Medication monitoring and ADHD Follow up clinics

ADHD medication monitoring and follow up clinics: key learning points

At each clinic session:

Obtain information from parents on child's progress as well as written feedback from school
Check- height/weight/BP/Pulse and complete centile chart for growth/BP
Check if medication side effects are present e.g. using a side effects rating scale
Consider whether dose of medication should remain the same, be increased, decreased, stopped or whether an alternative should be trialed.
Write to GP and copy letter to parents (if requested) and child's school (with parental permission)

The ADHD follow-up clinic

As a general principle, all children on medication for ADHD should be monitored on a regular basis. At present this tends to happen in either a community paediatric or specialist CAMHS setting depending on local arrangements. It is thought that with appropriate training the model would adapt well to a General Practitioner with a special interest (GPWsi) clinic.

The American Academy of Child and Adolescent Psychiatry have published a practice parameter for the assessment and treatment of children and adolescents with Attention-Deficit/Hyperactivity Disorder (2007) which gives up to date recommendations on the pharmacological management of ADHD. Additional information relevant to UK practitioners is available from the National Institute for Health and Clinical Excellence (p.44-46) who have produced guidance for the assessment and management of ADHD (see www.nice.org.uk/CG072).

Personnel involved

Although the monitoring of children on stimulant medication used to be undertaken either by child and adolescent psychiatrists or by paediatricians with special expertise, the increasing number of children requiring long-term follow-up has necessitated a more flexible approach involving other staff both medical e.g. GPWsi's and clinical assistants and non-medical e.g. senior CAMHS nurses. The following points will help ensure the safe and smooth running of ADHD follow up clinics:

All staff running ADHD follow-up clinics need to have a thorough knowledge of the condition and it's management. Such knowledge can be acquired by attending relevant courses and conferences, by observing a number of ADHD assessment and follow-up clinics run by more experienced members of staff and by reading appropriate books and journal articles on the subject.
Staff who are not senior child and adolescent psychiatrists or paediatricians should initially run ADHD follow up clinics in parallel with a consultant or other senior doctor, who is seeing other children at similar intervals. In this way, less experienced staff have easy access to expert medical advice as and when required.
Non-medical staff should not make alterations to a child's medication without discussing the case first with a senior doctor. The doctor must clearly document the discussion in the child's notes and make a note of any changes to the medication agreed.
In situations where medical advice is needed and can not be obtained immediately whilst the child and family are in the clinic setting, the latter should either be offered a appointment with a doctor as soon as possible or be telephoned at home once the case has been discussed with a suitably experienced doctor.

Frequency and duration of appointments in ADHD follow up clinics.

Once a child has been started on medication for ADHD, subsequent outpatient follow-ups should take place at approximately one month (for stimulants) or 6 weeks (for atomoxetine), 3 months, 6 months and 12 months (or more frequently if there is a clinical indication). When a child has been on stimulant medication for more than a year and is stable, it may be possible to agree to a shared care arrangement with the child's general practitioner whereby the child receives an annual appointment in the specialist ADHD Clinic, and is reviewed by the general practitioner at least once in between.

Routine medication monitoring appointments can be offered at half hourly intervals. This will usually allow enough time to cover the areas outlined in the protocol below as well as to dictate a short letter to the child's general practitioner (see downloads for examples of clinic letters). Written appointments for ADHD clinics should state the appointment time and duration and invite parents to request a longer appointment on a different date should they feel this is required (see downloads for example of appointment letter).

Suggested Protocol for ADHD follow-up clinics

With parental consent, as part of the monitoring process, the child's school should be requested to complete and return a standardized behaviour rating scale e.g. the Conner's abbreviated behaviour questionnaire, prior to every follow-up appointment (see downloads for example of letter to school).
As part of the monitoring process, the child's parent/carer should complete a stimulant drug side effects rating scale and a standardized behaviour rating scale e.g. SDQ (The SDQ is freely downloadable via http://www.sdqinfo.com/) or Conners questionnaire (see http://www.pearsonassessments.com/tests/crs-r.htm). The 10-item abbreviated Conners questionnaire is suitable for use when monitoring effects of medication for children with ADHD. A suitable side effects rating scale is available on line via http://adc.bmjjournals.com/ .This web address takes you to the home page. Enter Hill in the author box and ADHD in the keywords box and this will lead you to a page detailing 2 papers by this author. Alongside detail of the Auditable protocol for treating attention deficit/hyperactivity disorder click on 'example of questionnaire's. Patients on Atomoxetine should be monitored for signs of depression, suicidal thoughts or suicidal behaviour and referred for appropriate treatment if necessary. David Coghill from the University of Dundee has developed the Dundee Difficult Times of the Day Scale (D-DTODS)- a clinician administered scale that should be completed with the parent on behalf of the child or with parent and young person together. The questionnaire provides an insight into the child’s typical day and looks at potential times of difficulty including: getting dressed in the morning; making the most of the school day; taking part in after-school activities; socialising with family and friends; completing early-evening homework and going to bed and sleeping.
Routine measurements of height, weight, blood pressure and pulse should be taken and charted at every appointment (maximum interval recommended is 6 monthly). The National Institute for Health and Clinical Excellence (p.44) guidance on the diagnosis and management of ADHD (see www.nice.org.uk/CG072) recommends that height should be measured every 6 months, weight should be measured 3 and 6 months after medication is started and 6 monthly thereafter and both should be plotted on a centile chart and reviewed by the treating clinician. These guidelines also recommend that heart rate and blood pressure are taken and recorded on a centile chart before and after every dose change and routinely every 3 months. Referral should be made to a paediatrician if a child or young person has a sustained resting tachycardia, arrhythmia or systolic BP greater than the 95th centile measured on 2 occasions.
For children and young people on annual follow up at the ADHD specialist clinic, these measurements can be taken between appointments in a primary care setting. NB. It is recommended that children and young people taking TCA’s for ADHD should have regular ECG monitoring and checking of serum levels. This is mandatory if doses above the recommended limits of 1-2mg/kg/day for imipramine and amitriptyline and 0.5mg-1mg/kg/day for nortryptyline are used. For children on clonidine, blood pressure, pulse and ECG should be monitored. ECG’s are not recommended unless there is a clinical indication however for children and young people on methylphenidate, dexamphetamine and atomoxetine.
The manufacturers of methylphenidate and dexamphetamine recommend 'periodic' blood tests for haematological abnormalities. The European clinical guidelines for hyperkinetic disorder- first upgrade (Taylor et al, 2004, p.14) states however that " we are aware of no evidence for this practice and think that the remote chance of benefit is usually outweighed by the unpleasantness for the child". Despite the rare risk of hepatic disorder with atomoxetine, routine monitoring of liver function is not recommended due to the idiosyncratic nature of the reaction. Blood testing should therefore only be carried out when there is a clinical indication.
At regular intervals (e.g. yearly), the clinician should consider whether it would be appropriate for the child to have a short (up to 2 weeks) 'trial without medication' to help determine if medication is still required. In practice, for many children this occurs in an unplanned way as a result of occasional lapses to the medication regime.
Discussion should occur about the child's progress in home and school settings and consideration be given to medication adjustments in light of this feedback and the feedback received from the child's school
A letter to the child’s GP (copied to school with parents permission and parents if requested) should be written after every appointment showing medication dosage in bold type, detailing the current situation and any concerns and advising of the interval until the next clinic appointment (see downloads for examples of clinic letters).
Parental consent should be sought by the prescribing doctor to notify the school in writing of any changes to the medication dosage rather than this information simply being relayed to them by the parents or the child.

Writing letters to General Practitioners and schools after ADHD follow clinics

A letter should be written to the child's GP after every clinic appointment. This should be copied to the parent/carer and young person if considered appropriate.
If parents/carers consent, copies of clinic letters should be sent to the child's school. This ensures the school have an up to date record of the child's medication and are aware of the ongoing medical monitoring
Drug names and doses should be written in bold type
If the child does not attend for the appointment and no contact is made with the clinic to explain the non attendance, a standard letter should be sent to parents and copied to the child's GP which requests that they contact the clinic for another appointment to be made. In some situations (and where parental consent has been obtained for such information exchange) the clinician might want to consider copying this letter to the child's school.

Useful websites on medication monitoring

Further information on monitoring the response to methylphenidate can be found via http://www.rcpsych.ac.uk/traindev/cpd/adhd/drug/mpd16.htm