Attention deficit hyperactivity disorder Implementing NICE guidance 2008 NICE clinical guideline 72

Related guidance This guideline incorporates recommendations from two technology appraisals: Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents. NICE technology appraisal guidance 98 Parent-training/education programmes in the management of children with conduct disorders. NICE technology appraisal guidance 102

What this presentation covers Background Key priorities for implementation Costs Discussion Find out more

Background: 1 Definition of ADHD - a heterogeneous behavioural syndrome with core symptoms of inattention, hyperactivity and impulsivity Incidence of ADHD Symptoms of ADHD

Background: 2 Diagnosis Assessing severity

Key priorities for implementation Assessment and diagnosis of ADHD Training and the role of specialist teams Parent-training/education Comprehensive treatment plans Drug treatment

ADHD symptoms should: - meet diagnostic criteria in DSM-IV or ICD-10, and - be associated with at least moderate impairment in multiple settings, and - be pervasive, occurring in two or more settings Diagnosis should include assessment of: - the persons needs - coexisting disorders - social, family, educational/occupational circumstances - physical health Assessment and diagnosis For children and young people, assess parent or carer mental health

Trusts should ensure that specialist ADHD teams develop age-appropriate training programmes Teachers who have received training about ADHD should provide behavioural interventions in class Training and the role of specialist teams

Offer parents or carers of pre-school children referral to a parent-training/education programme as first-line treatment Offer parents or carers of school-age children with moderate impairment referral to a group parent- training/education programme A group treatment programme for school-age children (CBT and/or social skills training) may also be offered Parent-training/education

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 Develop transition service models according to best practice guidance Comprehensive treatment plans: children and young people

Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs Comprehensive treatment plans: adults

Drug treatments: 1 Pre-drug treatment assessment Choice of drug treatment Response to treatment Licensing

School-age children or young peopleAdults Drug Severe ADHD - offer drug treatment as first line for: Moderate/severe impairment - offer drug treatment as first line methylphenidate ADHD without significant comorbidity ADHD with comorbid conduct disorder Tics, Tourettes syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion Normally first choice atomoxetine Treatment with methylphenidate ineffective Intolerance to low or moderate dose methylphenidate Tics, Tourettes syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion As for children Drug treatments: 2

Costs Recommendations with significant costs First year (£000s) At full implementation (£000s) Group programmes (recurrent cost)66331 Drug treatment and monitoring of adults with ADHD (recurrent cost) 7,09939,399 Individual psychological interventions (such as CBT and/or social skills training) for older adolescents aged 16 or 17 years (recurrent cost) Estimated recurrent cost of implementation7,21639,958 Assessment for adults with ADHD before starting drug treatment (non-recurrent cost) 3,85519,277

For discussion What training is available locally for healthcare professionals who come into contact with a young person or adult with ADHD? How do we involve young people or adults with ADHD and their parents/carers in making decisions about their care? To what extent is current provision of parent/carer training programmes or group training programmes meeting local needs? What is our local care pathway (for all ages) and how does this integrate with other organisations? How do young people transfer to adult services in our area?

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