NICE Guidance on ADHD

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.

DIAGNOSIS

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
  with ADHD.
• 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.

MONITORING

• 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