Management

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.

Reference:

• (1) NICE (October 2000). Guidance on the Use of Methylphenidate (Ritalin, Equasym) for Attention Deficit / Hyperactivity Disorder (ADHD) in childhood.
• (2) NICE (March 2018). Attention deficit hyperactivity disorder Diagnosis and management of ADHD in children, young people and adults
• (3) Candido RCF et al. Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews 2021, Issue 1. Art. No.: CD013011