Attention deficit hyperactivity disorder: diagnosis and management of attention deficit hyperactivity disorder in children, young people and adults

National Institute for Health and Clinical Excellence

Introduction

• This guideline covers the diagnosis and management of attention deficit hyperactivity disorder (ADHD) in children aged 3 years and older, young people and adults. The term ‘children‘ refers to those between 3 and 11 years; ‘young people’ refers to those between 12 and 18 years
• ADHD is a heterogeneous behavioural syndrome characterised by the core symptoms of inattention, hyperactivity and impulsivity. Not every person with ADHD has all of these symptoms—some people are predominantly hyperactive and impulsive; others are mainly inattentive. Symptoms of ADHD are distributed throughout the population and vary in severity; only those people with at least a moderate degree of psychological, social and/or educational or occupational impairment in multiple settings should be diagnosed with ADHD. Determining the severity of ADHD is a matter for clinical judgement, taking into account severity of impairment, pervasiveness, individual factors and familial and social context
• Symptoms of ADHD can overlap with those of other disorders, and ADHD cannot be considered a categorical diagnosis. Therefore care in differential diagnosis is needed. ADHD is also persistent and many young people with ADHD will go on to have significant difficulties in adult life

Key priorities for implementation

• Trusts should ensure that specialist ADHD teams for children, young people and adults jointly develop age-appropriate training programmes for the diagnosis and management of ADHD for mental health, paediatric, social care, education, forensic and primary care providers and other professionals who have contact with people with ADHD
• For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
  • meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder) 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
• As part of the diagnostic process, include an assessment of the person’s needs, co-existing 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
• Healthcare professionals should offer parents or carers of pre-school children with ADHD a referral to a parent-training/education programme as the first-line treatment if the parents or carers have not already attended such a programme or the programme has had a limited effect
• Teachers who have received training about ADHD and its management should provide behavioural interventions in the classroom to help children and young people with ADHD
• If the child or young person with ADHD has moderate levels of impairment, the parents or carers should be offered referral to a group parent-training/education programme, either on its own or together with a group treatment programme (cognitive behavioural therapy [CBT] and/or social skills training) for the child or young person
• 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
• Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions
• When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider:
  • methylphenidate for ADHD without significant comorbidity
  • methylphenidate for ADHD with co-morbid conduct disorder
  • methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
  • atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate
• Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs
• Following a decision to start drug treatment in adults with ADHD, methylphenidate should normally be tried first

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG72

National Institute for Health and Clinical Excellence. Diagnosis and management of attention deficit hyperactivity disorder in children, young people and adults. Quick Reference Guide. September 2008