Nice Guidlelines of ADHD

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Attention deficit hyperactivity disorder: diagnosis and management

• NICE guideline
• Reference number:NG87
• Published: 14 March 2018
• Last updated: 13 September 2019

 

Attention deficit hyperactivity disorder (ADHD) is widely recognised as a complex neurodevelopmental disorder in childhood. It is marked by a ‘persistent pattern (at least six months) of inattention and/or hyperactivity-impulsivity that has a direct negative impact in more than one setting on academic, occupational, or social functioning’ (ICD-11; World Health Organization 2019). The eleventh revision of the International Classification of Diseases (ICD-11) identifies more indicative symptoms but is less prescriptive about diagnostic thresholds and allows milder presentations than the tenth version (ICD-10), which brings it more in line with the definition and criteria for ADHD in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association 2013; Gomez et al. 2023).

A recent meta-analysis estimated the prevalence of childhood ADHD (in children aged 3 to 12 years) as 7.6% and adolescent ADHD (young people aged 12 to 18 years) as 5.6% (Salari et al. 2023). The persistence of ADHD into adulthood has only gained significant recognition – and become a focus for research and clinical management – over the past two decades (Nutt et al. 2007). The National Institute for Health and Care Excellence (NICE) reviewed the diagnostic construct of ADHD across the lifespan and concluded that when ADHD persists into adulthood, it is often associated with significant impairment (NICE 2018, updated 2019). A meta-analysis focused on adults estimated the prevalence of persistent adult ADHD (with childhood onset) as 2.58% and symptomatic adult ADHD (regardless of childhood onset) as 6.76%, translating to 139.84 million and 366.33 million affected adults in 2020 globally (Song et al. 2021). The prevalence of both were found to decrease with advancing age.

Adults with ADHD tend to have fewer academic qualifications, probably because of difficulties with distractibility and restlessness, as well as problems with organising time, prioritising tasks and meeting deadlines (Nutt et al. 2007). Academic achievement and performance, however, can be improved with intervention (Arnold et al. 2020). APMS 2007 provided the first epidemiological data on the prevalence of ADHD characteristics in the adult population in England. Findings from APMS 2007 and 2014 found that screening positive for ADHD varied by relationship and household circumstances, and was more prevalent among those who were unemployed, in receipt of out-of-work benefits, or who had substance misuse disorders (McManus et al. 2009; McManus et al. 2016). 12% of treatment-seeking patients with substance abuse disorders (van de Glind et al. 2014) and 31% of ex-prisoners (Bebbington et al. 2021) have been found to screen positive for ADHD. It is associated with increased rates of criminal convictions (Lichtenstein et al. 2012), transport accidents (Chang et al. 2014), early mortality (Dalsgaard et al. 2015) and suicidal behaviour (Forte et al. 2020; Balazs et al. 2017). Additional costs to society may be incurred through absenteeism, reduced productivity and poorer work performance (Kessler et al. 2005a).

Findings from the 2007 and 2014 surveys indicated strong associations between screening positive for ADHD and other mental health conditions (McManus et al. 2009; McManus et al. 2016). Substantial increased risk for a range of other secondary mental health conditions has been found in people with ADHD (Nigg et al. 2020). These include meeting criteria for personality disorders, particularly those characterised by emotional instability such as antisocial personality disorder and borderline personality disorder. ADHD symptoms also commonly co-occur with other neurodevelopmental disorders such as autism and intellectual (learning) disability, and specific learning difficulties (Rong et al. 2021). This may result in additional or alternative diagnoses (Nutt et al. 2007; Asherson et al. 2022). ADHD in adults may also go unrecognised or be misdiagnosed by mental health professionals (Asherson 2005; Asherson et al. 2022) given that some characteristic features of ADHD are also seen in other psychiatric conditions, such as the disrupted concentration or agitation that can occur with depression, bipolar disorder, and generalized anxiety disorder (Choi et al. 2022; Milberger et al. 1995). If ADHD in adulthood is unrecognised due to comorbidity, service provision and treatment of other comorbid mental health conditions may be ineffective. Undiagnosed adults with ADHD have been found to experience worse general health than their diagnosed peers (Able et al. 2007).

Timely detection and treatment may moderate risks and improve outcomes in individuals diagnosed with ADHD (Shaw et al. 2012). Service provision and treatment for ADHD in childhood is now well established, but is much less available for adults with the condition including those seeking a diagnosis in adulthood (Smith et al. 2024; Price et al. 2024). In 2024, NHS England launched a new ADHD taskforce, bringing together expertise from across a range of sectors, including health, education and justice, to better understand the challenges affecting those with ADHD and help provide a joined-up approach in response to concerns around rising demand for services. ADHD was the second most viewed health condition on the NHS website in 2023, after COVID-19, with 4.3 million page views over the course of the year (NHS England 2024).

Information about the prevalence of screening positive for possible ADHD and the use of mental health services by adults presenting with characteristic features of ADHD in the population is essential for planning improvements in diagnosis and service provision. This chapter describes the general population distribution of characteristic behavioural symptoms associated with ADHD and changes over time, examines their association with age, gender, and sociodemographic characteristics, and profiles the use of mental health treatment and services.

Child and adult psychiatrists, paediatricians, and other child and adult mental health professionals (including those working in forensic services) should undertake training so that they are able to diagnose ADHD and provide treatment and management in accordance with this guideline. [2008]

1.2 Recognition, identification and referral

Recognition

1.2.1

Be aware that people in the following groups may have increased prevalence of ADHD compared with the general population:

• people born preterm (see NICE’s guideline on developmental follow-up of children and young people born preterm)
• looked-after children and young people
• children and young people diagnosed with oppositional defiant disorder or conduct disorder
• children and young people with mood disorders (for example, anxiety and depression)
• people with a close family member diagnosed with ADHD
• people with epilepsy
• people with other neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability [intellectual disability] and specific learning difficulties)
• adults with a mental health condition
• people with a history of substance misuse
• people known to the Youth Justice System or Adult Criminal Justice System
• people with acquired brain injury. [2018]

1.2.2

Be aware that ADHD is thought to be under-recognised in girls and women and that:

• they are less likely to be referred for assessment for ADHD
• they may be more likely to have undiagnosed ADHD
• they may be more likely to receive an incorrect diagnosis of another mental health or neurodevelopmental condition. [2018]

To find out why the committee made the 2018 recommendations on recognition and how they might affect practice, see the rationale and impact section on recognition .

Full details of the evidence and the committee’s discussion are in evidence review A: risk factors.

Identification and referral

1.2.3

Universal screening for ADHD should not be undertaken in nursery, primary and secondary schools. [2008]

1.2.4

When a child or young person with disordered conduct and suspected ADHD is referred to a school’s special educational needs coordinator (SENCO), the SENCO, in addition to helping the child with their behaviour, should inform the parents about local parent-training/education programmes. See NICE’s guideline on antisocial behaviour and conduct disorders in children and young people. [2008, amended 2018]

1.2.5

Referral from the community to secondary care may involve health, education and social care professionals (for example, GPs, paediatricians, educational psychologists, SENCOs, social workers) and care pathways can vary locally. The person making the referral to secondary care should inform the child or young person’s GP. [2008]

1.2.6

When a child or young person presents in primary care with behavioural and/or attention problems suggestive of ADHD, primary care practitioners should determine the severity of the problems, how these affect the child or young person and the parents or carers, and the extent to which they pervade different domains and settings. [2008]

1.2.7

If the child or young person’s behavioural and/or attention problems suggestive of ADHD 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 (this should not wait for a formal diagnosis of ADHD).

  If the behavioural and/or attention problems persist with at least moderate impairment, the child or young person should be referred to secondary care (that is, a child psychiatrist, paediatrician, or specialist ADHD CAMHS) for assessment. [2008, amended 2018]

1.2.8

If the child or young person’s behavioural and/or attention problems are associated with severe impairment, referral should be made directly to secondary care (that is, a child psychiatrist, paediatrician, or specialist ADHD CAMHS) for assessment. [2008]

1.2.9

Primary care practitioners should not make the initial diagnosis or start medication in children or young people with suspected ADHD. [2008]

1.2.10

Adults presenting with symptoms of ADHD in primary care or general adult psychiatric services, who do not have a childhood diagnosis of ADHD, should be referred for assessment by a mental health specialist trained in the diagnosis and treatment of ADHD, where there is evidence of typical manifestations of ADHD (hyperactivity/impulsivity and/or inattention) that:

• began during childhood and have persisted throughout life
• are not explained by other psychiatric diagnoses (although there may be other coexisting psychiatric conditions)
• have resulted in or are associated with moderate or severe psychological, social and/or educational or occupational impairment. [2008]

1.2.11

Adults who have previously been treated for ADHD as children or young people and present with symptoms suggestive of continuing ADHD should be referred to general adult psychiatric services for assessment. The symptoms should be associated with at least moderate or severe psychological and/or social or educational or occupational impairment. [2008]

1.3 Diagnosis

1.3.1

ADHD should only be diagnosed by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in diagnosing ADHD, on the basis of:

• a full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person’s everyday life and
• a full developmental and psychiatric history and
• observer reports and assessment of the person’s mental state. [2008]

  As an option, use QbTest to help diagnose ADHD in people aged 6 to 17 years as recommended in NICE’s diagnostics guidance on digital technologies for assessing ADHD. [2024]

1.3.2

A diagnosis of ADHD should not be made solely on the basis of rating scale or observational data. However, rating scales such as the Conners’ rating scales and the Strengths and Difficulties Questionnaire are helpful added tools, and observations (for example, at school) are useful when there is doubt about symptoms. [2008]

1.3.3

For an ADHD diagnosis, symptoms of hyperactivity, impulsivity or inattention should:

• meet the diagnostic criteria for hyperkinetic disorder in DSM‑5 or ICD‑11 (but exclusion based on a pervasive developmental disorder or an uncertain time of onset is not recommended) and
• cause at least moderate psychological, social, or educational or occupational impairment based on interview or direct observation in multiple settings and
• be happening often, occurring in 2 or more important settings including social, familial, educational or occupational settings. [2008, amended 2018]

 

As part of the diagnostic process, include an assessment of the person’s needs, coexisting conditions, social, familial and educational or occupational circumstances, and physical health. For children and young people, their parents’ or carers’ mental health should also be assessed. [2008, amended 2018]

1.3.5

Consider ADHD in all age groups, with symptom criteria adjusted for age-appropriate changes in behaviour. [2008]

1.3.6

Take children and young people’s views into account wherever possible when determining the clinical significance of impairment resulting from ADHD symptoms. [2008]

 

How is ADHD diagnosed?

Deciding if a person has ADHD is a process with several steps. There is no single test to diagnose ADHD, and many other problems, such as sleep disorders, anxiety, depression, and certain types of learning disabilities, can also have symptoms similar to ADHD.

 

 

Table 7DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison

DSM-5
Disorder Class: Neurodevelopmental Disorders
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 or older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 or older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless).
d. Often unable to play or take part in leisure activities quietly.
e. Is often “on the go” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
h. Often has trouble waiting his/her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings, (e.g., at home, school or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
Specify whether: Combined presentation: If enough symptoms of both criteria inattention and hyperactivity- impulsivity were present for the past 6 months Predominantly inattentive presentation: If enough symptoms of inattention, but not hyperactivity- impulsivity, were present for the past 6 months Predominantly hyperactive-impulsive presentation: If enough symptoms of hyperactivity-impulsivity but not inattention were present for the past 6 months. Specify if: In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still results in impairment in social, academic, or occupational functioning. Specify current severity: Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. Moderate: Symptoms or functional impairment between “mild” and “severe” are present. Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

 

 

ICD criteria for ADHD

The ICD-11 (6A05) defines ADHD as a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity that significantly impairs functioning in multiple settings. It is classified as a neurodevelopmental disorder (6A0) characterized by symptoms arising in childhood, with a 12-year-old threshold for onset. 

NHS England Digital +3

Key Components of ICD-11 Diagnosis:

• Core Symptom Clusters:
  • Inattention: Significant difficulty sustaining attention, distractibility, and organizational problems.
  • Hyperactivity/Impulsivity: Excessive motor activity, restlessness (specifically for adolescents/adults), and tendency to act without deliberation.
• Presentations (6A05):
  • 6A05.0: Predominantly inattentive.
  • 6A05.1: Predominantly hyperactive-impulsive.
  • 6A05.2: Combined.
  • 6A05.Y: Other specified presentation.
  • 6A05.Z: Presentation unspecified.
• Requirements:
  • Duration: Symptoms must persist for at least 6 months.
  • Pervasiveness: Must be evident in multiple settings (e.g., home, school, work).
  • Onset: Symptoms often emerge in early-to-mid childhood, though they may not be recognized until later.
  • Functional Impact: Direct negative impact on social, academic, or occupational functioning.
  • Differential Diagnosis: Symptoms are not better explained by another mental disorder (e.g., mood, anxiety, personality disorder)

 

MAJOR DIFFERENCES BETWEEN DSM-5-TR AND ICD-11

There are at least four major differences between DSM-5-TR and ICD-11 and their previous editions that are noteworthy of consideration.

Difference in splitting one inattentive symptom criterion

First, in contrast to DSM-5-TR which lists nine inattention (IA) symptoms, ICD-11 has 11 IA symptoms. The specific DSM-5-TR IA symptom for “Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities” is split into two separate IA symptoms in ICD-11: “Lacking attention to detail”, and “Making careless mistakes in school or work assignments”. This gives rise to the first extra symptom.

Additional IA and hyperactivity/IMP symptoms in ICD-11

In addition, the specific DSM-5-TR IA symptom “Is often forgetful in daily activities” is also partitioned into two separate similar IA symptoms in ICD-11: “Is forgetful in daily activities” and “Has difficulty remembering to complete upcoming daily tasks or activities”. This gives rise to the second extra symptom. A new IA symptom for ICD-11, not present in DSM-5-TR, is “Frequently appears to be daydreaming or to have mind elsewhere”. This is the third extra symptom. However, this symptom could be regarded as being more in line with the “sluggish cognitive tempo (SCT)” symptom when considered in light of the SCT literature[4]. In addition, the specific DSM-5-TR IA symptom “Often has trouble holding attention on tasks or play activities” is not present in ICD-11.

With reference to hyperactivity (HY)/impulsivity (IM) symptoms, ICD-11 lists 10. Two of these relate to overactive behavior: “Has difficulty sitting still without fidgeting” and “Feelings of physical restlessness, a sense of discomfort with being quiet or sitting still”. ICD-11 specifies that the former be applied to younger children, and the latter be applied to adolescents and adults (i.e., age 17 years or older). These can be regarded as developmental variants of the same symptom. For this reason, there are in reality 10 HY/IM symptoms in ICD-11. The symptom of “is often ‘on the go’, acting as if ‘driven by a motor….’ experienced by others as being restless…” in DSM-5-TR is absent in ICD-11; however, this could potentially be comparable to ‘feelings of physical restlessness’ in ICD-11. A new HY/IM symptom in ICD-11, which is absent in DSM-5-TR, is “A tendency to act in response to immediate stimuli without deliberation or consideration of risks and consequences (e.g., engaging in behaviors with potential for physical injury; impulsive decisions; reckless driving)”. This symptom captures the classical description of dispositional trait IM. In contrast, in DSM-5-TR, IM is solely represented by three directly observable behavioral symptoms (i.e., ‘blurt out’, ‘can’t wait’ and ‘interrupt’), as an absence of deliberation or risk consideration that cannot be directly observed, but often only inferred or disclosed by the actor upon retrospective reflection.

In summary, DSM-5-TR has nine IA and nine HY/IM symptoms, whereas ICD-11 has 11 IA and 11 HY/IM symptoms (but 10 if ‘fidgeting’ in children and ‘mental restlessness’ in adults are combined as one).

 

Comorbid conditions with ADHD

 

ADHD and Coexisting Conditions

 

Coexisting Disorder	Children with ADHD	Children without ADHD
Learning Disability	45%	5%
Conduct Disorder	27%	2%
Anxiety	18%	2%
Depression	15%	1%
Speech Problems	12%	3%

 

These are the most common co-occurring conditions in children and adolescents according to a study by Elia et al. (2008):

• Oppositional Defiance Disorder (ODD) was most common, appearing 41% of the time.
• Minor Depression/Dysthymia (MDDD) was second, with a rate of 22%.
• Generalized Anxiety Disorder (GAD) was third, appearing 15% of the time.

 

By ADHD Subtypes

 

Coexisting Condition	ADHD Inattentive	ADHD Hyperactive-Impulsive	ADHD Combined
Oppositional Defiance Disorder (ODD)	21%	42%	50.7%
Minor Depression/ Dysthymia (MDDD)	21%	21%	21.7%
Generalized Anxiety Disorder (GAD)	19%	19%	12.4%

 

Learning & Writing Disabilities

31% to 45% of children with ADHD have a learning disability, and vice versa (DuPaul 2013).

“It is estimated that as many as one-third of those with LD also have ADHD” (NCLD 2014).

Boys with ADHD have about a 65% risk of having writing disabilities, compared to 16.5% of boys without ADHD, while girls with ADHD have a 57% risk compared to a 9.4% risk for girls without ADHD (Yoshimasu 2011).

 

Heart Disease

ADHD appears to be more prevalent in children with heart disease. A study by Kraut et al. (2013) examined 13,460 children using ADHD medication and found that 2% had a preexisting heart disorder compared with 1.2% of children not using medication.

 

ADULTS

The prevalence of coexisting conditions found by the National Comorbidity Survey Replication (NCS-R) in 3,199 adults with ADHD (ages 18-44) is as follows (Kessler et al. 2006):

 

Coexisting Condition	Adults with ADHD	Adults without ADHD
Any mood disorder	38.3%	11.1%
Major depressive disorder	18.6%	7.8%
Dysthymia (mild, chronic depression)	12.3%	1.9%
Bipolar disorder	19.4%	3.1%
Any anxiety disorder	47.1%	19.5%
Generalized anxiety disorder	8.0%	2.6%
PTSD	11.9%	3.3%
Panic disorder	8.9%	3.1%
Agoraphobia	4.0%	0.7%
Specific phobia	22.7%	9.5%
Social phobia	29.3%	7.8%
Obsessive-compulsive disorder (OCD)	2.7%	1.3%
Any substance abuse disorder	15.2%	5.6%
Alcohol abuse	5.9%	2.4%
Alcohol dependence	5.8%	2.0%
Drug abuse	2.4%	1.4%
Drug dependence	4.4%	0.6%
Intermittent explosive disorder	19.6%	6.1%

 

Obesity

Obesity prevalence increases by about 70% in adults with ADHD compared to adults without ADHD. In children with ADHD, obesity prevalence increases by about 40% when compared to children without ADHD (Cortese, 2015).

Analysis of data from the Collaborative Psychiatric Epidemiology Surveys found the following association between adult ADHD and obesity (Pagoto, 2009):

 

Coexisting Condition	Adults with ADHD	Adults without ADHD
Overweight	33.0%	28.8%
Obese	29.4%	21.6%

 

 

Supporting people with ADHD

1.4.3

Following a diagnosis of ADHD, have a structured discussion with people (and their families or carers as appropriate) about how ADHD could affect their life. This could include:

• the positive impacts of receiving a diagnosis, such as:
  • improving their understanding of symptoms
  • identifying and building on individual strengths
  • improving access to services
• the negative impacts of receiving a diagnosis, such as stigma and labelling
• a greater tendency for impulsive behaviour
• the importance of environmental modifications to reduce the impact of ADHD symptoms
• education issues (for example, reasonable adjustments at school and college)
• employment issues (for example, impact on career choices and rights to reasonable adjustments in the workplace)
• social relationship issues
• the challenges of managing ADHD when a person has coexisting neurodevelopmental or mental health conditions
• the increased risk of substance misuse and self-medication
• the possible effect on driving (for example, ADHD symptoms may impair a person’s driving and ADHD medication may improve this; people with ADHD must declare their diagnosis to the DVLA if their ADHD symptoms or medication affect their ability to drive safely).

  This structured discussion should inform the shared treatment plan. [2018]

1.4.4

Inform people receiving a diagnosis of ADHD (and their families or carers as appropriate) about sources of information, including:

• local and national support groups and voluntary organisations
• websites
• support for education and employment.

  People who have had an assessment but whose symptoms and impairment fall short of a diagnosis of ADHD may benefit from similar information. [2018]

1.4.5

Provide information to people with ADHD (and their families and carers as appropriate) in a form that:

• takes into account their developmental level, cognitive style, emotional maturity and cognitive capacity, including any learning disabilities, sight or hearing problems, delays in language development or social communication difficulties
• takes into account any coexisting neurodevelopmental and mental health conditions
• is tailored to their individual needs and circumstances, including age, gender, educational level and life stage. [2018]

Supporting families and carers

1.4.6

Ask families or carers of people with ADHD how the ADHD affects themselves and other family members, and discuss any concerns they have. [2018]

1.4.7

Encourage family members or carers of people with ADHD to seek an assessment of their personal, social and mental health needs, and to join self-help and support groups if appropriate. [2018]

1.4.8

Think about the needs of a parent with ADHD who also has a child with ADHD, including whether they need extra support with organisational strategies (for example, with adherence to treatment, daily school routines). [2018]

1.4.9

Offer advice to parents and carers of children and young people with ADHD about the importance of:

• positive parent– and carer–child contact
• clear and appropriate rules about behaviour and consistent management
• structure in the child or young person’s day. [2018]

1.4.10

Offer advice to families and carers of adults with ADHD about:

• how ADHD may affect relationships
• how ADHD may affect the person’s functioning
• the importance of structure in daily activities. [2018]

1.4.11

Explain to parents and carers that any recommendation of parent-training/education does not imply bad parenting, and that the aim is to optimise parenting skills to meet the above-average parenting needs of children and young people with ADHD. [2018]

Involving schools, colleges and universities

1.4.12

When ADHD is diagnosed, when symptoms change, and when there is transition between schools or from school to college or college to university, obtain consent and then contact the school, college or university to explain:

• the validity of a diagnosis of ADHD and how symptoms are likely to affect school, college or university life
• other coexisting conditions (for example, learning disabilities) are distinct from ADHD and may need different adjustments
• the treatment plan and identified special educational needs, including advice for reasonable adjustments and environmental modifications within the educational placement
• the value of feedback from schools, colleges and universities to people with ADHD and their healthcare professionals. [2018]

Involving other healthcare professionals

1.4.13

When a person with ADHD has a coexisting condition, contact the relevant healthcare professional, with consent, to explain:

• the validity, scope and implications of a diagnosis of ADHD
• how ADHD symptoms are likely to affect the person’s behaviour (for example, organisation, time management, motivation) and adherence to specific treatments
• the treatment plan and the value of feedback from healthcare professionals. [2018]

To find out why the committee made the 2018 recommendations on information and support, and how they might affect practice, see the rationale and impact section on information and support .

Full details of the evidence and the committee’s discussion are in evidence review B: information and support.

1.5 Managing ADHD

Planning treatment

1.5.1

Healthcare providers should ensure continuity of care for people with ADHD. [2018]

1.5.2

Ensure that people with ADHD have a comprehensive, holistic shared treatment plan that addresses psychological, behavioural and occupational or educational needs. Take into account:

• the severity of ADHD symptoms and impairment, and how these affect or may affect everyday life (including sleep)
• their goals
• their resilience and protective factors
• the relative impact of other neurodevelopmental or mental health conditions. [2018]

1.5.3

Regularly discuss with people with ADHD, and their family members or carers, how they want to be involved in treatment planning and decisions; such discussions should take place at intervals to take account of changes in circumstances (for example, the transition from children’s to adult services) and developmental level, and should not happen only once. [2018]

1.5.4

Before starting any treatment for ADHD, discuss the following with the person, and their family or carers as appropriate, encouraging children and young people to give their own account of how they feel:

• the benefits and harms of non-pharmacological and pharmacological treatments (for example, the efficacy of medication compared with no treatment or non-pharmacological treatments, potential adverse effects and non-response rates)
• the benefits of a healthy lifestyle, including exercise
• their preferences and concerns (it is important to understand that a person’s decision to start, change or stop treatment may be influenced by media coverage, teachers, family members, friends and differing opinion on the validity of a diagnosis of ADHD)
• how other mental health or neurodevelopmental conditions might affect treatment choices
• the importance of adherence to treatment and any factors that may affect this (for example, it may be difficult to take medication at school or work, or to remember appointments).

  Record the person’s preferences and concerns in their treatment plan. [2018]

1.5.5

Ask young people and adults with ADHD if they wish a parent, partner, close friend or carer to join discussions on treatment and adherence. [2018]

1.5.6

Reassure people with ADHD, and their families or carers as appropriate, that they can revisit decisions about treatments. [2018]

To find out why the committee made the 2018 recommendations on managing ADHD – planning treatment, and how they might affect practice, see the rationale and impact section on managing ADHD – planning treatment .

Full details of the evidence and the committee’s discussion are in evidence review H: managing treatment.

Children under 5 years

These recommendations are for healthcare professionals with training and expertise in diagnosing and managing ADHD. See recommendation 1.4.3 for details of ADHD-focused information.

1.5.7

Offer an ADHD-focused group parent-training programme to parents or carers of children under 5 years with ADHD as first-line treatment. See recommendations 1.5.1 to 1.5.10 in NICE’s guideline on antisocial behaviour and conduct disorders in children and young people.

This does not imply that all children under 5 years with ADHD have antisocial behaviour or conduct disorder, but that the same general principles of care apply. [2018]

1.5.8

If after an ADHD-focused group parent-training programme, ADHD symptoms across settings are still causing a significant impairment in a child under 5 years after environmental modifications have been implemented and reviewed, obtain advice from a specialist ADHD service with expertise in managing ADHD in young children (ideally a tertiary service). [2018]

1.5.9

Do not offer medication for ADHD for any child under 5 years without a second specialist opinion from an ADHD service with expertise in managing ADHD in young children (ideally a tertiary service). [2018]

To find out why the committee made the 2018 recommendations on managing ADHD – children under 5 years, and how they might affect practice, see the rationale and impact section on managing ADHD – children under 5 years .

Full details of the evidence and the committee’s discussion are in evidence review E: non-pharmacological efficacy and adverse events and evidence review F: combination treatment.

Children aged 5 years and over and young people

These recommendations, covering children aged 5 years and over and young people, are for healthcare professionals with training and expertise in diagnosing and managing ADHD. March 2018 – medicines used for treating ADHD did not have a UK marketing authorisation for children aged 5 years or under (off-label use). See NICE’s information on prescribing medicines.

1.5.10

Give information about ADHD (see recommendation 1.4.3) and offer additional support to parents and carers of all children aged 5 years and over and young people with ADHD. The support should be ADHD focused, can be group based and as few as 1 or 2 sessions. It should include:

• education and information on the causes and impact of ADHD
• advice on parenting strategies
• with consent, liaison with school, college or university (see recommendation 1.4.12)
• both parents and carers if feasible. [2018]

1.5.11

If a child aged 5 years or over or young person has ADHD and symptoms of oppositional defiant disorder or conduct disorder, offer parents and carers a parent-training programme in line with recommendations 1.5.1 to 1.5.10 in NICE’s guideline on antisocial behaviour and conduct disorders in children and young people, as well as group-based ADHD-focused support. [2018]

1.5.12

Consider individual parent-training programmes for parents and carers of children and young people with ADHD and symptoms of oppositional defiant disorder or conduct disorder when:

• there are particular difficulties for families in attending group sessions (for example, because of disability, needs related to diversity such as language differences, learning disability [intellectual disability], parental ill-health, problems with transport, or where other factors suggest poor prospects for therapeutic engagement)
• a family’s needs are too complex to be met by group-based parent-training programmes. [2018]

1.5.13

Offer medication for children aged 5 years and over and young people only if:

• their ADHD symptoms are still causing a persistent significant impairment in at least one domain after environmental modifications have been implemented and reviewed
• they and their parents and carers have discussed information about ADHD (see recommendation 1.5.4)
• a baseline assessment has been carried out (see recommendation 1.7.4).

  See the recommendations on medication. [2018]

1.5.14

Consider a course of cognitive behavioural therapy (CBT) for young people with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain, addressing the following areas:

• social skills with peers
• problem-solving
• self-control
• active listening skills
• dealing with and expressing feelings. [2018]

To find out why the committee made the 2018 recommendations on managing ADHD – children aged 5 years and over and young people, and how they might affect practice, see the rationale and impact section on managing ADHD – children aged 5 years and over and young people .

Full details of the evidence and the committee’s discussion are in evidence review E: non-pharmacological efficacy and adverse events and evidence review F: combination treatment.

Adults

These recommendations are for healthcare professionals with training and expertise in diagnosing and managing ADHD. See recommendation 1.4.3 for details of ADHD-focused information.

1.5.15

Offer medication to adults with ADHD if their ADHD symptoms are still causing a significant impairment in at least one domain after environmental modifications have been implemented and reviewed. See the recommendations on medication choice. [2018]

1.5.16

Consider non-pharmacological treatment for adults with ADHD who have:

• made an informed choice not to have medication
• difficulty adhering to medication
• found medication to be ineffective or cannot tolerate it. [2018]

1.5.17

Consider non-pharmacological treatment in combination with medication for adults with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain. [2018]

1.5.18

When non-pharmacological treatment is indicated for adults with ADHD, offer the following as a minimum:

• a structured supportive psychological intervention focused on ADHD
• regular follow‑up either in person or by phone.

  Treatment may involve elements of or a full course of CBT. [2018]

To find out why the committee made the 2018 recommendations on managing ADHD – adults, and how they might affect practice, see the rationale and impact section on managing ADHD – adults .

Full details of the evidence and the committee’s discussion are in evidence review E: non-pharmacological efficacy and adverse events and evidence review F: combination treatment.

1.6 Dietary advice

1.6.1

Healthcare professionals should stress the value of a balanced diet, good nutrition and regular exercise for children, young people and adults with ADHD. [2008]

1.6.2

Do not advise elimination of artificial colouring and additives from the diet as a generally applicable treatment for children and young people with ADHD. [2016]

1.6.3

Ask about foods or drinks that appear to influence hyperactive behaviour as part of the clinical assessment of ADHD in children and young people, and:

• if there is a clear link, advise parents or carers to keep a diary of food and drinks taken and ADHD behaviour
• if the diary supports a relationship between specific foods and drinks and behaviour, offer referral to a dietitian
• ensure that further management (for example, specific dietary elimination) is jointly undertaken by the dietitian, mental health specialist or paediatrician, and the parent or carer and child or young person. [2016]

1.6.4

Do not advise or offer dietary fatty acid supplementation for treating ADHD in children and young people. [2016]

1.6.5

Advise the family members or carers of children with ADHD that there is no evidence about the long-term effectiveness or potential harms of a ‘few food’ diet for children with ADHD, and only limited evidence of short-term benefits. [2016]

1.7 Medication

These recommendations, with the exception of recommendation 1.7.29, are for healthcare professionals with training and expertise in diagnosing and managing ADHD.

1.7.1

Use this guideline with NICE’s guideline on medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. [2018]

1.7.2

All medication for ADHD should only be initiated by a healthcare professional with training and expertise in diagnosing and managing ADHD. [2018]

1.7.3

Healthcare professionals initiating medication for ADHD should:

• be familiar with the pharmacokinetic profiles of all the short- and long-acting preparations available for ADHD
• ensure that treatment is tailored effectively to the individual needs of the child, young person or adult
• take account of variations in bioavailability or pharmacokinetic profiles of different preparations to avoid reduced effect or excessive adverse effects. [2018]

Baseline assessment

1.7.4

Before starting medication for ADHD, people with ADHD should have a full assessment, which should include:

• a review to confirm they continue to meet the criteria for ADHD and need treatment
• a review of mental health and social circumstances, including:
  • presence of coexisting mental health and neurodevelopmental conditions
  • current educational or employment circumstances
  • risk assessment for substance misuse and drug diversion
  • care needs
• a review of physical health, including:
  • a medical history, taking into account conditions that may be contraindications for specific medicines
  • current medication
  • height and weight (measured and recorded against the normal range for age, height and sex)
  • baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
  • a cardiovascular assessment.

    An electrocardiogram (ECG) is not needed before starting stimulants, atomoxetine or guanfacine, unless the person has any of the features in recommendation 1.7.5, or a co-existing condition that is being treated with a medicine that may pose an increased cardiac risk. [2018, amended 2019]

1.7.5

Refer for a cardiology opinion before starting medication for ADHD if any of the following apply:

• history of congenital heart disease or previous cardiac surgery
• history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
• shortness of breath on exertion compared with peers
• fainting on exertion or in response to fright or noise
• palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
• chest pain suggesting cardiac origin
• signs of heart failure
• a murmur heard on cardiac examination
• blood pressure that is classified as hypertensive for adults (see NICE’s guideline on hypertension in adults). [2018]

1.7.6

Refer to a paediatric hypertension specialist before starting medication for ADHD if blood pressure is consistently above the 95th centile for age and height for children and young people. [2018]

To find out why the committee made the 2018 recommendations on medication – baseline assessment, and how they might affect practice, see the rationale and impact section on medication – baseline assessment .

Full details of the evidence and the committee’s discussion are in evidence review D: pharmacological safety.

Medication choice – children aged 5 years and over and young people

Recommendations 1.7.7 to 1.7.10 update NICE’s technology appraisal guidance on methylphenidate, atomoxetine and dexamfetamine for ADHD in children and adolescents (TA98).

1.7.7

Offer methylphenidate (either short or long acting) as the first line pharmacological treatment for children aged 5 years and over and young people with ADHD.

March 2018 – this is an off-label use for children aged 5 years. See NICE’s information on prescribing medicines. [2018]

1.7.8

Consider switching to lisdexamfetamine for children aged 5 years and over and young people who have had a 6‑week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment.

March 2018 – this is an off-label use for children aged 5 years. See NICE’s information on prescribing medicines. [2018]

1.7.9

Consider dexamfetamine for children aged 5 years and over and young people whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.

March 2018 – dexamfetamine is only licensed to treat ADHD in children and young people aged 6 to 17 years when response to methylphenidate is clinically inadequate. It is not licensed for children and young people aged 5 to 17 years who have responded to but are intolerant of lisdexamfetamine.See NICE’s information on prescribing medicines. [2018]

1.7.10

Offer atomoxetine or guanfacine to children aged 5 years and over and young people if:

• they cannot tolerate methylphenidate or lisdexamfetamine or
• their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

  March 2018 – this is an off-label use of atomoxetine and guanfacine for children aged 5 years. See NICE’s information on prescribing medicines. [2018]

Medication choice – adults

1.7.11

Offer lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adults with ADHD.

March 2018 – this is an off-label use of lisdexamfetamine for adults with no ADHD symptoms in childhood. See NICE’s information on prescribing medicines. Not all preparations of methylphenidate are licensed for treating symptoms of ADHD in adults. [2018]

1.7.12

Consider switching to lisdexamfetamine for adults who have had a 6‑week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment. [2018]

1.7.13

Consider switching to methylphenidate for adults who have had a 6‑week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment. [2018]

1.7.14

Consider dexamfetamine for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.

March 2018 – this is an off-label use of dexamfetamine. See NICE’s information on prescribing medicines. [2018]

1.7.15

Offer atomoxetine to adults if:

• they cannot tolerate lisdexamfetamine or methylphenidate or
• their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

  March 2018 – this is an off-label use of atomoxetine for adults with no ADHD symptoms in childhood. See NICE’s information on prescribing medicines. [2018]

Further medication choices

1.7.16

Obtain a second opinion or refer to a tertiary service if ADHD symptoms in a child aged 5 years or over, a young person or adult are unresponsive to one or more stimulants and one non-stimulant. [2018]

1.7.17

Do not offer any of the following medication for ADHD without advice from a tertiary ADHD service:

• guanfacine for adults (off-label use)
• clonidine for children with ADHD and sleep disturbance, rages or tics (off-label use)
• atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability
• medication not included in recommendations 1.7.7 to 1.7.15.

  See NICE’s information on prescribing medicines. [2018]

Medication choice – people with coexisting conditions

1.7.18

Offer the same medication choices to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD. [2018]

1.7.19

For children aged 5 years and over, young people and adults with ADHD experiencing an acute psychotic or manic episode:

• stop any medication for ADHD
• consider restarting or starting new ADHD medication after the episode has resolved, taking into account the individual circumstances, risks and benefits of the ADHD medication. [2018]

To find out why the committee made the 2018 recommendations on medication choice, and how they might affect practice, see the rationale and impact section on medication – choice .

Full details of the evidence and the committee’s discussion are in evidence review C: pharmacological efficacy and sequencing.

Considerations when prescribing ADHD medication

1.7.20

When prescribing stimulants for ADHD, think about modified-release once-daily preparations for the following reasons:

• convenience
• improving adherence
• reducing stigma (because there is no need to take medication at school or in the workplace)
• reducing problems of storing and administering controlled drugs at school
• the risk of stimulant misuse and diversion with immediate-release preparations
• their pharmacokinetic profiles.

  Immediate-release preparations may be suitable if more flexible dosing regimens are needed, or during initial titration to determine correct dosing levels. [2018]

1.7.21

When prescribing stimulants for ADHD, be aware that effect size, duration of effect and adverse effects vary from person to person. [2018]

1.7.22

Think about using a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect. [2018]

1.7.23

Be cautious about prescribing stimulants for ADHD if there is a risk of diversion for cognitive enhancement or appetite suppression. [2018]

1.7.24

Do not offer immediate-release stimulants or modified-release stimulants that can be easily injected or insufflated if there is a risk of stimulant misuse or diversion. [2018]

1.7.25

Prescribers should be familiar with the requirements of controlled drug legislation governing the prescription and supply of stimulants. See NICE’s guideline on controlled drugs. [2018]

Dose titration

1.7.26

During the titration phase, ADHD symptoms, impairment and adverse effects should be recorded at baseline and at each dose change on standard scales by parents and teachers, and progress reviewed regularly (for example, by weekly telephone contact) with a specialist. [2018]

1.7.27

Titrate the dose against symptoms and adverse effects in line with the BNF or BNF for Children until dose optimisation is achieved, that is, reduced symptoms, positive behaviour change, improvements in education, employment and relationships, with tolerable adverse effects. [2018]

1.7.28

Ensure that dose titration is slower and monitoring more frequent if any of the following are present in people with ADHD:

• neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability [intellectual disability])
• mental health conditions (for example, anxiety disorders [including obsessive–compulsive disorder], schizophrenia or bipolar disorder, depression, personality disorder, eating disorder, post-traumatic stress disorder, substance misuse)
• physical health conditions (for example, cardiac disease, epilepsy or acquired brain injury). [2018]

To find out why the committee made the 2018 recommendations on medication – considerations when prescribing and dose titration, and how they might affect practice, see the rationale and impact section on medication – considerations when prescribing and dose titration .

Full details of the evidence and the committee’s discussion are in evidence review D: pharmacological safety.

Shared care for medication

1.7.29

After titration and dose stabilisation, prescribing and monitoring of ADHD medication should be carried out under Shared Care Protocol arrangements with primary care. [2018]

To find out why the committee made the 2018 recommendations on medication – care arrangements, and how they might affect practice, see the rationale and impact section on medication – care arrangements .

Full details of the evidence and the committee’s discussion are in evidence review D: pharmacological safety.

1.8 Maintenance and monitoring

1.8.1

Monitor effectiveness of medication for ADHD and adverse effects, and document in the person’s notes. [2018]

1.8.2

Encourage people taking medication for ADHD to monitor and record their adverse effects, for example, by using an adverse effect checklist. [2018]

1.8.3

Consider using standard symptom and adverse effect rating scales for clinical assessment and throughout the course of treatment for people with ADHD. [2018]

1.8.4

Ensure that children, young people and adults receiving treatment for ADHD have review and follow‑up according to the severity of their condition, regardless of whether or not they are taking medication. [2018]

Height and weight

1.8.5

For people taking medication for ADHD:

• measure height every 6 months in children and young people
• measure weight every 3 months in children 10 years and under
• measure weight at 3 and 6 months after starting treatment in children over 10 years and young people, and every 6 months thereafter, or more often if concerns arise
• measure weight every 6 months in adults
• plot height and weight of children and young people on a growth chart and ensure review by the healthcare professional responsible for treatment. [2018]

1.8.6

If weight loss is a clinical concern, consider the following strategies:

• taking medication either with or after food, rather than before meals
• taking additional meals or snacks early in the morning or late in the evening when stimulant effects have worn off
• obtaining dietary advice
• consuming high-calorie foods of good nutritional value
• taking a planned break from treatment
• changing medication. [2018]

1.8.7

If a child or young person’s height over time is significantly affected by medication (that is, they have not met the height expected for their age), consider a planned break in treatment over school holidays to allow ‘catch‑up’ growth. [2018]

1.8.8

Consider monitoring BMI of adults with ADHD if there has been weight change as a result of their treatment, and changing the medication if weight change persists. [2018]

Cardiovascular

1.8.9

Monitor heart rate and blood pressure and compare with the normal range for age before and after each dose change and every 6 months. [2018]

1.8.10

Do not offer routine blood tests (including liver function tests) or ECGs to people taking medication for ADHD unless there is a clinical indication. [2018]

1.8.11

If a person taking ADHD medication has sustained resting tachycardia (more than 120 beats per minute), arrhythmia or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on 2 occasions, reduce their dose and refer them to a paediatric hypertension specialist or adult physician. [2018]

1.8.12

If a person taking guanfacine has sustained orthostatic hypotension or fainting episodes, reduce their dose or switch to another ADHD medication. [2018]

Tics

1.8.13

If a person taking stimulants develops tics, think about whether:

• the tics are related to the stimulant (tics naturally wax and wane) and
• the impairment associated with the tics outweighs the benefits of ADHD treatment. [2018]

1.8.14

If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine (off-label use for adults with no ADHD symptoms in childhood), clonidine (off-label use for children)^, or stopping medication.

Clonidine should only be considered for people under 18 years after advice from a tertiary ADHD service. [2018]

Sexual dysfunction

1.8.15

Monitor young people and adults with ADHD for sexual dysfunction (that is, erectile and ejaculatory dysfunction) as potential adverse effects of atomoxetine. [2018]

Seizures

1.8.16

If a person with ADHD develops new seizures or a worsening of existing seizures, review their ADHD medication and stop any medication that might be contributing to the seizures. After investigation, cautiously reintroduce ADHD medication if it is unlikely to be the cause of the seizures. [2018]

Sleep

1.8.17

Monitor changes in sleep pattern (for example, with a sleep diary) and adjust medication accordingly. [2018]

Worsening behaviour

1.8.18

Monitor the behavioural response to medication, and if behaviour worsens adjust medication and review the diagnosis. [2018]

Stimulant diversion

1.8.19

Healthcare professionals and parents or carers should monitor changes in the potential for stimulant misuse and diversion, which may come with changes in circumstances and age. [2018]

To find out why the committee made the 2018 recommendations on medication – monitoring adverse effects, and how they might affect practice, see the rationale and impact section on medication – monitoring effectiveness and adverse effects .

Full details of the evidence and the committee’s discussion are in evidence review D: pharmacological safety.

1.9 Adherence to treatment

1.9.1

Use this guideline with NICE’s guideline on medicines adherence to improve the care for adults with ADHD. The principles also apply to children and young people. [2018]

1.9.2

Be aware that the symptoms of ADHD may lead to people having difficulty adhering to treatment plans (for example, remembering to order and collect medication). [2018]

1.9.3

Ensure that people are fully informed of the balance of risks and benefits of any treatment for ADHD and check that problems with adherence are not due to misconceptions (for example, tell people that medication does not change personality). [2018]

1.9.4

Encourage the person with ADHD to use the following strategies to support adherence to treatment:

• being responsible for their own health, including taking their medication as needed
• following clear instructions about how to take the medication in picture or written format, which may include information on dose, duration, adverse effects, dosage schedule (the instructions should stay with the medication, for example, a sticker on the side of the packet)
• using visual reminders to take medication regularly (for example, apps, alarms, clocks, pill dispensers, or notes on calendars or fridges)
• taking medication as part of their daily routine (for example, before meals or after brushing teeth)
• attending peer support groups (for both the person with ADHD and for the families and carers). [2018]

1.9.5

Encourage parents and carers to oversee ADHD medication for children and young people. [2018]

Supporting adherence to non-pharmacological treatments

1.9.6

Support adherence to non-pharmacological treatments (for example, CBT) by discussing the following:

• the balance of risks and benefits (for example, how the treatment can have a positive effect on ADHD symptoms)
• the potential barriers to continuing treatment, including:
  • not being sure if it is making any difference
  • the time and organisational skills needed to commit to the treatment
  • the time that might be needed outside of the sessions (for example, to complete homework)
• strategies to deal with any identified barriers (for example, scheduling sessions to minimise inconvenience or seeking courses with child care provision)
• a possible effect of treatment being increased self-awareness, and the challenging impact this may have on the person and the people around them
• the importance of long-term adherence beyond the duration of any initial programme (for example, by attending follow‑up/refresher support to sustain learned strategies). [2018]

To find out why the committee made the 2018 recommendations on adherence to treatment and how they might affect practice, see the rationale and impact section on adherence to treatment .

Full details of the evidence and the committee’s discussion are in evidence review G: adherence.

1.10 Review of medication and discontinuation

1.10.1

A healthcare professional with training and expertise in managing ADHD should review ADHD medication at least once a year and discuss with the person with ADHD (and their families and carers as appropriate) whether medication should be continued. The review should include a comprehensive assessment of the:

• preference of the child, young person or adult with ADHD (and their family or carers as appropriate)
• benefits, including how well the current treatment is working throughout the day
• adverse effects
• clinical need and whether medication has been optimised
• impact on education and employment
• effects of missed doses, planned dose reductions and periods of no treatment
• effect of medication on existing or new mental health, physical health or neurodevelopmental conditions
• need for support and type of support (for example, psychological, educational, social) if medication has been optimised but ADHD symptoms continue to cause a significant impairment. [2018]

1.10.2

Encourage people with ADHD to discuss any preferences to stop or change medication and to be involved in any decisions about stopping treatments. [2018]

1.10.3

Consider trial periods of stopping medication or reducing the dose when assessment of the overall balance of benefits and harms suggests this may be appropriate. If the decision is made to continue medication, the reasons for this should be documented. [2018]

To find out why the committee made the 2018 recommendations on review of medication and discontinuation, and how they might affect practice, see the rationale and impact section on review of medication and discontinuation .

Full details of the evidence and the committee’s discussion are in evidence review I: withdrawal and drug holidays.

Terms used in this guideline

Domains

Domains refer to areas of function, for example, interpersonal relationships, education and occupational attainment, and risk awareness.

Environmental modifications

Environmental modifications are changes that are made to the physical environment in order to minimise the impact of a person’s ADHD on their day-to-day life. Appropriate environmental modifications will be specific to the circumstances of each person with ADHD and should be determined from an assessment of their needs. Examples may include changes to seating arrangements, changes to lighting and noise, reducing distractions (for example, using headphones), optimising work or education to have shorter periods of focus with movement breaks (including the use of ‘I need a break’ cards), reinforcing verbal requests with written instructions and, for children, the appropriate use of teaching assistants at school.

Reasonable adjustments

Reasonable adjustments is a term that refers to the legal obligations of employers and higher education providers to make sure that workers or students with disabilities, or physical or mental health conditions are not substantially disadvantaged when doing their jobs or during their education.

Settings

Settings refer to the physical location, for example, home, nursery, friends or family homes.

Shared treatment plan

A written treatment plan shared between healthcare professional and the person with ADHD; for children, this may be shared more widely (for example, with families, schools or social care, if relevant and agreed).