Diagnosis and management of ADHD in children, young people and adults

664 Pages·2009·6.34 MB·English

ADHD cover_cover 16/04/2013 14:23 Page 1
(cid:31)This book provides a comprehensive and discerning reference that
will be of interest to students, clinicians and researchers, not only for
its clinical practice guidelines, but also for its thorough review of the
history, epidemiology
and aetiology of ADHD. The guideline development group has tackled
thorny issues in a systematic and evidenced?based manner. Readers
will find sounadn swers to the many questions about ADHD that arise
in research and practicDeo:e s it remit in adulthood? Is it caused by
genes or environment? How should it be diagnosed and treated
throughout the lifespan? What impairments afflict patients and
families? And what are the costs to society? Although this book was
developed to provide a national clinical practice guideline for the UK,
that description does not do justice to the breadth and depth of the
work.
It is most certainly relevant to students and researchers and to
cliniciasn around the world who will likely keep it close at hand as a
definitive guide to ADHD.(cid:31)
Stephen V. Faraone, Professor of Psychiatry and of Neuroscience and Physiology,
SUNY Upstate Medical University
This guideline, commissioned by NICE and developed by the National Collaborating
Centre for Mental Health, sets out clear, evidence-based recommendations for
healthcare and educational staff on how to diagnose and manage ADHD in children, Attention de ficit
young people and adults to significantly improve their treatment and care. ha
ADHD is a common disorder. It is associated with serious impairments in childhood yt
t
p
and those with a sustained diagnosis often develop significant difficulties in e
adulthood, including personality disorder and substance misuse. The NICE guideline en hype rac tivit y
is an important tool in helping professionals to make appropriate decisions about rt
ai
treating and caring for people with ADHD and improving their long-term outcomes. o
c
This publication brings together all of the evidence that led to the recommendations n disorde r
t
in the NICE guideline. This includes the evidence for the validity of the diagnosis, i
vd
psychological interventions and parent training, pharmacological treatment,
interventions for children in educational settings, dietary interventions, and ite
combining and comparing psychological and pharmacological treatment. yf
i THE NICE GUIDE LINE ON DIAGNOS IS AND
The book also contains a useful overview of ADHD, and chapters on the organisation c
of care and on service user experience of treatment and care for ADHD, including a i MANAGE ME NT OF ADHD IN CHILDRE N,
t
YOUNG P E OP LE AND ADULTS
study of children and young people’s views of stimulant medication, which was
commissioned especially for this guideline.
March 2013: In treatment for children and young people footnote 14 has
An accompanying CD contains further information about the evidence, including:
● included and excluded studies been updated. Recommendations 7.5.2.5, 7.5.2.7, 12.5.1.7 and 12.5.1.9 have
● profile tables that summarise both the quality of the evidence and the results of been removed and replaced by recommendations 1.5.2 and 1.5.4 in ‘Antisocial
the evidence synthesis Behaviour and Conduct Disorders in Children and Young People’ (NICE clinical
● all meta-analytical data presented as forest plots
guideline 158). Recommendations 7.5.2.8 and 12.5.1.7.10 have been removed.
ISBN 978-1-85433-471-8
9 781854 334718
1563.qxd:1563 16/2/09 16:01 Page i
Praise for
Attention Deficit Hyperactivity Disorder:
Diagnosis and Management of ADHD in children,
young people and adults
“This book provides a comprehensive and discerning reference
that will be of interest to students, clinicians and researchers, not
only for its clinical practice guidelines but also for its thorough
review of the history, epidemiology and aetiology of ADHD.
The guideline development group has tackled thorny issues in a
systematic and evidenced-based manner. Readers will find sound
answers to the many questions about ADHD that arise in research
and practice: Does it remit in adulthood? Is it caused by genes or
environment? How should it be diagnosed and treated throughout
the lifespan? What impairments afflict patients and families?
And what are the costs to society? Although this book was
developed to provide a national clinical practice guideline
for the UK, that description does not do justice to the breadth
and depth of the work. It is most certainly relevant to students
and researchers and to clinicians around the world who will likely
keep it close at hand as a definitive guide to ADHD.”
STEPHEN V. FARAONE,
Professor of Psychiatry and of Neuroscience and Physiology,
SUNY Upstate Medical University
“This NICE clinical guideline provides clear, authoritative advice
on the diagnosis and management of ADHD. It is most helpful
that there should be such a strong, evidence-based document
available to guide practitioners in this controversial field.
It should be essential reading for all commissioners,
managers, primary care and specialist clinicians who are
involved with people with this diagnosis.”
PHILIP GRAHAM,
Emeritus Professor of Child Psychiatry,
Institute of Child Health, University of London
1563.qxd 10/2/09 12:30 PM Page 1
ATTENTION DEFICIT
HYPERACTIVITY
DISORDER
Diagnosis and management
of ADHD in children, young
people and adults
National Clinical Practice Guideline Number 72
National Collaborating Centre for Mental Health
commissioned by the
National Institute for Health
& Clinical Excellence
published by
The British Psychological Society and The Royal College of
Psychiatrists
1563.qxd 10/2/09 12:30 PM Page 2
© The British Psychological Society
& The Royal College of Psychiatrists, 2009
The views presented in this book do not necessarily reflect those of the British
Psychological Society, and the publishers are not responsible for any error of
omission or fact. The British Psychological Society is a registered charity
(no. 229642).
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from
the publishers. Enquiries in this regard should be directed to the British
Psychological Society.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from
the British Library.
ISBN-: 978-1-85433-471-8
Printed in Great Britain by Alden Press.
Additional material: data CD-Rom created by Pix18
(www.pix18.co.uk)
developed by National Collaborating Centre for Mental Health
Royal College of Psychiatrists’ Research and Training Unit
4th Floor, Standon House
21 Mansell Street
London
E1 8AA
www.nccmh.org.uk
commissioned by National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn
London
WCIV 6NA
www.nice.org.uk
published by The British Psychological Society
St Andrews House
48 Princess Road East
Leicester
LE1 7DR
www.bps.org.uk
and
The Royal College of Psychiatrists
17 Belgrave Square
London
SW1X 8PG
www.rcpsych.ac.uk
1563.qxd 10/2/09 12:30 PM Page 3
Contents
CONTENTS
1. PREFACE 10
1.1 National guidelines 10
1.2 The national ADHD guideline 13
2. ATTENTION DEFICIT HYPERACTIVITY DISORDER 15
2.1 The disorder 15
2.2 Diagnosis and assessment 18
2.3 Epidemiology 26
2.4 Aetiology 28
2.5 Current care and treatment of ADHD for children in the NHS 29
2.6 ADHD from an educational perspective 33
2.7 Adults with ADHD 34
2.8 The economic cost of ADHD 38
3. METHODS USED TO DEVELOP THIS GUIDELINE 41
3.1 Overview 41
3.2 The scope 41
3.3 The Guideline Development Group 42
3.4 Clinical questions 44
3.5 Systematic clinical literature review 45
3.6 Health economics methods 56
3.7 Focus group methodology 58
3.8 Stakeholder contributions 61
3.9 Validation of this guideline 62
4. THE EXPERIENCE OF TREATMENT AND CARE FOR ADHD 63
4.1 Introduction 63
4.2 The experiences of children and young people of ADHD
and stimulant medication 63
4.3 The experience of diagnosis in adult life 67
4.4 Personal accounts from people with ADHD and their carers 69
4.5 Living with ADHD 87
4.6 Recommendations 92
5. DIAGNOSIS 94
5.1 Introduction 94
5.2 Definitions of terms 94
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Contents
5.3 The validity of ADHD as a diagnostic category 95
5.4 Methodology 96
5.5 Reviewing the validity of the diagnosis: summary
of the evidence 97
5.6 Is the cluster of symptoms that defines ADHD associated
with significant clinical and psychosocial impairments? 104
5.7 Is there evidence for a characteristic pattern of developmental
changes, or outcomes associated with the symptoms,
that define ADHD? 107
5.8 Is there consistent evidence of genetic, environmental or
neurobiological risk factors associated with ADHD? 108
5.9 Limitations 114
5.10 Summary of validation of the diagnosis of ADHD 116
5.11 Defining significant impairment 116
5.12 Position statement on the validity of ADHD 117
5.13 Consensus conference 118
5.14 Summary from review of the diagnosis 124
5.15 Implications for practice 124
5.16 Differentiating ADHD in adults from other
coexisting conditions 129
5.17 Recommendations 132
5.18 Research recommendations 133
6. THE ORGANISATION OF CARE FOR ADHD 135
6.1 Introduction 135
6.2 Stepped care model for ADHD: school-age children
and young people 135
6.3 Stepped-care model for ADHD: pre-school children 138
6.4 Services for adults with ADHD 139
6.5 Models of care for adults with ADHD in established services 140
6.6 Competencies for evaluation of ADHD in children
and young people 141
6.7 Assessment framework and competencies for evaluation
of ADHD in adults 143
6.8 Recommendations 145
7. PSYCHOLOGICAL INTERVENTIONS AND PARENT TRAINING 148
7.1 Introduction 148
7.2 Psychological interventions for children with ADHD 156
7.3 Psychological interventions for adults with ADHD 189
7.4 Other non-pharmacological approaches 201
7.5 Recommendations 203
7.6 Research recommendations 206
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Contents
8. INTERVENTIONS FOR CHILDREN WITH ADHD
IN EDUCATIONAL SETTINGS 208
8.1 Introduction 208
8.2 Databases searched and inclusion criteria 209
8.3 Studies considered 209
8.4 Clinical evidence for screening for ADHD in educational settings 210
8.5 Clinical evidence for advice to teachers about ADHD,
effective classroom interventions and teacher training 212
8.6 From evidence to recommendations 224
8.7 Recommendations 224
8.8 Research recommendations 225
9. DIETARY INTERVENTIONS 227
9.1 Introduction 227
9.2 Elimination diets 227
9.3 Supplementation diets 228
9.4 Recommendations 229
10. PHARMACOLOGICAL TREATMENT 231
10.1 Introduction 231
10.2 Prescribing for children, young people and adults 231
10.3 The regulatory framework 232
10.4 Databases searched and inclusion/exclusion criteria
for clinical evidence 234
10.5 Studies considered in the systematic review of clinical evidence 234
10.6 Methylphenidate (stimulant) 235
10.7 Dexamfetamine (stimulant) 255
10.8 Atomoxetine 258
10.9 Clonidine 275
10.10 Bupropion 280
10.11 Modafinil 285
10.12 Antidepressants 289
10.13 Atypical antipsychotics 290
10.14 Efficacy/harms in special circumstances 290
10.15 Conclusion from clinical evidence 291
10.16 Health economics evidence 292
10.17 From evidence to recommendations 302
10.18 Recommendations 303
10.19 Research recommendations 314
11. COMBINING AND COMPARING PSYCHOLOGICAL AND
PHARMACOLOGICAL INTERVENTIONS 316
11.1 Introduction 316
11.2 Combined interventions for children with ADHD 316
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Contents
11.3 Comparing psychological and pharmacological interventions
for children with ADHD 328
11.4 The MTA study: implications for treatment decisions 333
11.5 Health economics evidence 337
11.6 From evidence to recommendations: treatment decisions
and combined treatment for children with ADHD 358
11.7 Recommendation 359
12. SUMMARY OF RECOMMENDATIONS 360
12.1 Prerequisites of treatment and care for all people with ADHD 360
12.2 Identification, pre-diagnostic intervention in the community
and referral to secondary services 362
12.3 Diagnosis of ADHD 364
12.4 Post-diagnostic advice 365
12.5 Treatment for children and young people 365
12.6 Transition to adult services 372
12.7 Treatment of adults with ADHD 373
12.8 How to use drugs for the treatment of ADHD 375
12.9 Research recommendations 380
13. APPENDICES 383
14. REFERENCES 621
15. ABBREVIATIONS 659
6
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Guideline development group members
GUIDELINE DEVELOPMENT GROUP MEMBERS
Professor Eric Taylor (Chair, Guideline Development Group)
Head of Department of Child and Adolescent Psychiatry,
Institute of Psychiatry, London
Dr Tim Kendall (Facilitator, Guideline Development Group)
Joint Director, The National Collaborating Centre for Mental Health;
Deputy Director, Royal College of Psychiatrists’ Research and Training Unit;
Consultant Psychiatrist and Medical Director, Sheffield Health and Social Care Trust
Professor Philip Asherson
Professor of Molecular Psychiatry and Honorary Consultant Psychiatrist, Medical
Research Council (MRC) Social, Genetic and Developmental Psychiatry Centre,
Institute of Psychiatry, London
Mr Simon Bailey (2006–2007)
Service User Representative
Dr Karen Bretherton
Consultant Psychiatrist for Children with Learning Disabilities, Child and
Adolescent Mental Health Services, Leicestershire Partnership NHS Trust
Ms Amy Brown (2006–2007)
Research Assistant, The National Collaborating Centre for Mental Health
Ms Liz Costigan (2006–2007)
Project Manager, The National Collaborating Centre for Mental Health
Mr Alan Duncan
Systematic Reviewer, The National Collaborating Centre for Mental Health
Dr Val Harpin
Consultant Paediatrician (Neurodisability), Ryegate Children’s Centre,
Sheffield Children’s NHS Foundation Trust
Professor Chris Hollis
Professor of Child and Adolescent Psychiatry, Division of Psychiatry,
University of Nottingham, Queens Medical Centre, Nottingham
Dr Daphne Keen
Consultant Developmental Paediatrician, Developmental Paediatrics,
St George’s Hospital, London
Ms Angela Lewis (2007–2008)
Research Assistant, The National Collaborating Centre for Mental Health
Dr Ifigeneia Mavranezouli
Senior Health Economist, The National Collaborating Centre for Mental Health
7
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Guideline development group members
Dr Christine Merrell
Education Specialist, Curriculum, Evaluation and Management Centre,
Durham University, Durham
Ms Diane Mulligan
Carer Representative
Dr Alejandra Perez
Systematic Reviewer, The National Collaborating Centre for Mental Health
Dr Catherine Pettinari (2007–2008)
Centre Manager, The National Collaborating Centre for Mental Health
Ms Noreen Ryan
Nurse Consultant, Child and Adolescent Mental Health Services,
Bolton NHS Hospital Trust, Bolton
Dr Nicola Salt
General Practitioner, Thurleigh Road Surgery, London
Dr Kapil Sayal
Senior Lecturer in Child and Adolescent Psychiatry, Institute of Mental Health
and University of Nottingham, Nottingham
Ms Linda Sheppard (2006–2007)
Carer Representative
Ms Sarah Stockton
Senior Information Scientist, The National Collaborating Centre for Mental Health
Dr Clare Taylor
Editor, The National Collaborating Centre for Mental Health
Dr Geoff Thorley
Head Clinical Child and Adolescent Psychologist, Child and Adolescent Mental
Health Services, Leicestershire Partnership NHS Trust, Leicester
Ms Jenny Turner (2006–2007)
Research Assistant, The National Collaborating Centre for Mental Health
Professor Peter Tymms
Professor of Education and Director of the Curriculum, Evaluation
and Management Centre, Durham University
Dr Miranda Wolpert (2006–2007)
Director, CAMHS Evidence Based Practice Unit, University College London
and Anna Freud Centre, London
Professor Ian Wong
Professor of Paediatric Medicine Research, Centre for Paediatric Pharmacy
Research, The School of Pharmacy, London
Dr Susan Young
Senior Lecturer in Forensic Clinical Psychology, Institute of Psychiatry, Kings’
College London, Honorary Consultant Clinical and Forensic Psychologist,
Broadmoor Hospital, West London Mental Health Trust
8