This is a guideline from NICE on ADHD. It was written in 2008, then updated in March 2018. The changes are relatively subtle, so I shall outline the changes, then give a bit of a summary of the guideline.
They have taken out the idea of grading patients into 'mild', 'moderate' and 'severe'. Instead management is guided by the impact the ADHD is having.
Instead of a long course, this can now just be a 1-2 session group giving information on ADHD and advice on parenting strategies.
Oppositional defiant disorder or conduct disorder.
Where these are coexistent, offer separate support for them.
This should be used when ADHD is still causing a persistent and significant impairment in at least one domain after parenting classes and environmental modifications. Before, medication was reserved for children with severe symptoms. In adults, environmental modifications should be made before using medication (whereas before medication was first line).
There are subtle changes here, which we should note.
- Weight. In kids 10 and under, weight should be monitored every 3m (it was every 3m, then 6m, then every 6m).
- Centile charts. We should also be plotting height and weight on a centile chart.
- Heart rate and BP. On the upside, heart rate and BP now need monitoring every 6m, whereas before the advice was every 3m.
Summary of the guideline
ADHD is something that I still struggle a bit to get to grips with and to know who to refer and when, given how frequently parents bring up behavioural issues. I thought a summary of the useful things for us would therefore be helpful.
Diagnosis should be made by a specialist and should be based on interview and/or direct observation of the patient in multiple settings.
The DSM V criteria, or the ICD-10 criteria (it is referred to as hyperkinetic disorder in ICD-10) are used for diagnosis. These are helpful to refer to if you have a child where you are uncertain about whether to refer. A few key points:
- Symptoms should be present for at least 6m.
- Symptoms should be inappropriate for the developmental level.
- Symptoms should cause at least moderate impairment in multiple settings (at least 2).
- In adults, symptoms should have started in childhood.
Assessment in Primary Care
- Watchful waiting for up to 10w.
- Offer referral to group based support for ADHD (you don't have to have a formal diagnosis to do this).
- If problems persist with moderate severity, then refer to ADHD services.
- If there is severe impairment, then refer directly to ADHD services.
- If school has concerns, then the child should be referred to a special educational needs coordinator. They should help the child with their behaviour, should inform parents about local ADHD training programmes and support groups and can also refer to secondary care.
Refer straightaway if they have typical manifestations of ADHD and:
- Symptoms began in childhood and have persisted through life.
- Symptoms are not explained by other psychiatric diagnoses (though they may be coexistent).
- Symptoms have resulted in moderate or severe psychological, social, educational or occupational impairment.
I won't go into all the detail here as it's not relevant to us.
- Remember the potential for all the medications to have a significant cardiovascular impact when reviewing children.
- All people need a Shared Treatment Plan and general advice.
- One thing I hadn't previously appreciated was that if ADHD, or it's medication is having an impact on driving, then the DVLA should be informed.
Medication for over 5s
Under 5s should still only rarely be medicated and then under tertiary care advice.
- Methylphenidate first line.
- Lisdexamfetamine second line if there hasn't been adequate response to methylphenidate. This is a change to guidance - it wasn't in previous guidance and atomoxetine was second line - which has now been bumped down the list.
- Dexamfetamine if they respond to Lisdexamfetamine, but can't tolerate the longer side-effect profile.
- Atomoxetine or guanfacine if they haven't responded adequately to the above.
- Clonidine with tertiary centre advice. It is good for tics, sleep disturbance and rages.
CBT can be used alongside medication if there is still significant impairment in at least one domain.
Medication for adults
- Lisdexamfetamine or methylphenidate first line.
- Second line - try the other one.
- Dexamfetamine can be used if they have responded to lisdexamfetamine, but can't tolerate the longer side-effect profile.
- Atomoxetine if they haven't responded to any of the above.
CBT can be used alongside medication in adults, or instead of medication (if they so choose or if they have difficult adhering to medication), if they still have significant impairment in at least one domain.
Follow up and monitoring
Specialist review should be at least annual once the patient is stable.
At least every 6m.
- 10s and under - every 3m (this used to be 6m).
- 10s - 3m, then 6m, then every 6m.
- Adults - every 6m
If there are concerns about weight, then they can:
- Take the medication with or after food.
- Extra snacks (high calorie, nutritional snacks) once the stimulatory effect has worn off.
- Dietary advice.
Plot height and weight on a centile chart at each review.
Heart rate and BP
At every dose change then every 6m.
Refer to a paediatrician if there is:
- Sustained resting tachycardia of > 120
- BP > 95th percentile or a significant increase on 2 occasions.
Simple parenting advice
This isn't in the NICE guideline, but I was told it on a course and I think it is really helpful to have something to say to parents.
- Set realistic expectations of your child.
- Take pride in small achievements (eg 1 jigsaw piece may be a big deal).
- Structure and clarity in life - give clear instructions and boundaries.
- Social manipulation - avoid other kids who aggravate the problem. Sit at the front of the class. Use 1:1 care where possible.
- "Stop and think". This can be quite hard to teach kids, but is worth trying.
- As their child grows older, they may always have traits of ADHD, but they often develop better coping mechanisms and learn to channel it by choosing certain kinds of jobs.
- Positive parent - child interactions (this is in NICE). It is easy to always be telling the child off and for them to be told they are 'naughty' all the time. So build on the positives. Praise as much as they can. Try to avoid the negatives.