Update information

Update information

September 2019: Recommendation 1.7.4 was amended to indicate that an electrocardiogram is not needed before starting stimulants, atomoxetine or guanfacine if cardiovascular history and examination are normal and the person is not on medicine that poses an increased cardiovascular risk. The corresponding rationale section was also updated to reflect this change. This recommendation is marked [2018, amended 2019].

April 2018: Following publication, some amendments were made to recommendations 1.5.10, 1.5.12, 1.5.13, 1.7.4, 1.7.7 and 1.8.14 and the related rationale and impact sections to clarify their meaning. A footnote about the marketing authorisation for methylphenidate was also added to recommendation 1.7.11.

March 2018: This guideline updates and replaces NICE guideline CG72 (published September 2008).

New recommendations have been added on recognition, information and support, managing attention deficit hyperactivity disorder (ADHD; including non-pharmacological treatment), medication, follow‑up and monitoring, adherence, and review of medication and discontinuation.

These are marked as [2018].

Some recommendations were amended in 2018 without an evidence review. These are marked as [2008, amended 2018]. Reasons for the amendments are shown in the table below.

Recommendation in 2008 guideline

Recommendation in current guideline

Reason for amendment

Mental health trusts, and children's trusts that provide mental health/child development services, should form multidisciplinary specialist ADHD teams and/or clinics for children and young people and separate teams and/or clinics for adults. These teams and clinics should have expertise in the diagnosis and management of ADHD, and should:

• provide diagnostic, treatment and consultation services for people with ADHD who have complex needs, or where general psychiatric services are in doubt about the diagnosis and/or management of ADHD

• put in place systems of communication and protocols for information sharing among paediatric, child and adolescent, forensic, and adult mental health services for people with ADHD, including arrangements for transition between child and adult services

• produce local protocols for shared care arrangements with primary care providers, and ensure that clear lines of communication between primary and secondary care are maintained

• ensure age-appropriate psychological services are available for children, young people and adults with ADHD, and for parents or carers.

The size and time commitment of these teams should depend on local circumstances (for example, the size of the trust, the population covered and the estimated referral rate for people with ADHD). (1.1.1.2)

Mental health services for children, young people and adults and child health services, should form multidisciplinary specialist ADHD teams and/or clinics for children and young people and separate teams and/or clinics for adults. These teams and clinics should have expertise in the diagnosis and management of ADHD, and should:

• provide diagnostic, treatment and consultation services for people with ADHD who have complex needs, or where general psychiatric services are in doubt about the diagnosis and/or management of ADHD

• put in place systems of communication and protocols for information sharing among paediatric, child and adolescent, forensic, and adult mental health services for people with ADHD, including arrangements for transition between child and adult services

• produce local protocols for shared care arrangements with primary care providers, and ensure that clear lines of communication between primary and secondary care are maintained

• ensure age-appropriate psychological services are available for children, young people and adults with ADHD, and for parents or carers.

The size and time commitment of these teams should depend on local circumstances (for example, the size of the trust, the population covered and the estimated referral rate for people with ADHD). (1.1.2)

Updated to clarify services.

Every locality should develop a multi-agency group, with representatives from multidisciplinary specialist ADHD teams, paediatrics, mental health and learning disability trusts, forensic services, child and adolescent mental health services (CAMHS), the Children and Young People's Directorate (CYDP) (including services for education and social services), parent support groups and others with a significant local involvement in ADHD services. The group should:

• oversee the implementation of this guideline

• start and coordinate local training initiatives, including the provision of training and information for teachers about the characteristics of ADHD and its basic behavioural management

• oversee the development and coordination of parent-training/education programmes

• consider compiling a comprehensive directory of information and services for ADHD including advice on how to contact relevant services and assist in the development of specialist teams. (1.1.1.3)

Every locality should develop a multi-agency group, with representatives from multidisciplinary specialist ADHD teams, paediatrics, mental health and learning disability trusts, forensic services, child and adolescent mental health services (CAMHS), the Directorate for Children and Young People (DCYP) (including services for education and social services), parent support groups and others with a significant local involvement in ADHD services. The group should:

• oversee the implementation of this guideline

• start and coordinate local training initiatives, including the provision of training and information for teachers about the characteristics of ADHD and its basic behavioural management

• oversee the development and coordination of parent-training/education programmes

• consider compiling a comprehensive directory of information and services for ADHD including advice on how to contact relevant services and assist in the development of specialist teams. (1.1.3)

Updated with current name of Directorate for Children and Young People.

A young person with ADHD receiving treatment and care from CAMHS or paediatric services should be reassessed at school-leaving age to establish the need for continuing treatment into adulthood. If treatment is necessary, arrangements should be made for a smooth transition to adult services with details of the anticipated treatment and services that the young person will require. Precise timing of arrangements may vary locally but should usually be completed by the time the young person is 18 years. (1.6.1.1)

A young person with ADHD receiving treatment and care from CAMHS or paediatric services should be reassessed at school-leaving age to establish the need for continuing treatment into adulthood. If treatment is necessary, arrangements should be made for a smooth transition to adult services with details of the anticipated treatment and services that the young person will require. Precise timing of arrangements may vary locally but should usually be completed by the time the young person is 18 years. See NICE's guideline on transition from children's to adults' services for young people using health or social care services. (1.1.4)

Updated with cross-reference to NICE's guideline on transition from children's to adults' services.

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. (1.2.1.2)

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. (1.2.4)

Updated with cross-reference to NICE's guideline on antisocial behaviour and conduct disorders in children and young people.

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 a parent-training/education programme (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. (1.2.1.5)

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. (1.2.7)

Updated to clarify that the training should be group-based and ADHD-focused support.

For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:

• meet the diagnostic criteria in DSM‑IV or ICD‑10 (hyperkinetic disorder) , and

• be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and

• be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings.

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, there should also be an assessment of their parents' or carers' mental health. (1.3.1.3)

For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:

• meet the diagnostic criteria in DSM‑5 or ICD‑10 (hyperkinetic disorder) , and

• cause at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and

• be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings.

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, there should also be an assessment of their parents' or carers' mental health. (1.3.3)

Updated to reflect the most recent version of DSM.

ISBN: 978-1-4731-2830-9

  • National Institute for Health and Care Excellence (NICE)