In 2018, a version of the German guidelines for the diagnosis and management of attention-deficit hyperactivity disorder (ADHD), or hyperkinetic disorder (HKD), in childhood, adolescence and adults was published,1 updating the 2003 Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde guidelines for ADHD in adults2 to 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 children, adolescents and adults with ADHD and in all care settings involved in the management of these individuals in Germany.1 This summary provides a brief overview of the recommendations set out in the 2018 guidelines on the diagnosis and management of ADHD in Germany, but it is not exhaustive of all recommendations and should not be used for diagnosis or treatment. Healthcare professionals should consult the full guidelines document, applicable for the diagnosis and management of ADHD in Germany.
These guidelines are directed at healthcare professionals in Germany, some of the medications recommended may not be approved in other countries.
The first section of guideline recommendations discusses the diagnosis of ADHD, and recommends 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 10th Revision (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5TM).1 Note that in 2018, the ICD-10 was updated to the International Classification of Diseases 11th Revision (ICD-11), where HKD is now referred to as ADHD.3 The German guidelines 2018 also outline the importance of various diagnostic methods, comprising self-assessment, questionnaires, behavioural observation, psychological tests and laboratory/instrument-based testing. Regarding age at diagnosis, the German guidelines 2018 note that the younger the individual, the more difficult it may be to distinguish symptoms of ADHD from normal variations in behaviour, and as such, a diagnosis of ADHD is not recommended to be made in those younger than 3 years. The diagnosis section of the guidelines also details those psychological disorders that are recommended to be considered during a differential diagnosis along with common psychiatric comorbidities that may impact on ADHD management, and which may require dedicated therapeutic management.1
Once a diagnosis of ADHD has been made, the guidelines recommend that all available management options are explained to the individual with ADHD and/or their carers, so all treatment decisions can be made in an informed manner and the individual is fully involved in the decision-making process. The German guidelines 2018 emphasise that treatment is recommended to be delivered in the context of a multimodal treatment plan, which may 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 individual and their social network. Classification of severity (mild, moderate, severe) is recommended to be based on the DSM-5TM, combining both severity of symptoms and level of functional impairment.1 An overview of the non-pharmacological and pharmacological treatments are outlined in Figure 1. In general, the guidelines recommend that psychosocial interventions should be tried first before pharmacological interventions.1
Figure 1: Non-pharmacological and pharmacological management of ADHD in children, adolescents and adults. Figure developed using information from the German guidelines 2018.1
The German guidelines 2018 for ADHD emphasise the multimodal management of ADHD in children, adolescents and adults, and recommend that both the severity of the disorder and individual or carer 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 children, adolescents or adults with ADHD with applicable recommendations to ensure individualised treatment.1
Where pharmacological therapy is indicated, it is recommended that it be initiated by a qualified specialist with experience in that specific age group. Treatment choice is recommended to take into account relevant factors such as the individual’s age, symptom and impairment severity, treatment preferences and efficacy of previous or ongoing psychosocial interventions. The German guidelines 2018 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 individuals with ADHD are non-responsive to treatment, it is recommended that the physician confirms the diagnosis, any psychiatric comorbid conditions, attitudes to the interventions used and motivation towards treatment, and ensures 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 2018 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 individual be referred to a specialist for diagnosis if needed. The guidelines recommend that comorbid psychiatric conditions are treated in accordance with the relevant treatment guidelines, but the severity of the comorbid psychiatric disorders is considered when deciding the treatment course to take and which disorder is treated first. When considering pharmacological treatment, the German guidelines 2018 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 are recommended to be considered.1
- Banaschewski T, Hohmann S, Millenet S. Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im Kindes-, Jugend- und Erwachsenenalter. DGKJP, DGPPN and DGSPJ German guidelines. 2018.
- Ebert D, Krause J, Roth-Sackenheim C. [ADHD in adulthood–guidelines based on expert consensus with DGPPN support]. Nervenarzt 2003; 74: 939-946.
- World Health Organization. ICD-11: International Classification of Diseases 11th Revision. 2018. Available at: https://icd.who.int/. Accessed January 2021.
- Shire Pharmaceuticals Ltd. Elvanse Adult Summary of Product Characteristics. Last updated November 2020.