ADHD
Questionnaire/history: Inattention symptoms (including) : Failing to give close attention to detail or making careless mistakes in schoolwork, work, or other activities? Difficulty in maintaining concentration when performing tasks or play activities? Appearing not to listen to what is being said, as if the mind is elsewhere, without any obvious distraction?
Failing to follow through on instructions or finish a task (not because of oppositional behavior or failure to understand)? Difficulty in organizing tasks and activities?
Reluctance, dislike, or avoidance of tasks that require sustained mental effort? Losing items necessary for tasks or activities such as pencils, mobile phones, or wallets?
Easy distraction by extraneous stimuli? Forgetfulness with regard to daily activities?
Hyperactivity-impulsivitiy symptoms (including): Fidgeting with or tapping hands or feet, or squirming when seated? Leaving the seat where remaining seated is expected, such as in a classroom? Running about or climbing in situations where inappropriate (in adolescents or adults, this may be limited to a feeling of restlessness)? An inability to play or engage in leisure activities quietly? Being 'in the go' or acting as if 'driven by a motor' (others may experience the person to be restless or difficult to keep up with)? Talking excessively? Blurting out an answer before a question has been completed? Difficult waiting his or her turn? Interrupting or intruding on others? Above symptoms: Started before 12 years of age?
Occurred in two or more settings such as at home and school?
Been present for at least 6 months?
Clearly interfered with, or reduced the quality of social, academic or occupational functioning?
Not occurred exclusively during the course of a psychotic disorder and are not better explained by another disorder such as oppositional defiant disorder or conduct disorder?
Children: Attention deficit hyperactivity disorder (ADHD) suspected as at least six inattention symptoms and/or at least six hyperactivity-impulsivity symptoms?
Assessment of the social and educational impact of symptoms: School-age children? Self-care? Eating? Hygiene? Forming positive relationships with other family members?
Making and keeping friends?
Travelling independently? Achievement in school? Developing a positive self-image? Maintaining emotional states free of excessive anxiety and unhappiness? Understanding and avoiding common hazards?
Avoiding criminal activity? Avoiding substance misuse? Adolescents? Occupational or educational underachievement? Difficulties in carrying out daily activities (such as shopping and organising household tasks)?
Difficulties in making and keeping friends? Difficulties in intimate relationships (for example, excessive disagreement)?
Dangerous driving? Questionnaires: Strength and Difficulties Questionnaire (www.sdquinfo.org)?
Conners' rating scale (www.pearsonclinical.co.uk)?
Adults: Attention deficit hyperactivity disorder (ADHD) suspected in a child as a least five inattention symptoms and/or at least five hyperactivity-impulsivity symptoms?
Assessment of the psychological, social, educational or occupational impact of the symptoms? Educational or occupational underachievement? Difficulties in carrying out daily activities (such as shopping and organising household tasks)? Difficulties in making and keeping friends? Difficulties in intimate relationships (for example, excessive disagreement)?
Difficulties in childcare?
Gambling? Dangerous driving?
Diagnosis:
Note: Formal diagnosis should be carried out by a specialist Children:
Adults:
Adult Self-Report Scale (ASRS v1.1) for ADHD
Diagnostic Interview for ADHD in adults (DIVA)
NICE:
Digitial technologies for assessing attention deficit hyperactivity disorder (ADHD)
Management:
Suspected ADHD?
Children:
Symptoms having only a moderate impairment to the ability to function socially and at school?
Options: Period of watchful waiting of up to 10 weeks and encouraging self-help and simple behavioural management?
Offering parents or carers a referral to group-based ADHD-focused support? Referral to a CAMHS professional, specialist paediatrician, or child psychiatrist?
- Severe symptoms?
- Period of watchful waiting not acceptable?
- Behavioural and/or attention problems persist with a least moderate impairment following a period of watchful waiting or a parent support programme?
Adults:
Symptoms associated with moderate or severe psychological, social and/or educational impact? - If no prior diagnosis of childhood ADHD referral for assessment by a mental health specialist trained in the diagnosis and treatment of ADHD?
- If treated for ADHD as children or young people referral to general adult psychiatric services for assessment?
Confirmed ADHD?
Note: The management of people with confirmed ADHD should be initiated and coordinated by specialists. Drug treatments initiated and titrated by a specialist?
Effectiveness? Adverse effects? Weight (every 3 months in children 10 years old and younger, otherwise 3 months and 6 months after treatment has started, and every 6 months thereafter in children and young people over 10 years old, and every 6 months in adults?
Height (every 6 months in children and young people with plotting height and weight on a growth chart and review by the healthcare professional responsible for their treatment)?
Blood pressure and heart rate (before and after each dose change, and routinely every six months)?
Sleep diary if problems with sleep? How does the ADHD affects the family or carers? Encouraged family or carers to seek an assessment of their personal, social and mental health needs, and to join self-help and support groups if appropriate? If appropriate reinforced advice to parents and carers of children and young people with ADHD about the importance of a positive parent- and carer-child contact, clear and appropriate rules about behaviour and consistent management, and a structure in the child or young person's day? Written information about self-help, local and national support groups, and voluntary organizations given as appropriate? - National Attention Deficit Disorder Information and Support Service (ADDISS - www.addiss.co.uk)? - Adult Attention Deficit Disorder UK (AADDUK - www.aadduk.org)? - Mind (www.mind.org.uk)?
Specialist advice needed? - Sustained resting tachycardia over 120 bpm? - Arrhythmia? - Systolic blood pressure greater than 95th percentile (or a clinically significant increase) measured on two occasions? - Significant adverse effects? - Height not expected for age? - Break in treatment over school holidays required to allow 'catch-up' growth?
Advised: If on amfetamine (for example dexamfetamine or lisdexamfetamine) to not drive if feeling drowsy, dizzy, unable to concentrate or make decisions, of if blurred or double vision It is now an offence to drive having more than a specified amount of amfetamines in the body To keep the other half of the prescription in the car to show intake of amfetamines in accordance with medical advice Normal healthy diet
Regular exercise
Diary of food and drink consumed and associated behaviour if there appears to be a link between certain foods or drinks and ADHD symptoms
To see a dietician if the diary supports a relationship between specific foods or drinks and behaviour
(Note: A joint management by a dietician, specialist, the parent or carer and the child or young person is recommended before specific dietary elimination is considered.)
To consider seeking specialist dietary advice if weight loss becomes a problem and/or to take ADHD medication either with or after food, rather than before meals, to take additional meals or snacks early in the morning or late in the evening, when the effect of the drug have worn off, and to consume high-calorie foods of good nutritional value.
Secondary care management of ADHD:
Note: The treatment options offered by a specialist depend on the person's age and the degree of functional impairment. Preschool children? ADHD-focused group parent-training programme as normally recommended first-line treatment?
Advice from a specialist ADHD service with expertise in managing ADHD in young children (ideally a tertiary service) if ADHD symptoms across settings are still causing a significant impairment after environmental modifications have been implemented and reviewed?
Drug treatment considered with input from this service?
School-age children and young people?
Group-based support offered to parents/carers and/or young people including education and information on the causes and impact of ADHD and advice on parenting strategies? With consent, liaised with school, college or university?
Individual parent-training programmes for parents and carers of children and young people offered when there are particular difficulties for families in attending group sessions (for example, because of disability, needs related to diversity such as language differences, learning disability, parental ill-health, problems with transport, where other factors suggest poor prospects for therapeutic engagement, or when a family's needs are too complex to be met by group-based parent-training programmes?
Medication offered if ADHD symptoms still causing a persistent significant impairment after environmental modifications have been implemented and reviewed? Methylphenidate offered as usual first-line, with lisdexamfetamine, dexamfetamine, and atomoxetine as possible alternatives if methylphenidate contraindicated, not tolerated, or ineffective?
Melatonin prescribed for children and adolescents aged 6-17 years with ADHD who have insomnia, where sleep hygiene measures have been insufficient?
A course of cognitive behavioural therapy (CBT) offered to young people with ADHD who have benefited from medication but whose symptoms are still causing significant impairment, addressing areas such as social skills with peers, problem-solving, self-control, active listening skills, and dealing with and expressing feelings?
Adults?
Medication offered if ADHD symptoms still causing a significant impairment after environmental modifications have been implemented and reviewed?
Lisdexamfetamine or methylphenidate offered as usual first-line, with dexamfetamine or atomoxetine as possible alternatives if lisdexamfetamine and/or methylphenidate are contraindicated, not tolerated, or ineffective?
Non-pharmacological treatment in combination with medication considered for adults with ADHD who have benefited from medication but whose symptoms are still causing significant impairment, which could include a structured supportive psychological intervention focused on ADHD, regular follow-up either in person or by phone, and/or elements of a full course of CBT?
Resource(s):
NICE CKS: Attention deficit hyperactivity disorder
Information for patient/carer(s):
Adult Attention Deficit Disorder UK (AADDUK) (www.aadduk.org)
National Attention Deficit Disorder Information and Support Service (ADDISS) (www.addiss.co.uk)
NHS Health A to Z: ADHD in children and young people
NHS Health A to Z: ADHD in adults
Patient UK: Can diet affect your ADHD?