Attention deficit hyperactivity disorder: diagnosis and management
Attention deficit hyperactivity disorder. NICE guideline [NG87]
Definition
Attention deficit hyperactivity disorder (ADHD) is a behavioural syndrome characterized by hyperactivity, impulsivity, and inattention.
Pure attention deficit hyperactivity disorder is unusual .
It is frequently co-morbid with other developmental and psychiatric disorders:
dyslexia, dyspraxia, autism, tic disorders, antisocial personality, emotional lability, substance misuse.
Incidence
Symptoms typically appear in children 3–7 years of age, but may not be recognized until after 7 years of age, especially if hyperactivity is not present.
Assessment of symptoms
Hyperactivity/ impulsivity
Inattention
Present since childhood
Age-inappropriate
Result in significant psychological, social, and/or educational functional impairment
Present for at least 6 months
Pervasive in at least two settings: home, school, social situations, or work
Exclude other causes
learning difficulties; anxiety; depression; abuse; trauma
medical conditions, such as unsuspected hearing problems or epilepsy.
Risk factors
preterm
looked-after children and young people
oppositional defiant disorder or conduct disorder
mood disorders (for example, anxiety and depression)
family member diagnosed with ADHD
epilepsy
neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability)
adults with a mental health condition
substance misuse
known to Youth Justice System or Adult Criminal Justice System
acquired brain injury
Inattention:
1. Careless with detail
2. Fails to sustain attention
3. Appears not to listen
4. Does not finish instructed tasks
5. Poor self-organisation
6. Avoids tasks requiring sustained mental effort
7. Loses things
8. Easily distracted
9. Seems forgetful
Hyperactivity/impulsivity:
1. Fidgets
2. Leaves seat when should be seated
3. Runs and climbs excessively and inappropriately
4. Noisy in play
5. Persistent motor overactivity unmodified by social context
6. Blurts out answers before questions are even completed
7. Fails to wait turn in queue
8. Interrupts conversations or games
9. Talks excessively for social context
Specialist referral to establish a diagnosis
Primary care practitioners should not make the initial diagnosis or start medication in children or young people with suspected ADHD.
Referral should be made directly to:
Specialist paediatrician
Child psychiatrist
Specialist ADHD CAMHS
Adult psychiatrist
A young person with ADHD receiving treatment and care from CAMHS or paediatric services should be reassessed at school-leaving age to establish the need for continuing treatment into adulthood
Management
Overall, the management of people with confirmed ADHD should be initiated and co-ordinated by specialists: multidisciplinary specialist ADHD teams.
In children not yet given a formal diagnosis of ADHD
If symptoms are suggestive of ADHD and are having an adverse impact on their development or family life, consider:
a period of watchful waiting of up to 10 weeks
offering parents or carers a referral to group-based ADHD-focused support (before diagnosis is conferred)
Children under 5 years
Offer an ADHD-focused group parent-training programme to parents or carers
Children aged 5 years and over and young people
Offer an ADHD-focused group parent-training programme to parents or carers
Drug treatment (initiated by secondary care specialist diagnosing and managing ADHD)
methylphenidate
lisdexamfetamine
dexamfetamine
atomoxetine
Course of cognitive behavioural therapy [CBT] and/or social skills training
People with a diagnosis of ADHD should eat a balanced diet and take regular exercise.
Eliminating artificial colourings and additives from the diet is not recommended unless there appears to be a link between certain foods or drinks and a person’s ADHD symptoms.
Patient monitoring programmes if using methylphenidate, lisdexamfetamine, dexamfetamine or atomoxetine
Monitor for appearance or worsening of anxiety, depression or tics or psychiatric disorders.
Check pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.
Suicidal ideation. Patients and their carers should be informed about the risk and told to report clinical worsening, suicidal thoughts or behaviour, irritability, agitation, or depression.
Hepatic impairment. Patients and carers should be advised of the risk and be told how to recognise symptoms; prompt medical attention should be sought in case of abdominal pain, unexplained nausea, malaise, darkening of the urine, or jaundice.