management

Last edited 03/2021 and last reviewed 03/2021

If a diagnosis of Hyperkinetic Disorder or Attention Deficit/ Hyperactivity Disorder is suspected then the patient should be referred for specialist assessment (child psychiatrist or paediatrician with specialist expertise in this area) (1).

Management includes:

  • non-drug management
  • drug management

Notes (2):

  • children under 5 years of age:
    • first-line treatment is an ADHD-focused group parent-training programme to parents or carers of children under 5 years with ADHD
    • if after an ADHD-focused group parent-training programme, ADHD symptoms across settings are still causing a significant impairment in a child under 5 years after environmental modifications have been implemented and reviewed, obtain advice from a specialist ADHD service with expertise in managing ADHD in young children (ideally a tertiary service)
    • medication for ADHD should not be offered for any child under 5 years without a second specialist opinion from an ADHD service with expertise in managing ADHD in young children (ideally a tertiary service)

  • children aged 5 years and over and young people
    • appropriate informatin about ADHD should be given and offer additional support to parents and carers of all children aged 5 years and over and young people with ADHD. The support should be ADHD focused, can be group based and as few as 1 or 2 sessions
    • if a child aged 5 years or over or young person has ADHD and symptoms of oppositional defiant disorder or conduct disorder, offer parents and carers a parent-training programme as well as group-based ADHD-focused support
    • medication for children aged 5 years and over and young people should only be offered only if:
      • their ADHD symptoms are still causing a persistent significant impairment in at least one domain after environmental modifications have been implemented and reviewed
      • they and their parents and carers have discussed information about ADHD
      • a baseline assessment has been carried out
    • a course of cognitive behavioural therapy (CBT) should be considered for young people with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain, addressing the following areas:
      • social skills with peers
      • problem-solving
      • self-control
      • active listening skills
      • dealing with and expressing feelings

  • adults with ADHD:
    • medication should be offered to adults with ADHD if their ADHD symptoms are still causing a significant impairment in at least one domain after environmental modifications have been implemented and reviewed
    • non-pharmacological treatment should be considered for adults with ADHD who have:
      • made an informed choice not to have medication
      • difficulty adhering to medication
      • found medication to be ineffective or cannot tolerate it
    • non-pharmacological treatment should be considered in combination with medication for adults with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain
    • when non-pharmacological treatment is indicated for adults with ADHD, NICE have suggested that the following should be offered as a minimum:
        • a structured supportive psychological intervention focused on ADHD
        • regular follow-up either in person or by phone
      • treatment may involve elements of or a full course of CBT
    • drug treatment
      • lisdexamfetamine or methylphenidate are options as first-line pharmacological treatment for adults with ADHD
      • a systematic review concluded (3):
        • found no certain evidence that intermediate release (IR) methylphenidate compared with placebo or lithium can reduce symptoms of ADHD in adults (low- and very low-certainty evidence)
        • adults treated with IR methylphenidate are at increased risk of gastrointestinal and metabolic-related harms compared with placebo. Clinicians should consider whether it is appropriate to prescribe IR methylphenidate, given its limited efficacy and increased risk of harms.

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