Review of international clinical guidelines for adolescents on transition to Adult Mental Health Services and adults with attention-deficit hyperactivity disorder and their application to an irish context.

OBJECTIVES: To review the available clinical guidelines from Canada, North America, Europe and the United Kingdom for the diagnosis and management of attention-deficit hyperactivity disorder (ADHD) for adolescents previously diagnosed in Child and Adolescent Mental Health Services (CAMHS) on transition to Adult Mental Health Services (AMHS) and for adults presenting with a diagnostic query re-ADHD. This article seeks to apply the available guidelines to an Irish context. METHOD: Various clinical guidelines and consensus statements were identified by a literature search of PubMed, incorporating literature from the past 10 years from English speaking countries and inclusion of any additional guidelines of clinical relevance. A clinical guideline with specific reference for Irish clinicians was proposed for the diagnosis and management of adults presenting for the first time with a diagnostic query re-ADHD and also to include those young adults previously diagnosed in CAMHS on transition to AMHS. CONCLUSIONS: ADHD is a lifelong disorder, which if undiagnosed or untreated can lead to significant impairment resulting in a high economic cost for society. Stimulant medication is a first-line treatment option for adults with ADHD; however, some formulations are unlicensed in Ireland. Recent licensing of Atomoxetine, for both adolescents on transition and for adults with newly diagnosed ADHD is a welcome development. Third-line agents are rarely prescribed due to their side effect profiles and are prescribed off-label: It is important to establish clinical guidelines for an Irish context incorporating a biopsychosocial approach. Further discussion amongst clinicians and stakeholders is needed to plan service development.

Review of clinical guidelines for children and adolescents with attention deficit hyperactivity disorder and their application to an Irish context.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with international prevalence rates estimated to be 5%. It is currently the most common disorder treated in Child and Adolescent Mental Health Services in Ireland. There have been a number of guidelines worldwide produced to aid clinicians in the diagnosis and treatment of ADHD; however, there are no guidelines available specifically for the Irish population and healthcare system. OBJECTIVES: The aim of this paper is to review the available clinical guidelines for the diagnosis and management of ADHD in children adolescents across North America, Canada, Europe and the United Kingdom and to apply these to an Irish context. METHODS: A number of international guidelines were reviewed. A proposed pathway for the assessment and treatment of children and adolescents with ADHD has been devised with the recommendation that a formalised consensus guideline should be implemented. CONCLUSION: This review paper has highlighted that there is consensus between the guidelines for the diagnosis of ADHD with a thorough clinical history remaining the gold standard. They further agree on the importance of identifying co-morbid disorders. When it comes to the treatment, the guidelines are less unified. This current paper has devised a proposed care pathway for ADHD in Ireland to ensure high quality cost effective care within its healthcare system.

Paediatric psychotropic prescribing practices in Ireland.

OBJECTIVES: This study describes the attitudes, knowledge and prescribing of psychotropic medication in children. METHOD: A study-specific questionnaire was mailed to all child psychiatrists, paediatricians and a group of registered general practitioners (GPs) from a selected Child and Adolescent Mental Health Services catchment area. RESULTS: In the 116 respondents who replied (39% response rate), psychotropic medication was generally valued and used by all groups (70.1%). Respondents believed that the majority (61.9%) of their non-medical colleagues would also value/support the use of medication and this endorsement influenced the respondents' prescribing rates. Initiating medication was viewed as the province of child psychiatry (78.6%). Medication is felt to be justified in a wide variety of mental health disorders, their use being reserved for severe presentations, with psychostimulants and selective serotonin reuptake inhibitors being most used. A significant number of GPs (60.9%) and paediatricians (63.4%) were felt to be lacking in competence in psychotropic prescribing, with a general request for more seminars in this area (61.5%) with almost half (45%) of them believing that they would prescribe more often. CONCLUSION: The use of psychotropic medication in children remains a valued and common practice in Ireland. Attitudinal and practice differences across professional groups exist, and although the experience is one of relative safety there was a strong desire for further education leading to a perceived increase in utilisation. The impact of perceived public opinion regarding psychotropic prescribing along with a lack of competence may represent a major barrier to effective prescribing, thus highlighting the importance of ongoing professional development and increased public health initiatives to increase knowledge and understanding in this increasingly important area.

An audit of orthodontic referrals using IOTN as a comparison.

UNLABELLED: It is important that resources for orthodontic treatment within the Health Service Executive (HSE) are directed towards those children most in need of treatment. At present, children are referred using existing HSE guidelines. OBJECTIVES: To assess the level of treatment need in a sample of patients on the orthodontic waiting list in the North Eastern division of the HSE using the Index of Orthodontic Treatment Need (IOTN) as an objective comparison. Also, to compare these results with the findings of a similar audit in 2003 and to assess the effectiveness of recommendations from the 2003 audit. METHOD: Fifty models from each of two orthodontic units were selected. These were scored for the dental health component (DHC) and aesthetic component (AC) of IOTN by a calibrated examiner. RESULTS: In the 2005 audit, 100% of patients fell into DHC grades 4 or 5. These grades constitute a great need for treatment on dental health grounds. In the 2003 audit, 97% of patients fell into these two grades. The remaining 3% of children in 2003 were fostered and therefore entitled to orthodontic treatment under HSE guidelines. An average of 63.5% of patients fell into AC grades 8-10, i.e., deemed to be in great need of treatment on aesthetic grounds. CONCLUSION: The HSE screening guidelines identify patients in great need of orthodontic treatment using IOTN as an objective assessment of this need. The sensitivity of these guidelines requires assessment by measuring the level of unmet treatment need in 15-year-olds in the region. Recommendations arising from the 2003 audit relating to the filling of referral forms and the improvement of study model quality were found to have been effective.