Dr Shahid Ahmad discusses the diagnosis and treatment of attention deficit hyperactivity disorder in children and adolescents
  • ADHD has a serious impact on the lives of individuals and families
  • The symptoms of ADHD results in significant impairment in psychosocial and educational domains, and may change over time
  • Primary care is well placed to identify people with ADHD although GPs should not make the initial diagnosis or start drug treatment
  • Diagnosis is based on:
    • history
    • mental state examination
    • physical examination
    • social and family assessment
    • investigations
  • Treatment options for ADHD include psychological therapies and pharmacotherapy
  • Implementation of the NICE guideline on ADHD has led to the establishment of specialist multidisciplinary teams, parent-training programmes, and care pathways; it is important to ensure that patients are able to access appropriate treatment.

ADHD=attention deficit hyperactivity disorder


NICE Clinical Guideline 72 on Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults has been awarded the NHS Evidence Accreditation Mark.
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed neurodevelopmental disorders.1 It is a lifespan disorder that can have a serious negative impact on the lives of individuals and their families. To date, the majority of ADHD research has been focused on boys; however there are many girls with ADHD who remain undiagnosed as they have low levels of over activity and few conduct problems.2

Attention deficit hyperactivity disorder is considered as a disorder of executive functions (i.e. it affects the individual's ability to organise, plan, and attend to and remember relevant information). The pathophysiology of ADHD is poorly understood: there is evidence that dopaminergic and noradrenergic pathways are involved in the genesis of ADHD3 and there may be a genetic predisposition to the condition.4

NICE Clinical Guideline (CG) 72 on ADHD covers the care, treatment, and support of children, young people, and adults;5 treatment of children younger than 3 years or treatment of co-morbid conditions is outside of its scope. This personal view article focuses on ADHD in children and adolescents.

Implementation of NICE CG72 on ADHD has led to the establishment of specialist multidisciplinary teams, parent-training programmes, and appropriate care pathways; however, myths, misperceptions, and stigma still exist, and despite the availability of evidence-based interventions many children and adolescents still do not receive appropriate treatment.


Presentation of ADHD in children and adolescents

Key symptoms of ADHD include:5

  • poor attention and concentration
  • overactivity/fidgetiness
  • impulsivity
  • distractibility
  • poor sense of danger
  • underachievement
  • sleep difficulties
  • deficiency in emotional self control.

The above problems are usually pervasive in nature, occur across a range of situations, and result in significant functional impairment in psychosocial and educational domains. Children with ADHD are impulsive and act without thinking. They are prone to accidents, and are frequent visitors to GP surgeries and accident and emergency departments.6 The symptoms of ADHD continue to change over time: hyperactivity decreases with age; however, impulsivity and poor attention remain the same.7

Diagnosis of ADHD

General practitioners are well placed to observe and identify children with ADHD; however, this is a challenging task, because co-morbidities such as anxiety disorders, bipolar disorders, depression, dyspraxia, Tourette's syndrome, and epilepsy influence the clinical picture, and cause diagnostic confusion.

It has been reported that approximately 20% of children with epilepsy have clinical ADHD, and that children with ADHD have a higher rate of electroencephalographic abnormalities.8

Heavy alcohol consumption, drug abuse, and smoking during pregnancy, and premature birth are risk factors for the development of ADHD;9 and a history of these should alert the GP to the possibility of this condition. According to NICE CG72, primary care practitioners should not make the initial diagnosis of ADHD or start drug treatment; this should be performed by a specialist.5

The diagnosis of ADHD is based on the following:5

  • history
  • mental state examination
  • physical examination
  • social and family assessment
  • investigations (e.g. school reports and observations and use of appropriate rating scales).

Principles of treatment

According to the NICE recommendations, all children and adolescents with ADHD should be treated in the context of an integrated multimodal care plan, delivered by a suitably trained multidisciplinary team, and in close liaison with the child's school.5 It is recommended that professionals managing ADHD should be familiar with local and national guidelines on confidentiality, the rights of the child, the child's level of understanding, parental consent and responsibilities, and child protection issues.5

Treatment of ADHD

Clinicians should clarify the nature of ADHD and its co-morbidities. It is important to deal with myths, misperceptions, and stigma. Information should be given about local and national support groups and voluntary organisations.

Treatment approaches to ADHD include:5

  • psychological therapies
  • pharmacotherapy.

Psychological therapies

It is recommended that children and adolescents with mild ADHD receive a trial of psychological therapies first. This should focus on problem solving, social-skills training, and improving peer relationships. Parents should be given an opportunity to benefit from parent-training/education programmes. If these interventions do not help, medication should then be considered.5

Pharmacotherapy

The following pharmacological treatment options for ADHD are recommended by NICE:5,10

  • methylphenidate hydrochloride (longer-acting formulations are recommended because of the convenience of a once-daily dose, confidentiality at school, and better compliance).
  • atomoxetine
  • dexamphetamine sulphate.

Full details of the NICE recommendations on the use of these therapies in the treatment of ADHD in children and adolescents are available in Technology Appraisal 98.10

It is good clinical practice to start with a low dose of medication and increase slowly. If there is more than one drug that is appropriate, the product with the lowest cost should be prescribed.10 The use of antipsychotics for treatment of ADHD is not recommended by NICE.5

Conclusion

The publication of NICE CG72 has helped to increase GP awareness of ADHD and the guideline provides advice on when it is appropriate to refer to specialist ADHD teams. It has facilitated shared-care arrangements and improved communications between primary and secondary care teams, and provided healthcare professionals with a framework for evidence-based practice, enabling them to provide need-sensitive care.


View the Guidelines summary of the NICE guideline on diagnosis and management
of ADHD in children, young people and adults at: egln.co.uk/go/4421

  • CCGs should review their commissioned services to ensure they meet the recommendations laid out by NICE, and provide an easily identified referral pathway for GPs to follow
  • Awareness programs for ADHD could be made available to local health and educational staff to ensure accurate case finding
  • CCGs should consider shared-care agreements between secondary and primary care services for those patients receiving pharmacotherapy to ensure accurate prescribing and appropriate monitoring
  • Diagnosis of ADHD and initiation of pharmacotherapy should always be made by specialists
  • CCGs should consider and address the needs of patients with ADHD in transition from paediatric to adult services to avoid any disruption to their care.

CCG=clinical commissioning groups; ADHD=attention deficit hyperactivity disorder

  1. Ohashi K, Vitaliano G, Polcari A, Teicher M. Unraveling the nature of hyperactivity in children with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2010; 67 (4): 388–396.
  2. Biederman J, Kwon A, Alreadi M et al. Absence on gender effects on attention deficit hyperactivity disorder: findings in non-referred subjects. Am J Psychiatry 2005; 6: 1083–1089.
  3. Engert V, Pruessner J. Dopaminergic and noradrenergic contributions to functionality in ADHD: the role of methylphenidate. Curr Neuropharmacol 2008; 6 (4): 322–328.
  4. Faraone S, Perlis R, Doyle A et al. Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry 2005; 57 (11): 1313–1323.
  5. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. Clinical Guideline 72. London: NICE, 2008. Available at: www.nice.org.uk/guidance/CG72 nhs_accreditation
  6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington: American Psychiatric Association, 2004.
  7. Biederman J, Mick E, Faraone S. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry 2000; 157 (5): 816–818.
  8. Kaufmann R, Goldberg-Stern H, Shuper A. Attention-deficit disorders and epilepsy in childhood: incidence, causative relations and treatment possibilities. Child Neurol 2009; 24 (6): 727–733.
  9. Banerjee T, Middleton F, Faraone S. Environmental risk factors for attention-deficit hyperactivity disorder. Acta Paediatrica 2007; 96 (9): 1269–1274.
  10. National Institute for Health and Care Excellence. Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Technology Appraisal 98. London: NICE, 2006. Available at: www.nice.org.uk/guidance/TA98 G