“You’re 18 now, goodbye”: The experiences of young people with Attention Deficit Hyperactivity Disorder of the transition from child to adult services

This is the author accepted manuscript. The final version is available from Taylor & Francis (Routledge) via the DOI in this record.The term ‘transition’ is used to refer to the process of moving from child to adult services. Among child and adolescent mental health services attenders, young people with Attention Deficit Hyperactivity Disorder (ADHD) are less likely to transition successfully, but there is a gap in understanding their views and why they might disengage from services. The aim of this study was to explore the experiences of transition of young people with ADHD in Southwest England using semi-structured interviews and thematic analysis. Seven young people aged 17-19 years participated. Four key themes were identified: professionals’ roles and relationships with young people; the role of ADHD medication, uncertainties around transition and medication management, and identified needs and increasing independence. Although this study presents the experiences of a small number of people, their stories suggest that best practice around transition is not always being followed. There is consequently a need to better understand the facilitators and barriers to best practice implementation.This research was funded as part of a Doctoral Research Fellowship from the National Institute for Health Research held by Tamsin Newlove-Delgado(Reference: DRF-2012-05- 221). Tamsin Newlove-Delgado is currently funded by an NIHR Academic Clinical Lectureship. Ken Stein is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula at Royal Devon and Exeter NHS Foundation Trust. This report is independent research and the views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health

Prescribing for young people with Attention Deficit Hyperactivity Disorder in UK primary care: analysis of data from the Clinical Practice Research Datalink

This is the author accepted manuscript. The final version is available from Springer via the DOI in this record.Background Guidance on management of Attention Deficit Hyperactivity Disorder [ADHD] in the UK was issued by the National Institute for Clinical Excellence [NICE] in 2008. No UK study has examined all psychotropic prescribing in young people with ADHD since the introduction of the guidance; this is especially relevant due to the high prevalence of psychiatric comorbidity in this population. Aim To describe primary care prescribing of ADHD and other psychotropic medication for young people with ADHD. Design and setting Analysis of records of patients with an ADHD diagnosis in the UK Clinical Practice Research Datalink from 2005 to 2013. Methods Estimation of the prevalence of prescribing of ADHD and other psychotropic medication over 8 years follow-up for cases aged 10 to 20 years in 2005. Results Of 9,390 ADHD cases, 61.6% (95% confidence interval (CI) = 60.6% to 62.5%) had a prescription at some point for ADHD medication. Prescribing of other psychotropic medication was higher in girls than boys (36.4% versus 22.7%; p<0.001). ADHD prescribing prevalence declined steeply between the ages of 16 and 18 from 37.8% (95% CI 36.6 to 38.9) to 23.7% (95% CI: 22.7 to 24.6%). There was a parallel increase in prescribing of other psychotropics from 3.8% (95% CI: 3.4% to 4.3%) to 6.6% (95% CI 6.0 to 7.3%). Conclusion There is scope to optimise the management of ADHD and psychiatric comorbidities in young people, and a need for sustainable models of ADHD care for young adults, supported by appropriate training and specialist services.National Institute for Health Research (NIHR

Resumption of Attention Deficit Hyperactivity Disorder medication in early adulthood: findings from a UK primary care prescribing study

This is the author accepted manuscript. The final version is available from Springer via the DOI in this record.This study aimed to examine resumption of Attention Deficit Hyperactivity Disorder (ADHD) prescriptions in early adulthood in young people whose ADHD prescriptions stopped in adolescence. Whilst prescribing studies indicate that the proportion of those with ADHD stopping treatment in late adolescence remains in excess of the proportion expected to be symptom free, very few studies have examined patterns of resumption amongst young adults previously prescribed medication. Primary care records from the UK Clinical Practice Research Datalink from 2008 to 2013 were used to examine the outcome of resumption of ADHD prescriptions from age 20 years in a sample of cases with ADHD whose prescriptions stopped aged 14-18. A Cox regression model was fitted to explore variables that could theoretically be associated with resumption of prescriptions. Of 1,440 cases, 109 (7.6%) had their ADHD prescriptions resumed. Characteristics associated with an increased probability of resumption included female gender, learning disability, referral to adult mental health services, and prescription of antipsychotic medication. In this study, only a small proportion of adolescents who stopped ADHD medication subsequently resumed their prescriptions in primary care. Those that did resume were a more complex group. As many vulnerable individuals with ongoing ADHD symptoms may not have the resources required to surmount the barriers to re-enter services, the implication is that not all those who could benefit from resuming medication are able to do so. The findings raise questions around whether current care models are flexible enough and whether primary care are adequately supported in managing this group

G240 Prevalence and patterns of mental health-related paediatric hospital admissions

Aims Concerns have been raised about a perceived rise in children and young people admitted to paediatric wards with mental health difficulties, and about the support available for them. However, there has been no detailed analysis to date of mental health (MH) related admissions data.The main aims of this project were to investigate regional MH-related paediatric admissions by:Describing the prevalence of admissions with an MH code, and the most common codes associated with admissions.Examining trends in prevalence over time.Methods We used data from 2006–2017 obtained from six acute trusts in one region as part of an ongoing hospital admissions project. A comprehensive coding list was developed to identify admissions with MH-related codes; subdivided into codes for mental, behavioural and neurodevelopmental disorders and codes for intentional self-harm. For each Trust we calculated the proportion of all admissions that had an MH-related code, identified the most common codes, and examined changes in prevalence of MH-related admissions over time. We also described whether MH-related diagnoses were coded as primary diagnoses.Results The overall proportion of admissions which were MH-related varied by trust from 0.45% to 7.97%, and the proportion with an intentional self-harm code ranged from 0.30% to 3.41%. In all trusts, less than 1% of admissions had an MH-related code as the primary diagnosis. The proportion of admissions with an MH-related code increased over time, both for mental, behavioural and neurodevelopmental disorders and for intentional self-harm, for all trusts. The most common MH-related codes used as primary diagnoses were acute alcohol intoxication and anorexia nervosa.Conclusion Our findings suggest there has been a rise in MH-related paediatric admissions over time, and that this rise is not solely due to an increase in self-harm. This has implications for prevention, for planning appropriate care and pathways for those admitted with an MH problem, and for staff training and support. Perhaps most importantly, Trusts that only capture primary diagnosis codes risk underestimating mental health needs in the paediatric population.Acknowledgement Thanks to National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula and to the Academy of Medical Sciences INSPIRE programme who funded the lead author for a medical student summer scholarship

Psychosocial interventions for recurrent abdominal pain in childhood

This is the final version. Available from the publisher via the DOI in this record.BACKGROUND: This review supersedes the original Cochrane review first published in 2008 (Huertas-Ceballos 2008).Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. No organic cause for this pain can be found on physical examination or investigation for the majority of such children. Although many children are managed by reassurance and simple measures, a large range of psychosocial interventions involving cognitive and behavioural components have been recommended. OBJECTIVES: To determine the effectiveness of psychosocial interventions for reducing pain in school-aged children with RAP. SEARCH METHODS: In June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the references of identified studies and relevant reviews. SELECTION CRITERIA: Randomised controlled trials comparing psychosocial therapies with usual care, active control, or wait-list control for children and adolescents (aged 5 to 18 years) with RAP or an abdominal pain-related functional gastrointestinal disorder defined by the Rome III criteria were eligible for inclusion. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Five review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and adolescents with RAP between the ages of 6 and 18 years. The interventions were classified into four types of psychosocial therapy: cognitive behavioural therapy (CBT), hypnotherapy (including guided imagery), yoga, and written self-disclosure. The studies were carried out in the USA, Australia, Canada, the Netherlands, Germany, and Brazil. The majority of the studies were small and short term; only two studies included more than 100 participants, and only five studies had follow-up assessments beyond six months. Small sample sizes and the degree of assessed risk of performance and detection bias in many studies led to the overall quality of the evidence being rated as low to very low for all outcomes.For CBT compared to control, we found evidence of treatment success postintervention (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.18 to 27.32; Z = 2.16; P = 0.03; 4 studies; 175 children; very low-quality evidence), but no evidence of treatment success at medium-term follow-up (OR 3.08, 95% CI 0.93 to 10.16; Z = 1.85; P = 0.06; 3 studies; 139 children; low-quality evidence) or long-term follow-up (OR 1.29, 95% CI 0.50 to 3.33; Z = 0.53; P = 0.60; 2 studies; 120 children; low-quality evidence). We found no evidence of effects of intervention on pain intensity scores measured postintervention (standardised mean difference (SMD) -0.33, 95% CI -0.74 to 0.08; 7 studies; 405 children; low-quality evidence), or at medium-term follow-up (SMD -0.32, 95% CI -0.85 to 0.20; 4 studies; 301 children; low-quality evidence).For hypnotherapy (including studies of guided imagery) compared to control, we found evidence of greater treatment success postintervention (OR 6.78, 95% CI 2.41 to 19.07; Z = 3.63; P = 0.0003; 4 studies; 146 children; low-quality evidence) as well as reductions in pain intensity (SMD -1.01, 95% CI -1.41 to -0.61; Z = 4.97; P < 0.00001; 4 studies; 146 children; low-quality evidence) and pain frequency (SMD -1.28, 95% CI -1.84 to -0.72; Z = 4.48; P < 0.00001; 4 studies; 146 children; low-quality evidence). The only study of long-term effect reported continued benefit of hypnotherapy compared to usual care after five years, with 68% reporting treatment success compared to 20% of controls (P = 0.005).For yoga therapy compared to control, we found no evidence of effectiveness on pain intensity reduction postintervention (SMD -0.31, 95% CI -0.67 to 0.05; Z = 1.69; P = 0.09; 3 studies; 122 children; low-quality evidence).The single study of written self-disclosure therapy reported no benefit for pain.There was no evidence of effect from the pooled analyses for any type of intervention on the secondary outcomes of school performance, social or psychological functioning, and quality of daily life.There were no adverse effects for any of the interventions reported. AUTHORS' CONCLUSIONS: The data from trials to date provide some evidence for beneficial effects of CBT and hypnotherapy in reducing pain in the short term in children and adolescents presenting with RAP. There was no evidence for the effectiveness of yoga therapy or written self-disclosure therapy. There were insufficient data to explore effects of treatment by RAP subtype.Higher-quality, longer-duration trials are needed to fully investigate the effectiveness of psychosocial interventions. Identifying the active components of the interventions and establishing whether benefits are sustained in the long term are areas of priority. Future research studies would benefit from employing active control groups to help minimise potential bias from wait-list control designs and to help account for therapist and intervention time.The work of the evidence synthesis team is funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC). However, the funder had no role in the review itself

Dietary interventions for recurrent abdominal pain in childhood

This is the final version of the article. Available from Wiley via the DOI in this record.BACKGROUND: This is an update of the original Cochrane review, last published in 2009 (Huertas-Ceballos 2009). Recurrent abdominal pain (RAP), including children with irritable bowel syndrome, is a common problem affecting between 4% and 25% of school-aged children. For the majority of such children, no organic cause for their pain can be found on physical examination or investigation. Many dietary inventions have been suggested to improve the symptoms of RAP. These may involve either excluding ingredients from the diet or adding supplements such as fibre or probiotics. OBJECTIVES: To examine the effectiveness of dietary interventions in improving pain in children of school age with RAP. SEARCH METHODS: We searched CENTRAL, Ovid MEDLINE, Embase, eight other databases, and two trials registers, together with reference checking, citation searching and contact with study authors, in June 2016. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing dietary interventions with placebo or no treatment in children aged five to 18 years with RAP or an abdominal pain-related, functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We grouped dietary interventions together by category for analysis. We contacted study authors to ask for missing information and clarification, when needed. We assessed the quality of the evidence for each outcome using the GRADE approach. MAIN RESULTS: We included 19 RCTs, reported in 27 papers with a total of 1453 participants. Fifteen of these studies were not included in the previous review. All 19 RCTs had follow-up ranging from one to five months. Participants were aged between four and 18 years from eight different countries and were recruited largely from paediatric gastroenterology clinics. The mean age at recruitment ranged from 6.3 years to 13.1 years. Girls outnumbered boys in most trials. Fourteen trials recruited children with a diagnosis under the broad umbrella of RAP or functional gastrointestinal disorders; five trials specifically recruited only children with irritable bowel syndrome. The studies fell into four categories: trials of probiotic-based interventions (13 studies), trials of fibre-based interventions (four studies), trials of low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diets (one study), and trials of fructose-restricted diets (one study).We found that children treated with probiotics reported a greater reduction in pain frequency at zero to three months postintervention than those given placebo (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.98 to -0.12; 6 trials; 523 children). There was also a decrease in pain intensity in the intervention group at the same time point (SMD -0.50, 95% CI -0.85 to -0.15; 7 studies; 575 children). However, we judged the evidence for these outcomes to be of low quality using GRADE due to an unclear risk of bias from incomplete outcome data and significant heterogeneity.We found that children treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (odds ratio (OR) 1.63, 95% CI 1.07 to 2.47; 7 studies; 722 children). The estimated number needed to treat for an additional beneficial outcome (NNTB) was eight, meaning that eight children would need to receive probiotics for one to experience improvement in pain in this timescale. We judged the evidence for this outcome to be of moderate quality due to significant heterogeneity.Children with a symptom profile defined as irritable bowel syndrome treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (OR 3.01, 95% CI 1.77 to 5.13; 4 studies; 344 children). Children treated with probiotics were more likely to experience improvement in pain at three to six months postintervention compared to those receiving placebo (OR 1.94, 95% CI 1.10 to 3.43; 2 studies; 224 children). We judged the evidence for these two outcomes to be of moderate quality due to small numbers of participants included in the studies.We found that children treated with fibre-based interventions were not more likely to experience an improvement in pain at zero to three months postintervention than children given placebo (OR 1.83, 95% CI 0.92 to 3.65; 2 studies; 136 children). There was also no reduction in pain intensity compared to placebo at the same time point (SMD -1.24, 95% CI -3.41 to 0.94; 2 studies; 135 children). We judged the evidence for these outcomes to be of low quality due to an unclear risk of bias, imprecision, and significant heterogeneity.We found only one study of low FODMAP diets and only one trial of fructose-restricted diets, meaning no pooled analyses were possible.We were unable to perform any meta-analyses for the secondary outcomes of school performance, social or psychological functioning, or quality of daily life, as not enough studies included these outcomes or used comparable measures to assess them.With the exception of one study, all studies reported monitoring children for adverse events; no major adverse events were reported. AUTHORS' CONCLUSIONS: Overall, we found moderate- to low-quality evidence suggesting that probiotics may be effective in improving pain in children with RAP. Clinicians may therefore consider probiotic interventions as part of a holistic management strategy. However, further trials are needed to examine longer-term outcomes and to improve confidence in estimating the size of the effect, as well as to determine the optimal strain and dosage. Future research should also explore the effectiveness of probiotics in children with different symptom profiles, such as those with irritable bowel syndrome.We found only a small number of trials of fibre-based interventions, with overall low-quality evidence for the outcomes. There was therefore no convincing evidence that fibre-based interventions improve pain in children with RAP. Further high-quality RCTs of fibre supplements involving larger numbers of participants are required. Future trials of low FODMAP diets and other dietary interventions are also required to facilitate evidence-based recommendations