ADHD
What is ADHD?
ADHD stands for Attention Deficit and Hyperactivity Disorder, and as the name suggests, it is usually associated with some level of difficulty in concentration, +/- physical overactivity.
In fact, ADHD can present with many symptoms such as poor focus, being easily distracted, feelings of restlessness, being impulsive, and being poorly organised. It is not unusual to have some changes to mood. The symptoms can be wide ranging.
It is very common to experience some, or all of these symptoms at different times in life without having a diagnosis of ADHD. Being at University is often the first time our patients have the experience of totally independent living and managing your own finances, housing, study, relationships, emotional wellbeing etc can be a challenge for anyone. This can make it harder to ascertain if the symptoms you feel are related to normal life experiences, or ADHD.
It is estimated that 3-4 % of the UK population have ADHD, though many of those will be undiagnosed at present. It is usually diagnosed in childhood and around 15% of those retain the full diagnosis by the age of 25 years, and a further 50% in ‘partial remission’. We are currently seeing an increase in adults seeking an assessment for diagnosis of ADHD and this is likely to be due to an increase in the information available about it. Sadly, we are waiting for services to catch up as there are limited resources available for making assessments, and the current waiting list in Sheffield is very long.
We are able to refer patients for an ADHD assessment via a pathway called ‘Right to Choose’. This means that the assessment would be done by a provider that is commissioned to provide this service in a different area to the one where you live. This has been introduced in order to reduce waiting times, however, it does mean that your assessment is likely to be done remotely (i.e. by video consult) rather than in person. The waiting lists for these services have also increased recently.
ADHD is often seen at a high rate in people with other significant clinical problems including substance abuse, unstable mood states, anxiety, depression, forensic cases and emerging or developed personality disorder. ADHD is often associated with specific learning difficulties and is a common problem in higher education. It is important to discuss any of these that affect you with your GP.
What do I do if I think I have ADHD - How can I access a referral?
If you are concerned that you may have ADHD you should make an appointment to speak to your GP to discuss your concerns. It is a complex area and you would need at least one full appointment to cover the areas needed, please do not add this issue on to the end of a consultation for a different complaint.
Currently all diagnoses of ADHD are made by specialists (a consultant psychiatrist) and if your GP feels you need further assessment, they will be able to make a referral.
You will also need to decide which route you want to be referred into for a formal assessment. The options would be via SAANS (Sheffield Adult Autism and Neurodevelopmental Service) which has a very long waiting list (several years), or alternatively you could access a ‘Right to Choose’ provider. The list of these providers changes, as does their waiting times, so we suggest that you do the research yourself to find the best fit for you. A good starting place is the ADHD UK Right To Choose webpage.
Once we have established that a referral is needed, and you have chosen your preferred route, your GP will ask you to fill in some self-rated questionnaires to help guide the referral process, but please note that these are only tools to help the process, they cannot be used alone to make a diagnosis.
Even though the Right to choose providers are commissioned to provide NHS services in other areas of the country, there has been some concern raised regarding the quality of their assessments provided remotely (not 'in person'), and Sheffield ICB is currently reviewing this provision.
Accessing a RTC provider DOES NOT automatically lead to UHS accepting Shared Care/agreeing to prescribe on the basis of their assessment. We will review any requests for SCA on a case by case basis to ensure they meet our requirements (including that the assessment has been done by a Psychiatrist).
If you have been referred for an assessment please be aware that your GP CANNOT influence the waiting time for your appointment and you must contact the service provider you have chosen with any queries about this.
How is a diagnosis of ADHD made?
The diagnosis of ADHD is dependent on fulfilling strict criteria defined in DSM-IV and ICD 10 (these are systems of classifying mental health conditions that are agreed on an international level). The symptoms must have started in childhood, and persist into adulthood. The symptoms must also be pervasive i.e. they must impact in several areas of life. This could mean they impact on relationships, social interactions, and education or employment. For a diagnosis to be made, the impact of the symptoms must also cause a moderate to severe impairment. Even if you recognise some of the symptoms described above, if they are only having a minimal impact on your day to day life, referral would not be indicated.
What about treatment?
Treatment for ADHD should form part of a comprehensive management plan set out by the specialist team. It should address psychological, behavioural and educational/occupational needs. In some instances medication may be suggested.
Depending on your own personal and family history, it may be necessary to have some medical checks e.g. an ECG (heart tracing), before starting on medication. Your specialist will make an assessment of your need and communicate this to your GP. If the request is in keeping with the NICE guidance, your GP is able to organise these tests for you.
The psychiatry team would be responsible for assessing which medication may be of benefit. They will prescribe the medication and follow a process of ‘titration’ (slowly increasing the dose of medication) until they feel the medications are effective and well tolerated. Once medications have been stable for a number of weeks, the specialist team will write to your GP to ask them to take over prescribing. This is called a Shared Care Agreement.
The Shared Care Agreement is exactly what it sounds like – an agreement between your specialist team, and your GP to share your care. This may mean that the GP can take over prescribing your medications (once you have been on a stable dose for several weeks). Your specialist would continue to be available in the instance of any queries or concerns, and should see you for an annual review. Once on medications it is usual to have some checks every 6 months (usually blood pressure, pulse rate, and weight). At UHS we have an excellent team of Clinical Pharmacists who manage the Shared Care Process, so if you have a question related directly to this you should ask reception to book you an appointment with a pharmacist to discuss this in the first instance.
The Sheffield ICB (Integrated Care Board) is responsible for commissioning NHS services in Sheffield, and they provide clear guidance about what responsibilities lie with the GP, and what remains with the specialist team, in our Sheffield Shared Care Agreement. We also use the NICE guidance to inform any decisions made about the care of our patients. The Shared Care Agreement is currently under review and we have 2 members of our team who are working with the ICB to develop this further.
What if I have a private assessment?
As with all areas of health care it is often quicker to be seen if you access private medical assessments (i.e. not NHS). There are many private companies offering ADHD assessments. We would not be able to advise you to seek private assessment, or recommend any particular provider. In some instances a private provider may ask your GP to carry out some health checks, medical investigations and to take over prescribing medication once you are stable.
At University Health we would review any requests for additional investigations on a case by case basis and they must follow the NICE Clinical Guidance for us to consider these. We would not agree to a Shared Care Agreement with a private provider, and we will insist that you continue to receive your care via your private provider. This is in keeping with the BMA advice on this matter
Some concerns have been raised about the quality of many of the ADHD diagnostic clinics which have been springing up in response to the increased demand. A recent BBC Panorama programme highlighted this issue. In some cases the assessment was brief and incomplete and few were carried out by a consultant psychiatrist.
International students / diagnosis outside of UK
If you have been assessed and received a diagnosis of ADHD outside of the UK you cannot assume that we will take over the prescribing of medication for ADHD. We are unable to verify the quality of assessment process outside of the NHS. In addition, you will need to have specialist oversight of your condition and medication. The most straightforward way to ensure you continue to have access to medication is for the doctors who you have seen in your home country to continue to provide this, for example by issuing a larger supply each time you are reviewed. Alternatively, you may seek the services of a private Psychiatrist for this purpose. If you are unable to organise this and wish for UHS to consider taking over the prescriptions, you will need to provide a copy of your full diagnostic report (officially translated, if not in English) and make an initial appointment to discuss the options with our specialist pharmacy team.
Other support available for people with ADHD
The services in this area are sadly lacking at present. There are some workshops that can be accessed and the DDSS (the University's Disability and Dyslexia Support Service) can arrange for a Learning Support Plan to be in place to help manage your studies. They can do this in the time period you are waiting to be assessed by a psychiatrist. You do not have to have a confirmed diagnosis to be able to access help from the DDSS but you will need to provide evidence that you have been referred. Your GP can fill in the DDSS referral form to help you access this.
Mental Health and Wellbeing Workshops and Support GroupsDisability and Dyslexia Support Service (DDSS)
For some more general information and support please visit: https://www.mind.org.uk/information-support/tips-for-everyday-living/adhd-and-mental-health/