Introduction

This quality standard covers the diagnosis and management of attention deficit hyperactivity disorder (ADHD) in children aged 3 years and older, young people and adults. For more information see the ADHD overview.

Why this quality standard is needed

ADHD is a behavioural syndrome characterised by the core symptoms of hyperactivity, impulsivity and inattention. Although these symptoms tend to cluster together, some people are predominantly hyperactive and impulsive, whereas others are primarily inattentive.

Two main diagnostic criteria are currently in use – the 'International Classification of Mental and Behavioural Disorders 10th revision' (ICD-10) and the 'Diagnostic and Statistical Manual of Mental Disorders 4th edition'[1] (DSM-IV). Instead of referring to ADHD, ICD-10 uses the term hyperkinetic disorder, which is defined using more stringent diagnostic criteria than DSM-IV uses to define ADHD. DSM-IV uses a broader definition which includes a number of different ADHD subtypes. Hyperkinetic disorder broadly corresponds to the DSM-IV ADHD combined subtype. Although ICD-10 excludes any comorbidity, coexisting conditions are accepted as a common aspect of the diagnosis and treatment of ADHD.

Based on the narrower criteria of ICD-10, hyperkinetic disorder is estimated to occur in 1–2% of children and young people in the UK. Using the broader criteria of DSM-IV, ADHD is thought to affect about 3–9% of school-age children and young people in the UK. The Health and Social Care Information Centre's Adult Psychiatric Morbidity in England – 2007 survey estimated that 8% of adults in England have ADHD.

Symptoms of ADHD can overlap with symptoms of other related disorders. Common coexisting conditions in children with ADHD include anxiety disorders and disorders of mood, conduct, learning, motor control and social communication; in adults they include personality disorders, bipolar disorder, obsessive–compulsive disorder and substance misuse.

How this quality standard supports delivery of outcome frameworks

NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 The Adult Social Care Outcomes Framework 2013–14

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life*

Outcome measures

People manage their own support as much as they wish, so that are in control of what, how and when support is delivered to match their needs.

1B Proportion of people who use services who have control over their daily life

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation.

1H Proportion of adults in contact with secondary mental health services living independently, with or without support**

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services.

3A Overall satisfaction of people who use services with their care and support

Outcome measures

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help.

3D The proportion of people who use services and carers who find it easy to find information about support

Aligning across the health and care system

* Indicator complementary

** Indicator shared

Table 2 NHS Outcomes Framework 2013/14

Domain

Overarching indicators and improvement areas

2 Enhancing quality of life for people with long‑term conditions

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition**

4 Ensuring that people have a positive experience of care

Improvement areas

Improving the experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Alignment across the health and social care system

** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)

Table 3 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

1.3 Pupil absence

1.4 First-time entrants to the youth justice system

1.5 16–18 year olds not in education, employment or training

1.6 People with mental illness or disability not in settled accommodation**

1.7 People in prison who have a mental illness or significant mental illness

1.8 Employment for those with a long-term health condition including those with a learning difficulty/disability or mental illness

2 Health improvement

Objective

People are helped to live health lifestyles, make healthy choices and reduce health inequalities

2.8 Emotional wellbeing of looked-after children

Alignment across the health and social care system

** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)

Coordinated services

The quality standard for ADHD specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole ADHD care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care people with ADHD.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality ADHD service are listed in Related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care practitioners involved in assessing, caring for and treating children, young people and adults with ADHD should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.



[1] NICE clinical guideline 72, the source guidance for this quality standard, used the 'Diagnostic and Statistical Manual of Mental Disorders 4th edition' as its reference for ADHD diagnostic criteria. An updated version of the 'Diagnostic and Statistical Manual of Mental Disorders 5th edition' was published in May 2013.