adhd clinical practice guidelines 2014 - ministry of health€¦ · adhd clinical practice...

Loving Hearts, Beautiful Minds

ADHD Clinical Practice Guidelines 2014

Daniel Fung

Chairman Medical Board Institute of Mental Health, Singapore


Financial Disclosures

• I have received no honorarium and sponsorship from commercial and pharmaceutical companies in the last 3 years


What is ADHD?


Classification in DSM 5

• Neurodevelopmental Disorders

• ADHD • Intellectual disability (intellectual

developmental disorder)

• Communication disorders

• Specific learning disorder

• Motor disorders

• Autism Spectrum Disorder

• Disruptive, Impulse-Control, and Conduct Disorders

• Oppositional Defiant Disorder

• Conduct Disorder

• Intermittent Explosive Disorder

• Antisocial Personality Disorder

• Pyromania

• Kleptomania


ADHD in DSM 5

• No change in criteria, numbers of symptoms required, and specifiers

• Text descriptions include illustrations of examples of symptoms to serve as guide

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (e.g. overlooks or misses details, work is inaccurate)

• For 17 years and above, 5 symptoms required

• Symptoms onset prior to 12 years old (vs. 7 years old in DSM IV)


Field Trials in DSM 5


Definitions

Behaviour Problems defined by:

• Intensity or severity

• Pervasiveness

• Persistence

• Appropriateness

• Functioning

ADHD is defined by:

• 6 (5) out of 9 symptoms of Inattention/ H-I

• More than 1 situation

• Before age 7 (12)

• Not explained by some other disorder

• Impaired functioning


Causes of ADHD

Input

(Cortex)

Executive Functions Planning Organising Monitoring Evaluating behaviour

(Hippocampus)

Memory

Output

(ACG)

Attention

(Amygdala +LS+STS+OFC)

Emotions and Socialising

Behaviour Genetics

Environmental

Risks

CNS injury or

Infection, toxins

http://www.spicyhumor.com/taf.php


How the ADHD Brain Works


ADHD and Academic Performance

Intelligence

Phonological Deficits Dyslexia


Areas of Concern

• Recluse

• Excuse

• Abuse


Why the need for a CPG?

Guidelines: Aims to streamline particular processes according to a set routine or sound practice

MOH: improving clinical practice

• Public health importance

• Variations in practice

• Good evidence of effective practice

• Likelihood to have an impact on practice


Public Health Issue


Variations in Practice

Modify Behaviour

Learning support

Medications

Train Parents


Variations in Practice

http://www.time.com/time/magazine/0,9263,7601031103,00.html


Good Evidence of Effective Practice


AMS MOH Clinical Practice Guidelines

AIMS

• Assessment towards diagnosis and treatment plan

• Evidence for non-pharmacological treatment approaches in Singapore

• Evidence for medication use in Singapore

TARGET GROUP

• Professionals who come into contact with children and adolescents below the age of 18 who have ADHD

Academy of Medicine,

Singapore

College of Family

Physicians, Singapore

College of Paediatrics and

Child Health



WORKGROUP

• Appointed by the Academy of Medicine, Singapore.

• Comprising psychiatrists, paediatricians, educational psychologists, a medical social worker, a pharmacist, an advanced practice nurse and a parent representative


Singapore

College of Family



Child Health



ACKNOWLEDGEMENTS

• Gordon Harper MD – Associate Professor of Psychiatry Harvard Medical School

• Scott H. Kollins PhD – Professor & Vice-Chair for Research Strategy & Development Director, Duke

ADHD Program Department of Psychiatry & Behavioral Sciences Professor, Department of Psychology & Neuroscience Duke University, Durham, NC

• Rosemary Tannock PhD – Professor Emeritus Ontario Institute of Studies in Education, University of

Toronto Senior Scientist Neurosciences & Mental Health Research Program Research Institute of the Hospital for Sick Children

• Toh Chin Lee MD – Senior Consultant Child and Adolescent Psychiatrist & Head of Department of

Psychiatry Hospital Selayang


Singapore

College of Family



Child Health



ACKNOWLEDGEMENTS

Subsidiary editors: • Dr Pwee Keng Ho

– Deputy Director (Health Technology Assessment) Performance & Technology Assessment Division Ministry of Health

• Mr Raymond Huang – Manager (Health Technology Assessment) Performance & Technology Assessment Division

Ministry of Health Secretariat team: • Ms Chin Mien Chew

– Information Specialist (Health Technology Assessment) Performance & Technology Assessment Division Ministry of Health

• Ms Suriana Taib – Manager (Health Technology Assessment) Performance & Technology Assessment Division

Ministry of Health


Singapore

College of Family



Child Health



ACKNOWLEDGEMENTS

Dr Edwin Chan Shih-Yen – Head, Epidemiology Singapore Clinical Research Institute Assoc Professor,

Duke-NUS Graduate Medical School, Singapore Director, Singapore Branch, Australasian Cochrane Centre; Head (Evidence-based Medicine) Performance & Technology Assessment Division Ministry of Health

AMS Support team:

• Syairah Bte Samsudin, Professional Affairs Sr Executive, Academy of Medicine, Singapore


Singapore

College of Family



Child Health


Models of Care Education Healthcare

RTI

Response to Interventions

RTI

Response to Illness

Universal Healthcare

Small

Group

Instruction

Early Interventions

Universal Education

Intensive

Individual

Intervention

Intensive

Individual

Intervention

Medical Consult

Improve Quality Effective, Accessible, Timely, Affordable, Safe


Redesigning Healthcare

Traditional Mental Healthcare Model:

Hospital and clinician centric

Resource intensive with accessibility issues

Traditional Prevention Model:

Screening for illness

Disorder/ Illness centric

Stigma and avoidance

Traditional Promotion Model:

Public education

Media centric

Costly and hard to reach all Educational Self Care:

Start young, leverage on technology, focus on

resilience and strengths based models


Desired Model

Treatment (Usually in Clinics)

Etiology

Current Model

Diagnosis:

Labelling

Basic Assessment at school entry

or earlier?

No labelling

Group Interventions

Individual Treatment

New Model of Care for Youths


Hospital Centric Model

Schools, IHLs Medical Services

Family

Treatment (Usually in Clinics)

Etiology

Social Services



Family

Social Services

70%

20%

10%

2. Training and

Capability Building

1. Professional

Helpline

3. Establishing

Community

Networks

Counsellors

Social workers

Educational

Psychologists

GPs

Response Early intervention & Assessment in Community mental Health


Roles of REACH Clinical Services

Advice on mental health issues through the REACH helpline Responsive evaluation of referred students through triaging system Early intervention of common child mental health problems

e.g. school refusal, ADHD, Anxiety etc.

Training Training of school counsellors in identifying and

managing mental health issues, as well as in mental health promotion.

Training of GPs & staff of social service agencies in managing mental health problems

Networking/Integrating care Facilitate linkages between schools,

social & community agencies, GPs & mental health service providers to integrate care processes

Inter-agency consultation & case conference


www.reachforstudents.com


Community Centric Model


Family

Social Services

4 hospitals

IMH, KKH, NUHS

KTPH

55,000 students

seeing

Counsellors

800 seen

31 GP Partners

45 GPs trained per year

800 referred

7000 calls

800 case conferences

372 schools

513,968 students

12 VWOs

21 SPED Schools


Vision 2020

Family

Tertiary Care

Primary Care

Secondary Care

Lifelong Care

Regional Health

Systems

Academic &

National Centres

Educational &

Social Systems

Educational Selfcare

Systems

Child

Developmental

Services

Children’s Homes Foster Care

Primary Care Providers

Robust Regional Healthcare Systems

Support from Community Partners

Offer Affordable & Quality Tertiary Care

Promote Mental Health

Train Mental Health Professionals

Conduct Mental Health Research

COMMUNITY

HOSPITAL

School Counsellor

School & Community Acceptance

Support from School

Public Education

Thank You

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