For ADHD in adults refer to the full guideline
IDENTIFICATION AND REFERRAL TO SECONDARY CARE
- Determine the severity of behavioural and/or attention problems suggestive of ADHD and how they affect the child or young person and their parents or carers in different domains and settings.
- If the problems are having an adverse impact on development or family life, consider:
- watchful waiting for up to 10 weeks.
- offering referral to a parent-training/education programme; this should not wait for a formal diagnosis of ADHD.
- If the problems persist with at least moderate impairment, refer to secondary care (paediatrician, child psychiatrist or specialist ADHD child and mental health services [CAMHS]).
- If the problems are associated with severe impairment, refer directly to secondary care.
- If a child or young person is currently receiving drug treatment for ADHD and has not yet been assessed in secondary care, refer to secondary care as a clinical priority.
For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
- meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder) and;
- be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and;
- be pervasive, occurring in at least two settings.
Note: Diagnosis should be made only by a specialist psychiatrist, paediatrician or other healthcare professional with training and expertise in the diagnosis of ADHD. Drug treatment should not be started in primary care.
ADVICE AFTER DIAGNOSIS
- Consider providing parents and carers with self-instruction manuals and other materials such as videos, based on positive parenting and behavioural techniques.
- Stress the value of a balanced diet, good nutrition and regular exercise for children and young people
- Advise parents or carers to keep a diary if there are foods or drinks that appear to affect behaviour - if the diary supports a link, offer referral to a dietician.
Note: Use of dietary fatty acids supplements and/or elimination of artificial colouring and additives from the diet are not recommended.
TREATMENT AND MANAGEMENT
- Drug treatment is not recommended for preschool children or as first-line treatment for school-age children and young people with moderate ADHD.
- School-age children and young people with severe ADHD should be offered drug treatment first-line. Parents should also be offered a group-based parent-training/education programme.
- Drug treatment should:
- be started only by a healthcare professional with expertise in ADHD.
- be based on comprehensive assessment.
- always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.
- GPs may continue prescribing and monitoring drug treatment under shared care arrangements.
- When a decision to start drug treatment has been made the following options should be considered:
- methylphenidate for ADHD without significant comorbidity.
- methylphenidate for ADHD with comorbid conduct disorder.
- methylphenidate or atomoxetine when tics, Tourette's syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present.
- atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate.
- Monitor children and young people starting drug treatment for side effects. In all cases monitor:
- height, every six months.
- weight, three and six months after start of treatment then every six months.
- heart rate and BP, before and after dose changes and every three months.
- In the case of atomoxetine:
- warn parents/carers about the potential for suicidal thinking and self-harm and ask them to report these effects.
- warn parents/carers about the occurrence of liver damage in rare cases (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice).
Further information: NICE Guidance on ADHD