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In 2018, the evidence-based guidelines for the diagnosis and management of attention-deficit hyperactivity disorder (ADHD), or hyperkinetic disorder (HKD), were published by the National Institute for Health and Care Excellence (NICE), with new and updated recommendations that built upon the guidelines originally released in 2008.1 While this summary provides a brief overview of some of the recommendations in the NICE guidelines 2018 on the diagnosis and management of ADHD, this is not exhaustive of all recommendations and should not be used for the diagnosis or treatment of ADHD. Healthcare professionals should consult the full NICE guideline document, which is available on the NICE website.

These guidelines are directed at healthcare professionals in the UK, some of the medications recommended may not be approved in other countries.

The first section of the NICE guidelines 2018 includes guidance on the services provided and departments involved, as well as cross-referencing with other NICE guidelines on transitioning children to adult services. Similarly, the guidance regarding identification and referral of suspected ADHD cases includes cross-referencing to NICE guidelines on antisocial behaviour and conduct disorders in children and young people, along with clarification specifying that parental support/training should be group-based and ADHD-focused. This section also includes guidance to make physicians aware of groups that may have an increased prevalence of ADHD.1

According to the NICE guidelines 2018, diagnosis of ADHD is recommended to be made according to the International Statistical Classification of Diseases and Related Health Problems, 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.2 The NICE guidelines 2018 also include a section that outlines available information and support across all aspects of life for individuals with ADHD, their families/carers and educational establishments, and for other relevant healthcare professionals (when co-existing conditions exist).1

To optimise management of ADHD, it is recommended that a treatment plan is developed. To ensure that individuals with ADHD and their families/carers are fully involved and have an understanding of the plan in place, the NICE guidelines 2018 include an overview of treatment planning to introduce ADHD management. It is recommended that individuals with ADHD have a comprehensive, holistic, shared treatment plan that takes into account multiple factors, including the severity of the disorder and treatment goals. To ensure that the treatment plan is tailored to the individual’s needs, physicians are recommended to discuss with the individual and their family/carer the potential benefits and negative effects of all available treatments, the potential benefits of a healthy lifestyle, individual preferences and the importance of adherence to treatment.1

Management recommendations are included for all age groups in the NICE guidelines 2018, covering non-pharmacological and pharmacological therapies. Information on baseline assessments prior to pharmacological treatment initiation are also included.1

Children with ADHD aged <5 years1:

  • Parents/carers of children under 5 years of age with ADHD are recommended to be offered an ADHD-focused group training programme as first-line treatment.
  • If ADHD symptoms still cause significant impairment in the child after group parental training and environmental modifications, a specialist ADHD service with expertise in managing ADHD in young children may be approached.
  • Medication for ADHD is not recommended for any child aged <5 years without a secondary specialist opinion from an ADHD service with expertise in managing the disorder in young children.

Children aged ≥5 years and young people with ADHD1:

  • Individual- or group-based education and support with environmental modification are recommended as first-line therapies for all individuals in this age group (irrespective of the severity of the disorder).
  • Medication is recommended to only be considered in those where ADHD symptoms continue to cause significant impairment.* Cognitive behavioural therapy may be considered in young people who have benefitted from medication but whose symptoms still cause significant impairment in one domain.
  • Treatment recommendations are not split between moderate and severe disorder groups within this age range.
  • Methylphenidate (either short- or long-acting) is recommended as a first-line pharmacological therapy.*
    • Switching to lisdexamfetamine may be considered in those who have had a 6-week trial of methylphenidate at an adequate dose with an inadequate response.
    • Dexamfetamine may be considered in those whose symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.

Atomoxetine or guanfacine can be offered to children aged ≥5 years* and young people with ADHD if they cannot tolerate methylphenidate or lisdexamfetamine, or if their symptoms have not responded to separate 6-week trials of methylphenidate and lisdexamfetamine, having considered alternative preparations and adequate dose.1

Adults1:

  • First-line pharmacological therapy is recommended to be initiated with either lisdexamfetamine or methylphenidate.
    • Switching to lisdexamfetamine or methylphenidate may be considered in those who have had a 6-week trial of lisdexamfetamine or methylphenidate at an adequate dose with an inadequate response.
    • Dexamfetamine may be considered in those whose symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.

Atomoxetine can be offered to adults with ADHD if they cannot tolerate lisdexamfetamine or methylphenidate, or if their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.1

For treatment of individuals with co-existing conditions, the NICE guidelines 2018 recommend that people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder are offered the same medication choices as other people with ADHD. It is also recommended that in children aged ≥5 years,* young people and adults with ADHD who experience an acute psychotic or manic episode, all ADHD medication is recommended to be stopped; re-initiation of medication may be considered after the episode has resolved.1

The NICE guidelines 2018 also include advice on medication choices beyond the first- and second-line pharmacotherapies if required, key considerations when prescribing ADHD medication (such as consideration of factors related to modified-release once-daily preparations, variance of effect size and duration of stimulants, and risks of stimulant misuse or diversion) and dose titration (including recommendations that titration be against symptoms and adverse effects in line with the British National Formulary [BNF]/BNF for Children, and that titration be slower in those with specific co-existing conditions). Once treatment dose has been stabilised, prescribing and monitoring of ADHD medication is recommended to be carried out under Shared Care Protocol arrangements with primary care.1

Guidance on maintenance and monitoring recommendations (including monitoring height, weight, cardiovascular parameters, tics, sexual dysfunction, seizures, sleep and behaviour), and on methods to improve adherence to treatment across both non-pharmacological and pharmacological therapies (including benefit/risk education) are included. Guidance on the management of ADHD concludes with recommendations regarding medication review and individual or carer discussions to determine whether treatment may be continued.1

The NICE guidelines 2018 emphasise the importance of individual preferences and needs. These guidelines are structured around services that assist physicians to provide a more holistic approach to the treatment of ADHD across the lifespan. The NICE guidelines 2018 are the result of a detailed review of available evidence, and while the application of these guidelines is not obligatory, healthcare professionals are recommended to take these guidelines into account alongside consideration of the needs, preferences and values of the individual with ADHD.1

 

*In the UK, guanfacine and atomoxetine are not approved to treat ADHD in children under 6 years of age.

 

  1. NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Accessed January 2021.
  2. World Health Organization. ICD-11: International Classification of Diseases 11th Revision. 2018. Available at: https://icd.who.int/. Accessed January 2021.
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