ADHD Updated NICE Guidelines 2018
The need for better organisation of care and integration of Child Health Services, CAMHS and Adult Mental Health Services is recognised.
Mental Health Services for children, young people and adults and child Health Services should form Multi-Disciplinary Specialist ADHD Teams . These teams or clinics should have expertise in the diagnosis and management of ADHD. Good systems should be in place for sharing of information between these teams where relevant with the provision also of age appropriate psychological services.
The size and time commitment from these teams will depend on local services.
Multi-agency groups are recommended to oversee implementation of this guideline (workshops for parents as well as signposting and training)
A young person with ADHD receiving medication should be reassessed at school leaving age to establish the need for continuing treatment into adulthood. A smooth transition to adult services is recommended by the time the young person is aged 18 with them fully involved in the transition.
The importance of adequate age appropriate training for these teams highlighted.
Recognition, identification and referral
Be aware that ADHD is increased in prevalence in the groups below
Looked after children and young people
Those diagnosed with ODD or CD (oppositional defiant disorder or conduct disorder)
Children and young people with anxiety/depression
Family History of ADHD
People with neurodevelopmental disorders such as ASD, tic disorder, learning disability and specific LD
Adults with a mental health condition
People with a history of substance misuse
People known to the criminal justice system
People with acquired brain injury
Also be aware that ADHD is under-recognised in girls and women therefore they are less likely to be referred for assessment.
Primary care practitioners should not make the initial diagnosis or start medication in young people with suspected ADHD.
Diagnosis should only be made by a Specialist Psychiatrist, Paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD on the basis of
A full clinical and psycho-social assessment of the person
Full developmental and or psychiatric history
Rating scales such as Conners and strengths and difficulties Questionnaire are a helpful adjuvant
For a diagnosis to be made of ADHD the symptoms should meet DSM-5 or ICD 10 criteria, cause at least moderate psychological, social and or educational/occupational impairment and be pervasive in at least 2 settings.
The assessment should include consideration of comorbid conditions.
It is also very important to ask the family members or carers how ADHD affects themselves and family life. Encourage family members to seek an assessment of their personal, social and mental health needs and to join self help or support groups if appropriate. Consider whether or not the parent with ADHD needs additional support to ensure adherence to medication for their child. Advice should be given about positive parent and carer child contact, clear and appropriate rules about behaviour and consistent management and structure in the child or young person’s day. Highlight that any recommendation of parent training/education does not imply bad parenting but the aim is to optimise parenting skills to meet the above average parenting needs of children and young people with ADHD.
Continuity of care is important for young people with ADHD and their families.
A comprehensive holistic shared treatment plan should be put in place that addresses psychological, behavioural and educational needs. The plan should take into account the severity of ADHD symptoms and how they affect daily life, their goals, their resilience and the impact of comorbid conditions.
Regularly discuss with parents and patients how they want to be involved in treatment planning and decisions. This should not happen only once.
Decisions regarding treatment can always be revisited.
First-line management for children under age of 5 should be Parent training programme.
No medication should be offered to children under the age of 5 without a second Specialist Opinion from a Tertiary Service
If a diagnosis of ADHD is made all parents should be given information on ADHD and its management, advice on parenting strategies and advice on liason with school/college.
If there are features of ODD or conduct disorder Behaviour advice/workshops should be recommended to parents on these conditions.
Medication should only be used for the treatment of ADHD if the young person’s symptoms are still causing significant impairment in at least one domain after environmental modifications have been implemented and reviewed.
The importance of a healthy diet and exercise should be highlighted to young people and their families and elimination of artificial colours and additives should not be recommended. If families think there is clear link to certain foods or drinks then a food diary should be recommended and if a clear relationship demonstrated to certain foods then referral to dietician and elimination can be recommended.
Dietary fatty acid supplementation for treatment of ADHD should not be recommended.
Baseline height, weight, bp and pulse compared with normal range for age , height and sex should be recorded.
Cardiovascular assessment should be carried out as well as ECG if medications affect QT interval.
Methylphenidate either short or long acting should be offered as the first line pharmacological treatment for ADHD in children over the age of five.
If a six week trial of methylphenidate is in effective for symptom control a trial of lisdexamphetamine or dexamphetamine (if the longer effect profile cannot be tolerated) should be considered.
If symptoms do not respond atomoxetine or guanfacine should be considered or used also for those who cannot tolerate side effects of stimulants.
Offer the same medication choices to people with ADHD and anxiety disorder, tic disorder or ASD as other people with ADHD.
When prescribing stimulants be aware that the duration, effect size and side effects vary from person to person.
Be aware of the risks of misuse and diversion.
Dose titrations should be slower in those with ADHD and another condition.
For people taking medication for ADHD:
Measure height every 6 months
Weight every 3 months in children under age of 10
Measure weight in children at 3 and 6 months after starting treatment and then 6mthly in children aged 10 and over.
Plot height and weight of children on a growth chart to ensure adequate growth.
If a child or young person’s height over time is significantly affected by medication then consider a break in medication over holidays.
Monitor bp and pulse every 6 mths and compare to the normal range for age.
If a young person on ADHD medication has a sustained resting tachycardia greater than 120 beats per minute , arrhythmia or systolic bp greater than 95 th centile or significant increase then reduce their dose and refer to cardiology.
If a young person taking Guanfacine has sustained orthostatic hypotension or fainting reduce their dose or consider switching to another ADHD medication.
If a person on ADHD medication develops tics consider whether these are pre-existing and whether or not the impairment of the tics outweighs the benefits of ADHD treatment.
Monitor changes in sleep pattern and adjust medication accordingly.
Encourage the young person with ADHD where appropriate to be responsible for their treatment with the use of clear instructions and visual reminders etc to support this.
As well as side effects being regularly monitored, clinical need and whether medication has been optimised should be considered. The effect of medication on existing conditions should also be considered.