Treatment and care should take into account people’s needs and preferences and in the case of children, those of their parents or carers. All people with ADHD, including children, should have the opportunity to be involved in decisions about their care and treatment in partnership with their healthcare professionals.

Good communication between healthcare professionals and people with ADHD is essential. It should be supported by evidence-based written information tailored to the person’s needs. Treatment and care, and the information people are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities and to people who do not speak or read English.

Care of young people in transition between paediatric and adult services should be planned and managed according to the best practice guidance described in 'Transition: getting it right for young people' (available here http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4132149.pdf).

1.1.2 Information, consent, the law and support for people with ADHD and their carers

Many people with ADHD, and their parents or carers, experience stigma and other difficulties because of the symptoms and impairment associated with ADHD and current practice within healthcare and education. The following recommendations have been developed based on the experiences of people with ADHD and their families.

• 1.1.2.1 Healthcare professionals should develop a trusting relationship with people with ADHD and their families or carers by:
• Respecting the person and their family’s knowledge and experience of ADHD
• Being sensitive to stigma in relation to mental illness.
• 1.1.2.2 Healthcare professionals should provide people with ADHD and their families or carers with relevant, age-appropriate information (including written information) about ADHD at every stage of their care. The information should cover diagnosis and assessment, support and self-help, psychological treatment, and the use and possible side effects of drug treatment.
• 1.1.2.6 Adults with ADHD should be given written information about local and national support groups and voluntary organisations.
• 1.1.2.7 Healthcare professionals should ask families or carers about the impact of ADHD on themselves and other family members, and discuss any concerns they may have. Healthcare professionals should:
• Offer family members or carers an assessment of their personal, social and mental health needs
• Encourage participation in self-help and support groups where appropriate

ADHD is a valid clinical disorder that can be distinguished from coexisting conditions (although it is most commonly comorbid) and the normal spectrum. ADHD differs from the normal spectrum because there are high levels of hyperactivity/impulsivity and/or inattention that result in significant psychological, social and/or educational or occupational impairment that occurs across multiple domains and settings and persists over time.

1.3.1.1 A diagnosis of ADHD should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of 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.

1.3.1.2 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 valuable adjuncts, and observations (for example, at school) are useful when there is doubt about symptoms.

1.3.1.3 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.

1.3.1.4 ADHD should be considered in all age groups, with symptom criteria adjusted for age-appropriate changes in behaviour.

Drug treatment is the first-line treatment for adults with ADHD with either moderate or severe levels of impairment. Methylphenidate is the first-line drug. Psychological interventions without medication may be effective for some adults with moderate impairment, but there are insufficient data to support this recommendation. If methylphenidate is ineffective or unacceptable, atomoxetine or dexamfetamine can be tried. If there is residual impairment despite some benefit from drug treatment, or there is no response to drug treatment, CBT may be considered. There is the potential for drug misuse and diversion in adults with ADHD, especially in some settings, such as prison, although there is no strong evidence that this is a significant problem.

1.7.1.1 For adults with ADHD, drug treatment should be the first-line treatment unless the person would prefer a psychological approach.

1.7.1.2 Drug treatment for adults with ADHD should be started only under the guidance of a psychiatrist, nurse prescriber specialising in ADHD, or other clinical prescriber with training in the diagnosis and management of ADHD.

1.7.1.3 Before starting drug treatment for adults with ADHD a full assessment should be completed, which should include:

• Full mental health and social assessment
• Full history and physical examination, including:
  
  
  • assessment of history of exercise syncope, undue breathlessness and other cardiovascular symptoms
  • heart rate and blood pressure (plotted on a centile chart)
  • weight
  • family history of cardiac disease and examination of the cardiovascular system
• An ECG if there is past medical or family history of serious cardiac disease, a history of sudden death in young family members or abnormal findings on cardiac examination
• Risk assessment for substance misuse and drug diversion.

1.7.1.4 Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs.

1.7.1.5 Following a decision to start drug treatment in adults with ADHD, methylphenidate should normally be tried first.

1.7.1.6 Atomoxetine or dexamfetamine should be considered in adults unresponsive or intolerant to an adequate trial of methylphenidate (this should usually be about 6 weeks)15. Caution should be exercised when prescribing dexamfetamine to those likely to be at risk of stimulant misuse or diversion.

1.7.1.7 When starting drug treatment, adults should be monitored for side effects. In particular, people treated with atomoxetine should be observed for agitation, irritability, suicidal thinking and self-harming behaviour, and unusual changes in behaviour, particularly during the initial months of treatment, or after a change in dose. They should also be warned of potential liver damage in rare cases (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice). Younger adults aged 30 years or younger should also be warned of the potential of atomoxetine to increase agitation, anxiety, suicidal thinking and self-harming behaviour in some people, especially during the first few weeks of treatment.

1.7.1.8 For adults with ADHD stabilised on medication but with persisting functional impairment associated with the disorder, or where there has been no response to drug treatment, a course of either group or individual CBT to address the person’s functional impairment should be considered. Group therapy is recommended as the first-line psychological treatment because it is the most cost effective.

1.7.1.9 For adults with ADHD, CBT may be considered when:

• The person has made an informed choice not to have drug treatment
• Drug treatment has proved to be only partially effective or ineffective or the person is intolerant to it
• People have difficulty accepting the diagnosis of ADHD and accepting and adhering to drug treatment
• Symptoms are remitting and psychological treatment is considered sufficient to target residual (mild to moderate) functional impairment.

1.7.1.10 Where there may be concern about the potential for drug misuse and diversion (for example, in prison services), atomoxetine may be considered as the first-line drug treatment for ADHD in adults.

1.7.1.11 Drug treatment for adults with ADHD who also misuse substances should only be prescribed by an appropriately qualified healthcare professional with expertise in managing both ADHD and substance misuse. For adults with ADHD and drug or alcohol addiction disorders there should be close liaison between the professional treating the person’s ADHD and an addiction specialist.

1.7.1.12 Antipsychotics are not recommended for the treatment of ADHD in adults.

1.8.4.1 Healthcare professionals should consider using standard symptom and side effect rating scales throughout the course of treatment as an adjunct to clinical assessment for people with ADHD.

1.8.4.2 In people taking methylphenidate, atomoxetine, or dexamfetamine:

• weight should be measured 3 and 6 months after drug treatment has started and every 6 months thereafter in children, young people and adults

1.8.4.3 If there is evidence of weight loss associated with drug treatment in adults with ADHD, healthcare professionals should consider monitoring body mass index and changing the drug if weight loss persists.

1.8.4.6 In people with ADHD, heart rate and blood pressure should be monitored and recorded on a centile chart before and after each dose change and routinely every 3 months.

1.8.4.10 In young people and adults, sexual dysfunction (that is, erectile and ejaculatory dysfunction) and dysmenorrhoea should be monitored as potential side effects of atomoxetine.

1.8.4.11 For people taking methylphenidate, dexamfetamine or atomoxetine who have sustained resting tachycardia, arrhythmia or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions should have their dose reduced and be referred to a paediatrician or adult physician.

1.8.4.12 If psychotic symptoms (for example, delusions and hallucinations) emerge in children, young people and adults after starting methylphenidate or dexamfetamine, the drug should be withdrawn and a full psychiatric assessment carried out. Atomoxetine should be considered as an alternative.

1.8.4.15 Anxiety symptoms, including panic, may be precipitated by stimulants, particularly in adults with a history of coexisting anxiety. Where this is an issue, lower doses of the stimulant and/or combined treatment with an antidepressant used to treat anxiety can be used; switching to atomoxetine may be effective.

• The patient version of the guidelines can be downloaded here: http://www.nice.org.uk/nicemedia/pdf/CG72UNG.pdf
• The quick reference guide to the guidelines for healthcare professionals and others involved in the care of people with ADHD can be downloaded here: http://www.nice.org.uk/nicemedia/pdf/CG72QRG.pdf
• The full guidelines are available here: http://www.nice.org.uk/nicemedia/pdf/ADHDFullGuideline.pdf
• The shorter version of the guidelines containing recommendations for health professionals and NHS Trusts can be downloaded here: http://www.nice.org.uk/nicemedia/pdf/CG072NiceGuidelineV2.pdf