The National Institute for Health and Clinical Excellence has published a guideline on the diagnosis and management of ADHD in children, young people and adults. But what are its implications for schools?

At the end of September, the National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Mental Health published their guideline on attention deficit hyperactivity disorder (ADHD). A common behavioural disorder in children and young people, ADHD is estimated to affect up to 3% of school-age children and young people in the UK and about 2% of adults worldwide. It usually starts in early childhood, with some people continuing to have ADHD
into adulthood.

The prevalence of ADHD in the UK has risen sharply: from an estimate of 0.5 per 1,000 children diagnosed 30 years ago, to more than 3 per 1,000 receiving ADHD medication in the late 1990s. A UK survey of 10,438 children between the ages of 5 and 15 years carried out in 2003 found that 3.62% of boys and 0.85% of girls had the condition. Based on these figures and national population statistics it is estimated that about 210,000 children aged between five and 18 years are affected in England and Wales. This is still significantly lower than the US prevalence rate: A study conducted by researchers at Cincinnati Children’s Hospital Medical Center and published in 2007 in Archives of Pediatrics & Adolescent Medicine, found that 8.7 percent of children in the US between the ages of eight and 15 (approximately 2.4 million children) meet validated ADHD diagnostic criteria.

Diagnosis and assessment
The guideline defines ADHD as ‘a complex disorder resulting from multiple genetic and environmental risk factors, representing the extreme and impaired tail of a normally distributed trait in the population. The disorder is recognised by the presence of a high level of pervasive and enduring problems with attention, overactivity and impulsiveness when they lead to a significant degree of clinical, psychosocial and/or academic impairments.’

Where a child is suspected of having ADHD, a full assessment is necessary to confirm the diagnosis. This will typically include a clinical interview, a medical examination and administration of rating scales to parents and teachers. Other components – such as direct observation in educational settings, cognitive, neuropsychological, developmental and literacy skills assessments – may be necessary. As the guideline notes, ‘Referral pathways can be complicated, and are subject to considerable variation in the local organisation of mental health services for children and young people.’ According to a survey conducted by the World Federation for Mental Health in 2005, the average waiting time to receive an assessment and subsequent diagnosis is 2.44 years, with 17% waiting for more than five years.

A paediatrician, psychiatrist, clinical psychologist or specialist nurse usually carries out the clinical interview. One aim of this is to rule out undiagnosed disorders with symptoms that may mimic or cause some aspects of ADHD, such as hearing impairment, epilepsy, thyroid disorder and iron deficiency anaemia.

A detailed clinical interview in a child mental health practice will typically take between two and three hours, often arranged over two sessions. An understanding of a child or young person’s adjustment at school is an important component of the assessment. In addition to providing information gathered by questionnaire, teachers may be asked to provide specific information on social and academic functioning. Educational and clinical psychologists may undertake further assessments if learning difficulties, including poor literacy skills, dyslexia or other problems such as dyscalculia or non-verbal learning difficulties, are suspected. These may help to explain the presence of attentional problems; and even if ADHD is present as well, they will need addressing.

According to the guideline, a diagnosis of ADHD does not imply a medical or neurological cause: ‘ADHD involves the interplay of multiple genetic and environmental factors. ADHD is viewed as a heterogeneous disorder with different sub-types resulting from different combinations of risk factors acting together.’ Environmental factors considered include biological, dietary and psychosocial. Currently, the guideline says, recognition of ADHD is ‘unsystematic and driven largely by the extent to which parents are knowledgeable about the condition or recognise that their child might have hyperactive behaviour.’ Multi-agency working in relation to ADHD is also considered to be deficient.

Impact on learning
The core behaviours associated with ADHD clearly impact a child’s academic performance (see box, below). Children and adolescents with ADHD have been shown to have greater impaired attention; less impulse control; and greater off-task, restless and vocal behaviour. They also have higher rates of both specific and generalised learning disabilities, poor reading skills, and speech and language problems compared with healthy peers. As well as having academic problems, children with ADHD find it more difficult to make friends and are more likely to engage in anti-social behaviour such as drug-taking and petty crime.

The core behaviours of ADHD include being:

  • Inattentive – unable to concentrate for very long or finish a task, disorganised, often losing things, easily distracted and forgetful, unable to listen when people are talking
  • Hyperactive – fidgety and unable to sit still, restless (children may be running or climbing much of the time), talking constantly, noisy, having difficulty doing quiet activities
  • Impulsive – speaking without thinking about the consequences, interrupting, unable to wait or take turns.

The guideline proposes a stepped care model for ADHD, in which children and families move up (or down) a step on the care pathway according to their particular needs and outcomes as well as what has already been tried. In the case of ADHD, a stepped care-model for a child of school age might start with a parent or carer speaking to what the guideline calls a ‘tier 1 professional’ such as a teacher, health visitor, GP, school or practice nurse. Teachers who are asked for advice should direct the parent to self-help approaches (for example, parent organisations, books, manuals, videos or DVDs and websites), or refer the child to either a child and adolescent mental health services or paediatric services.

Here the guideline states: ‘These professionals should have a basic understanding of ADHD and be able to ask key questions to ascertain possible symptoms and level of impairment. This can be backed up by the use of rating scales (broad-band rating scales such as the strengths and difficulties questionnaire or narrow-band rating scales such as the Conners’ rating scales). For this to be feasible, and to enhance awareness and accurate knowledge about ADHD and associated conditions, tier 1 professionals will require access to appropriate training or materials.’ The guideline spells out elsewhere what the tier 1 competencies should be. Primary care practitioners should not make the initial diagnosis or start drug treatment in children or young people with suspected ADHD.

If a teacher decides to maintain a watching brief and/or suggest self-help approaches, it is suggested that the child should be registered under school action; if an external referral is made to an educational psychologist, to outreach specialist teaching services through behaviour and learning support or to a child and adolescent mental health service (CAMHS) professional or paediatrician, then the child should be registered under school action plus. Under the school action option, the teacher should carry out a review at the end of the parent-training/education programme (the guideline suggests after 10 weeks). If the ADHD symptoms remain prominent, the child should be referred for assessment by a tier 2 professional, who will then decide whether to refer the child to tier 3. Where there is a high level of uncertainty about a diagnosis, marked severity or complexity, or complex issues around psychopharmacology, there should be access to a regional ADHD service that supports a tier 3 CAMHS specialist or a paediatrician.

A child or young person who is already on medication for a presumptive diagnosis of ADHD, but has not yet been assessed by a specialist in ADHD, should be referred for assessment to a child psychiatrist, paediatrician or specialist ADHD CAMHS as a matter of clinical priority.

This stepped care model is replicated when it comes to proposed therapeutic interventions. Where the child with ADHD has moderate levels of impairment, it is proposed that in the first instance the parents or carers should be offered referral to a group parent-training/education programme, either on its own or alongside a group treatment programme for the child or young person (cognitive behaviour therapy and/or social skills training). The guideline suggests areas to be targeted, including social skills with peers, problem-solving, self-control, listening skills and dealing with and expressing feelings.

In the case of children with more severe ADHD, the guideline concludes that on the whole, the evidence indicates that medication (methylphenidate or Ritalin) has moderate to highly beneficial effects on ADHD core symptoms and conduct problems. However, an economic analysis for the guideline comparing psychological, pharmacological and combined treatments for school-aged children with ADHD indicated that group behavioural therapy or group CBT were more cost-effective than medication.

The guideline concludes: ‘Drug treatment is not indicated as the first-line treatment for all school-age children and young people with ADHD. It 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.’

In the case of school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. 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.