent Mental Health Services moving into adult mental health services. Broad stakeholder representation was present.
Design thinking is an approach used for practical and creative problem-solving. It uses solution focused thinking seeking to understand people’s needs in order to generate solutions.
Feedback from service-users prior to the event generated some powerful food for thought around communication, information, access and support.
During the first workshop, a Design Thinking “Problem statement” was generated, barriers were identified and stakeholder mapping was completed.
The second workshop involved “ideation”, where solutions are explored from as many angles as possible. A “concept proposition” was described and a “Prototype” developed from this, in which critical elements of a successful transition pathway were defined.
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.
ASD prevalence in young people with ADHD
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.
No objective instrument for the diagnosis of ADHD currently exists. However, continuous performance tasks (CPTs), measures of an individual’s ability to maintain attention and refrain from responding to certain images in a boring task, have emerged as an objective tool to assist in clinical decision-making.
The QbTest is a CPT with the addition of motion tracking to measure levels of hyperactivity. Despite being well-liked and well-tolerated by clinicians, patients and their families, existing research suggests that the QbTest is sub-standard in the diagnosis of ADHD and performs poorly when asked to distinguish between other disorders like Bipolar II/Borderline Personality Disorder, schizophrenia, substance use disorder, other neurodevelopmental disorders and ADHD. This is particularly troubling as comorbid neurodevelopmental/psychiatric diagnoses are the rule, rather than the exception, in ADHD.
With such a high prevalence of ADHD symptoms of hyperactivity, impulsivity and inattention in autism spectrum disorder12, with this project we want to look further into the ability of the QbTest to discriminate between ADHD and ASD, and just how much it adds above and beyond traditional diagnostic tools. To do this, we will apply machine learning techniques to a large dataset from the ADMiRE ADHD clinic. It is hoped that through this data-driven approach, we will provide a meaningful and empirical contribution Ireland’s mental health services, facilitating a decision about the merits of including the QbTest as part of the diagnostic process for ADHD.
Researchers: Dr Marie Bolton, Dr Louise O’Rourke, Dr Udo Reulbach, Dr Dermot Cohen, Prof Jane McGrath
Background:
The Long Term Illness (LTI) Scheme was established under Section 59(3) of the Health Act 1970 (as amended), to provide medication and medical/surgical appliances directly related to the treatment of a patients’ scheduled illness free of charge. Regulations subsequent to The Health Act 1970 have specified sixteen ‘scheduled illnesses’, one of which is mental illness (including Attention Deficit Hyperactivity Disorder) in a person under 16 years of age.
Anecdotal evidence from clinicians has noted limited knowledge of the LTI scheme amongst prescribing clinicians (Consultants, Non-Consultant Hospital Doctors, Registered Nurse Prescribers, Advanced Nurse Practitioners) in CAMHS and we wish to formally assess this hypothesis.
Aims:
The primary aim of this survey is to investigate CAMHS prescribers’ knowledge of The Long Term Illness Scheme, with a specific focus on one of the sixteen ‘scheduled illnesses’ - mental illness. This anonymous survey will focus on prescribing clinicians in a number of clinical CHO sites nationally.
A secondary aim is to provide education to those who complete the survey, so as to improve knowledge of the LTI scheme. Educational components are embedded within the survey.
Methods:
An anonymous survey will be circulated to CAMHS prescribing clinicians. Data will be collected to ascertain the current level of knowledge of the LTI scheme amongst prescribing clinicians. All data and measurable outcomes will be evaluated.