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Keywords:

  • ADHD;
  • hyperkinetic disorder;
  • service use;
  • medication

Abstract

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Background:  Little is known about ongoing service use among young people with ADHD, but this information is important to the development of services to support these young people.

Methods:  A cohort of young people with ADHD or hyperkinetic disorder (n = 115) was followed up five to seven years after diagnosis. Details are presented of their use of public sector services over the 12 months preceding reassessment, compared to young people with ADHD from a large epidemiological study.

Results:  Most children remained in contact with CAMHS, with high rates of contact with schools, educational professionals and the criminal justice system. Nearly all had taken medication at some point, while many still were using it. There were low reported rates of psychological and group interventions within the last twelve months, but this does not rule out earlier access to such treatments.

Conclusions:  Children with ADHD utilise long-term support from public sector services, and cross agency strategies or clinics may help to optimise functioning.


Key Practitioner Message:

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References
  •  Many children with ADHD continue to need support from CAMHS into adolescence and early adulthood.
  •  Many children with ADHD need additional support at school on a long-term basis.
  •  Health visitors, general practitioners and teachers were the first professionals approached by parents, so their knowledge and understanding of ADHD is very important.
  •  Girls with ADHD are less likely to be referred to CAMHS.

Introduction

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Little is known about the long-term outcome of attention deficit/hyperactivity disorder (ADHD) in relation to service use, yet this kind of information is important for those planning and developing services. Symptoms of ADHD persist into adolescence and adulthood in a significant proportion of children, although estimates of persistence vary according to how cases are defined (Barkley et al., 2002; Faraone, Biederman, & Mick, 2006; Steinhausen et al., 2003; Willoughby, 2003). Children with ADHD have higher rates of conduct disorder in adolescence and antisocial personality disorder and substance abuse in adulthood in comparison with young people attending non-psychiatric medical clinics (Manuzza et al., 1998; Taylor et al., 1996). They have lower academic attainment, lower status jobs and are more likely to become involved in criminal activities (Babinski et al., 1999; Hartsough & Lambert, 1999; Manuzza et al., 1993; Taylor et al., 1996). Although effective interventions exist, few studies have followed children beyond eighteen months, or examined outcomes other than psychopathology (Gillberg et al., 1997; MTA cooperative group, 2004a; Paternite et al., 1999). Data are presented on service use over a twelve month period from a British cohort of young people who had been identified as having ADHD or hyperkinetic disorder in secondary health care clinics at least five years before and compare their service use to that of children with ADHD from a general population survey.

Method

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Samples

Clinic group.  The Cardiff Longitudinal ADHD Study sample (CLASS) consists of 375 British children with suspected ADHD, aged between 6–15 years, who were recruited from Child and Adolescent Mental Health Services (CAMHS) and paediatric clinics in North and South West England and South Wales. Children with learning disability (IQ < 70), neurological conditions, Tourette's syndrome, pervasive developmental disorder or who were looked after by the local authority were excluded. This analysis included those whose initial assessment was made at least five years previously, were aged 12 or over, and who had ADHD or hyperkinetic disorder according to DSM-IV or ICD-10 at baseline (n = 157) (American Psychiatric Association, 1994; World Health Organization, 1993). Children who only met criteria for DSM-IIIR ADHD at baseline (n = 41) were excluded from this analysis. All but five of the 157 eligible young people were successfully traced five years later, and 126 (80%) participated in the follow up study, with 115 parents providing information on services.

Epidemiological group.  The 1999 British Child and Adolescent Mental Health Survey involved 10,438 children aged 5–15 (Meltzer et al., 2000). The three year follow up sample comprised all those with a disorder (n = 929) in the initial survey and a random third of those without disorder (n = 3063) (Meltzer et al., 2003). In the three year follow up, some parents were selected for detailed telephone interviews about service use, either because of reported service contact (n = 411) or because the parents reported persistent concerns about their child's mental health but had not reported seeking help (n = 63), with a response rate of 85% (Ford, Hamilton, & Goodman, 2005). Children who participated in the three year follow up telephone interviews and were age 12 or over at follow up were selected as an epidemiological comparison group (n = 242).

Psychiatric diagnoses

The presence of the psychiatric disorders listed in Table 1 in CLASS was assessed at both time points using the parent version of the Child and Adolescent Psychiatric Assessment (CAPA) and the Child Attention Deficit Hyperactivity Disorder Teacher Telephone Interview (ChATTI) (Angold et al., 1995; Holmes et al., 2004). The CAPA is a semi-structured diagnostic interview that was administered by trained psychology graduates and a post-doctoral researcher. The ChATTI was required to assess whether the child fulfilled the pervasiveness criterion for ADHD or hyperkinetic disorder. Diagnoses were assigned using DSM-IV (ADHD) or ICD-10 (all other diagnoses) criteria with high inter-rater reliability (κ = 1.0 for both ADHD and hyperkinetic disorder at time 1).

Table 1.   Comparison of rates of socio-demographic characteristics and service use over the past 12 months among the epidemiological and CLASS samples
ServiceADHD in community % (n = 35)Conduct disorder (no ADHD) in the community % (n = 51)Emotional disorder (no disruptive disorder) in the community % (n = 41)No disorder in the community % (n = 109)CLASS % (n = 115)p value
  1. 1Other secondary health care = contact with the school medical system, hospital and community paediatrics or adult secondary physical health care. 2School contacts = teachers, Special Educational Needs Coordinators, learning support assistants and extra help from teachers. 3SEN professionals = educational psychologists, educational social workers, and behavioral support workers.

Mean age (standard deviation)14.4 (1.9)15.1 (1.8)15.0 (1.8)14.5 (1.9)14.0 (1.7).003
Female gender203544497<.001
Mental health services3416332370<.001
Primary health care1722423462<.001
Secondary health care1642118.3
Schools23137373871<.001
SEN professionals3111217617.1
Social services31412413.05
Police and youth justice1167422<.001

Epidemiological sample.  Psychiatric diagnoses at time 1 were made according to DSM-IV (ADHD) or ICD-10 (all other disorders) using the Development and Well-being Assessment (DAWBA), which combines structured interviews with parents and children aged over 11 and a postal questionnaire to teachers with a clinical review of verbatim transcripts about reported symptoms (Goodman et al., 2000). As with the clinical sample, children with ADHD or hyperkinetic disorder include children with comorbid disorders. However, in the comparison with CLASS (see Table 1), ‘conduct disorders’ excluded those with a comorbid hyperkinetic disorder who were already accounted for, and ‘emotional disorders’ excluded those with a comorbid disruptive disorder to avoid double counting of young people in the table.

Service use

Service use related to mental health was measured in both samples using the Children's Service Interview with parents, which combines a semi-structured approach with a structured screen, and shows moderate or better reliability and concordance with clinical records (Ford et al., 2007). In both samples, data were collected on service use over the preceding 12 months.

Socio-demographic and educational measures in CLASS

Intellectual and reading ability were assessed at baseline using the Wechsler Intelligence Scale for Children (WISC III) and the Weschler Objective Reading Dimension (WORD) (Wechsler, 1991, 1993). In accordance with DSM-IV criteria, children scoring at a significantly lower level on the WORD than would be predicted by their age and intelligence quotient were classified as having a specific reading disorder. Parents supplied demographic data, and socio-economic status was classified as high (professional or managerial), medium (non-manual or skilled manual) and low (unskilled manual or unemployed) according to the classification used in the 1991 census (Office for National Statistics, 1995).

Analysis

The analysis was conducted using SPSS version 12.01 and STATA version 8. After demonstrating that there were no significant differences in baseline characteristics between the young people from CLASS with service use information and those that did not participate at time 2, or who participated but did not complete the Children's Services Interview (details available on request), service use in CLASS was compared to the epidemiological sample. The patterns of service use are described using means and standard deviations where the distribution of continuous variables is approximately normal, and medians with the inter-quartile range where the data were significantly skewed. Patterns of service use are explored in CLASS and by stratifying the sample according to the persistence of ADHD or hyperkinetic disorder at time 2 and the presence of comorbid oppositional defiant or conduct disorder at baseline.

Results

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Comparison of service use among epidemiological and CLASS samples

The age and gender of CLASS and the different groups within the epidemiological samples differed significantly, but there was no significant difference between the age of the young people with ADHD in both groups (t = 0.9, p = .3). Young people in CLASS were more likely than young people from the epidemiological survey to have had contact with most services within the preceding twelve months; the exceptions being specialist educational resources and secondary health care. When the comparison was restricted to the young people from the epidemiological sample with ADHD, young people from CLASS were significantly more likely to access primary healthcare (χ2 = 21.4, p < .001), CAMHS (χ2 = 14.1, p < .001), and teachers (χ2 = 18.1, p < .001), but not secondary health care, special educational needs resources or the police and youth justice system. These results emphasise that children selected from clinics are not representative of children with a disorder in the community and that the following descriptions can only be applied to children whose ADHD or hyperkinetic disorder has been identified by secondary health care.

Recognition of ADHD in the CLASS sample

Parental reports of the age at which they first became worried about their child in relation to ADHD varied greatly, ranging from infancy to 11 years, with the peak age of concern in the toddler and preschool years (mean 3.8 years, standard deviation 2.2). Half the parents reported discussing their concerns with a professional within six months, but some waited several years to do so (median 0.5 years, inter-quartile range 0–2 years). The first professional approached was commonly a teacher (46%) or primary health care staff (general practitioner 33%, health visitor 16%) emphasising the need for both groups to be able to identify ADHD; particularly as parents reported several years delay between the first professional contact and receiving a diagnosis (median 2.5 years, inter-quartile range 1–4 years).

Mental health service interventions over the 12 months preceding time 2 in CLASS

Psychopathology at follow up is explored in depth in a companion paper (Fowler et al., 2007), but almost two thirds (60%) of the young people still met criteria for either ADHD or hyperkinetic disorder at time 2. A similar proportion (70%) had been in contact with CAMHS within the year preceding time 2, rising to 80% among those who still met criteria for a diagnosis of ADHD or hyperkinetic disorder. There were no reported contacts with adult mental health services, although there were 14 young people aged 17+ in the sample, three of whom still met diagnostic criteria for ADHD or hyperkinetic disorder. There were no reports of admissions to adolescent day or inpatient units.

Table 2 shows that most young people had attended CAMHS for a few relatively brief appointments during the previous twelve months and mostly saw psychiatrists and nurses. Nearly a fifth (18%) saw two CAMHS professionals, mostly a psychiatrist and a nurse (87%), while only one saw more than two clinicians. Seeing more than one CAMHS professional was not related to baseline socio-demographic characteristics or the level of psychopathology at baseline or follow up. As shown in Table 3, the commonest interventions by CAMHS within the last twelve months were to monitor mental state and/or height, weight, and blood pressure and to recommend and/or prescribe medication. There were no reports of group interventions for either parents or young people, while two young people had received anger management packages.

Table 2.   Details of CAMHS service input in the past 12 months for the 80 young people in contact with CAMHS among the clinical sample
Professional discipline% of CAMHS attendees seen1Median number of appointments offered (inter-quartile range)2Median duration of appointments in minutes (inter-quartile range)2
  1. 1Children could see more than one CAMHS professional, thus the total is more than 80. 2Inter-quartile range gives the range of values that contains the middle 50% (i.e. 25–75%) of responses.

Nurse23.82.0 (2.0–4.0)13 (7–30)
Psychiatrist90.02.0 (2.0–3.0)30 (20–60)
Family therapist1.36.060
Psychologist2.51.5 (1.0–2.0)75 (60–90)
Art therapist1.325.060.0
Unspecified1.33.013.0
Table 3.   Mental health related interventions reported by parents in the year preceding the time 2 follow up in the clinical sample
Source of helpIntervention% (n = 115)
Informal servicesTelephone help line5.2 (6)
Self help group5.2 (6)
Voluntary agency9.6 (11)
Internet22.6 (26)
Discussed with religious minister0.9 (1)
Primary health care (All GPs)Referred to specialist2.6 (3)
Prescribed drugs–specialist advice52.2 (60)
Prescribed drugs–own initiative2.6 (3)
Monitored growth/cardiovascular function6.9 (8)
Support/reassurance8.7 (10)
Secondary health care (not mental health)Assessment0.9 (1)
Advises/prescribed medication1.7 (2)
Advice on parenting0.9 (1)
Monitored growth/cardiovascular function4.3 (5)
Mental health servicesAssessment0.9 (1)
Prescribe/recommend medication57.0 (65)
Saw child alone9.7 (11)
Worked with family67.0 (77)
Saw parents alone2.6 (3)
Ordered investigation0.9 (1)
Monitored growth/cardiovascular function63.5 (73)
Private mental healthAssessment1.7 (2)
 SchoolStatement of special educational need26.1 (30)
Extra help in classroom22.6 (26)
Extra help in small group out of class room7.8 (9)
Extra help 1:1 outside class room6.1 (7)
Special unit within mainstream school1.7 (2)
Special school7.0 (8)
Social servicesParents approached social services for help11.3 (13)
Social services assessment6.1 (7)
Allocated social worker4.3 (5)
Referral to other services1.7 (2)
Outreach worker0.9 (1)
Police and youth justicePolice contact no formal proceedings5.3 (6)
1 or more formal cautions10.5 (12)
Conviction2.6 (3)
Probation/community service0.9 (1)
Youth justice worker6.1 (7)
In prison0.9 (1)

Medication in CLASS

By time 2, nearly all the young people (93.0%) had taken medication at some point, particularly methylphenidate (91.3%), while a few young people had taken dexamfetamine (6.1%), atomoxetine (4.3%), antipsychotics (2.6%), or clonidine (0.9%). Over a third (37.4%) of children had tried a modified-release preparation of methylphenidate. The mean age of starting medication reported by parents was 8 years old (standard deviation 1.9).

At time 2 assessment, 66.1% of young people were taking medication. Nearly two thirds were taking some sort of stimulant; 36.5% modified-release methylphenidate, 26.1% immediate-release methylphenidate, and 2.6% dexamfetamine. A few young people were taking non-stimulant drugs; 1.7% antipsychotics, 0.9% clonidine, and 0.9% atomoxetine. Two young people were also taking melatonin while there was no reported use of pemoline, selective serotonin re-uptake inhibitors or tricyclic antidepressants. Given the high proportion of young people taking stimulant medication at both time points, the prevalence of tics was low (8.7% at time 1, 4.3% at time 2), with very few young people having ‘persistent’ tics (2.6%) or an onset of tics (1.7%).

General Practitioners were prescribing with the support of a specialist for most (81.8%) of the young people taking medication at follow up, while paediatricians recommended or prescribed medication for two young people. The majority of young people taking medication at follow up still met criteria for either ADHD or hyperkinetic disorder (71%), compared to 39% of those not taking medication (χ2 = 10.6, p = .001). Among young people no longer meeting diagnostic criteria, the mean number of ADHD symptoms was higher, but not statistically so, in young people taking medication as opposed to those who were not taking medication (10.8 (6.1) vs. 8.0 (6.1), t = 1.5, p = .1). Interestingly, reported symptoms levels were very similar among the young people still meeting diagnostic criteria for ADHD or hyperkinetic disorder at follow up, whether or not they were taking medication (15.9 (3.1) on medication vs.16.1 (2.6), t = 0.3, p = .8). However, parents in contact with CAMHS whose children were taking medication were more likely to report that CAMHS contact had lead to improvement (61% vs. 31%), and less likely to report that CAMHS contact had made no difference (35% vs. 46%) or made things worse (5% vs. 15%) than the parents of children not taking medication (χ2 = 9.2, p = .03).

In addition to meeting diagnostic criteria for ADHD or hyperkinetic disorder, taking medication at follow up was associated with higher levels of comorbidity (56.0% versus 29.7%, χ2 = 6.9, p = .009) and ADHD symptomatology (mean number of symptoms 12.8 vs. 7.8, t = 2.5, p = .01) at time 2. The level of symptoms and comorbidity at time 1, age, gender, socioeconomic status, intellectual ability and specific reading disorder were not associated with medication status at follow up. There were too few young people who had never taken medication to analyse further.

Mental health related contacts with non-mental health services over the 12 months preceding time 2 in CLASS

Table 3 shows the interventions accessed from different settings. Alternative health therapy was reported by only one parent, and there were no reported contacts with nurses or health visitors. The latter is not surprising given the age of the sample and that most contacts with primary health care involved the prescription of medication in shared care with mental health services (85%). There were too few contacts with hospital or community paediatrics to analyse in detail, but all but one contact was with a doctor.

Over half (57%) of the young people who were still attending school or college had officially recognised special educational needs, of which 90% were related to mental health. Slightly less than a third of these young people had a ‘statement’, and half had had these needs officially recognised for eight years (inter-quartile range 6–9) at time 2, suggesting that educational difficulties persist for young people with ADHD. Many young people had additional help at school, which was provided by learning support assistants (53%), teachers (33%) or behavioural support workers (14%).

Nearly all (87%) of the families in contact with social services had approached social services themselves and nearly half (47%) had undergone an assessment. Only 33% had an allocated social worker, while one young person was put in contact with an outreach worker. No families were offered respite care and none of the young people had been in the care of the local authority over the previous year. While extensive involvement with the criminal justice system was uncommon, being stopped by the police or cautioned was extremely common (Fowler et al., 2007).

Patterns of service use within CLASS

Table 4 shows the rates of contact with each type of provision according to the presence or absence of ADHD or hyperkinetic disorder at follow up and the presence or absence of oppositional defiant or conduct disorder at baseline. The largest of the groups had persistent ADHD or hyperkinetic disorder with oppositional defiant or conduct disorder at baseline, while the size of the other three groups limits the power of our comparison. Contact with schools, primary health care and CAMHS was most prevalent in the two groups with persisting ADHD/hyperkinetic disorder, while the groups with conduct disorder at baseline were most likely to be without a school place or in contact with the criminal justice system.

Table 4.   Percentage of mental health related contacts with public sector services during the past twelve months according to the presence of absence of ADHD or hyperkinetic disorder (HKD) at time 2 and the presence or absence of oppositional defiant disorder or conduct disorder (ODD/CD) at time 1 in the clinical sample
 No ADHD/HKD at time 2 with no ODD/CD time 1 (n = 20)ADHD/HKD at time 2 with no ODD/CD at time 1 (n = 22)No ADHD/HKD at time 2 and ODD/CD at time 1 (n = 26)ADHD/HKD at time 2 and ODD/CD at time 2 (n = 47)χ2 (p value)
  1. 1Other secondary health care = contact with the school medical system, hospital and community paediatrics or adult secondary physical health care. 2School contacts = teachers, SENCO's, learning support assistants and extra help from teachers. 3SEN professionals = educational psychologists, educational social workers, and behavioral support workers. 4PRU = pupil referral unit.

CAMHS4591627511.8 (.008)
Primary health care457350706.4 (.09)
Other secondary health care1558111.1 (.8)
Social services0923145.7 (.1)
Police & youth justice51439307.5 (.03)
Schools25582508513.9 (.003)
SEN professionals301819235.5 (.1)
Statement102331365.2 (.1)
Mainstream school/college90836284To many cells with small  numbers to test reliably
Special unit in mainstream0402 
Special school/college013146 
In employment100142 
PRU4 or permanently excluded00106 

Discussion

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Substantive findings

As this study provides a great deal of information about children with ADHD in the UK, a few key points have been picked out for specific comment. Nearly all the young people had taken stimulant medication at some point, which is encouraging given the Health Technology Appraisal that stimulant medication may be most cost-effective as a first line treatment (National Institute for Clinical Excellence, 2006). The two-year follow up of the Multimodal Treatment Study of ADHD (MTA) sample demonstrated persisting but decreased impact of both medication and psychological treatment (MTA cooperative group, 2004b). The extent of the deterioration was partially explained by the proportion taking medication in each group at follow up, but parental decisions about medication were linked to adverse effects, indicating that symptom control alone is an inadequate means for assessing outcome (MTA cooperative group, 2004a). Most of the health service contacts in this study were related to medication, although a few young people had accessed psychological interventions within the last twelve months. It is possible that parents did not recall or recognise non-pharmacological treatments, or that many young people had received psychological interventions closer to the time of diagnosis. While the MTA trial suggests that medication offers the largest impact, it remains possible that behavioural management does benefit some areas of functioning, maybe helpful for specific groups (e.g. those with anxiety disorder) and may reduce the dosage of medication needed (Taylor, 1999). Thus, an international consensus statement suggests that behavioural management remains part of, but should not be the only, service offered to children with ADHD (Kutcher et al., 2004). There is also the need for intervention for comorbid disorders, particularly oppositional defiant or conduct disorder.

An epidemiological study of four US communities found that only 12.5% of children with ADHD had been treated with stimulants in the previous 12 months and those prescribed stimulants who did not reach diagnostic criteria still had evidence of pervasive hyperactivity (Jensen et al., 1999). However, national surveys of physicians and prescriptions suggest large increases in prescriptions of stimulant drugs, while the Great Smoky Mountain study suggested that most of children taking these drugs did not meet diagnostic criteria for ADHD (Angold et al., 2000; Hoagwood et al., 2000). In contrast, epidemiological studies in Britain have found evidence of under-prescribing among those with hyperkinetic disorder (Ford, Goodman, & Meltzer, 2003; Green et al., 2005). Symptoms may be masked in children taking medication, and these findings may in part relate to whether information about medication fed into the diagnostic process. While 29% of the young people taking medication in the follow up of CLASS no longer met diagnostic criteria, it should be remembered that the whole sample met stringently applied diagnostic criteria at baseline. Although young people taking medication had higher levels of symptomatology than those that were not, this difference disappeared when broken down according to the presence or absence of a diagnosis, reiterating that symptom control is not the only issue for families and clinicians in decisions about medication.

We found that children with ADHD made heavy demands on the education system and youth justice systems. According to the Department for Education and Skills (2006), only 2.9% of the school population has a statement of special educational needs and only 1% attend special schools (versus 28% and 8% respectively in CLASS). Given that the core symptoms are often most troubling within school, this is not surprising, but research is required to develop and evaluate interventions that maximise the chances of academic and vocational success for young people with ADHD. Similarly, an epidemiological sample of young people with all types of psychiatric disorder followed up over three years reported 9.5% had been in contact with the police while 3.2% had been formally cautioned or convicted (versus 21% and 10.5% respectively in CLASS) (Ford et al., 2005). Results from the CLASS sample suggest that comorbid oppositional defiant disorder and conduct disorder may have driven a large part of this association. Given that most of these young people had been in contact with services during the preceding year, this suggests that despite interventions that reduce symptoms, there is a need to look to additional interventions that might improve other adverse outcomes for these young people in real-life clinic settings, not just randomised controlled trials.

Clinical and policy implications

Two thirds of CLASS still met diagnostic criteria for ADHD, and many were still involved with CAMHS, suggesting that ADHD clinics should be developed with long-term contact in mind. A retrospective assessment of childhood ADHD in a large epidemiological sample of adults in the USA reported an association between treatment in childhood with persistence in adulthood, even after controlling for severity (Kessler et al., 2005). In contrast, a follow up children treated with stimulants into young adulthood showed better social functioning and mental health among those with a good response to medication (Paternite et al., 1999). Either way, clinical services for adults with ADHD need developing as increasing numbers of young people ‘graduate’ from CAMHS.

Training and supervision in the detection of ADHD for teachers and primary health care professionals might avoid some of the delays in diagnosis and intervention reported in this study, provided that CAMHS and child health services were able to deal with the volume of children referred. Our finding that girls were under-represented in CLASS is not novel, but suggests that clinicians and others working with children need to be more alert to ADHD in girls and young women (Szatmari, 1992; Sharp et al., 1999).

Methodological issues

To our knowledge, this is the largest and longest follow up of a cohort of children with ADHD in Britain. It used the same standardised measures at both time points. It was possible to compare findings with those from a national epidemiological sample. However, the epidemiological comparison group was small and based over a wider geographical area, used a different measure of psychiatric disorder and psychiatric disorder was assessed three rather than five to seven years prior to follow up. The latter might be expected to increase the rates of services use, making our findings of lower rates of service use in the epidemiological sample robust.

Despite following 115 children, the CLASS sample is too small to examine the outcomes of different subgroups of children. Hence, our analysis is largely descriptive. Although ‘persistent’ ADHD and hyperkinetic disorder have been discussed, in fact there are only two snapshots of these young people at least five years apart. Although clinical experience would suggest that there would be a high degree of persistence in those meeting diagnostic criteria at both time points, nothing is known about their functioning between assessments. Service use data were collected from parents only, and thus may have missed some contacts that parents did not know about, which is particularly likely for the police and school counsellors. However, investigators have reported high levels of agreement between parents and children about service contact, with agreement improving in older children (Ascher et al., 1996; Stiffman et al., 2000).

Conclusion

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Many children from CLASS continued to meet criteria for ADHD or hyperkinetic disorder in adolescence, and most were still involved with CAMHS. It is encouraging that most had received evidence-based treatments but few parents recalled non-pharmacological interventions, although these might have been accessed earlier in the child's therapeutic pathway. Young people with ADHD in childhood need and seem to access substantial input from the education system in addition to CAMHS. Disappointingly, a significant proportion of young people were involved in low-level offending despite long-term contact with services. Interventions aimed at improving comorbid disorders may further improve outcomes. As children with ADHD need long-term support from public sector services, it is important to identify cross agency strategies and interventions that may help to optimise functioning.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

This research was funded by the Wellcome Trust, Department of Health (England) and Janssen Cilag (1 year funding supporting Tom Fowler). Anita Thapar has received sponsorship from pharmaceutical companies for organising meetings. We are grateful to Dr Marianne vanden Bree, Professor Michael Owen and Professor Michael O'Donovan for their input to the original study, and Professor Eric Taylor for his comments on the manuscript. The Department of Health also funded the three-year follow up of the British Child and Adolescent Mental Health Survey.

References

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  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References
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