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Attention deficit hyperactivity disorder overview

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Attention deficit hyperactivity disorder

About

What is covered

This pathway covers the diagnosis and management of ADHD in children 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 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.

Updates

Updates to this pathway

16 February 2016 Recommendations on dietary advice for children and young people amended in advice after diagnosis in line with the update of NICE guideline CG72 on attention deficit hyperactivity disorder.
24 November 2015 Link to NICE pathway on attachment difficulties in children and young people added.
10 November 2015 Minor maintenance update.
29 May 2015 Link to NICE pathway on challenging behaviour and learning disabilities added.
4 March 2015 Minor maintenance update.
23 September 2014 Minor maintenance update.
10 July 2014 Minor maintenance update.
1 July 2014 Minor maintenance update.
18 February 2014 Minor maintenance update.
12 August 2013 Minor maintenance update.
12 September 2013 Correction made to starting dose for atomoxetine for childen aged 6 years and older and young people (over 70 kg body weight).

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Diagnosis and management of ADHD in children, young people and adults

What is covered

This pathway covers the diagnosis and management of ADHD in children 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 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.

Updates

Updates to this pathway

16 February 2016 Recommendations on dietary advice for children and young people amended in advice after diagnosis in line with the update of NICE guideline CG72 on attention deficit hyperactivity disorder.
24 November 2015 Link to NICE pathway on attachment difficulties in children and young people added.
10 November 2015 Minor maintenance update.
29 May 2015 Link to NICE pathway on challenging behaviour and learning disabilities added.
4 March 2015 Minor maintenance update.
23 September 2014 Minor maintenance update.
10 July 2014 Minor maintenance update.
1 July 2014 Minor maintenance update.
18 February 2014 Minor maintenance update.
12 August 2013 Minor maintenance update.
12 September 2013 Correction made to starting dose for atomoxetine for childen aged 6 years and older and young people (over 70 kg body weight).

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.

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.

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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 each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Diagnosing ADHD in children and young people

Diagnosis should only be made by a specialist psychiatrist, paediatrician or other healthcare professional with training and expertise in the diagnosis of ADHD.
Diagnosis should be based on:
  • a full clinical and psychosocial assessment. Discuss behaviour and symptoms in the different domains and settings of the child or young person's everyday life
  • a full developmental and psychiatric history and
  • observer reports and an assessment of mental state.
Diagnosis should be made when symptoms of hyperactivity/impulsivity and/or inattention:
  • meet the criteria in DSM-IV or ICD-10 (hyperkinetic disorder; note that the ICD-10 exclusion on the basis of a pervasive development disorder being present, or the time of onset being uncertain, is not recommended) and
  • are associated with at least moderate impairment based on interview and/or observation in multiple settings and
  • are pervasive, occurring in 2 or more settings.
As part of the diagnostic process, include an assessment of needs, coexisting conditions, social, familial and educational circumstances and physical health. Include an assessment of the parents' or carer's mental health.
Do not diagnose ADHD based on rating scales or observational data alone. However, rating scales (for example, Conners' rating scales and the Strengths and Difficulties questionnaire) are valuable adjuncts, and observations (for example, at school) are useful if there is doubt about symptoms.
ADHD should be considered in all age groups. Adjust symptom criteria for age-appropriate changes in behaviour.
Take into account children or young people's views when determining the clinical significance of impairment.

Methylphenidate: immediate- and modified-release dose equivalents (mg)

10
-
10
10
15
18
-
-
20
-
20
20
30
36
30
30
-
-
-
40
45
54
-
-
60
72
60
-

Monitoring and intervention

Consider using standard symptom and side effect rating scales during treatment as an adjunct to clinical assessment.
Routine blood tests and ECGs are not recommended unless there is a clinical indication.
Liver damage is a rare and idiosyncratic side effect of atomoxetine – routine liver tests are not recommended. Warn people with ADHD and parents or carers of the rare potential for liver damage (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice).
Monitoring and intervention
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.
Children and young people
Children and young people
Children and young people
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.
Children, young people and adults.
Children, young people and adults.
Children, young people and adults.
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.
Children, young people and adults.
Children, young people and adults.
Children young people and adults.
Reproductive system and sexual function
Monitor for dysmenorrhoea, erectile dysfunction and ejaculatory dysfunction.
-
Young people and adults.
-
Seizures
If exacerbated in a child or young person with epilepsy or de novo seizures emerge, discontinue methylphenidate or atomoxetine immediately.
Consider dexamfetamine instead after discussion with a regional tertiary specialist treatment centre.
For more information about epilepsy see the NICE pathway on epilepsy.
Children and young people.
Children and young people.
-
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.
Children, young people and adults.
-
Children, young people and adults.
Psychotic symptoms (delusions, hallucinations)
Withdraw drug treatment and carry out full psychiatric assessment.
Consider atomoxetine instead.
Children, young people and adults.
-
Children, young people and adults.
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 to treat anxiety.
Switching to atomoxetine may be effective.
For more information about anxiety see the NICE pathway on generalised anxiety disorder.
Children, young people and adults.
-
Children, young people and adults.
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.
For more information about self-harm see the NICE pathway on self-harm.
-
Children, young people and adults.
-
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.
For more information about drug misuse see the NICE pathway on drug misuse.
Children and young people
-
Children and young people

Diagnosing ADHD

Diagnosis should only be made by a specialist psychiatrist or other healthcare professional with training and expertise in the diagnosis of ADHD.
Diagnosis should be based on:
  • a full clinical and psychosocial assessment. Discuss behaviour and symptoms in the different domains and settings of the person's everyday life
  • a full developmental and psychiatric history, and
  • observer reports and an assessment of mental state.
Diagnosis should be made when symptoms of hyperactivity/impulsivity and/or inattention:
  • meet the criteria in DSM-IV or ICD-10 (hyperkinetic disorder; note that the ICD-10 exclusion on the basis of a pervasive development disorder being present, or the time of onset being uncertain, is not recommended) and
  • are associated with at least moderate impairment based on interview and/or observation in multiple settings and
  • are pervasive, occurring in two or more settings.
As part of the diagnostic process, include an assessment of needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health.
Do not diagnose ADHD based on rating scales or observational data alone. However, rating scales (for example, Conners' rating scales and the Strengths and Difficulties questionnaire) are valuable adjuncts, and observations are useful if there is doubt about symptoms.
ADHD should be considered in all age groups. Adjust symptom criteria for age-appropriate changes in behaviour.

Glossary

attention deficit hyperactivity disorder
British National Formulary
Child and Adolescent Mental Health Services
cognitive behavioural therapy
between 3 and 11 years
between 3 and 11 years
brand of modified-release methylphenidate; Concerta XL is licensed up to 54 mg
a type of social or personal functioning in which people ordinarily achieve competence, such as achievement in schoolwork or homework, dealing with physical risks and avoiding common hazards, and forming positive relationships with family and peers
where the drug is passed on to others for non-prescription use
Diagnostic and Statistical Manual of Mental Disorders 4th edition
electrocardiogram
brand of modified-release methylphenidate
immediate-release methylphenidate
International Classification of Mental and Behavioural Disorders 10th revision
psychological, social and/or educational or occupational impairment
brand of modified-release methylphenidate
when symptoms of hyperactivity/impulsivity and/or inattention, or all 3, occur together and are associated with at least moderate impairment in multiple settings and multiple domains
special educational needs coordinator
home, school, work or a healthcare setting
corresponds approximately to the ICD-10 diagnosis of hyperkinetic disorder. This is when inattention, impulsivity and hyperactivity are all present in multiple settings, and when impairment is severe, affecting multiple domains in multiple settings
between 12 and 18 years
between 12 and 18 years

Paths in this pathway

Pathway created: July 2013 Last updated: February 2016

© NICE 2016

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