Loving Hearts, Beautiful Minds
ADHD Clinical Practice Guidelines 2014
Daniel Fung
Chairman Medical Board Institute of Mental Health, Singapore
Loving Hearts, Beautiful Minds
Financial Disclosures
• I have received no honorarium and sponsorship from commercial and pharmaceutical companies in the last 3 years
Loving Hearts, Beautiful Minds
Classification in DSM 5
• Neurodevelopmental Disorders
• ADHD • Intellectual disability (intellectual
developmental disorder)
• Communication disorders
• Specific learning disorder
• Motor disorders
• Autism Spectrum Disorder
• Disruptive, Impulse-Control, and Conduct Disorders
• Oppositional Defiant Disorder
• Conduct Disorder
• Intermittent Explosive Disorder
• Antisocial Personality Disorder
• Pyromania
• Kleptomania
Loving Hearts, Beautiful Minds
ADHD in DSM 5
• No change in criteria, numbers of symptoms required, and specifiers
• Text descriptions include illustrations of examples of symptoms to serve as guide
• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (e.g. overlooks or misses details, work is inaccurate)
• For 17 years and above, 5 symptoms required
• Symptoms onset prior to 12 years old (vs. 7 years old in DSM IV)
Loving Hearts, Beautiful Minds
Definitions
Behaviour Problems defined by:
• Intensity or severity
• Pervasiveness
• Persistence
• Appropriateness
• Functioning
ADHD is defined by:
• 6 (5) out of 9 symptoms of Inattention/ H-I
• More than 1 situation
• Before age 7 (12)
• Not explained by some other disorder
• Impaired functioning
Loving Hearts, Beautiful Minds
Causes of ADHD
Input
(Cortex)
Executive Functions Planning Organising Monitoring Evaluating behaviour
(Hippocampus)
Memory
Output
(ACG)
Attention
(Amygdala +LS+STS+OFC)
Emotions and Socialising
Behaviour Genetics
Environmental
Risks
CNS injury or
Infection, toxins
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ADHD and Academic Performance
Intelligence
Phonological Deficits Dyslexia
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Why the need for a CPG?
Guidelines: Aims to streamline particular processes according to a set routine or sound practice
MOH: improving clinical practice
• Public health importance
• Variations in practice
• Good evidence of effective practice
• Likelihood to have an impact on practice
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Variations in Practice
Modify Behaviour
Learning support
Medications
Train Parents
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Variations in Practice
Loving Hearts, Beautiful Minds
AMS MOH Clinical Practice Guidelines
AIMS
• Assessment towards diagnosis and treatment plan
• Evidence for non-pharmacological treatment approaches in Singapore
• Evidence for medication use in Singapore
TARGET GROUP
• Professionals who come into contact with children and adolescents below the age of 18 who have ADHD
Academy of Medicine,
Singapore
College of Family
Physicians, Singapore
College of Paediatrics and
Child Health
Loving Hearts, Beautiful Minds
AMS MOH Clinical Practice Guidelines
WORKGROUP
• Appointed by the Academy of Medicine, Singapore.
• Comprising psychiatrists, paediatricians, educational psychologists, a medical social worker, a pharmacist, an advanced practice nurse and a parent representative
Academy of Medicine,
Singapore
College of Family
Physicians, Singapore
College of Paediatrics and
Child Health
Loving Hearts, Beautiful Minds
AMS MOH Clinical Practice Guidelines
ACKNOWLEDGEMENTS
• Gordon Harper MD – Associate Professor of Psychiatry Harvard Medical School
• Scott H. Kollins PhD – Professor & Vice-Chair for Research Strategy & Development Director, Duke
ADHD Program Department of Psychiatry & Behavioral Sciences Professor, Department of Psychology & Neuroscience Duke University, Durham, NC
• Rosemary Tannock PhD – Professor Emeritus Ontario Institute of Studies in Education, University of
Toronto Senior Scientist Neurosciences & Mental Health Research Program Research Institute of the Hospital for Sick Children
• Toh Chin Lee MD – Senior Consultant Child and Adolescent Psychiatrist & Head of Department of
Psychiatry Hospital Selayang
Academy of Medicine,
Singapore
College of Family
Physicians, Singapore
College of Paediatrics and
Child Health
Loving Hearts, Beautiful Minds
AMS MOH Clinical Practice Guidelines
ACKNOWLEDGEMENTS
Subsidiary editors: • Dr Pwee Keng Ho
– Deputy Director (Health Technology Assessment) Performance & Technology Assessment Division Ministry of Health
• Mr Raymond Huang – Manager (Health Technology Assessment) Performance & Technology Assessment Division
Ministry of Health Secretariat team: • Ms Chin Mien Chew
– Information Specialist (Health Technology Assessment) Performance & Technology Assessment Division Ministry of Health
• Ms Suriana Taib – Manager (Health Technology Assessment) Performance & Technology Assessment Division
Ministry of Health
Academy of Medicine,
Singapore
College of Family
Physicians, Singapore
College of Paediatrics and
Child Health
Loving Hearts, Beautiful Minds
AMS MOH Clinical Practice Guidelines
ACKNOWLEDGEMENTS
Dr Edwin Chan Shih-Yen – Head, Epidemiology Singapore Clinical Research Institute Assoc Professor,
Duke-NUS Graduate Medical School, Singapore Director, Singapore Branch, Australasian Cochrane Centre; Head (Evidence-based Medicine) Performance & Technology Assessment Division Ministry of Health
AMS Support team:
• Syairah Bte Samsudin, Professional Affairs Sr Executive, Academy of Medicine, Singapore
Academy of Medicine,
Singapore
College of Family
Physicians, Singapore
College of Paediatrics and
Child Health
Loving Hearts, Beautiful Minds
Models of Care Education Healthcare
RTI
Response to Interventions
RTI
Response to Illness
Universal Healthcare
Small
Group
Instruction
Early Interventions
Universal Education
Intensive
Individual
Intervention
Intensive
Individual
Intervention
Medical Consult
Improve Quality Effective, Accessible, Timely, Affordable, Safe
Loving Hearts, Beautiful Minds
Redesigning Healthcare
Traditional Mental Healthcare Model:
Hospital and clinician centric
Resource intensive with accessibility issues
Traditional Prevention Model:
Screening for illness
Disorder/ Illness centric
Stigma and avoidance
Traditional Promotion Model:
Public education
Media centric
Costly and hard to reach all Educational Self Care:
Start young, leverage on technology, focus on
resilience and strengths based models
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Desired Model
Treatment (Usually in Clinics)
Etiology
Current Model
Diagnosis:
Labelling
Basic Assessment at school entry
or earlier?
No labelling
Group Interventions
Individual Treatment
New Model of Care for Youths
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Hospital Centric Model
Schools, IHLs Medical Services
Family
Treatment (Usually in Clinics)
Etiology
Social Services
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Schools, IHLs Medical Services
Family
Social Services
70%
20%
10%
2. Training and
Capability Building
1. Professional
Helpline
3. Establishing
Community
Networks
Counsellors
Social workers
Educational
Psychologists
GPs
Response Early intervention & Assessment in Community mental Health
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Roles of REACH Clinical Services
Advice on mental health issues through the REACH helpline Responsive evaluation of referred students through triaging system Early intervention of common child mental health problems
e.g. school refusal, ADHD, Anxiety etc.
Training Training of school counsellors in identifying and
managing mental health issues, as well as in mental health promotion.
Training of GPs & staff of social service agencies in managing mental health problems
Networking/Integrating care Facilitate linkages between schools,
social & community agencies, GPs & mental health service providers to integrate care processes
Inter-agency consultation & case conference
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Community Centric Model
Schools, IHLs Medical Services
Family
Social Services
4 hospitals
IMH, KKH, NUHS
KTPH
55,000 students
seeing
Counsellors
800 seen
31 GP Partners
45 GPs trained per year
800 referred
7000 calls
800 case conferences
372 schools
513,968 students
12 VWOs
21 SPED Schools
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Vision 2020
Family
Tertiary Care
Primary Care
Secondary Care
Lifelong Care
Regional Health
Systems
Academic &
National Centres
Educational &
Social Systems
Educational Selfcare
Systems
Child
Developmental
Services
Children’s Homes Foster Care
Primary Care Providers
Robust Regional Healthcare Systems
Support from Community Partners
Offer Affordable & Quality Tertiary Care
Promote Mental Health
Train Mental Health Professionals
Conduct Mental Health Research
COMMUNITY
HOSPITAL
School Counsellor
School & Community Acceptance
Support from School
Public Education