CNWL Adult ADHD Assessment and Treatment Service

ADHD is a neuro-developmental disorder that is present from childhood, but symptoms often persist into adulthood. It is often first diagnosed in childhood, but not always. Adult ADHD is increasingly being diagnosed after the age of 18 and sometimes into older age. Approximately 65 per cent of children diagnosed with ADHD will have symptoms that persist into adult life. The UK prevalence of ADHD is around 2.5% per cent (Simon et al 2009), so it is common. Whilst clinical services for children with ADHD have been well established for many decades, specialist adult services across the UK have been lacking. But due to the increased recognition of ADHD as a ‘lifespan’ disorder that persists into adulthood, adult services are increasingly more common.

Symptoms of ADHD can include a lack of attention and concentration, distractibility, day dreaming, overactive thinking, disorganisation, physical over activity, restlessness, impulsiveness and mood instability, which can lead to considerable behavioural and psychological impairments. ADHD is often seen more frequently in people with a history of substance abuse, anxiety, depression, and personality disorder. ADHD is often associated with specific learning difficulties including dyslexia and dyscalculia, and in people on the Autistic Spectrum.

It is increasingly being diagnosed amongst adults struggling to fulfil their potential in employment and education settings, as the symptoms in childhood may have been masked by good family structures and school support. People with ADHD often struggle in their personal lives and can experience difficulties in relationships with friends, colleagues and family. ADHD is heritable disorder and frequently exists in families across the generations, and in the clinic we sometimes diagnose parents of children with ADHD, who themselves were never diagnosed in childhood.

ADHD can be associated with antisocial behaviour in a certain proportion of people who have had behavioural problems earlier in life, and there is an overrepresentation of Adult ADHD amongst the prison population, with the finding that 25 per cent of prisoners fulfilled the diagnostic criteria. 

While the core symptoms of ADHD are found in many people some of the time, when they are severe and persistent over time and lead to impairments across different settings, a diagnosis can be made.  ADHD can impact on low self-esteem, cause distress from the symptoms of ADHD, impaired social interactions and relationships, behavioural problems, and the development of comorbid psychiatric conditions such as anxiety, depression, addictions.

Medication is the first-line treatment for adults with ADHD with either moderate or severe levels of impairment. Usual treatments include methylphenidate and dexamphetamine preparations (frequently referred to as stimulants). Second line treatments (such as atomoxetine) are also used where stimulant prescribing is not appropriate.

Psychological interventions without medication may be effective for some adults with mild to moderate impairment, but there is insufficient research evidence to support this recommendation. Psychological treatments for ADHD symptoms alone is not readily available on the NHS but if the individual is experiencing comorbid problems such as anxiety, depression or substance addiction, psychological interventions should be accessible via the patient’s GP, or from secondary care mental health services.

CNWL ADHD service is aimed at:

Adults over 18 years old registered with a GP under the following commissioning boroughs:

• Brent
• Camden
• Ealing
• Hammersmith and Fulham
• Harrow
• Hillingdon
• Hounslow
• Kensington and Chelsea (Central and Westminster)
   

These adults may:

• Already have an adult ADHD diagnosis and require a review of the management of their ADHD or
• Adults previously diagnosed with ADHD in childhood and with symptoms suggestive of continuing ADHD or
• People suspected of having ADHD in adulthood with supporting evidence such as onset in childhood as well as details of current symptoms and impairment

The patient must be referred by their GP.

Other mental healthcare professionals can ask the patient’s GP to include their recommendations/report in the GP’s referral to the CNWL Adult ADHD Service. The referral form can be downloaded here.

Once completed, the referral can be sent to the clinic directly via email: adhd.cnwl@nhs.net

Additional referral information

We request the following from the GP

• Blood pressure
• Pulse
• Electrocardiogram (ECG) Only required if the patient has a history of any cardiac condition or a family history of sudden death before the age of 40 years)

Once we have received the referral form you will receive a letter to confirm receipt of the referral.

Please note: We are not an urgent/crisis service. Please refer patients to relevant local services for urgent mental health difficulties.

Please be aware that we have a long waiting time for the initial appointment. Currently our waiting time is approximately 18 to 24 months. This time frame is subject to change.

Prior to your appointment you will receive a letter with your appointment details. We will ask you to confirm you can make the appointment and can offer you an alternative appointment if you cannot make it. All our appointments will be conducted virtually.

A week before your appointment you will be sent a link to electronically complete the following pre-assessment forms.

• ADHD Self Report Scale (ASRS1) Symptom Checklist.
• Informant Parent 
• Informant Partner

We will inform you when to complete these, so please do not send this to us until requested.

The assessment process will include:

1. An initial assessment
2. Up to three follow up appointments to review medication response
3. One follow up appointment within six months of discharge if required

The initial appointment

The initial virtual appointment can last up to 90 minutes.

A clinician will conduct a detailed assessment using the DIVA, a semi-structured diagnostic assessment tool, during the appointment.

If the patient is diagnosed with ADHD, the patient is offered a trial of medication. A prescription will be posted via the Royal Mail to the patient’s local pharmacy. If it is agreed that a medication trial is not needed, the patient will be discharged back to the GP.

We do not currently offer psychological therapy for ADHD within our service, but our clinicians will be happy to signpost you to relevant resources in this regard.

Follow up appointments: medication trial

If it is agreed to trial medication to treat the ADHD, they will need to attend up to three follow up appointments. These will be conducted virtually and can last up to 30 minutes each.

The purpose of these appointments is to review response to treatment.

Discharge

Once the patient’s medication is stabilised, they are discharged back to the GP with a shared care agreement. The discharge letter will include advice on continuation and monitoring of treatment.

We are happy to review patients within 6 months of discharge if required. After 6 months the patient will need to be re-referred with a new referral letter from the GP explaining the need for a review.

All of our appointments are carried out virtually.

The main base for the CNWL Adult ADHD Service is: The Mental Health Centre at Northwick Park Hospital, Watford Road, Harrow HA1 3UJ

The DVLA stipulates that conditions that affect driving, including ADHD, must be reported. Regarding ADHD specifically, the DVLA states you must tell DVLA if your attention deficit hyperactivity disorder (ADHD) affects your ability to drive safely. Further information is available from this website.

The ADHD service also offers specialist training for Psychiatric trainees on the CNWL and West London training schemes, as a special interest session for 12 months, and the session comes with an attached grant for the trainee to use in developing a project for the benefit of both the trainee and the ADHD service. For further details please contact Dr Dr Nishi Yarger, lead clinician for ADHD at adhd.cnwl@nhs.net