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Attention deficit hyperactivity disorder: diagnosis and management

Prerequisites of treatment and care for all people with attention deficit hyperactivity disorder

  • Healthcare professionals should develop a trusting relationship with people with attention deficit hyperactivity disorder (ADHD) and their families or carers by:
    • respecting the person and their family's knowledge and experience of ADHD
    • being sensitive to stigma in relation to mental illness
  • Healthcare professionals should provide people with ADHD and their families or carers with relevant, age-appropriate information (including written information) about ADHD at every stage of their care. The information should cover diagnosis and assessment, support and self-help, psychological treatment, and the use and possible side-effects of drug treatment
  • When assessing a child or young person with ADHD, and throughout their care, healthcare professionals should:
    • allow the child or young person to give their own account of how they feel, and record this in the notes
    • involve the child or young person and the family or carer in treatment decisions
    • take into account expectations of treatment, so that informed consent can be obtained from the child's parent or carer or the young person before treatment is started
  • Healthcare professionals working with children and young people with ADHD should be:
    • familiar with local and national guidelines on confidentiality and the rights of the child
    • able to assess the young person's understanding of issues related to ADHD and its treatment (including Gillick competence)
    • familiar with parental consent and responsibilities, child protection issues, the Mental Health Act (2007) and the Children Act (1989)
  • Healthcare professionals should work with children and young people with ADHD and their parents or carers to anticipate major life changes (such as puberty, starting or changing schools, the birth of a sibling) and make appropriate arrangements for adequate personal and social support during times of increased need. The need for psychological treatment at these times should be considered
  • Adults with ADHD should be given written information about local and national support groups and voluntary organisations
  • Healthcare professionals should ask families or carers about the impact of ADHD on themselves and other family members, and discuss any concerns they may have. Healthcare professionals should:
    • offer family members or carers an assessment of their personal, social and mental health needs
    • encourage participation in self-help and support groups where appropriate
    • offer general advice to parents and carers about positive parent– and carer–child contact, clear and appropriate rules about behaviour, and the importance of structure in the child or young person's day
    • explain that parent-training/education programmes do not necessarily imply bad parenting, and that their aim is to optimise parenting skills to meet the above-average parenting needs of children and young people with ADHD

Identification, pre-diagnostic intervention in the community and referral to secondary services

  • Children and young people with behavioural problems suggestive of ADHD can be referred by their school or primary care practitioner for parent-training/education programmes without a formal diagnosis of ADHD. The diagnosis of ADHD in children, young people and adults should take place in secondary care

Identification and referral in children and young people with ADHD

  • Universal screening for ADHD should not be undertaken in nursery, primary and secondary schools
  • When a child or young person with disordered conduct and suspected ADHD is referred to a school's special educational needs coordinator (SENCO), the SENCO, in addition to helping the child with their behaviour, should inform the parents about local parent-training/education programmes
  • Referral from the community to secondary care may involve health, education and social care professionals (for example, GPs, paediatricians, educational psychologists, SENCOs, social workers) and care pathways can vary locally. The person making the referral to secondary care should inform the child or young person's GP
  • When a child or young person presents in primary care with behavioural and/or attention problems suggestive of ADHD, primary care practitioners should determine the severity of the problems, how these affect the child or young person and the parents or carers and the extent to which they pervade different domains and settings
  • If the child or young person's behavioural and/or attention problems suggestive of ADHD are having an adverse impact on their development or family life, healthcare professionals should consider:
    • a period of watchful waiting of up to 10 weeks
    • offering parents or carers a referral to a parent-training/education programme (this should not wait for a formal diagnosis of ADHD)
  • If the child or young person's behavioural and/or attention problems are associated with severe impairment, referral should be made directly to secondary care (that is, a child psychiatrist, paediatrician, or specialist ADHD CAMHS) for assessment
  • Group-based parent-training/education programmes are recommended in the management of children with conduct disorders*
  • Primary care practitioners should not make the initial diagnosis or start drug treatment in children or young people with suspected ADHD
  • A child or young person who is currently treated in primary care with methylphenidate, atomoxetine, dexamfetamine, or any other psychotropic drug for a presumptive diagnosis of ADHD, but has not yet been assessed by a specialist in ADHD in secondary care, should be referred for assessment to a child psychiatrist, paediatrician, or specialist ADHD CAMHS as a matter of clinical priority

Identification and referral in adults with ADHD

  • Adults presenting with symptoms of ADHD in primary care or general adult 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, where 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 and/or educational or occupational impairment
  • Adults who have previously been treated for ADHD as children or young people and present with symptoms suggestive of continuing ADHD should be referred to general adult psychiatric services for assessment. The symptoms should be associated with at least moderate or severe psychological and/or social or educational or occupational impairment

Post-diagnostic advice

  • After diagnosis people with ADHD and their parents or carers may benefit from advice about diet, behaviour and general care

General advice

  • Following a diagnosis of ADHD, healthcare professionals should consider providing all parents or carers of all children and young people with ADHD self-instruction manuals, and other materials such as videos, based on positive parenting and behavioural techniques

Dietary advice

  • Healthcare professionals should stress the value of a balanced diet, good nutrition and regular exercise for children, young people and adults with ADHD
  • 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

How to use drugs for the treatment of ADHD

  • Good knowledge of the drugs used in the treatment of ADHD and their different preparations is essential (refer to the BNF and summaries of product characteristics). It is important to start with low doses and titrate upwards, monitoring effects and side-effects carefully. Higher doses may need to be prescribed to some adults. The recommendations on improving adherence in children and young people may also be of use in adults

General principles

  • Prescribers should be familiar with the pharmacokinetic profiles of all the modified-release and immediate-release preparations available for ADHD to ensure that treatment is tailored effectively to the individual needs of the child, young person or adult
  • Prescribers should be familiar with the requirements of controlled drug legislation governing the prescription and supply of stimulants
  • 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
  • Following titration and dose stabilisation, prescribing and monitoring should be carried out under locally agreed shared care arrangements with primary care
  • Side-effects resulting from drug treatment for ADHD should be routinely monitored and documented in the person's notes
  • If side-effects become troublesome in people receiving drug treatment for ADHD, a reduction in dose should be considered
  • Healthcare professionals should be aware that dose titration should be slower if tics or seizures are present in people with ADHD

Initiation and titration of methylphenidate, atomoxetine and dexamfetamine in children and young people

  • During the titration phase, symptoms and side-effects should be recorded at each dose change on standard scales (for example, Conners' 10-item scale) by parents and teachers, and progress reviewed regularly (for example, by weekly telephone contact and at each dose change) with a specialist clinician
  • If using methylphenidate in children and young people with ADHD aged 6 years and older:
    • initial treatment should begin with low doses of immediate-release or modified-release preparations consistent with starting doses in the BNF
    • the dose should be titrated against symptoms and side-effects over 4–6 weeks until dose optimisation is achieved
    • modified-release preparations should be given as a single dose in the morning
      • immediate-release preparations should be given in two or three divided doses
  • If using atomoxetine in children and young people with ADHD aged 6 years and older:
    • for those weighing up to 70 kg, the initial total daily dose should be approximately 0.5mg/kg; the dose should be increased after 7 days to approximately 1.2 mg/kg/day
    • for those weighing more than 70 kg, the initial total daily dose should be 40mg; the dose should be increased after 7 days up to a maintenance dose of 80 mg/day
    • a single daily dose can be given; two divided doses may be prescribed to minimise side-effects
  • If using dexamfetamine in children and young people with ADHD:
    • initial treatment should begin with low doses consistent with starting doses in the BNF
    • the dose should be titrated against symptoms and side-effects over 4–6 weeks
    • treatment should be given in divided doses increasing to a maximum of 20 mg/day
    • for children aged 6–18 years, doses up to 40 mg/day may occasionally be required

Initiation and titration of methylphenidate, atomoxetine and dexamfetamine in adults

  • In order to optimise drug treatment, the initial dose should be titrated against symptoms and side-effects over 4–6 weeks
  • During the titration phase, symptoms and side-effects should be recorded at each dose change by the prescriber after discussion with the person with ADHD and, wherever possible, a carer (for example, a spouse, parent or close friend). Progress should be reviewed (for example, by weekly telephone contact and at each dose change) with a specialist clinician
  • If using methylphenidate in adults with ADHD:
    • initial treatment should begin with low doses (5 mg three times daily for immediate-release preparations; the equivalent dose for modified-release preparations)
    • the dose should be titrated against symptoms and side-effects over 4–6 weeks
    • the dose should be increased according to response up to a maximum of 100 mg/day
    • modified-release preparations should usually be given once daily and no more than twice daily
    • modified-release preparations may be preferred to increase adherence and in circumstances where there are concerns about substance misuse or diversion
    • immediate-release preparations should be given up to four times daily
  • If using atomoxetine in adults with ADHD:
    • for people with ADHD weighing up to 70 kg, the initial total daily dose should be approximately 0.5 mg/kg; the dose should be increased after 7 days to approximately 1.2mg/kg/day
    • for people with ADHD weighing more than 70 kg, the initial total daily dose should be 40mg; the dose should be increased after 7 days up to a maintenance dose of 100 mg/ day
    • the usual maintenance dose is either 80 or 100 mg, which may be taken in divided doses
    • a trial of 6 weeks on a maintenance dose should be allowed to evaluate the full effectiveness of atomoxetine
  • If using dexamfetamine in adults with ADHD:
    • initial treatment should begin with low doses (5 mg twice daily)
    • the dose should be titrated against symptoms and side-effects over 4–6 weeks
    • treatment should be given in divided doses
    • the dose should be increased according to response up to a maximum of 60mg/day
    • the dose should usually be given between two and four times daily

Monitoring side-effects and the potential for misuse in children, young people and adults

  • Healthcare professionals should consider using standard symptom and side-effect rating scales throughout the course of treatment as an adjunct to clinical assessment for people with ADHD
  • In people taking methylphenidate, atomoxetine, or dexamfetamine:
    • height should be measured every 6 months in children and young people
    • weight should be measured 3 and 6 months after drug treatment has started and every 6months thereafter in children, young people and adults
    • height and weight in children and young people should be plotted on a growth chart and reviewed by the healthcare professional responsible for treatment
  • If there is evidence of weight loss associated with drug treatment in adults with ADHD, healthcare professionals should consider monitoring body mass index and changing the drug if weight loss persists
  • Strategies to reduce weight loss in people with ADHD, or manage decreased weight gain in children, include:
    • taking medication either with or after food, rather than before meals
    • taking additional meals or snacks early in the morning or late in the evening when the stimulant effects of the drug have worn off
    • obtaining dietary advice
    • consuming high-calorie foods of good nutritional value
  • If growth is significantly affected by drug treatment (that is, the child or young person has not met the height expected for their age), the option of a planned break in treatment over school holidays should be considered to allow 'catch-up' growth to occur
  • In people with ADHD, heart rate and blood pressure should be monitored and recorded on a centile chart before and after each dose change and routinely every 3 months
  • For people taking methylphenidate, dexamfetamine and atomoxetine, routine blood tests and ECGs are not recommended unless there is a clinical indication
  • Liver damage is a rare and idiosyncratic adverse effect of atomoxetine and routine liver function tests are not recommended
  • For children and young people taking methylphenidate and dexamfetamine, healthcare professionals, and parents or carers should monitor changes in the potential for drug misuse and diversion, which may come with changes in circumstances and age. In these situations, modified-release methylphenidate or atomoxetine may be preferred
  • In young people and adults, sexual dysfunction (that is, erectile and ejaculatory dysfunction) and dysmenorrhoea should be monitored as potential side-effects of atomoxetine
  • For people taking methylphenidate, dexamfetamine or atomoxetine who have sustained resting tachycardia, arrhythmia or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions should have their dose reduced and be referred to a paediatrician or adult physician
  • If psychotic symptoms (for example, delusions and hallucinations) emerge in children, young people and adults after starting methylphenidate or dexamfetamine, the drug should be withdrawn and a full psychiatric assessment carried out. Atomoxetine should be considered as an alternative
  • If seizures are exacerbated in a child or young person with epilepsy, or de novo seizures emerge following the introduction of methylphenidate or atomoxetine, the drug should be discontinued immediately. Dexamfetamine may be considered as an alternative in consultation with a regional tertiary specialist treatment centre
  • If tics emerge in people taking methylphenidate or dexamfetamine, healthcare professionals should consider whether:
    • the tics are stimulant-related (tics naturally wax and wane)
    • tic-related impairment outweighs the benefits of ADHD treatment
  • If tics are stimulant-related, reduce the dose of methylphenidate or dexamfetamine, consider changing to atomoxetine, or stop drug treatment
  • Anxiety symptoms, including panic, may be precipitated by stimulants, particularly in adults with a history of coexisting anxiety. Where this is an issue, lower doses of the stimulant and/or combined treatment with an antidepressant used to treat anxiety can be used; switching to atomoxetine may be effective

Improving adherence to drug treatment

  • For children and young people with ADHD, the strategies outlined in the recommendations below should be considered to improve treatment adherence. Similar strategies, adapted for age, may be considered for adults
  • Communication between the prescriber and the child or young person should be improved by educating parents or carers and ensuring there are regular three-way conversations between prescriber, parent or carer and the child or young person. For adults with ADHD, and with their permission, a spouse, partner, parent, close friend or carer wherever possible should be part of these conversations. Clear instructions about how to take the drug should be offered in picture or written format, which may include information on dose, duration, side-effects, dosage schedule, the need for supervision and how this should be done
  • Healthcare professionals should consider suggesting peer-support groups for the child or young person with ADHD and their parents or carers if adherence to drug treatment is difficult or uncertain
  • Simple drug regimens (for example, once-daily modified-release doses) are recommended for people with ADHD
  • Healthcare professionals should encourage children and young people with ADHD to be responsible for their own health, including taking their medication as required, and support parents and carers in this endeavour
  • Healthcare professionals should advise parents or carers to provide the child or young person with visual reminders to take medication regularly (for example, alarms, clocks, pill boxes, or notes on calendars or fridges)
  • Healthcare professionals should advise children and young people and their parents or carers that taking medication should be incorporated into daily routines (for example, before meals or after brushing teeth)
  • Where necessary, healthcare professionals should help parents or carers develop a positive attitude and approach in the management of medication, which might include praise and positive reinforcement for the child or young person with ADHD

* See also recommendations about parent-training programmes in NICE guideline CG158 on antisocial behaviour and conduct disorders in children and young people, and recommendation 1.5.1.4 in the current guideline for the extended use of these programmes to include children with ADHD

© NICE 2008. Attention deficit hyperactivity disorder: diagnosis and management. Available from: www.nice.org.uk/guidance/CG72. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: October 2008.