Synonyms: hyperkinetic disorder, attention deficit disorder (ADD)
Attention deficit hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity and impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. The Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10) uses the term hyperkinetic disorder for a more restricted diagnosis. It differs from the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders classification in that all three problems of attention, hyperactivity, and impulsiveness must be present. For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
- Meet the diagnostic criteria in DSM-4 (has been updated to DSM-5 since publication of the NICE guideline) 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.
The DSM-5 diagnostic criteria for ADHD
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:
- Inattention: six or more symptoms of inattention for children up to age 16, or five or more for adolescents aged 17 and older and adults; symptoms of inattention have been present for at least six months, and they are inappropriate for developmental level:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
- Often has trouble holding attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (eg, loses focus, becomes side-tracked).
- Often has trouble organising tasks and activities.
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
- Often loses things necessary for tasks and activities (eg, school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted
- Is often forgetful in daily activities.
- Hyperactivity and impulsivity: six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least six months to an extent that is disruptive and inappropriate for the person’s developmental level:
- Often fidgets with or taps hands or feet, or squirms in seat.
- Often leaves seat in situations when remaining seated is expected.
- Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
- Often unable to play or take part in leisure activities quietly.
- Is often 'on the go' acting as if 'driven by a motor'.
- Often talks excessively.
- Often blurts out an answer before a question has been completed.
- Often has trouble waiting his/her turn.
- Often interrupts or intrudes on others (eg, butts into conversations or games).
- In addition, the following conditions must be met:
- Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
- Several symptoms are present in two or more settings, (eg, at home, school or work; with friends or relatives; in other activities).
- There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
- The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
- Combined presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past six months
- Predominantly inattentive presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
- Predominantly hyperactive-impulsive presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.
- The prevalence of ADHD is estimated to be around 2.4% of children in the UK.
- ADHD is most often diagnosed in children aged 3-7 years, but it may not be recognised until later in life and sometimes not until adulthood.
- ADHD is more commonly diagnosed in boys than in girls.
- ADHD is more common in first-degree relatives of affected children and studies of twins suggest a significant genetic contribution. There are a number of genes that are thought to have a small effect (eg, DRD4 and DRD5) but it is unlikely that any individual genes have a large effect.
- ADHD is more common in learning-disabled children. Other environmental risk factors include obstetric complications and family conflict.
Prevalence and prescribing rates for ADHD have risen steeply over the period of a decade, partly in response to concerns about underdiagnosis and undertreatment. Recent US data showed that 86% of children diagnosed with ADHD are described as having 'mild or moderate' disorder, and some are diagnosed without fulfilling diagnostic criteria for ADHD.
- Young people and adults with ADHD may have associated problems - eg, self-harm, a predisposition to road traffic (and other) accidents, substance misuse, delinquency, anxiety states and academic underachievement.
- ADHD is a part of a spectrum of disorders. 70% also have other conditions such as generalised or specific learning difficulties (eg, dyslexia, language disorders, autistic spectrum disorder), dyspraxia, Gilles de la Tourette's syndrome or tic disorder.
- Oppositional defiant disorder or conduct disorder is present in most children with ADHD; other associated disorders include mood disorder, anxiety disorder and specific developmental disorders such as dyslexia or dyspraxia.
- ADHD should be considered in all age groups. Diagnosis should only be made by a specialist psychiatrist, paediatrician or other healthcare professional with training and expertise in the diagnosis of ADHD. Diagnosis should be based on:
- A full clinical and psychosocial assessment. Discuss behaviour and symptoms in the different domains and settings of the person's everyday life.
- A full developmental and psychiatric history, and observer reports and an assessment of mental state.
- An assessment should include an assessment of the person's needs, co-existing 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.
- Determine the severity of behavioural and/or attention problems suggestive of ADHD and how they affect the child or young person and their parents or carers in different domains and settings.
- As part of the diagnostic process, include an assessment of needs, co-existing conditions, social, familial and educational or occupational circumstances and physical health. For children and young people, also include an assessment of the parents' or carer's mental health.
- A number of conditions, such as thyroid disease, anxiety, depression, and substance use disorders, have symptoms similar to those of ADHD.
- Steroids, antihistamines, anticonvulsants, beta-agonists, caffeine, and nicotine can also have adverse effects that mimic ADHD symptoms.
Specialist referral is needed to confirm the diagnosis and to start management. Referral may be to a specialist paediatrician, a child psychiatrist, Child and Adolescent Mental Health Services (CAMHS), or an adult psychiatrist, depending on the age of the person and local service provision. Adults suspected of having ADHD and adults with continuing ADHD from childhood should be referred to a psychiatrist.
Medication should be prescribed for children with severe and persistent symptoms of ADHD, when the diagnosis has been confirmed by a specialist. Children with moderate symptoms of ADHD can be treated with CNS stimulants when psychological interventions have been unsuccessful or are unavailable. Prescribing of CNS stimulants may be continued by general practitioners, under a shared-care arrangement. Treatment of ADHD often needs to be continued into adolescence, and may need to be continued into adulthood.
Drug treatment of ADHD should be part of a comprehensive treatment programme. Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every six months thereafter. The need to continue drug treatment for ADHD should be reviewed at least annually and this may involve suspending treatment.
- Parents and affected children need a great deal of explanation and support. There is a great deal of unproven advice available for parents and it is very important that time be taken to explain properly and to discuss the diagnosis and appropriate treatments. Consider providing parents and carers with self-instruction manuals and other materials (such as DVDs) based on positive parenting and behavioural techniques.
- Stress the value of a balanced diet, good nutrition and regular exercise for children and young people with ADHD.
- Eliminating artificial colouring and additives from the diet is not recommended as a generally applicable treatment for ADHD.
- Dietary fatty acid supplements are not recommended for the treatment of ADHD.
- Advise parents or carers to keep a diary if there are foods or drinks that appear to affect behaviour. If the diary supports a link between any foods or drinks and behaviour, offer referral to a dietitian.
- Further management (such as elimination of specific foods) should be jointly undertaken by the dietitian, mental health specialist or paediatrician, and the family.
- If the problems are having an adverse impact on development or family life, consider:
- Watchful waiting for up to ten weeks.
- Offering referral to a parent-training/education programme; this should not wait for a formal diagnosis of ADHD.
- If the problems persist with at least moderate impairment, refer to secondary care, ie paediatrician, child psychiatrist or specialist ADHD CAMHS.
- If the problems are associated with severe impairment, refer directly to secondary care.
- Do not diagnose or start drug treatment for ADHD in children and young people in primary care.
- If a child or young person is currently receiving drug treatment for ADHD and has not yet been assessed in secondary care, refer to a paediatrician, child psychiatrist or to specialist ADHD CAMHS as a clinical priority.
- Drug treatment is usually not recommended for pre-school children with ADHD, for whom parent-training/education programmes for parents or carers are normally first-line treatment.
- For school-age children and young people with ADHD, drug treatment should be reserved for those with severe symptoms and impairment or for those with moderate levels of impairment who have refused non-drug interventions, or whose symptoms have not responded sufficiently to parent-training/education programmes or group psychological treatment.
- Following treatment with a parent-training/education programme, children and young people with ADHD and persisting significant impairment should be offered drug treatment.
- In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered a group-based parent-training/education programme.
- Where drug treatment is considered appropriate, methylphenidate, atomoxetine and dexamfetamine are recommended.
- Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.
- Baseline physical assessment before starting drug treatment should include measurement of pulse, blood pressure, weight and height (plotted on centile charts). An ECG should also be considered on an individual basis.
- When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider:
- Methylphenidate for ADHD without significant comorbidity.
- Methylphenidate for ADHD with comorbid conduct disorder.
- Methylphenidate or atomoxetine when tics, Gilles de la Tourette's syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present.
- Atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate.
- Adults with ADHD:
- Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs.
- Following a decision to start drug treatment in adults with ADHD, methylphenidate should normally be tried first.
- Dexamfetamine should be considered when symptoms are unresponsive to a maximum tolerated dose of methylphenidate or atomoxetine.
- If there is no response to methylphenidate, atomoxetine or dexamfetamine, the affected person should be referred to tertiary services. Further treatment may include drugs unlicensed for ADHD (eg, bupropion, clonidine, modafinil and imipramine), or combination treatments (including psychological treatments for the parent or carer and the child or young person).
- Follow-up and monitoring:
- Drug treatment should be reviewed at least once every six months.
- Review should include physical review (height, weight, blood pressure and general health), medication review for efficacy, safety and compliance, and a review of the child's functioning at school, at home, socially and psychologically. Monitoring should include regular feedback from parents, teachers and others in close contact with the child.
- Parents or carers of pre-school children with ADHD should be offered a referral to a parent-training/education programme as the first-line treatment if the parents or carers have not already attended a programme or the programme has had a limited effect.
- Teachers who have received training about ADHD and its management should provide behavioural interventions in the classroom to help children and young people with ADHD.
- If the child or young person with ADHD has moderate levels of impairment, the parents or carers should be offered referral to a group parent-training/education programme, either on its own or together with a group treatment programme (cognitive behavioural therapy (CBT) and/or social skills' training) for the child or young person.
- CBT, behaviour modification and intensive contingency treatment have been used. The latter two treatments are more effective than CBT in improving behaviour and academic performance.
- Family therapy without medication may help to develop structure in the family, help to manage children's behaviour, and may help families cope with distress from the presence of the disorder.
- Underlying learning difficulties will require additional individual or small-group remedial instruction.
- Other allied health professionals may be involved. Occupational therapists can provide specific programmes for handwriting or gross motor difficulties. Speech therapists may be required for language difficulties.
Psychological treatment for adults with ADHD
- Consider group or individual CBT for adults who:
- Are stabilised on medication but have persisting functional impairment associated with ADHD.
- Have partial or no response to drug treatment or who are intolerant to it.
- Have made an informed choice not to have drug treatment.
- Have difficulty accepting the diagnosis of ADHD and accepting and adhering to drug treatment.
- Have remitting symptoms and psychological treatment is considered sufficient to treat mild-to-moderate residual functional impairment.
- Offer group therapy first because it is the most cost-effective.
Many alternative treatments have been promoted and used for ADHD but evidence for their safety and efficacy is limited.
A recent meta-analysis of follow-up studies of children with ADHD found that:
- About 15% continued to have ADHD.
- 65% had persistence of some symptoms and continuing functional impairment, with psychological, social, or educational difficulties.
Further reading and references
Evidence-based guidelines for management of attention deficit hyperactivity disorder in adolescents in transition to adult services and in adults; British Association for Psychopharmacology (2006)
Attention deficit hyperactivity disorder: diagnosis and management; NICE Clinical Guideline (September 2008)
Highlights of Changes from DSM-IV-TR to DSM-5; American Psychiatric Association, 2013
Attention deficit hyperactivity disorder; NICE CKS, August 2013
Biederman J, Faraone SV; Attention-deficit hyperactivity disorder. Lancet. 2005 Jul 16-22366(9481):237-48.
Thomas R, Mitchell GK, Batstra L; Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ. 2013 Nov 5347:f6172. doi: 10.1136/bmj.f6172.
Post RE, Kurlansik SL; Diagnosis and management of adult attention-deficit/hyperactivity disorder. Am Fam Physician. 2012 May 185(9):890-6.
Management of attention deficit and hyperkinetic disorders in children and young people; Scottish Intercollegiate Guidelines Network - SIGN (October 2009)
Weber W, Newmark S; Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism. Pediatr Clin North Am. 2007 Dec54(6):983-1006
Faraone SV, Biederman J, Mick E; The age-dependent decline of attention deficit hyperactivity disorder: a Psychol Med. 2006 Feb36(2):159-65.
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