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Attention deficit hyperactivity disorder (ADHD) is a behavioural syndrome characterised by core symptoms of inattention, hyperactivity, and impulsivity. Two different diagnostic criteria are used to define ADHD:

• the International classification of mental and behavioural disorders (ICD-10) uses a narrow definition that detects those severely affected by ADHD¹
• the Diagnostic and statistical manual of mental disorders (DSM IV) uses a broad definition, which includes a number of different subtypes such as combined ADHD, predominately inattentive or predominately hyperactive subtypes.²

The symptoms that occur in ADHD are distributed across a spectrum throughout the general population. In affected individuals the symptoms cluster and are more severe.

In order to make a diagnosis of ADHD it has to be shown that the symptoms are impairing—in other words, the symptoms have a significant effect on the individual’s ability to function in a number of different domains (i.e. psychological, social, educational, or occupational).³

Incidence

The incidence of ADHD, as determined by the more severe ICD-10 criteria, is around 1–2% of the childhood population. If using the broader DSM criteria, ADHD is thought to affect 3–9% of children and young people, and up to 2% of adults.³

Primary care focus of the guideline

The recent NICE guideline on Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults³ focuses on the importance of correct diagnosis. It consolidates the advice from earlier Technology Appraisal 98 on Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents that the diagnosis of ADHD, and any initiation of drug therapy, should be made by specialist teams in secondary care.^3,4

In the guideline, primary care teams are encouraged to focus on selecting those individuals who need to be referred to secondary care for further assessment.³ The guideline also acknowledges the large amount of literature supporting the short-term benefits of stimulant medication in children with ADHD;⁵ however, uncertainty still surrounds the balance of risks and benefits of long-term treatment.⁶ Therefore, the NICE guideline includes an increased emphasis on non-drug therapies for mild to moderately affected children.⁷

There is also helpful advice on monitoring and prescribing for those patients who need ongoing drug treatment after it has been initiated in the secondary care setting. The importance of good shared-care guidelines and communication between primary and secondary care is emphasised.³

The guideline focuses on the importance of:³

• person-centred care
• listening to the views and preferences of the adults and young people who are affected
• involving parents and carers of the younger children in important decisions regarding their treatment.

Good communication between all parties is essential, as is providing people with evidence-based information to allow them to make informed decisions about their care.³

Diagnosis of ADHD

Children and young people with possible ADHD are likely to be recognised either in educational settings or if they present to primary care. The guideline advises that there is no place for universal screening in schools, but that teachers who have received appropriate training, usually in their role as Special Educational Needs Co-ordinators, should help to detect and support affected children. These teachers may refer children either to the GP or directly to specialist ADHD teams. The NICE guideline recommends that if a child is referred directly to specialist care from the school setting, either the school or the specialist team should inform the general practitioner.³

The remaining young people and all affected adults will usually present to primary care where the general practitioner will need to determine if they warrant referral to a specialist team.³

Individuals with ADHD should fulfil the diagnostic criteria. This means that they should display symptoms of hyperactivity, inattention, and impulsivity. These symptoms should be pervasive, that is they should have occurred consistently over a long period of time, and be impairing in multiple settings, therefore causing the individual at least moderate problems in psychological, social, and educational/occupational areas.³

It is very useful to ask the following screening question to parents: ‘does the child demonstrate behaviour problems at home as well as school?’ If there are no problems at all in one area, a diagnosis of ADHD is less likely. It is also important to be aware that even a severely affected child can behave well for short periods of time, especially if they are in a novel setting. This means that direct observation of the child in the surgery for the duration of a GP consultation is unlikely to be helpful.³

General practitioners who carry out the initial assessment of individuals that are potentially affected by ADHD should also be aware of the high co-morbidity associated with this condition. Affected children are more likely to have problems with mood, conduct, anxiety, and communication disorders; while in adults, co-existing personality disorder, bipolar illness, obsessive compulsive disorder, and substance misuse are common.³

If a GP feels that ADHD symptoms are having an adverse effect on a child’s development and family life, the guideline suggests a number of options:³

• in those children where symptoms are mild or moderate, a period of watchful waiting for up to 10 weeks could be considered. Alternatively parents can be referred to specialist parent-training/education programmes—it is not necessary to wait for a formal diagnosis from secondary care to initiate this
• in children who fail to respond to these measures, or in children who initially present with severe impairment, direct referral to secondary care should be considered.

A care pathway for children or young people with suspected ADHD is presented in Figure 1.⁸

For adults who have ADHD symptoms and moderate or severe impairment, the GP should check that the symptoms have persisted since childhood and cannot be explained by any other psychiatric condition—although other conditions may co-exist. Those adults who are diagnosed with ADHD should be referred to a mental health specialist who has been trained in the management of the condition.³ It should also be ensured that adults who were treated for ADHD in childhood and who have ongoing symptoms suggestive of ADHD are referred to general adult psychiatric services.³

Figure 1: Care pathway for ADHD in children and young people8

ADHD=attention deficit hyperactivity disorder National Institute for Health and Clinical Excellence (NICE) (2008) CG72. Diagnosis and management of ADHD in children, young people and adults. Quick reference guide. London: NICE. Available from www.nice.org.uk. Reproduced with permission.

Treatment

Once specialist secondary care teams have formally diagnosed ADHD, general support should be offered to parents and carers by both specialist and primary care teams. The value of a balanced diet, good nutrition, and regular exercise should be stressed. Although a number of studies have looked at this area,⁹ there is insufficient evidence to advocate the elimination of either artificial colourings and additives, or the use of dietary fatty acid supplements in all affected individuals. However, if parents report clear links between behavioural problems and specific foods, the child should be referred to a dietician for further assessment.³

Pre-school children
Drug therapy is not recommended in pre-school children. Parents should be referred to parent-training/education programmes; however, if this proves ineffective, referral to tertiary services is advised.³

School-aged children and young people with moderate symptoms
Drug therapy is not recommended as a first-line treatment in this group. Referral of parents to group parent-training/education programmes and/or group treatments in cognitive behavioural therapy and/or social skills for the child or young person is initially advised.
Drug therapy is considered only in those who refuse psychological therapies (in young children this is usually due to refusal by parents or carers and in older children it may be either the parent/carer or the young person themself who refuses) or who demonstrate significant persisting impairment after psychological intervention.³

School-aged children and young people with severe symptoms

Drug therapy should be the first-line treatment for this group of patients. The guideline recommends methylphenidate, atomoxetine, and dexamfetamine within their licensed indications as options for the management of ADHD. In children and young people with ADHD without significant co-morbidity, or if co-morbid conduct disorder is present, methylphenidate is the first-line recommendation. Parents of these patients should also be offered a place on a training programme.³

Adults

In adults, drug treatment should be the first-line therapy unless the person prefers psychological therapy. Methylphenidate would normally be the first drug prescribed in a case of adult ADHD. Drug treatment should be part of a comprehensive treatment programme that assesses psychological, behavioural, and educational/occupational needs.³

Monitoring

The formal diagnosis and initiation of drug therapy, where appropriate, will be carried out by specialist secondary care teams. In those individuals who require drug therapy, the correct drug will be selected and the management regimen will be stabilised.³ Once symptoms are well controlled and children can tolerate drug treatment without significant side-effects, they may be transferred back to primary care for ongoing prescribing and monitoring. The guideline provides clear advice that this transfer should take place under shared-care agreements, with clear channels of communication between primary and secondary care.³

Reviews of individuals who are stable on drug therapy should take place on a 3- to 6-monthly basis in either a primary or secondary care setting. The review should involve:³

• an assessment of clinical benefits and side-effects, taking on board the views of the young person or carer about the effectiveness of treatment
• an evaluation of co-existing conditions
• a look at the need for psychological or social support.

The reviews are also used to monitor for side-effects caused by treatment with methylphenidate, atomoxetine, and dexamfetamine (see Table 1). There is no need to carry out routine blood tests or echocardiograms unless there is a specific clinical indication, such as pre-existing cardiac problems.³ As drug therapy with all the agents can induce poor appetite, weight and height should be checked and plotted on a growth chart. Cardiovascular assessment using blood pressure and heart rate should also be carried out. These checks should be more frequent after any change of dose.³

Table 1: Monitoring side-effects8
Age (years)	Monitor according to drug treatment
	Methylphenidate	Atomoxetine	Dexamfetamine
Height Measure every 6 months. Plot on a growth chart, which should be reviewed by the healthcare professional responsible for treatment If growth is affected significantly consider a break in drug treatment over school holidays to allow ‘catch-up’ growth	C, YP	C, YP	C, YP
Weight Measure 3 and 6 months after the start of treatment, and every 6 months thereafter. In children and young people, plot weight on a growth chart, which should be reviewed by the healthcare professional responsible for treatment In adults, if weight loss is associated with drug treatment, consider monitoring body mass index and changing the drug if weight loss persists Strategies to reduce weight loss, or manage decreased weight gain in children, include: taking medication either with or after food, rather than before meals eating additional meals or snacks early morning or late evening when stimulant effects have worn off obtaining dietary advice and eating high-calorie foods of good nutritional value	C, YP, A	C, YP, A	C, YP, A
Cardiac function and blood pressure Monitor heart rate and blood pressure and record on a centile chart before and after each dose change, and every 3 months Sustained resting tachycardia, arrhythmia, or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions should prompt dose reduction and referral to a paediatrician or physician	C, YP, A	C, YP, A	C, YP, A
Reproductive system and sexual function Monitor for dysmenorrhoea, erectile dysfunction, and ejaculatory dysfunction	–	YP, A	–
Seizures If exacerbated in a child with epilepsy or de novo seizures emerge, discontinue methylphenidate or atomoxetine immediately Consider dexamfetamine instead after discussion with a regional tertiary specialist treatment centre	C, YP	C, YP	–
Tics Consider whether tics are stimulant-related, and whether tic-related impairment outweighs the benefits of ADHD treatment If stimulant-related, reduce the dose or stop drug treatment or consider using atomoxetine instead	C, YP, A	–	C, YP, A
Psychotic symptoms (delusions, hallucinations) Withdraw drug treatment and carry out full psychiatric assessment Consider atomoxetine instead	C, YP, A	–	C, YP, A
Anxiety symptoms including panic Where symptoms are precipitated by stimulants, particularly in adults with a history of coexisting anxiety, use lower doses of the stimulant and/or combined treatment with an antidepressant used to treat anxiety Switching to atomoxetine may be effective	C, YP, A	–	C, YP, A
Agitation, irritability, suicidal thinking, and self-harm Closely observe especially during the initial months of treatment or after a change in dose Warn parents/carers about the potential for suicidal thinking and self-harm with atomoxetine, ask them to report these effects Warn adults (aged 30 years or younger) of possible increased agitation, anxiety, suicidal thinking and self-harming behaviour, especially in the first weeks of treatment	–	C, YP, A	–
Drug misuse and diversion Monitor changes in potential for misuse and diversion, which may come with changes in circumstances and age. Modified-release methylphenidate or atomoxetine may be preferred	C, YP	–	C, YP
C=children; YP=young people; A=adults National Institute for Health and Clinical Excellence (NICE) (2008) CG 72 Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Quick Reference Guide. Reproduced with permission. Available from www.nice.org.uk

Implementation

Currently provision of specialist care for ADHD is variable across the country. In particular there are very few specialist adult services. The setting up of specialist multidisciplinary teams is a priority for PCTs and it is worth finding out who is providing your service locally.

The increased focus on parent-training, CBT, and social-skills training for mild cases of ADHD may also put pressure on resources; however, the parent-training/education programmes are the same as those recommended in the NICE guideline for conduct disorder,¹⁰ and therefore should already have been developed locally. If not currently in place, development of good local shared-care guidelines to support GPs caring for stable individuals in the community should be a priority.

Key points

For a patient to be diagnosed with ADHD, it should be shown that the symptoms have a significant effect on the individual’s ability to function in a number of areas, including psychological, social, educational, or occupational If ADHD is suspected in a child, watchful waiting for up to 10 weeks should be considered Healthcare professionals in primary care should identify patients with suspected ADHD and refer to a specialist for diagnosis The following treatment is recommended: pre-school children—group parent-training/education programmes school-aged children and young people with moderate symptoms—group parent-training/education programmes and group treatment in cognitive behavioural therapy and/or social skills for the child or young person is first-line option school-aged children and young people with severe symptoms—drug therapy (methylphenidate, atomoxetine, or dexamfetamine) is first-line option adults—drug therapy is first-line option unless psychological therapy preferred Once diagnosis and initiation of treatment have taken place in secondary care, stable patients can be monitored in primary care with appropriate shared-care arrangements in place If a patient is on drug therapy, a review should take place every 3–6 months

ADHD=attention deficit hyperactivity disorder

Practice-based commissioning take home messages

written by Dr David Jenner, NHS Alliance PBC Lead The NICE guideline on ADHD seeks to resolve some of the controversy in the diagnosis and treatment of this condition It recognises that diagnosis and drug treatment of ADHD should be initiated in secondary care The role of primary care is to select patients for referral and assessment by secondary care services. Once a specialist has initiated treatment, monitoring and supervision can be performed in primary care The guideline clearly identifies the need for a tier of services based in the community into which schools and GPs can refer for initial assessment Non-pharmacological treatment—in particular parent-training/education and group therapy—are proposed and these services will need to be commissioned and funded There is no tariff applicable to mental health services—ADHD services are ideal for joint commissioning through PBC, education, and local authorities

PBC=practice-based commissioning; ADHD=attention deficit hyperactivity disorder

NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on the diagnosis and management of attention deficit hyperactivity disorder. The tools are now available to download from the NICE website: www.nice.org.uk Costing tools National cost reports and local cost templates for the guideline have been produced: costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets. Slide set The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself. Audit support Audit support has been developed to support the implementation of the NICE guidance on attention deficit hyperactivity disorder. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

Summary

The NICE guideline on ADHD clarifies that formal diagnosis of this complex condition should be made by specialist teams in secondary care only. The guidance provides recommendations for GPs about how to select patients for referral, and discusses the trend towards using psychological therapies as first-line treatment for mildly affected individuals. Finally, the guideline details how individuals on drug therapy should be safely monitored and gives good advice regarding shared-care agreements.

References

1. World Health Organization. International classification of mental and behavioural diseases, 10th revision. WHO and DIMDI, 2007. Available at: www.who.int/classifications/apps/icd/icd10online/
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition. Washington DC: APA, 1994.
3. National Institute for Health and Clinical Excellence. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Clinical Guideline 72. London: NICE, 2008.
4. National Institute for Health and Clinical Excellence. Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Technology Appraisal 98. London: NICE, 2006.
5. Schachter H, Pham B, King J et al. How efficacious and safe is short-acting methylphenidate for the treatment of attention deficit hyperactivity disorder in children and adolescents? A meta-analysis. CMAJ 2001; 165 (11): 1475–1488.
6. Jensen P, Arnold L, Swanson J et al. 3-year follow up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry 2007; 46 (8): 989–1002.
7. National Collaborating Centre for Mental Health. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. London: NICE, 2008.
8. National Institute for Health and Clinical Excellence. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Clinical Guideline 72. Quick reference guide. London: NICE, 2008.
9. Stevens L, Zhang W, Peck L et al. EFA supplementation in children with inattention, hyperactivity and other disruptive behaviours. Lipids 2003; 38 (10): 1007–1021.
10. National Institute for Health and Clinical Excellence. Parent-training/education programmes in the management of children with conduct disorders. Technology Appraisal 102. London: NICE, 2006.G

Dr Niki Salt
General Practitioner, Thurleigh Road Surgery, London
Member of the NICE guideline development group

Click here for CPD questions on this article and the NICE guideline on the diagnosis and management of ADHD