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NICE Guidance on attention deficit hyperactivity disorder. Clinical Guideline No.72. September 2008
NICE has issued guidance on the diagnosis and management of attention deficit hyperactivity disorder (ADHD) in children (3–11 years), young people (12–18 years) and adults. Healthcare professionals and others involved in the management of ADHD should familiarise themselves with this guideline.
The advice in the NICE guideline covers the care, treatment and support that children, young people and adults with ADHD should be offered, and outlines how families and carers can support people with ADHD. NICE points out that people with ADHD require integrated care that addresses a wide range of personal, social, educational and occupational needs. Trusts should ensure that healthcare and educational professionals are adequately trained in the diagnosis and management of ADHD.
A care pathway sets out how people with ADHD should receive help, treatment and care from different services, from the community (including primary care and education) through to secondary and tertiary services. Transition between child and adult services is also considered. Recommendations are made around the identification and referral of people with ADHD, and on its diagnosis and severity grading. Diagnosis should not be made in primary care and, for a diagnosis to be made, 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.
Drug treatment is not recommended for pre-school children with ADHD. Parents or carers of these children should be offered referral to a parent-training/education programme as the first-line treatment.
For children or young people with moderate ADHD, 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 and/or social skills training) for the child or young person. Drug treatment is not indicated first-line.
Drug treatment should be offered as the first-line treatment in school-age children and young people with severe ADHD as part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions. In addition, parents should also be offered a group-based parent-training/education programme.
If drug treatment is thought to be appropriate, NICE advises that the following should be considered in children and young people:
- methylphenidate for ADHD without significant comorbidity or with comorbid 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 is first-line in adults with ADHD and should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs. If drug treatment is required methylphenidate should normally be tried first, although it is not currently licensed for use in adults.
General principles surrounding the drug treatment of ADHD are discussed in the guideline. Drug treatment should only be initiated by a specialist, although, following titration and dose stabilisation, prescribing and monitoring (particularly height and weight) may be carried out in primary care under a shared care agreement.
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