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Attention deficit hyperactivity disorder

About

What is covered

This interactive flowchart covers children under 5 years, children and young people aged 5 to 17 years, and adults aged 18 years or over who are at risk of ADHD or have a diagnosis of ADHD.

Updates

Updates to this interactive flowchart

13 March 2018 Updated on publication of NICE guideline NG87 on attention deficit hyperactivity disorder: diagnosis and management.

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing attention deficit hyperactivity disorder (ADHD) in children, young people and adults in an interactive flowchart

What is covered

This interactive flowchart covers children under 5 years, children and young people aged 5 to 17 years, and adults aged 18 years or over who are at risk of ADHD or have a diagnosis of ADHD.

Updates

Updates to this interactive flowchart

13 March 2018 Updated on publication of NICE guideline NG87 on attention deficit hyperactivity disorder: diagnosis and management.

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 for 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 for attention deficit hyperactivity disorder 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.
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

Attention deficit hyperactivity disorder: diagnosis and management (2018) NICE guideline NG87, recommendation 1.2.8

Definitions of terms used in this quality statement

ADHD specialist
A psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.3.1]
Diagnosis of ADHD
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.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.3.1]
Symptoms of ADHD
For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
  • meet the diagnostic criteria for ADHD in DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders 5th edition) or for hyperkinetic disorder in ICD-10The ICD-10 exclusion on the basis of a pervasive developmental disorder being present, or the time of onset being uncertain, is not recommended. (the International Classification of Mental and Behavioural Disorders 10th revision) and
  • cause 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.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.3.3]

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 for attention deficit hyperactivity disorder 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.
Outcome
Rates of new diagnosis of ADHD in adults.
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 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

Attention deficit hyperactivity disorder: diagnosis and management (2018) NICE guideline NG87, recommendation 1.2.10

Definitions of terms used in this quality statement

ADHD specialist
A psychiatrist or paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.3.1]
Symptoms of ADHD for adult referral
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.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.2.10]
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 for attention deficit hyperactivity disorder 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.
Outcome
Adults feel supported to manage their ADHD.
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 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

Attention deficit hyperactivity disorder: diagnosis and management (2018) NICE guideline NG87 recommendation 1.2.11

Definitions of terms used in this quality statement

Symptoms of continuing ADHD for adult referral
Symptoms of ADHD should be associated with at least moderate or severe psychological, social, educational or occupational impairment.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.2.11]
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 for attention deficit hyperactivity disorder and should be read in full.

Quality statement

Parents or carers of children and young people 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.
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.
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.
Outcome
a) Parent or carer satisfaction with the provision of parent training programmes.
Data source: Local data collection.
b) Parents or carers feel supported to manage their child’s condition.
Data source: Local data collection.

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
Parent training programmes should be offered in line with recommendations 1.5.1 to 1.5.10 in NICE’s guideline on antisocial behaviour and conduct disorders in children and young people.
[NICE’s guidelines on attention deficit hyperactivity disorder, recommendation 1.5.7 and 1.5.11, and antisocial behaviour and conduct disorders in children and young people, recommendations 1.5.1 to 1.5.10]
Symptoms of ADHD
For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
  • meet the diagnostic criteria for ADHD in DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders 5th edition) or for hyperkinetic disorder in ICD-10 (the International Classification of Mental and Behavioural Disorders 10th revision) and
  • cause 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’s guideline on attention deficit hyperactivity disorder, recommendation 1.3.3]
NICE eligibility criteria
The NICE eligibility criteria for referral to a parent training programme are:
  • parents or carers of children under 5 years with ADHD
  • parents or carers of children over 5 years with ADHD and symptoms of oppositional defiant disorder or conduct disorder.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.5.7 and 1.5.11]
Children and young people
Children are aged between 3 and 11 years. Young people are aged 12 to 18 years.

Equality and diversity considerations

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.

Starting drug treatment

This quality statement is taken from the attention deficit hyperactivity disorder quality standard. The quality standard defines clinical best practice for attention deficit hyperactivity disorder 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.
Outcome
Rates of drug-related side effects in people starting drug treatment for ADHD.
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 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 psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.3.1]
Initial drug dose
Doses should be titrated against symptoms and adverse effects in line with the BNF or BNF for Children until dose optimisation is achieved, that is reduced symptoms, positive behaviour change, improvements in education, employment and relationships, with tolerable adverse effects.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.7.27]

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 for attention deficit hyperactivity disorder 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.
Outcome
People with ADHD feel supported to manage their condition.
Data source: Local data collection.

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
This 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
This should include a comprehensive assessment of the following:
  • preference of the child, young person or adult with ADHD (and their family or carers as appropriate)
  • benefits, including how well the current treatment is working throughout the day
  • adverse effects
  • clinical need and whether medication has been optimised
  • impact on education and employment
  • effects of missed doses, planned dose reductions and periods of no treatment
  • effect of medication on existing or new mental health, physical health or neurodevelopmental conditions
  • need for support and type of support (for example, psychological, educational, social) if medication has been optimised but ADHD symptoms continue to have a significant impact.
[NICE’s guideline on attention deficit hyperactivity disorder, recommendation 1.10.1]

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.

Psychological treatments for children and young people

This statement has been removed. For more details see update information.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Do not advise elimination of artificial colouring and additives from the diet as a generally applicable treatment for children and young people with ADHD.
Ask about foods or drinks that appear to influence hyperactive behaviour as part of the clinical assessment of ADHD in children and young people, and:
  • if there is a clear link, advise parents or carers to keep a diary of food and drinks taken and ADHD behaviour
  • if the diary supports a relationship between specific foods and drinks and behaviour, offer referral to a dietitian
  • ensure that further management (for example, specific dietary elimination) is jointly undertaken by the dietitian, mental health specialist or paediatrician, and the parent or carer and child or young person.
Do not advise or offer dietary fatty acid supplementation for treating ADHD in children and young people.
Advise the family members or carers of children with ADHD that there is no evidence about the long-term effectiveness or potential harms of a 'few food' diet for children with ADHD, and only limited evidence of short-term benefits.
Environmental modifications are changes that are made to the physical environment in order to minimise the impact of a person's ADHD on their day-to-day life. Appropriate environmental modifications will be specific to the circumstances of each person with ADHD and should be determined from an assessment of their needs. Examples may include changes to seating arrangements, changes to lighting and noise, reducing distractions (for example, using headphones), optimising work or education to have shorter periods of focus with movement breaks (including the use of 'I need a break' cards), reinforcing verbal requests with written instructions and, for children, the appropriate use of teaching assistants at school.
Reasonable adjustments is a term that refers to the legal obligations of employers and higher education providers to make sure that workers or students with disabilities, or physical or mental health conditions are not substantially disadvantaged when doing their jobs or during their education.
A written treatment plan shared between healthcare professional and the person with ADHD; for children this may be shared more widely (for example, with families, schools or social care, if relevant and agreed).

Recognition

Evidence showed that the prevalence of ADHD is higher in some groups than in the general population. The committee agreed that a recommendation was needed to raise awareness of these groups among non-specialists to help them avoid missing a diagnosis of ADHD. Although no evidence was identified for a higher prevalence in people known to the Youth Justice System or Adult Criminal Justice System and people with acquired brain injury, the committee agreed that in their experience, these groups often receive a late diagnosis of ADHD or a misdiagnosis. No evidence was found on the increased risk of missing a diagnosis of ADHD in girls. But the committee discussed the different symptoms often found in this group, and agreed to make a recommendation to raise awareness.

How the recommendations might affect practice

The recommendations are to raise awareness among non-specialists of a possible diagnosis of ADHD in groups of people that they are already seeing. The recommendations may increase the rates of diagnosis and referral for ADHD, but these should be accurate and therefore appropriate.
See the committee's full discussion in evidence review A: risk factors.

Provide information

Good information and support tailored to needs and circumstances are important for all people using NHS services, but some aspects are particularly important for people with ADHD. Evidence identified the need for information tailored to family circumstances, particularly when a child has ADHD, and to highlight the importance of daily structure for adults with ADHD.
In the committee's experience, people who are assessed for ADHD but not given a formal diagnosis are a neglected group who would benefit from advice on where to get support for troublesome symptoms.

How the recommendations might affect practice

The recommendations should reflect good current practice. Healthcare professionals may spend more time discussing the potential impacts of a diagnosis, but this is likely to mean improved quality of life for the person with ADHD and better management of their symptoms.
See the committee's full discussion in evidence review B: information and support.

Structured discussion

Evidence showed the importance of discussing key areas following a diagnosis of ADHD, particularly the positive impacts of receiving a diagnosis, such as improving understanding of symptoms. The committee used the evidence and their experience to agree other areas for discussion, including driving and possible issues with education and employment. They noted that schools, colleges and universities may sometimes question a diagnosis of ADHD and not understand how symptoms can affect daily functioning. In addition, healthcare professionals treating a coexisting condition may not be aware of how ADHD symptoms may affect behaviour (organisation and time management) and adherence to treatment.

How the recommendations might affect practice

The recommendations should reflect good current practice. Healthcare professionals may spend more time discussing the potential impacts of a diagnosis, but this is likely to mean improved quality of life for the person with ADHD and better management of their symptoms.
See the committee's full discussion in evidence review B: information and support.

Supporting families and carers

There was evidence that parents of children with ADHD often feel a sense of isolation when attending parent-training programmes. The committee agreed that healthcare professionals should explain to parents that an invitation to attend a parent-training programme does not imply bad parenting. The committee discussed the difficulties in families where parents may also have ADHD and made a recommendation to remind healthcare professionals that these families may need extra support.

How the recommendations might affect practice

The recommendations should reflect good current practice. Healthcare professionals may spend more time discussing the potential impacts of a diagnosis, but this is likely to mean improved quality of life for the person with ADHD and better management of their symptoms.
See the committee's full discussion in evidence review B: information and support.

Planning treatment

Evidence showed the importance of joint decision-making when planning treatment; particularly important was the discussion before starting treatment. This was also the committee's experience and they recommended that these discussions should be repeated throughout care.
The committee recommended key areas highlighted in the evidence that should be discussed with the person and their family before starting treatment. This included the benefits and harms of medications and consideration of these alongside other treatment choices.
In the committee's experience, other mental health and neurodevelopmental conditions may affect treatment choices and how successful these are. The committee emphasised the importance of a holistic approach to managing ADHD.
Evidence indicated that parents and carers of children with ADHD found it hard to make decisions about treatment and wanted time to think about the effect of any environmental modifications. The committee recognised that systematic use of environmental modifications is important for limiting the impact of ADHD symptoms. The committee agreed that the effect of environmental modifications should be reviewed and taken into account when considering other treatment options. The committee also recognised the importance of having the opportunity to regularly revisit and discuss earlier decisions and so recommended that healthcare professionals remind people that they can do this if they wish.
The committee acknowledged that it is important to include children and young people in any treatment discussions and recommended they should be encouraged to say how they feel. This should include their views on the aims and effect of any treatments. Healthcare professionals should be aware that these will change as the child matures and will need revisiting. The committee also recognised that it was important that young people and adults should have as much support as they need and should be asked if they would like someone to join discussions about treatment. Decisions around treatment can have many influences, including teachers, peers and the media.

How the recommendations might affect practice

The recommendations should reflect good current practice. Where practice might change, it is predominantly the approach to care that will be affected.
See the committee's full discussion in evidence review H: managing treatment.

Children under 5

In a very young child, the impact of ADHD symptoms on behaviour is assessed across different settings. Evidence showed a clinically important benefit on some measures of symptoms of an ADHD-focused group parent-training programme for children under 5 years. There was limited evidence on the efficacy of medication and because of concerns and lack of evidence about the long-term effects of medication in very young children, particularly in terms of growth and development, the committee agreed to recommend a group-based parent-training programme as first-line treatment. However, the committee agreed that untreated ADHD can have far-reaching long-lasting negative impacts on a child's life and some children may still have a significant impairment after the programme and environmental modifications. For these exceptional circumstances, the committee drew on their experience to recommend that healthcare professionals should seek further specialist advice, ideally from a tertiary service.

Children 5 and over and young people

The committee discussed evidence on non-pharmacological interventions and evidence on medication for managing ADHD in children and young people.
Evidence indicated that some parents and carers of children aged 5 years and over and young people can benefit from group support. After discussion of current good practice and consideration of the balance of benefits and costs, the committee decided to recommend offering additional support that could be group-based ADHD-focused support and as few as 1 or 2 sessions for parents and carers of all children and young people with ADHD.
Evidence showed the benefit of medication in this age group in improving ADHD symptoms and this was in line with the committee's experience. The committee acknowledged there are concerns about recommending medication for ADHD and particularly the uncertainty over the long-term adverse effects of medication in growing children. However, the committee agreed that untreated ADHD can have far-reaching long-lasting negative impacts on a child or young person's life (for example, affecting academic performance, interpersonal relationships, work, personal issues, substance use and driving). Medication offers a better balance of benefits and costs than non-pharmacological interventions so the committee agreed to recommend it when ADHD symptoms are persistent and still causing a significant impairment in at least one domain of everyday life despite the implementation and review of environmental modifications. The committee was aware of the implications of medication in this young population and made several recommendations to ensure its responsible use. These include recommendations on:
  • checking that environmental modifications have been done before starting medication
  • carrying out a thorough baseline assessment
  • ensuring that medication is initiated only by healthcare professionals with training and expertise in diagnosing and managing ADHD
  • early review of medication to optimise its use (including checking for adverse effects)
  • regular review to ensure that medication is continued only for as long as it is needed
  • offering ADHD-focused support for all children and young people with ADHD.
Combining a full parent-training programme with medication did not offer a good balance of benefits and costs for all children and young people in this age group, so the committee decided not to make a recommendation on this.
Some evidence showed a benefit of cognitive-behavioural therapy (CBT) in young people with ADHD. The committee agreed that this should be considered when a young person has benefited from medication but still has symptoms that are causing a significant impairment. They used their experience to recommend areas that a programme should address.

How the recommendations might affect practice

The 2018 recommendations ensure that parents and carers of all children and young people with ADHD receive ADHD-focused information and support. Children and young people aged 5 years and over are offered medication by a healthcare professional with training and expertise in diagnosing and managing ADHD only if ADHD symptoms are still causing a significant impairment in at least one domain of their everyday life despite implementation of environmental modifications. This choice follows discussion with the child or young person and their parents or carers and a full baseline assessment. The recommendations make it clear that where a child has symptoms of oppositional defiant disorder or conduct disorder, parents and carers should be offered a parent-training programme in line with the recommendations in NICE's guideline on antisocial behaviour and conduct disorders.
The current categorisation of ADHD focuses on the presence of significant impairment in the different domains of everyday life and across settings, rather than using the previously used terms of mild, moderate and severe ADHD. There is considerable overlap with the guideline population described in the 2008 recommendation. The 2018 recommendations reflect current practice and are unlikely to result in a substantial increase in prescribing and resource use.

Adults

Evidence directly comparing medication with non-pharmacological treatment supported the use of medication for first-line treatment of ADHD in adults. The committee acknowledged there are concerns about recommending medication for ADHD and in particular the uncertainty over the long-term benefits and the adverse effects of medication. However, the committee agreed that untreated ADHD can have a negative impact on a person's life, with lower educational attainment, and higher criminality. So they agreed to recommend medication when ADHD symptoms are still causing a significant impairment in at least one domain of everyday life despite environmental modifications.
Evidence indicated a benefit of non-pharmacological treatment, although this was less than for medication. There was also evidence of the importance of offering a choice of treatments, so the committee agreed that non-pharmacological treatment should be considered for adults who have made an informed choice not to have medication, have difficulty adhering to medication or have found they cannot tolerate medication or it is ineffective. Based on their experience, the committee recommended that the treatment may include elements of or a full programme of CBT and should include a structured supportive psychological intervention focused on ADHD, with regular follow-up and information.
Combining medication with non-pharmacological treatment did not offer the best balance of benefits and costs, so the committee decided that combination treatment should only be considered when medication has offered some benefit but symptoms continue to cause a significant impairment.

Treatment initiation and ongoing prescribing and monitoring

The committee discussed the roles of different healthcare professionals in initiating, monitoring and reviewing medication. They agreed, based on their experience, that medication should only be initiated and titrated by a healthcare professional with training and expertise in diagnosing and managing ADHD. But after dose stabilisation, prescribing and monitoring should be carried out under Shared Care Protocol arrangements with primary care. The exact balance between primary and secondary care will vary depending on the circumstances of the person with ADHD and the available primary and secondary care services.
See the committee's full discussion in evidence review D: pharmacological safety.

Baseline assessment

The committee noted that it is important to carry out a baseline assessment before starting ADHD medication. Evidence was limited on what should be assessed clinically, but the committee used their experience and expert advice to recommend a general review of health and social circumstances, and a review of physical health, including an electrcardiogram (ECG), depending on the proposed treatment. The committee used their experience to outline criteria for referral for a cardiologist opinion.
See the committee's full discussion in evidence review D: pharmacological safety.

Medication choice

Evidence showed a clinically important benefit for monotherapy with the stimulants methylphenidate and lisdexamfetamine compared with placebo or other drugs. This was supported by the committee's experience that stimulants work more quickly than non-stimulant drugs (for example, atomoxetine and guanfacine), which can take longer to have an effect. The committee used the evidence, their experience and the drug licensing to recommend methylphenidate as a treatment for children aged 5 years and over and young people, and lisdexamfetamine or methylphenidate as a treatment for adults.
The committee acknowledged the rising cost of dexamfetamine since 2008 and agreed that it should only be considered when lisdexamfetamine is effective but the longer effect profile is not well tolerated.
The committee agreed that if methylphenidate has not been effective for children aged over 5 years and young people, then lisdexamfetamine could be considered.
Atomoxetine and guanfacine were the non-stimulant drugs with the most convincing evidence. The committee noted that atomoxetine is more widely used and that there was stronger evidence for a benefit of atomoxetine compared with placebo than guanfacine compared with placebo. One trial directly comparing atomoxetine with guanfacine generally showed a clinically important benefit of guanfacine. Taking into account the licensing status of these drugs and the familiarity of most healthcare professionals with them, the committee recommended that in children aged 5 years and over and young people, either drug could be offered after intolerance or a lack of response to stimulants (methylphenidate and lisdexamfetamine). Because guanfacine is not licensed for use in adults and there was no evidence specifically supporting its use in this population, the committee recommended atomoxetine for adults with intolerance or a lack of response to stimulants.

Further medication choices

There was not enough evidence to justify specific recommendations for other drugs so the committee recommended that after at least one stimulant and non-stimulant had been tried, healthcare professionals should obtain a second opinion or refer to a tertiary service.

People with coexisting conditions

There was very little evidence on medication choice for people with ADHD and coexisting conditions and so the committee made research recommendations to address this gap. The committee agreed that neither the available evidence nor their experience justified a different choice of ADHD medication for people with ADHD and coexisting conditions, but there should be slower titration, more careful monitoring and recording of adverse effects, and regular weekly telephone contact. However, the committee recommended that ADHD medication should be stopped in people experiencing a psychotic episode because they agreed that ADHD medication could worsen psychotic symptoms.
See the committee's full discussion in evidence review C: pharmacological efficacy and sequencing.

Considerations when prescribing and dose titration

The committee discussed that the careful initiation of ADHD medication is key to a successful treatment plan. This includes starting and titrating medication according to the BNF or the BNF for Children and the person's tolerance until the dose is optimised (reduced symptoms, positive behaviour change, improvements in education, employment and relationships, and tolerable adverse effects). The committee agreed that healthcare professionals should be aware of the pharmacokinetic profiles of ADHD medication because preparations can vary in their profiles. This is important when considering which medication or formulation to prescribe.
See the committee's full discussion in evidence review D: pharmacological safety.

Monitoring effectiveness and adverse effects

Evidence showed clinically important differences in sleep disturbance, decreased appetite and weight changes in people taking ADHD medication. In the committee's experience, these are some of the most troublesome adverse effects. Because of concerns about decreased appetite and weight change, the committee advised that weight should be checked every 3 months in children aged 10 years and under, and at least every 6 months in older children and young people; BMI should be monitored in adults. The committee recommended that changes in sleep pattern should be recorded and medication adjusted accordingly.
There was some evidence that people on atomoxetine may experience sexual dysfunction, in particular erectile dysfunction, and the committee agreed that this should be monitored.
See the committee's full discussion in evidence review D: pharmacological safety.

Adherence to treatment

The evidence identified several factors that affect adherence to treatment and these were supported by the committee's own experience.
The evidence highlighted time management and forgetfulness as particular issues, so the committee made a recommendation that healthcare professionals should be aware that people with ADHD may have problems remembering to order and collect medication. The committee provided examples of how healthcare professionals might encourage people to follow strategies that support adherence (for example, following clear instructions and using visual reminders).
A common worry about treatment is that it might change personality and the committee agreed that this could affect adherence to both medication and non-pharmacological treatments. Misconceptions about the effects of treatment and worries about adverse effects were common themes identified, and the committee agreed that it was important that healthcare professionals address these.
Evidence identified that the attitudes of people close to a person with ADHD can influence adherence. The committee agreed that it was important that although children and young people should take responsibility for their own health (including taking medication), parents and carers should oversee them.
The committee discussed that adherence to non-pharmacological treatment was an important issue that was rarely addressed. They used their own experience to recommend that healthcare professionals discuss the commitment, time and organisational skills needed for successful adherence to non-pharmacological treatment.
See the committee's full discussion in evidence review G: adherence.

Review of medication

Evidence identified concerns around lack of follow-up and the opportunity to review medication choices and this was supported by the committee's experience. They agreed that a yearly review with an ADHD specialist should be a comprehensive assessment that revisits the areas discussed when starting treatment but also the effect of current treatment. This would ensure that decisions around continuing or stopping treatment are fully informed.
Limited evidence showed possible worsening of ADHD symptoms on stopping medication but supported a reduction in adverse effects after withdrawal. The committee used their experience to make a recommendation on emphasising the importance of assessing the overall benefits and harms of medication as part of a review. The committee agreed that it was important to highlight the elements of a medication review that are important for someone with ADHD; they based the elements on evidence on adverse effects of medication, management of treatment, adherence and information and support.
See the committee's full discussion in evidence review I: withdrawal and drug holidays.

Glossary

attention deficit hyperactivity disorder
Child and Adolescent Mental Health Services
cognitive behavioural therapy
areas of function, for example, interpersonal relationships, education and occupational attainment, and risk awareness
areas of function, for example, interpersonal relationships, education and occupational attainment, and risk awareness
Diagnostic and Statistical Manual of Mental Disorders 5th edition
electrocardiogram
International Classification of Mental and Behavioural Disorders 10th revision
special educational needs coordinator
a physical location, for example, home, nursery, friends or family homes

Paths in this pathway

Pathway created: July 2013 Last updated: April 2018

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