Written by Dr Tim Morris, East Lancashire Child and Adolescent Service, Accrington, UK
ADHD describes a well-recognised but heterogeneous group of neurobiological disorders: each affected patient presents with a unique set of symptoms, triggered by specific settings.1 Therefore, it is important that treatment decisions are tailored to the particular needs of an individual.1 Guidelines can help in this regard, but all patient-specific approaches should also take into account the needs of family members and other regular contacts (e.g. school staff),1 and sometimes there are contradictory demands that need to be reconciled.
There are a number of high-quality, authoritative guidelines in Europe, with perhaps the most comprehensive being those developed by the National Institute for Health and Clinical Excellence (NICE).1 While the NICE guidelines are UK-based, the clinical aspects remain highly relevant to those working throughout Europe. The guidelines suggest a clear structure for the organisation of care for people with ADHD across the full age range. They also include a detailed description of medication management, with guidance on titrating to therapeutic dosage and optimising treatment whilst monitoring for adverse events. In addition to considering the pharmacological treatment of ADHD, psychological and social interventions are also covered, although the descriptions of these approaches are broad, reflecting the available literature. Another feature of the NICE guidelines is the economic evaluation, which will vary depending on the healthcare system.2
European guidelines for ADHD and hyperkinetic disorder have also been developed.3,4
More recent European guidelines on the management of adverse events associated with ADHD medication are also particularly helpful, as they focus on the issues that many medical practitioners spend most of their time dealing with.5 Of note, the guidelines provide useful recommendations regarding the investigation of patients at risk of developing potentially serious cardiovascular side effects, which have been a concern with some medications. Common co-occurring conditions, including tics and epilepsy, are also explored, as well as less common psychotic symptoms.
The guidelines described above are perhaps most suited to specialist practitioners. Key difficulties surround the implementation of these guidelines in real-life clinical practice and how clinicians can keep up-to-date, particularly given the sheer volume of research on ADHD, and the multiple sources of advice, even in specialist services. However, these issues may be addressed in part by guidelines that provide helpful presentations of information in a user-friendly format, such as those developed by the Scottish Intercollegiate Guidelines Network (SIGN),6,7 and the ADHD Map of Medicine.8 In particular, the SIGN ‘Recommendations Online: Clinical Knowledge Evidence Translation’ (ROCKET) guidelines on ADHD include graphically presented advice designed for online access and backed up with more detailed evidence. They provide helpful and clear descriptions of broad treatment approaches for key groups of children with ADHD based on age and symptom severity. They also provide guidance for the treatment of patients with comorbid anxiety or oppositional behaviour disorder. The Map of Medicine is a similar concept, but aimed primarily at primary care practitioners.
However, there are areas that remain unclear within all of these guidelines, some of which are highlighted by the NICE guidelines.1 For example, the recommended frequency of follow-up visits is not clearly defined, which has practical implications for those delivering and organising integrated services. Transition between services for different developmental stages is already a difficult process to coordinate, particularly the move to adult services. This is partly because there may be differences between male and female patients, and because changes in ADHD symptoms do not always follow a straightforward linear pattern, meaning that even in previously stable patients the impact of ADHD may evolve significantly.
There is also limited guidance on dealing with comorbid disorders, which are very common in ADHD. This reflects the current lack of available evidence and an inherent tendency for such guidelines to focus on single disorders, without coverage of related conditions. However, the consideration of comorbidities is central to delivering clinically effective interventions. Clinicians need to integrate guidelines on a range of different disorders to provide each patient with individualised care.
Finally, there is limited evidence as to how therapeutic interventions can best address the long-term social consequences of ADHD that occur outside the model of a medical disorder. For example, the impact of ADHD on employment, driving convictions and relationships.
Authoritative, evidence-based guidelines are providing a positive basis for the development of individualised treatment plans for patients with ADHD. While there is a general consensus that medication provides a high level of symptomatic improvement, it should be supported by effective, individualised psychological and social intervention.1,3,4 The free availability of current guidelines means that these recommendations are readily accessible to both clinicians and patients, allowing them to make informed requests for the best possible treatment. However, it is important to recognise that the implementation of guidelines needs more than clinical input alone. A system of care requires commissioner and managerial support, if best practice outcomes are to be achieved, and there is also a need to monitor treatments (some guidelines [e.g. NICE]9 offer audit criteria to use as a benchmark). Moreover, a high level of critical clinical thinking will be needed in order to refine current guidelines and develop updates that reflect the continuous evolution of services and clinical evidence.
Disclaimer: The views expressed here are the views of the physician and not those of Shire.
- NICE (2008) Attention Deficit Hyperactivity Disorder: Diagnosis and Management of ADHD in Children, Young People and Adults. NICE clinical guideline 72. Available at www.nice.org.uk/CG72 [NICE guideline]. Accessed 10 January 2017.
- National Clinical Practice Guideline Number 72. The British Psychological Society and The Royal College of Psychiatrists, 2007. Available at www.nice.org.uk/guidance/cg72/resources/cg72-attention-deficit-hyperactivity-disorder-adhd-costing-report2. Accessed 10 January 2017.
- Kooij SJJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: the European Network Adult ADHD. BMC Psychiatry 2010; 10: 67.
- Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder – first upgrade. Eur Child Adolesc Psychiatry 2004; 13(Suppl 1): I/7-I/30.
- Graham J, Banaschewski T, Buitelaar J, et al. European guidelines on managing adverse effects of medication for ADHD. Eur Child Adolesc Psychiatry 2011; 20: 17-37.
- Scottish Intercollegiate Guidelines Network. Management of attention deficit and hyperkinetic disorders in children and young people: a national clinical guideline. Accessed 26 January 2017.
- Scottish Intercollegiate Guidelines Network. Management of attention deficit and hyperkinetic disorders in children and young people. Recommendations Online: Clinical Knowledge Evidence Translation. Accessed 26 January 2017.
- Attention Deficit Hyperactivity Disorder (ADHD) – Map of Medicine. Accessed 26 January 2017.
- National Institute for Health and Clinical Excellence. Attention deficit hyperactivity disorder: audit support. Accessed 26 January 2017.