This article aims to provide a brief summary of the National Institute for Health and Care Excellence guidelines on diagnosis and management of ADHD in adults, young people and children
Attention deficit hyperactivity disorder (ADHD) is a heterogeneous disorder characterised by the core symptoms of hyperactivity, impulsivity and inattentiveness which are excessive for a person’s age or level of overall development. Behavioural symptoms need to be both observed and reported to make a diagnosis. To make a diagnostic classification, healthcare professionals use two main diagnostic systems: the International Classification of Mental and Behavioural Disorders 10th revision (ICD‑10)1 and the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM‑V).2 Both require symptoms to be evident in early life and present in several settings with the symptoms adversely affecting psychological, social and/or educational/occupational functioning. The impact of ADHD may vary considerably in its severity (judged by considering the level of impairment, pervasiveness, and familial and social context) and can change over time. For ICD‑10, the symptoms should present by age 7 years and for DSM‑V, by age 12 years.1,2 ADHD persists into adult life. Prevalence rates are 1–2% in childhood for ICD‑10 criteria and 3–9% under DSM‑IV criteria3 (likely to be higher in the DSM-V). Symptoms of ADHD can overlap and/or coexist with other disorders; in children these include mood disorders, conduct, learning, motor control, language and communication, and anxiety disorders; in adults, they include personality disorders, bipolar disorder, obsessive-compulsive disorder and substance misuse. The causes of ADHD are not fully understood but a number of risk factors including genetic factors are associated with the condition.
NICE guideline
In view of rapid developments in the diagnosis and management of ADHD, the National Institute for Health and Care Excellence (NICE) published the ‘Attention deficit hyperactivity disorder: diagnosis and management’ guidelines on 14 March 2018.4 The guideline covers children under 5 years, children and young people aged 5–17 years, and adults aged 18 years or over at risk of ADHD or diagnosed with ADHD. The guideline covers NHS-funded primary, secondary and community care settings. The new guidelines build on the foundations laid by the original ADHD guidelines published in 2008 and the recommendations on management of suspected ADHD are based on evidence base informed by expert opinion. It aims to ‘improve recognition and diagnosis, as well as the quality of care and support for people with ADHD.
The new guidelines contain new and updated recommendations for healthcare professionals, commissioners, providers of services, researchers, people with ADHD, and their families and carers.
The guidelines take into consideration all the stakeholders and emphasise that professionals and practitioners take the guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their services. The guidelines were further amended in September 2019 with the recommendation that people starting atomoxetine or guanfacine do not require an ECG before starting treatment if the cardiovascular history and examination are normal, and the person is not on medicine that poses an increased cardiovascular risk.
Individual sections
The guidelines contain sections on service organisation and training, recognition, identification and referral, diagnosis, information and support, management, dietary advice, medication, maintenance and monitoring, adherence, discontinuation and recommendations for research, among others. Figure 1 shows a summary and pathway of these sections.5
Service organisation and training
This section provides updated guidance and recommends improved organisation of care and better integration of child health services, child
and adolescent mental health services (CAMHS) and adult mental health services. It emphasises that mental health services for children, young people and adults, and child health services, should form multidisciplinary specialist ADHD teams and/or clinics for children and young people, and separate teams and/or clinics for adults with expertise in the diagnosis and management of ADHD. The guidance suggests forming a ‘multi-agency group’ with representatives from multidisciplinary specialist ADHD teams, paediatrics, mental health and learning disability Trusts, forensic services, CAMHS, the Directorate for Children and Young People (including services for education and social services), parent support groups and others with a significant local involvement in ADHD services to oversee the implementation of the guidelines. It recommends a young person with ADHD receiving treatment and care from CAMHS or paediatric services should be reassessed at school-leaving age to establish the need for continuing treatment into adulthood and gives clear guidance about transitioning to adult ADHD services.3 Trusts should ensure that specialist ADHD teams jointly develop age-appropriate training programmes for the diagnosis and management of ADHD for professionals who have contact with people with ADHD and professionals are urged to undergo such training.
Recognition, identification and referral
This section has significant updates to include cross-referencing to NICE guidelines on antisocial behaviour and conduct disorders in children and young people.4 It also specifies that there should be and ADHD specific group-based parental support/training. It also contains updates about patient groups that may have increased prevalence of ADHD with the general population.4 It also clearly stipulates that ADHD is thought to be under-recognised in girls and women with a lower rate of referral and diagnosis and higher rates of misdiagnosis.4 For children diagnosed with ADHD the guidelines suggest the school Special Educational Needs Coordinator, should support both the child and parents in being able to access parent-training/education programmes locally. The guidance recommends that if the behavioural and/or attention problems persist with at least moderate impairment (severe only in 2008 guidance), the child or young person should be referred to secondary care for assessment.
Diagnosis
The guidance encourages early involvement of mental health specialists trained in the diagnosis and treatment of ADHD for children, young people and adults when there is at least moderate or severe psychological and/or social or educational or occupational impairment. The guidance clearly sets out the basis for a diagnosis of ADHD by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD. Guidance on diagnosis of ADHD has been updated and stipulates that diagnosis should be made according to the ICD-10 or the DSM-V.1,2,6
Information and support
Perhaps the most significant addition in the new guidance is the section on ‘information and support’. This section contains guidance to improve the experience of care for people with ADHD (Figure 2). It makes important recommendations about the information and support that should be made available across all aspects of life for patients, families, carers, and educational establishments, and for other relevant healthcare professionals (for co-existing conditions).4
Managing ADHD
The updated guidance now includes a section on ‘planning treatment’. It emphasises the importance of developing a comprehensive, holistic shared treatment plan that addresses psychological, behavioural and occupational or educational needs in conjunction with patients and their families or carers (Figure 3). The plan should take into account multiple factors, including the severity of the disorder and the patients’ goals of treatment.6 Healthcare professionals should discuss the potential benefits and negative effects of all available treatments, the potential benefits of a healthy lifestyle, patient preferences and the importance of adherence to treatment plan. The guidance includes a new comprehensive section on the management of ADHD covering all age groups and includes non-pharmacological and pharmacological treatment of ADHD.
Dietary advice
The guidance does not advise elimination of or additives to food and stresses the value of a balanced diet, good nutrition and regular exercise for children, young people and adults with ADHD. It recommends keeping a diary of food and drinks taken and ADHD behaviour.
Medication
NICE guidelines now include a comprehensive section on medication to treat ADHD symptoms and emphasises the importance of patients having a full baseline assessment including an assessment of their social circumstances, mental health and physical before starting medication (Figure 4). It differentiates between immediate and modified release preparations and specifies an adequate trial period, that is, six weeks. It also advises that once treatment dose has been stabilised, prescribing and monitoring of ADHD medication should be carried out under Shared Care Protocol/Arrangements with primary care physicians.
The guidelines also include important updates for treatment of ADHD in patients with co-existing conditions. NICE recommends that people with comorbid anxiety, tic or autism spectrum disorders are offered the same medication choices as others with ADHD. It also recommends that in children aged five years or over, young people and adults with ADHD experiencing an acute psychotic or manic episode, all ADHD medication should be stopped and re-initiation should only be considered once the episode has resolved.
The recommendations for treatment with medication are illustrated in Table 1 and should be read in conjunction with the complete guidelines.
Maintenance and monitoring
The 2018 update includes an extended section on maintenance and monitoring that includes recommendations for monitoring height, weight, cardiovascular health, tics, sexual dysfunction, seizures, sleep, worsening behaviour and stimulant diversion. Figure 5 illustrates the maintenance and monitoring recommendations.
Adherence to treatment
This too is a new section in the guidelines and recommends strategies to improve adherence to treatment across both non-pharmacological and pharmacological treatments.4 It recognises that the symptoms of ADHD may lead to people having difficulty adhering to treatment plans. It encourages clinicians to ensure people are fully informed of the balance of risks and benefits of any treatment and adherence problems are not due to misconceptions.
Review of medication and discontinuation
The guidelines conclude with a new section with recommendations for medication review. NICE recommends ADHD medication should be reviewed at least once a year and the person with ADHD their families and carers should be part of the discussion whether to continue medication or not. It recommends that healthcare professionals should encourage people with ADHD to discuss their preferences to stop or change medication and to be involved in any decisions about stopping treatments. They should also consider trial periods of stopping medication or reducing the dose when assessment of the overall balance of benefits and harms suggests this may be appropriate.
Conclusions
The updated guidance brings up to date the recommendations with regards to the practice and service delivery in ADHD. The guideline also aims to raise awareness of populations at risk and to provide clear advice on managing ADHD. The guidelines emphasise the importance of considering the preferences of patients, families and carers in the management of ADHD. NICE encourages healthcare professionals to take a more holistic approach in managing people with ADHD and makes recommendations for development of services that can support people with ADHD across the lifespan.
Key points
- Consider the preferences of patients, families and carers in the management of ADHD.
- Adequate trial period for medication is six weeks.
- Once treatment dose has been stabilised, prescribing and monitoring of ADHD medication should be carried out under Shared Care Protocol/Arrangements with primary care physicians.
- ADHD medication should be reviewed at least once a year.
Author biographies
Syed Naqvi MB BS MRCPsych MInstLM DipLM Associate Specialist, Service for Adults with ADHD/Autism Spectrum Disorders, South West Yorkshire NHS Foundation Trust, UK
Marios Adamou MD MSc MA LLM MBA PhD FRCPsych FFOM School of Human and Health Sciences, University of Huddersfield, UK
References
- International Classification of Mental and Behavioural Disorders 10th revision (ICD‑10).
- Diagnostic and Statistical Manual of Mental Disorders 5th ed. Arlington: American Psychiatric Association; 2013.
- Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: American Psychiatric Association; 1994.
- National Institute for Health and Care Excellence (NICE). Attention deficit hyperactivity disorder: diagnosis and management. 2018. www.nice.org.uk/guidance/ng87 (accessed May 2020).
- NICE Pathways. Attention deficit hyperactivity disorder overview. 2020. https://pathways.nice.org.uk/pathways/attention-deficit-hyperactivity-disorder (accessed May 2020).
- ADHD Institute. Update on NICE guidelines – ADHD: diagnosis and management guidelines 2018. https://adhd-institute.com/disease-management/guidelines/nice-guidelines/ (accessed May 2020).
