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Antisocial behaviour and conduct disorders in children and young people overview

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Antisocial behaviour and conduct disorders in children and young people HAI

About

What is covered

This pathway covers a range of interventions for conduct disorders in children and young people aged under 18 years, including treatment, indicated prevention and selective prevention. It does not cover universal prevention.
Conduct disorders, and associated antisocial behaviour, are the most common mental health and behavioural problems in children and young people, with a prevalence of 5% among children and young people aged between 5 and 16 years. Almost 40% of looked-after children, those who have been abused and those on child protection or safeguarding registers have a conduct disorder.
Conduct disorders are characterised by repetitive and persistent patterns of antisocial, aggressive or defiant behaviour that amounts to significant and persistent violations of age-appropriate social expectations. They have a significant impact on functioning and quality of life.

Updates

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on antisocial behaviour and conduct disorders in children and young people.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

16 April 2014 Antisocial behaviour and conduct disorders in children and young people quality standard (QS59) added to this pathway.
21 February 2014 Minor maintenance updates.
1 October 2013 Recommendation from clinical guideline 77 added to Parent and foster carer or guardian training programmes node.
29 July 2013 Attention deficit hyperactivity disorder (ADHD) quality standard (QS39) added to this pathway.
5 July 2013 Minor maintenance updates.
28 March 2013 Minor maintenance updates.

Short Text

Antisocial behaviour and conduct disorders in children and young people: recognition, intervention and management

What is covered

This pathway covers a range of interventions for conduct disorders in children and young people aged under 18 years, including treatment, indicated prevention and selective prevention. It does not cover universal prevention.
Conduct disorders, and associated antisocial behaviour, are the most common mental health and behavioural problems in children and young people, with a prevalence of 5% among children and young people aged between 5 and 16 years. Almost 40% of looked-after children, those who have been abused and those on child protection or safeguarding registers have a conduct disorder.
Conduct disorders are characterised by repetitive and persistent patterns of antisocial, aggressive or defiant behaviour that amounts to significant and persistent violations of age-appropriate social expectations. They have a significant impact on functioning and quality of life.

Sources

The NICE guidance that was used to create the pathway.
Antisocial personality disorder. NICE clinical guideline 77 (2009)

Quality standards

Attention deficit hyperactivity disorder

These quality statements are taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder and should be read in full.

Antisocial behaviour and conduct disorders in children and young people

These quality statements are taken from the antisocial behaviour and conduct disorders in children and young people quality standard. The quality standard defines clinical best practice for antisocial behaviour and conduct disorders in children and young people and should be read in full.

Quality statements

Confirmation of diagnosis

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder care and should be read in full.

Quality statement

Children and young people with symptoms of attention deficit hyperactivity disorder (ADHD) are referred to an ADHD specialist for assessment.

Rationale

Symptoms suggestive of ADHD are often identified in children and young people by their GP or teachers. In order to ensure an accurate diagnosis of ADHD it is important that a full assessment is carried out within secondary care by a healthcare professional with specialist training and expertise in ADHD.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with symptoms of ADHD are referred to an ADHD specialist for assessment.
Data source: Local data collection.
Process
Proportion of children and young people with symptoms of ADHD who are referred to an ADHD specialist for assessment.
Numerator – the number of children and young people in the denominator referred to an ADHD specialist for assessment.
Denominator – the number of children and young people aged 3 to 18 years with symptoms of ADHD.
Data source: Local data collection. NICE clinical guideline 72 audit support tool, services for adults (criteria for diagnosis), criteria 5 and 6, and NICE clinical guideline 72 audit support tool, services for children and young people, criteria 1 and 2.
Data are collected through the child and adolescent mental health services (CAMHS) secondary uses dataset on referral request received date (global number 17300670), source of referral for mental health (global number 17300760), appointment date (global number 17300800), care professional group type (global number 17300990), CAMH care team type (global number 17301210), provisional diagnosis date (global number 17303190), provisional diagnosis (global number 17303180), diagnosis date (global number 1730210), primary diagnosis (global number 17303670), diagnosis date (global number 17303210).
Outcome
Rates of new diagnosis of ADHD in children and young people.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for children and young people with symptoms of ADHD to be referred to an ADHD specialist for assessment.
Health and social care practitioners ensure that systems are in place for children and young people with symptoms of ADHD to be referred to an ADHD specialist for assessment.
Commissioners ensure that they commission specialist ADHD services for the assessment of children and young people with symptoms of ADHD.

What the quality statement means for patients, service users and carers

Children and young people with symptoms of ADHD are referred to an ADHD specialist for an assessment.

Source guidance

Definitions of terms used in this quality statement

ADHD specialist
A psychiatrist, paediatrician or mental health specialist with training and expertise in the diagnosis and treatment of ADHD. For the assessment and diagnosis of ADHD in children and young people this will be a child psychiatrist, paediatrician or specialist ADHD nurse.
Diagnosis of ADHD
NICE clinical guideline 72 recommendation 1.3.1.1 states that a diagnosis of ADHD must be made on the basis of:
  • a full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person's everyday life, and
  • a full developmental and psychiatric history, and
  • observer reports and assessment of the person's mental state.
Symptoms of ADHD
NICE clinical guideline 72 recommendation 1.3.1.3 states that for a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
  • meet the diagnostic criteria for ADHD in DSM-IV [the 'Diagnostic and Statistical Manual of Mental Disorders 4th edition'] or for hyperkinetic disorder in ICD-10 [the 'International Classification of Mental and Behavioural Disorders 10th revision'] and
  • be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and
  • be pervasive, occurring in 2 or more important settings including social, familial, educational and/or occupational settings.
As part of the diagnostic process, include an assessment of the person's needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health. For children and young people, there should also be an assessment of their parents' or carers' mental health.
Note: The ICD-10 exclusion on the basis of a pervasive developmental disorder being present, or the time of onset being uncertain, is not recommended.

Equality and diversity considerations

Services should take into account the needs of children and young people with symptoms of ADHD who may present to health and education services within the youth justice system.

Identification and referral in adults

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder care and should be read in full.

Quality statement

Adults who present with symptoms of attention deficit hyperactivity disorder (ADHD) who do not have a childhood diagnosis of ADHD are referred to an ADHD specialist for assessment.

Rationale

A diagnosis of ADHD requires a full clinical and psychosocial assessment of multiple aspects of a person's life, and should be undertaken by a healthcare professional with specialist training, knowledge and experience of ADHD diagnosis and treatment.
A number of adults being treated for coexisting mental health problems within general psychiatric services or who present directly to their GP have been found to have undiagnosed ADHD.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who present with symptoms of ADHD who do not have a childhood diagnosis of ADHD are referred to an ADHD specialist for assessment.
Data source: Local data collection.
Process
Proportion of adults who present with symptoms of ADHD without a childhood diagnosis of ADHD who are referred to an ADHD specialist for assessment.
Numerator – the number of people in the denominator who are referred to an ADHD specialist for assessment.
Denominator – the number of adults aged 18 years and over who present with symptoms of ADHD without a childhood diagnosis of ADHD.
Data source: Local data collection.
Data are collected through the Mental health minimum dataset (MHMDS) on, referral request received date (REFRECDATE), source of initial referral (REFERRAL), adult mental health team type (CLINTEAMGRP), primary diagnosis (PRIMDIAG) and secondary diagnosis (SECONDDIAG).
Outcome
Rates of new diagnosis of ADHD in adults.
Data source: Local data collection. Data will also be collected against the NHS outcomes framework 2013–14 indicator 2.1: proportion of people feeling supported to manage their condition.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for adults who present with symptoms of ADHD without a childhood diagnosis of ADHD to be referred to an ADHD specialist for assessment.
Health and social care practitioners ensure that adults who present with symptoms of ADHD without a childhood diagnosis of ADHD are referred to an ADHD specialist for assessment.
Commissioners ensure that they commission specialist services for the assessment of adults who present with suspected ADHD.

What the quality statement means for patients, service users and carers

Adults with symptoms of ADHD who have not had a diagnosis of ADHD in childhood are referred to an ADHD specialist for an assessment.

Source guidance

Definitions of terms used in this quality statement

ADHD specialist
A psychiatrist or mental health specialist with training and expertise in the diagnosis and treatment of ADHD. An ADHD specialist usually works as part of a multidisciplinary ADHD team.
Symptoms of ADHD
NICE clinical guideline 72 recommendation 1.2.2.1 states that adults presenting with symptoms of ADHD in primary care or adult general psychiatric services who do not have a childhood diagnosis of ADHD should be referred for assessment by a mental health specialist trained in the diagnosis and treatment of ADHD, if there is evidence of typical manifestations of ADHD (hyperactivity/impulsivity and/or inattention) that:
  • began during childhood and have persisted throughout life
  • are not explained by other psychiatric diagnoses (although there may be other coexisting psychiatric conditions)
  • have resulted in or are associated with moderate or severe psychological, social or educational or occupational impairment.
Adults
People aged 18 years and over.

Equality and diversity considerations

Consideration should be given to the provision of services for adults within the prison population who present with symptoms of ADHD.

Continuity of child to adult services

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder care and should be read in full.

Quality statement

Adults who were diagnosed with and treated for attention deficit hyperactivity disorder (ADHD) as children or young people and present with symptoms of continuing ADHD are referred to general adult psychiatric services.

Rationale

There are increasing numbers of adults with ADHD in the general adult population and in addition there are a large number of adolescents moving from children's to adult's services. Adults with continuing symptoms of ADHD often experience much reduced levels of support as adults and it is important that their symptoms are recognised so that appropriate onward referral can be made.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who present with symptoms of continuing ADHD are referred to general adult psychiatric services.
Data source: Local data collection.
Process
Proportion of adults with ADHD who present with symptoms of continuing ADHD who are referred to general adult psychiatric services.
Numerator – the number of people in the denominator who are referred to general adult psychiatric services.
Denominator – the number of adults aged 18 years and over with ADHD who present with symptoms of continuing ADHD.
Data source: Local data collection.
Data are collected through the Mental health minimum dataset (MHMDS) on, referral request received date (REFRECDATE), source of initial referral (REFERRAL), adult mental health team type (CLINTEAMGRP), primary diagnosis (PRIMDIAG) and secondary diagnosis (SECONDDIAG).
Outcome
Adults feel supported to manage their ADHD.
Data source: Local data collection. Data will also be collected against NHS outcomes framework 2013–14 indicator 2.1: proportion of people feeling supported to manage their condition, indicator 4.7: patient experience of community mental health services.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for adults who present with symptoms of continuing ADHD to be referred to general adult psychiatric services.
Health and social care practitioners ensure that adults who present with symptoms of continuing ADHD are referred to general adult psychiatric services.
Commissioners ensure they commission general adult psychiatric services for adults who present with symptoms of continuing ADHD.

What the quality statement means for patients, service users and carers

Adults who had ADHD when they were younger and who still have symptoms of ADHD are referred to general adult psychiatric services.

Source guidance

Definitions of terms used in this quality statement

Symptoms of ADHD should be associated with at least moderate or severe psychological, social, educational or occupational impairment.
Adults
People aged 18 years or over.

Equality and diversity considerations

Consideration should be given to the provision of services for adults within the prison population identified as having symptoms of continuing ADHD.

Parent training programmes

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder care and should be read in full.

Quality statement

Parents or carers of children with symptoms of attention deficit hyperactivity disorder (ADHD) who meet the NICE eligibility criteria are offered a referral to a parent training programme.

Rationale

Parent training and education programmes aim to provide parents or carers with coping strategies and techniques for managing the behaviour of their children with ADHD. These programmes can help improve the relationship between parents or carers and their children and improve the child's behaviour.

Quality measures

Structure
a) Evidence of local arrangements to ensure that parents or carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria are offered a referral to a parent training programme.
Data source: Local data collection.
b) Evidence of local arrangements for provision of parent training programmes.
Data source: Local data collection.
Process
a) Proportion of parents or carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria who are referred to a parent training programme.
Numerator – the number of people in the denominator referred to a parent training programme
Denominator – the number of parents or carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria.
Data source: Local data collection. NICE clinical guideline 72 audit support tool, services for children and young people, criterion 3.
Data are collected through the child and adolescent mental health services (CAMHS) secondary uses dataset on Strengths and difficulties questionnaire version (global number 17307030), assessment tool completion point (global number 17301350), heath of the nation outcome scale for children and adolescents (HONOS-CA) version (global number 17307050), assessment tool completion point (global number 17307140).
b) Proportion of parents or carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria who attend a parent training programme.
Numerator – the number of people in the denominator attending a parent training programme.
Denominator – the number of parents or carers of children and young people with symptoms of ADHD who are referred to a parent training programme.
Data source: Local data collection. NICE clinical guideline 72 audit support tool, services for children and young people, criterion 3.
Data are collected through the CAMHS secondary uses dataset on Strengths and difficulties questionnaire version (global number 17307030), assessment tool completion point (global number 17301350), heath of the nation outcome scale for children and adolescents (HONOS-CA) version (global number 17307050), assessment tool completion point (global number 17307140).
c) Proportion of parents and carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria who complete a parent training programme.
Numerator – the number of people in the denominator completing a parent training programme.
Denominator – the number of parents or carers of children and young people with symptoms of ADHD who attend a parent training programme.
Data source: Local data collection. NICE clinical guideline 72 audit support tool, services for children and young people, criterion 3.
Data are collected through the CAMHS secondary uses dataset on Strengths and difficulties questionnaire version (global number 17307030), assessment tool completion point (global number 17301350), heath of the nation outcome scale for children and adolescents (HONOS-CA) version (global number 17307050), assessment tool completion point (global number 17307140).
Outcome
a) Parent or carer satisfaction with the provision of parent training programmes.
Data source: Local data collection. Data will be collected against Public Health outcomes framework for England, 2013–16 indicators 1.3: pupil absence, indicator 1.4: first time entrants to the youth justice system, indicator 1.5: 16–18 year olds not in education, employment or training, indicator 2.8: emotional wellbeing of looked-after children.
b) Parents or carers feel supported to manage their child's condition.
Data source: Local data collection. Data will be collected against Public Health outcomes framework for England, 2013–16 indicators 1.3: pupil absence, indicator 1.4: first time entrants to the youth justice system, indicator 1.5: 16–18 year olds not in education, employment or training, indicator 2.8: emotional wellbeing of looked-after children.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for the referral of parents or carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria to a parent training programme.
Healthcare practitioners ensure that they offer parents or carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria a referral to a parent training programme.
Commissioners ensure that they commission parent training programmes for parents or carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria.

What the quality statement means for patients, service users and carers

Parents and carers of children and young people with symptoms of ADHD who meet NICE eligibility criteria are offered a referral to a parent training programme to help them manage their child's behaviour.

Source guidance

Definitions of terms used in this quality statement

Parent training programme
Parents or carers of children with symptoms of ADHD may be referred to parent training programmes by a primary care health professional o rschool's special needs coordinator (SENCO) before a formal diagnosis of ADHD is made by an ADHD specialist.
Symptoms of ADHD
NICE clinical guideline 72 recommendation 1.3.1.3 states that for a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
  • meet the diagnostic criteria for ADHD in DSM-IV [the 'Diagnostic and Statistical Manual of Mental Disorders 4th edition'] or for hyperkinetic disorder in ICD-10 [the 'International Classification of Mental and Behavioural Disorders 10th revision'] and
  • be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and
  • be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings.
NICE eligibility criteria
The NICE eligibility criteria for referral to a parent training programme are found within NICE clinical guideline 72. They are:
  • Pre-school children with ADHD if the parents or carers have not already attended such a programme or the programme has had a limited effect.
  • First-line treatment for parents and carers of children and young people of school age with ADHD and moderate impairment.
  • For children and young people (including older age groups) with ADHD and a learning disability.
  • In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered a group-based parent-training/education programme.
NICE clinical guideline 158 recommendation 1.5.2 states that group parent training programmes should involve both parents if this is possible and in the best interests of the child or young person, and should:
  • typically have between 10 and 12 parents in a group
  • be based on a social learning model, using modelling, rehearsal and feedback to improve parenting skills
  • typically consist of 10 to 16 meetings of 90 to 120 minutes' duration
  • adhere to the developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. The manual should have been positively evaluated in a randomised controlled trial.
Group-based parent training programmes are recommended for parents and carers of children with ADHD as the first-line treatment unless there are special circumstances as detailed in NICE clinical guideline CG72 recommendations 1.5.1.5 and 1.5.2.7.
Children are defined as aged 11 years and under.
Young people are defined as aged 12 to 18 years.

Equality and diversity considerations

Parent training programmes should be made available to all families who have children with ADHD. Thought should be given to ensuring that families have access to services by providing them at times and locations that are convenient. Parent training programmes should also be accessible to foster carers and guardians of looked-after children.
If there are particular difficulties for families in attending group sessions (for example, because of disability, needs related to diversity such as language differences, parental ill-health, problems with transport, or other factors that suggest poor prospects for therapeutic engagement) it may be appropriate to consider offering individual sessions to a family.
All information and advice should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

Psychological treatments for children and young people

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder care and should be read in full.

Quality statement

Children and young people with moderate attention deficit hyperactivity disorder (ADHD) are offered a referral to a psychological group treatment programme.

Rationale

ADHD affects many aspects of the lives of children and young people. Psychological treatment programmes aim to improve their daily functioning and their relationships with family members, carers and peers.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people with moderate ADHD are offered a referral to a psychological group treatment programme.
Data source: Local data collection.
b) Evidence of local arrangements for the provision of psychological group treatment programmes.
Data source: Local data collection.
Process
Proportion of children and young people with moderate ADHD who are referred to a psychological group treatment programme.
Numerator – the number of people in the denominator who are referred to a psychological group treatment programme.
Denominator – the number of children and young people with moderate ADHD.
Data source: Local data collection. NICE clinical guideline 72 audit support tool, services for children and young people, criterion 4.
Outcome
Children and young people feel able to manage their condition.
Data source: Local data collection. Data will be collected against Public Health outcomes framework for England, 2013–16 indicator 1.3: pupil absence, indicator 1.4: first time entrants to the youth justice system, indicator 1.5: 16–18 year olds not in education, employment or training, indicator 2.8: emotional wellbeing of looked-after children.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for children and young people with moderate ADHD to be offered a referral to a psychological group treatment programme.
Healthcare practitioners children and young people with moderate ADHD are offered a referral to a psychological group treatment programme.
Commissioners ensure that they commission psychological group treatment programmes for children and young people with moderate ADHD.

What the quality statement means for patients, service users and carers

Children and young people with moderate ADHD are offered a referral to a psychological group treatment programme.

Source guidance

Definitions of terms used in this quality statement

Psychological group treatment programmes should consist of cognitive behavioural therapy (CBT) or social skills training.
Such courses should cover:
  • solving problems
  • developing their ability to control themselves
  • listening when other people are talking to them
  • coping with and expressing their feelings
  • improving relationships with their friends and other children.
NICE clinical guideline 72 recommendation 1.5.2.6 states that for older adolescents with ADHD and moderate impairment, individual psychological interventions (such as CBT or social skills training) may be considered as they may be more effective and acceptable than group parent training and education programmes or group CBT or social skills training.
Children are defined as people aged 11 years and under.
Young people are defined as people aged 12 to 18 years.
Moderate ADHD in children and young people is present when one of more of the symptoms of hyperactivity, impulsivity or inattention, are present, and associated with at least moderate impairment, which should be present in multiple settings and in multiple domains, where the level appropriate to the child's chronological and mental age has not been reached.

Equality and diversity considerations

The presence of common coexisting conditions such as conduct disorders, mood disorders or learning disability should be considered when planning psychological group treatment programmes for children and young people.

Starting drug treatment

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder care and should be read in full.

Quality statement

People with attention deficit hyperactivity disorder (ADHD) who are starting drug treatment have their initial drug dose adjusted and response assessed by an ADHD specialist.

Rationale

People starting drug treatment for ADHD should be closely monitored for side effects, particularly during the initial treatment period. Initial drug doses should be adjusted to ensure that any unwanted effects are minimised while optimising beneficial effects.

Quality measures

Structure
Evidence of local arrangements to ensure that people with ADHD who are starting drug treatment have their initial drug dose adjusted and response assessed by an ADHD specialist.
Data source: Local data collection.
Process
Proportion of people with ADHD who are starting drug treatment who have their initial drug dose adjusted and response assessed by an ADHD specialist.
Numerator – the number of people in the denominator who have their initial drug dose adjusted and response assessed by an ADHD specialist.
Denominator – the number of people with ADHD who are starting drug treatment.
Data source: Local data collection. Data are collected through the child and adolescent mental health services (CAMHS) secondary uses dataset on prescribed medication (global number 17302890).
Outcome
Rates of drug-related side effects in people starting drug treatment for ADHD.
Data source: Local data collection. Data will also be collected against NHS outcomes framework 2013–14 indicator 2.1: proportion of people feeling supported to manage their condition.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people with ADHD who are starting drug treatment to have their initial drug dose adjusted and response assessed by an ADHD specialist.
Healthcare practitioners ensure that people with ADHD who are starting drug treatment have their initial drug dose adjusted and response assessed by an ADHD specialist.
Commissioners ensure that they commission services for people with ADHD who are starting drug treatment to have their initial drug dose adjusted and response assessed by an ADHD specialist.

What the quality statement means for patients, service users and carers

People with ADHD who are starting medication have their initial medication dose adjusted by an ADHD specialist, who should also check how well the medication is working.

Source guidance

Definitions of terms used in this quality statement

ADHD specialist
A mental health specialist trained in the diagnosis and treatment of ADHD. This may include a specialist psychiatrist or, for children, a paediatrician. Drugs for the treatment of ADHD may also be prescribed by a nurse prescriber specialising in ADHD or other clinical prescriber with training in the diagnosis and management of ADHD.
NICE clinical guideline 72 recommendation 1.8.1.3 states that during the titration phase doses should be gradually increased until there is no further clinical improvement in ADHD (that is, symptom reduction, behaviour change, improvements in education and/or relationships) and side effects are tolerable.
Drug doses should be adjusted during the titration phase in accordance with the manufacturer's recommendations contained within the summaries of product characteristics and with reference to the 'British national formulary'.

Annual review of drug treatment

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice in attention deficit hyperactivity disorder care and should be read in full.

Quality statement

People with attention deficit hyperactivity disorder (ADHD) who are taking drug treatment have a specialist review at least annually to assess their need for continued treatment.

Rationale

There are a number of potential side effects associated with drug treatment for ADHD; therefore people taking drugs for ADHD need to be monitored regularly. Side effects from drugs to treat ADHD can reduce adherence to treatment. In addition, without regular monitoring there is a greater risk that drugs prescribed to treat ADHD will be misused.

Quality measures

Structure
Evidence of local arrangements to ensure that people with ADHD who are taking drug treatment have a specialist review at least annually.
Data source: Local data collection.
Process
Proportion of people with ADHD who are taking drug treatment who receive a specialist review at least annually.
Numerator – the number of people in the denominator receiving a specialist review with the last review date no more than 1 year after the previous review.
Denominator – the number of people with ADHD who are taking drug treatment.
Data source: Local data collection. NICE clinical guideline 72 audit support tool, services for adults, criterion 13. Data are collected through the child and adolescent mental health services (CAMHS) secondary uses dataset on prescribed medication (global number 17302890).
Outcome
People with ADHD feel supported to manage their condition.
Data source: Local data collection. Data will also be collected against NHS outcomes framework 2013–14 indicator 2.1: proportion of people feeling supported to manage their condition, indicator 4.7: patient experience of community mental health services. The adult social care outcomes framework 2013–14 indicator 1B: proportion of people who use services who have control over their daily life.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with ADHD who are taking drug treatment to have a specialist review at least annually.
Healthcare practitioners ensure that people with ADHD who are taking drug treatment have a specialist review least annually.
Commissioners ensure that they commission services for people with ADHD who are taking drug treatment to have a specialist review at least annually.

What the quality statement means for patients, service users and carers

People who are taking medication to treat ADHD have their medication reviewed by a specialist at least once a year.

Source guidance

Definitions of terms used in this quality statement

Specialist review should be undertaken either by an ADHD specialist or, if agreed by the person with ADHD and their specialist, in primary care under a locally agreed shared care arrangement after titration and dose stabilisation.
Annual specialist review of drug treatment should include a comprehensive assessment of the following:
  • Clinical need, benefits and side effects.
  • The views of the person and those of a parent, carer, teacher, spouse, partner and close friends as appropriate.
  • The effect of missed doses, planned dose reductions and brief periods of no treatment should be taken into account and the preferred pattern of use should also be reviewed.
  • Coexisting conditions should be reviewed, and the person treated or referred if necessary.
The need for psychological, social and occupational support for the person and their parents or carers (as appropriate) should be assessed.

Equality and diversity considerations

All information and advice about treatment should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with ADHD should have access to an interpreter or advocate if needed.

Early intervention

This quality statement is taken from the antisocial behaviour and conduct disorders in children and young people quality standard. The quality standard defines clinical best practice for antisocial behaviour and conduct disorders in children and young people and should be read in full.

Quality statement

Children aged 3 to 7 years attending school classes where a high proportion of children are identified as at risk of developing a conduct disorder take part in a classroom-based emotional learning and problem-solving programme.

Rationale

A number of social factors increase the risk of a child developing a conduct disorder. Evidence suggests that early intervention can reduce this risk; classroom-based interventions for populations with a high proportion of children who are at risk of developing a conduct disorder have been shown to be effective in reducing antisocial behaviour in children. Given the variety of programmes available, it is important to deliver an evidence-based programme to ensure that this intervention is delivered effectively and appropriately.

Quality measures

Structure
a) Evidence of locally agreed protocols for the identification of school classes where a high proportion of children are at risk of developing a conduct disorder, by individuals or groups with relevant expertise in antisocial behaviour and conduct disorders in children.
b) Evidence of local arrangements for health and social care practitioners, managers and commissioners to work with colleagues in the education sector to design local pathways that include provision of classroom-based interventions for children at risk of developing a conduct disorder.
c) Evidence of local arrangements to ensure that children aged 3 to 7 years in classroom populations that have a high proportion of children identified to be at risk of developing a conduct disorder are offered a classroom-based emotional learning and problem-solving programme.
Data source: Local data collection.
Process
Proportion of school classes (for children aged 3 to 7 years) where a high proportion of children are identified to be at risk of developing a conduct disorder that receive a classroom-based emotional learning and problem-solving programme.
Numerator – the number of school classes in the denominator that receive a classroom-based emotional learning and problem-solving programme.
Denominator – the number of school classes (for children aged 3 to 7 years) that have a high proportion of children identified as at risk of developing a conduct disorder.
Data source: Local data collection.
Outcome
Rates of antisocial behaviour within a classroom population.
Data source: Local data collection

What the quality statement means for service providers, health and social care and education practitioners, and commissioners

Service providers ensure that they work with partner organisations, including schools, to identify classroom populations where a high proportion of children are at risk of developing a conduct disorder, and deliver classroom-based, evidence-based emotional learning and problem-solving programmes.
Health, social care and education practitioners work in collaboration to identify classroom populations where a high proportion of children are at risk of developing a conduct disorder, and deliver a classroom-based, evidence-based emotional learning and problem-solving programme.
Commissioners ensure that they work with partner organisations, including schools, to design local pathways that include identification of classroom populations where a high proportion of children are at risk of developing a conduct disorder, and deliver classroom-based, evidence-based emotional learning and problem-solving programmes.

What the quality statement means for patients, service users and carers

Children in school classes that have a lot of children who are at risk of developing antisocial or aggressive behaviour are offered a programme of activities as part of the class that helps them to learn about managing their emotions and solving problems.

Source guidance

Definitions of terms used in this quality statement

Children identified as at risk of developing a conduct disorder
The following factors have been associated with an increased risk of a child or young person developing a conduct disorder:
Classroom-based emotional learning and problem-solving programmes
These programmes should consist of interventions intended to:
  • increase children's awareness of their own and others' emotions
  • teach self-control of arousal and behaviour
  • promote a positive self-concept and good peer relations
  • develop children's problem-solving skills.
Typically the programmes should consist of up to 30 classroom-based sessions over the course of 1 school year. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.2.2]
High proportion of children identified as being at risk of developing a conduct disorder
This should be defined locally by individuals and/or groups with relevant expertise in antisocial behaviour and conduct disorders in children, and knowledge of the risk factors associated with an increased risk of a child developing a conduct disorder. These individuals and groups may include:
  • special educational needs coordinators (SENCO)
  • teachers
  • educational psychologists
  • local education authority departments.
  • Child and Adolescent Mental Health Services (CAMHS) departments
  • community paediatric departments. [Developed from expert consensus]

Equality and diversity considerations

It is important that schools have local protocols in place to ensure that parents and carers are made aware that their child will take part in a classroom-based emotional learning and problem-solving programme.
The workforce across agencies should, as far as possible, reflect the local community. Practitioners should have training to ensure that they have a good understanding of the culture of families with whom they are working. Interpreters should be provided if no practitioner is available who speaks a language in which the family members can converse fluently. Consideration should be given to the settings in which assessments are conducted to reflect cultural diversity.

Comprehensive assessment

This quality statement is taken from the antisocial behaviour and conduct disorders in children and young people quality standard. The quality standard defines clinical best practice for antisocial behaviour and conduct disorders in children and young people and should be read in full.

Quality statement

Children and young people with a suspected conduct disorder and any significant complicating factors have a comprehensive assessment, including an assessment of the child or young person's parents or carers.

Rationale

A number of factors can contribute to a child or young person developing a conduct disorder and continuing to have problems. It is important to consider all these factors when looking at possible causes and appropriate interventions. Where significant complicating factors are identified as part of initial assessment, a comprehensive assessment should be conducted. This should take into account the home environment which can be a significant risk factor, as well as one of the best places to target an intervention through working with parents or carers. Therefore, conducting a comprehensive assessment with the child or young person and an assessment of their parents or carers is important to inform any appropriate interventions and support plans.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with a suspected conduct disorder and any significant complicating factors have a comprehensive assessment, including an assessment of their parents or carers.
Data source: Local data collection.
Process
a) The proportion of children and young people with a suspected conduct disorder and any significant complicating factors who have a comprehensive assessment.
Numerator – the number of children and young people in the denominator who have a comprehensive assessment.
Denominator – the number of children and young people with a suspected conduct disorder and any significant complicating factors.
b) The proportion of parents or carers of children and young people with a suspected conduct disorder and any significant complicating factors who have a comprehensive assessment.
Numerator – the number of parents or carers in the denominator who have a comprehensive assessment.
Denominator – the number of parents or carers of children and young people with a suspected conduct disorder and any significant complicating factors.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that staff are trained and competent to carry out comprehensive assessments for children and young people with a suspected conduct disorder and significant complicating factors, and also to carry out and assessment of their parents or carers.
Health and social care practitioners ensure that they complete a comprehensive assessment for children and young people with a suspected conduct disorder and any significant complicating factors, and also carry out an assessment of their parents or carers.
Commissioners ensure that they commission services that have staff trained and competent to carry out comprehensive assessments for children and young people with a suspected conduct disorder and any significant complicating factors, and also to carry out an assessment of their parents or carers.

What the quality statement means for patients, service users and carers

Children and young people who are suspected to have a conduct disorder and who have other conditions (for example, problems with learning, communication or substance misuse, mental health problems, or conditions such as epilepsy and autism) have an assessment that looks at all the different parts of their life that can affect their behaviour, including their home and school environment and their parents.

Source guidance

Definitions of terms used in this quality statement

Comprehensive assessment of the child or young person
The standard components of a comprehensive assessment of conduct disorders should include, but is not restricted to, asking about and assessing the following:
  • core conduct disorders symptoms, including:
    • patterns of negativistic, hostile or defiant behaviour in children aged under 11 years
    • aggression to people and animals, destruction of property, deceitfulness or theft and serious violations of rules in children aged over 11 years
  • current functioning at home, at school or college and with peers
  • parenting style
  • history of any past or current mental or physical health problems
  • the presence or risk of physical, sexual and emotional abuse in line with local protocols for the assessment and management of these problems.
The assessment should take into account and address possible coexisting conditions such as:
  • learning difficulties or disabilities
  • neurodevelopmental conditions such as attention deficit hyperactivity disorder (ADHD) and autism
  • neurological disorders, including epilepsy and motor impairments
  • other mental health problems (for example, depression, post-traumatic stress disorder and bipolar disorder)
  • substance misuse
  • communication disorders (for example, speech and language problems).
When diagnosing coexisting conditions, it may be appropriate to use formal assessment instruments, such as the Strengths and Difficulties Questionnaire, for all children or young people to aid the diagnosis. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158) recommendations 1.3.10, 1.3.11, 1.3.12 and 1.3.14 and expert consensus]
Comprehensive assessment of the child or young person's parents or carers
A comprehensive assessment of the child or young person's parents or carers should cover:
  • positive and negative aspects of parenting, in particular any use of coercive discipline
  • the parent-child relationship
  • positive and negative adult relationships within the child or young person's family, including domestic violence
  • parental wellbeing, encompassing mental health, parental learning disability, substance misuse (including whether alcohol or drugs were used during pregnancy) and criminal behaviour.
This assessment should also include some assessment of parenting/care history, including identification of care in the child or young person's past, such as the number of placements within or outside the family. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.3.15 and expert consensus]
Significant complicating factors
Significant complicating factors assessed as part of the initial assessment of children and young people with a possible conduct disorder include:
Suspected conduct disorder
Children and young people are considered to have a suspected conduct disorder if their parents or carers, health or social care professionals, school or college, or peer group, raise concerns about persistent antisocial behaviour. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.3.2]

Equality and diversity considerations

Practitioners should support access to services and the uptake of interventions by children and young people, and their parents and carers, by being flexible in relation to settings and offering a range of support services. Recommendations 1.7.7 and 1.7.8 provide examples of settings and support services.
The workforce across agencies should, as far as possible, reflect the local community. Practitioners should have training to ensure that they have a good understanding of the culture of families with whom they are working. Interpreters should be provided if no practitioner is available who speaks a language in which the family members can converse fluently. Consideration should be given to the specific needs of:
  • girls and young women with conduct disorders
  • looked-after and adopted children and young people.

Improving access to services

This quality statement is taken from the antisocial behaviour and conduct disorders in children and young people quality standard. The quality standard defines clinical best practice for antisocial behaviour and conduct disorders in children and young people and should be read in full.

Quality statement

Children and young people with a conduct disorder who have been referred for treatment and support have a key worker to oversee their care and facilitate engagement with services.

Rationale

Children and young people with a conduct disorder and their families who have been referred for treatment and support have high treatment dropout rates and can sometimes find it difficult to access and engage with services. The identification of a key worker from one of the services in contact with the child or young person and their family is intended to support coordination of services and facilitate engagement.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with a conduct disorder who have been referred for treatment and support have a key worker to oversee their care and facilitate engagement with services.
Data source: Local data collection.
Process
Proportion of children and young people with a conduct disorder referred for treatment and support who have a key worker.
Numerator – the number of children and young people in the denominator who have a key worker.
Denominator – the number of children and young people with a conduct disorder who have been referred for treatment and support.
Data source: Local data collection.
Outcome
a) Treatment uptake rates.
b) Treatment completion rates.
c) 'Did not attend' rates for children and young people with conduct disorders and their families.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that they have sufficient resources in place and agreements with local partner agencies for children and young people with a conduct disorder who have been referred for treatment and support to have a key worker who will oversee their care and facilitate engagement with services.
Health and social care practitioners ensure that children and young people with a conduct disorder who have been referred for treatment and support have a key worker identified to oversee their care and facilitate engagement with services.
Commissioners ensure that they commission services that can provide children and young people with a conduct disorder who have been referred for treatment and support with a key worker identified to oversee their care and facilitate engagement with services.

What the quality statement means for patients, service users and carers

Children and young people with a conduct disorder who have been referred for treatment and support have a member of staff from one of the services they are in contact with to help coordinate their care and support them to access services.

Source guidance

Definitions of terms used in this quality statement

Key worker
This can include a member of staff from Child and Adolescent Mental Health Services (CAMHS), or a member of staff from a relevant social care, education or healthcare setting. The decision about who is the most appropriate professional will depend on what service is best placed to meet the needs of the child or young person – based on the severity and nature of the disorder. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.7.6]
Oversee care and facilitate engagement
This includes working with children, young people and their families or carers to support engagement (for example, through following up with people if they do not attend initial appointments) and access to services by facilitating:
  • assessment and interventions outside normal working hours
  • assessment and interventions in the person's home or other residential settings
  • specialist assessment and interventions in accessible community-based settings (for example, community centres, schools and colleges and social centres) and if appropriate, in conjunction with staff from those settings
  • both generalist and specialist assessment and intervention services in primary care settings
  • access to services that support engagement (for example, crèche facilities, assistance with travel, interpreters and advocacy services). [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendations 1.7.7 and 1.7.8]

Equality and diversity considerations

Practitioners should support access to services and the uptake of interventions by children and young people, and their parents and carers, by being flexible in relation to settings and offering a range of support services. Recommendations 1.7.7 and 1.7.8 provide examples of settings and support services.
The workforce across agencies should, as far as possible, reflect the local community. Practitioners should have training to ensure that they have a good understanding of the culture of families with whom they are working. Interpreters should be provided if no practitioner is available who speaks a language in which the family members can converse fluently. Consideration should be given to the specific needs of:
  • girls and young women with conduct disorders
  • looked-after and adopted children and young people.

Parent or carer training

This quality statement is taken from the antisocial behaviour and conduct disorders in children and young people quality standard. The quality standard defines clinical best practice for antisocial behaviour and conduct disorders in children and young people and should be read in full.

Quality statement

Parents or carers of children with a conduct disorder aged 3 to 11 years are offered a referral for group or individual parent or carer training programmes.

Rationale

Parent or carer training is an intervention to help people gain the skills needed to support children with a conduct disorder. Given the variety of training programmes available, it is important to offer this group an evidence-based programme to ensure that this intervention is delivered effectively and appropriately.

Quality measures

Structure
Evidence of local arrangements to ensure that parents or carers of children with a conduct disorder aged 3 to 11 years are offered a referral for group or individual parent or carer training programmes.
Data source: Local data collection.
Process
a) Proportion of parents or carers of children with a conduct disorder aged 3 to 11 years who are offered a referral for a group or individual parent or carer training programme.
Numerator – the number of parents or carers in the denominator who are offered a referral for a group or individual parent or carer training programme.
Denominator – the number of parents or carers of children with a conduct disorder aged 3 to 11 years.
b) Proportion of parents or carers of children with a conduct disorder aged 3 to 11 years who attend a group or individual parent or carer training programme.
Numerator – the number of parents or carers in the denominator who attend a group or individual parent or carer training programme.
Denominator – the number of parents or carers of children with a conduct disorder aged 3 to 11 years.
c) Proportion of parents or carers of children with a conduct disorder aged 3 to 11 years who complete a group or individual parent or carer training programme.
Numerator – the number of parents or carers in the denominator who complete a group or individual parent or carer training programme.
Denominator – the number of parents or carers of children with a conduct disorder aged 3 to 11 years.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that they provide group or individual parent or carer training programmes that adhere to an evidence-based model for any parents or carers of children with a conduct disorder aged 3 to 11 years.
Health and social care practitioners ensure that they offer parents or carers of children with a conduct disorder aged 3 to 11 years the opportunity to take part in group or individual parent or carer training programmes.
Commissioners ensure that they commission services that provide group or individual parent or carer training programmes that adhere to an evidence-based model for parents or carers of children with a conduct disorder aged 3 to 11 years.

What the quality statement means for patients, service users and carers

Parents or carers of children with a conduct disorder aged 3 to 11 years are offered the opportunity to take part in a training programme (either on their own or as part of group) to help them develop skills to manage and improve their child's behaviour.

Source guidance

Definitions of terms used in this quality statement

Individual and group parent or carer training programmes
These interventions are suitable for the parents or carers of children and young people who have a conduct disorder, are in contact with the criminal justice system for antisocial behaviour, or have been identified as being at high risk of a conduct disorder using established rating scales of antisocial behaviour (for example, the Child Behavior Checklist and the Eyberg Child Behavior Inventory). Where possible, a group parent or carer training programme should be offered. However, parents of children with severe or complex problems should be referred for individual training programmes. These interventions should be evidence-based and adhere to a developer's manual to ensure that care is effective, person-centred and individualised.
Group parent training programme
Group parent training programmes should involve both parents if this is possible and in the best interests of the child or young person, and should:
  • typically have between 10 and 12 parents in a group
  • be based on a social learning model, using modelling, rehearsal and feedback to improve parenting skills
  • typically consist of 10 to 16 meetings of 90 to 120 minutes' duration
  • adhere to a developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.5.2]
Individual parent training programmes
Individual parent training programmes should involve both parents if this is possible and in the best interests of the child or young person, and should:
  • be based on a social learning model using modelling, rehearsal and feedback to improve parenting skills
  • typically consist of 8 to 10 meetings of 60 to 90 minutes' duration
  • adhere to a developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.5.4]
Individual parent and child training programmes
Individual parent and child training programmes should involve both parents, foster carers or guardians if this is possible and in the best interests of the child or young person, and should:
  • be based on a social learning model using modelling, rehearsal and feedback to improve parenting skills
  • consist of up to 10 meetings of 60 minutes' duration
  • adhere to a developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.5.6]
Group foster carer/guardian training programmes
Group foster carer/guardian training programmes should involve both of the foster carers or guardians if this is possible and in the best interests of the child or young person, and should:
  • modify the intervention to take account of the care setting in which the child is living
  • typically have between 8 and 12 foster carers or guardians in a group
  • be based on a social learning model using modelling, rehearsal and feedback to improve parenting skills
  • typically consist of between 12 and 16 meetings of 90 to 120 minutes' duration
  • adhere to a developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.5.8]
Individual foster carer/guardian training programmes
Individual foster carer/guardian training programmes should involve both of the foster carers if this is possible and in the best interests of the child or young person, and should:
  • modify the intervention to take account of the care setting in which the child is living
  • be based on a social learning model using modelling, rehearsal and feedback to improve parenting skills
  • consist of up to 10 meetings of 60 minutes' duration
  • adhere to a developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.5.10]

Equality and diversity considerations

Practitioners should support access to services and the uptake of interventions by children and young people, and their parents and carers, by being flexible in relation to settings and offering a range of support services. Recommendations 1.7.7 and 1.7.8 provide examples of settings and support services.
Consideration will need to be given to representation of family units and recognising that family units can vary between cultures. Where possible, programme materials and the session, should be made available in different languages.

Multimodal interventions

This quality statement is taken from the antisocial behaviour and conduct disorders in children and young people quality standard. The quality standard defines clinical best practice for antisocial behaviour and conduct disorders in children and young people and should be read in full.

Quality statement

Children and young people aged 11 to 17 years who have a conduct disorder are offered a referral for multimodal interventions, with the involvement of their parents or carers.

Rationale

Multimodal interventions have been shown to be effective in helping older children and young people with a conduct disorder to manage their behaviour in different social settings. Parental participation is an important part of the intervention because the focus is on changing the environment around the young person, which can then help to change the young person's behaviour. Given the variety of interventions available, it is important to offer evidence-based multimodal interventions to ensure that the intervention is delivered effectively and appropriately.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people aged 11 to 17 years who have a conduct disorder are referred for multimodal interventions, which involve their parents or carers.
Data source: Local data collection.
Process
a) Proportion of children and young people aged 11 to 17 years who have a conduct disorder who take part in multimodal interventions.
Numerator – the number of children and young people in the denominator who take part in multimodal interventions.
Denominator – the number of children and young people aged 11 to 17 years who have a conduct disorder.
b) Proportion of parents or carers of children and young people aged 11 to 17 years who have a conduct disorder who are involved in multimodal interventions.
Numerator – the number of parents or carers in the denominator who are involved in multimodal interventions.
Denominator – the number of parents or carers of children and young people aged 11 to 17 years who have a conduct disorder.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that they provide multimodal interventions that adhere to an evidence-based model and involve parents or carers for children and young people aged 11 to 17 years who have a conduct disorder.
Health and social care practitioners ensure that they offer multimodal interventions to children and young people aged 11 to 17 years who have a conduct disorder and involve their parents or carers in the intervention.
Commissioners ensure that they commission services that provide multimodal interventions that adhere to an evidence-based model and involve parents or carers for children and young people aged 11 to 17 years who have a conduct disorder.

What the quality statement means for patients, service users and carers

Children and young people aged 11 to 17 years who have a conduct disorder take part in a programme of support, which involves their parents or carers and is focused on helping them to improve how they interact with their family, when they are at school and in other settings within their community.

Source guidance

Definitions of terms used in this quality statement

Multimodal interventions
These interventions are suitable for children and young people who have a diagnosis of a conduct disorder, those in contact with the criminal justice system for antisocial behaviour, or those who have been identified as being at high risk of a conduct disorder using established rating scales of antisocial behaviour (for example, the Child Behavior Checklist and the Eyberg Child Behavior Inventory).
Multimodal interventions should involve the child or young person and their parents and carers and should:
  • have an explicit and supportive family focus
  • be based on a social learning model with interventions provided at individual, family, school, criminal justice and community levels
  • be provided by specially trained case managers
  • typically consist of 3 to 4 meetings per week over a 3- to 5 month period
  • adhere to a developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.5.14]

Equality and diversity considerations

Practitioners should support access to services and the uptake of interventions by children and young people, and their parents and carers, by being flexible in relation to settings and offering a range of support services. Recommendations 1.7.7 and 1.7.8 provide examples of settings and support services.
Practitioners should have training to ensure that they have a good understanding of the culture of families with whom they are working. Interpreters should be provided if no practitioner is available who speaks a language in which the family members can converse fluently. Consideration should be given to the specific needs of:
  • girls and young women with conduct disorders
  • looked-after and adopted children and young people.

Monitoring adverse effects of pharmacological interventions

This quality statement is taken from the antisocial behaviour and conduct disorders in children and young people quality standard. The quality standard defines clinical best practice for antisocial behaviour and conduct disorders in children and young people and should be read in full.

Quality statement

Children and young people with a conduct disorder and severely aggressive behaviour who have been prescribed risperidone have a baseline physical and metabolic investigation and are monitored for efficacy and adverse effects at regular intervals.

Rationale

Pharmacological interventions should not be offered for the routine management of behavioural problems in children and young people with a conduct disorder. Risperidone may be considered for the short-term management of severely aggressive behaviour in children and young people with a conduct disorder who have problems with explosive anger and severe emotional dysregulation and which has not responded to psychosocial interventions. This medication can have significant physical effects and, in some cases, significant adverse effects. Current practice information suggests that there is variation in the baseline investigations and monitoring carried out in children and young people taking risperidone.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with a conduct disorder and severely aggressive behaviour who have been prescribed risperidone have a baseline physical and metabolic investigation and are monitored for efficacy and adverse effects at regular intervals.
Data source: Local data collection.
Process
a) The proportion of children and young people with a conduct disorder and severely aggressive behaviour who have been prescribed risperidone who have a baseline physical and metabolic investigation carried out and recorded before the start of treatment.
Numerator – the number of children and young people in the denominator who have a baseline physical and metabolic investigation carried out and recorded before the start of treatment.
Denominator – the number of children and young people with a conduct disorder and severely aggressive behaviour who have been prescribed risperidone.
b) The proportion of children and young people with a conduct disorder and severely aggressive behaviour who are taking risperidone who have physical and metabolic investigations repeated and recorded at regular intervals.
Numerator – the number of children and young people in the denominator who have physical and metabolic investigations repeated and recorded at regular intervals.
Denominator – the number of children and young people with a conduct disorder and severely aggressive behaviour who are taking risperidone.
c) The proportion of children and young people with a conduct disorder and severely aggressive behaviour who are taking risperidone who have changes in their symptoms and behaviour monitored and recorded at regular intervals.
Numerator – the number of children and young people in the denominator who have changes in their symptoms and behaviour monitored and recorded at regular intervals.
Denominator – the number of children and young people with a conduct disorder and severely aggressive behaviour who are taking risperidone.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are protocols in place for all children and young people with a conduct disorder and severely aggressive behaviour who have been prescribed risperidone to have a baseline physical and metabolic investigation and to be monitored for efficacy and adverse effects at regular intervals.
Healthcare professionals ensure that children and young people with a conduct disorder and severely aggressive behaviour who have been prescribed risperidone have a baseline physical and metabolic investigation and are monitored for efficacy and adverse effects at regular intervals.
Commissioners ensure that they commission services that have protocols in place for all children and young people with a conduct disorder and severely aggressive behaviour that have been prescribed risperidone to have a baseline physical and metabolic investigation and be monitored for efficacy and adverse effects at regular intervals.

What the quality statement means for patients, service users and carers

Children and young people who are taking risperidone to help treat their conduct disorder and aggressive behaviour have a number of physical checks carried out before they start treatment, and are regularly monitored to check whether the treatment is working and whether there are any unwanted side effects.

Source guidance

Definitions of terms used in this quality statement

Baseline physical and metabolic investigation
At the start of treatment, a suitably qualified healthcare professional with expertise in prescribing antipsychotics in children and young people for a range of conditions including conduct disorders, should undertake and record the following baseline investigations:
  • weight and height (both plotted on a growth chart)
  • waist and hip measurements
  • pulse and blood pressure
  • fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid and prolactin levels
  • assessment of any movement disorders
  • assessment of nutritional status, diet and level of physical activity. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.6.5 and expert consensus]
Regular intervals
Advice on the frequency of monitoring is provided in table 1 of Psychosis and schizophrenia in children and young people (NICE clinical guideline 155) and should be read in conjunction with the British national formulary (BNF), British national formulary for children (BNFC) and summary of product characteristics.
Severely aggressive behaviour
This refers to the behaviour of children and young people with a conduct disorder who have problems with explosive anger and severe emotional dysregulation. [Adapted from Antisocial behaviour and conduct disorders in children and young people (NICE clinical guideline 158), recommendation 1.6.3]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on antisocial behaviour and conduct disorders in children and young people.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

16 April 2014 Antisocial behaviour and conduct disorders in children and young people quality standard (QS59) added to this pathway.
21 February 2014 Minor maintenance updates.
1 October 2013 Recommendation from clinical guideline 77 added to Parent and foster carer or guardian training programmes node.
29 July 2013 Attention deficit hyperactivity disorder (ADHD) quality standard (QS39) added to this pathway.
5 July 2013 Minor maintenance updates.
28 March 2013 Minor maintenance updates.

Supporting information

Glossary

Attention deficit hyperactivity disorder
British national formulary for children
Child and adolescent mental health services
Glycosylated haemoglobin
Summary of product characteristics

Paths in this pathway

Pathway created: March 2013 Last updated: April 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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