DGKJP, DGPPN and DGSPJ German guidelines 2018
In June 2018, a new version of the German guidelines for the diagnosis and management of ADHD in childhood, adolescence and adults was released,1 updating the 2003 DGPPN guidelines for ADHD in adults2 to now include recommendations for children and adolescents.
These guidelines are evidence-based and were developed with consensus of an interdisciplinary team. They were created for use across all patients with ADHD (children, adolescents and adults) and in all care settings involved in the management of these patients in Germany.1 This summary provides a brief overview of the recommendations set out in the new guidelines on the diagnosis and management of ADHD in Germany, but it is not exhaustive of all recommendations and should not be used for the diagnosis or treatment of patients. Healthcare professionals should consult the full guidelines document, applicable for the diagnosis and management of ADHD in Germany.
The first section of guideline recommendations discusses the diagnosis of ADHD, and states that for a diagnosis of ADHD to be made, symptoms of the disorder (hyperactivity, impulsivity and/or inattention) must meet the criteria laid out in the International Classification of Diseases 11th Revision (ICD-11) or the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5TM). The recommendations also outline the importance of various diagnostic methods, comprising patient self-assessment, questionnaires, behavioural observation, psychological tests and laboratory/instrument-based testing. Regarding age at diagnosis, it is important to note that the younger the patient, the more difficult it is to distinguish symptoms of ADHD from normal variations in behaviour, and as such, a diagnosis of ADHD cannot be made in patients younger than 3 years. The diagnosis section of the guidelines also details those psychological disorders that must be considered during a differential diagnosis along with common psychiatric comorbidities that impact on ADHD management, which may require dedicated therapeutic management.1
Once a diagnosis of ADHD has been made, the guidelines recommend that all available management options should be explained to the patient and/or their caregivers, so all treatment decisions can be made in an informed manner and the patient is fully involved in the decision-making process. The recommendations emphasise that treatment should be delivered in the context of a multimodal treatment plan, which can combine psychosocial (including psychotherapeutic) and pharmacological (when appropriate) and supplementary interventions, according to the individual symptoms, the level of functioning, participation, and the preferences of the patient and their social network.1 Classification of severity (mild, moderate, severe) should be based on the DSM-5TM, combining both severity of symptoms and level of functional impairment. An overview of the pharmacological and non-pharmacological treatments can be seen in the figure below.
Figure: Pharmacological and non-pharmacological management of ADHD. Figure developed using information from German guidelines 2018.1
Where pharmacological therapy is indicated, it is recommended that it be initiated by a qualified specialist with experience in that specific patient group. Treatment choice should take into account relevant factors such as the patient age, symptom and impairment severity, treatment preferences and efficacy of previous/ongoing psychosocial interventions. The guidelines also make recommendations across criteria for appropriate drug selection, examinations required prior to initiation of pharmacological therapy and other factors to be taken into account during treatment, including issues relating to adherence to treatment.1
When patients are non-responsive to treatment, the physician should confirm diagnosis, psychiatric comorbid conditions, attitudes to the interventions used, motivation towards treatment etc, as well as ensuring any pharmacological therapy was taken as prescribed, in an adequate dosage and without significant adverse events.1
When considering ADHD with comorbid psychiatric conditions, the German guidelines provide direction across their diagnosis and treatment. During diagnosis, if there are signs of comorbid psychiatric disorders, or if a differential diagnosis against other psychiatric disorders is required, it is recommended that the patient is referred to a specialist for diagnosis if needed. The guidelines recommend that comorbid psychiatric conditions should be treated in accordance with the relevant treatment guidelines, but the severity of the comorbid psychiatric disorders should be considered when deciding the treatment course to take and which disorder should be treated first. When considering pharmacological treatment, the guidelines recommend initial medication with stimulants for ADHD with comorbid antisocial personality disorder, tic disorder (alternatively atomoxetine or guanfacine) and anxiety disorders (alternatively atomoxetine); where there is an increased risk of improper use of stimulant medication, long-acting formulations should be considered.
The 2018 German guidelines for ADHD emphasise the multimodal management of ADHD in children, adolescents and adults, ensuring that both the severity of the disorder and patient/caregiver preferences are taken into account. The guidelines are the result of an in-depth interdisciplinary review of the evidence, and provide primary care physicians and medical specialists in Germany who treat patients with ADHD (children, adolescents or adults) with applicable recommendations to ensure individualised treatment for each patient.1
- Banaschewski T, Hohmann S, Millenet S, et al. Aufmerksamkeitsdefizit- / Hyperaktivitätsstörung (ADHS) im Kindes-, Jugend- und Erwachsenenalter. DGKJP, DGPPN and DGSPJ German guidelines. 2018.
- Ebert D, Krause J, Roth-Sackenheim C. ADHS im Erwachsenenalter – Leitlinien auf der Basis eines Expertenkonsensus mit Unterstützung der DGPPN. Nervenarzt 2003; 74: 939-946.