• Attention deficit hyperactivity disorder (ADHD) is a behavioural disorder characterised by hyperactivity, impulsivity and inattention, which can lead to functional impairment such as psychological, social, educational or occupational difficulties. While these symptoms tend to co-exist, some patients are predominantly hyperactive and impulsive, while others are principally inattentive. Symptoms typically appear in children aged 3–7 years, but may not be recognised until after 7 years of age, especially if hyperactivity is not present. ADHD is more commonly diagnosed in males than in females.
• ADHD is usually a persisting disorder and some children continue to have symptoms throughout adolescence and into adulthood, where inattentive symptoms tend to persist, and hyperactive-impulsive symptoms tend to recede over time. ADHD is also associated with an increased risk of disorders such as oppositional defiant disorder (ODD), conduct disorder, and possibly mood disorders such as depression, mania, and anxiety, as well as substance misuse.

Aims of treatment :The aims of treatment are to reduce functional impairment, severity of symptoms, and to improve quality of life.

Non-drug treatment

• Children and their parents, or carers should be advised about the importance of a balanced diet, good nutrition and regular exercise. If hyperactivity appears to be influenced by certain foods or drinks, parents or carers should be advised to keep a diary of food or drinks consumed and the associated behaviour. A referral to a dietician should be made where appropriate.
• Environmental modifications are changes made to the physical environment that can help reduce the impact of ADHD symptoms on a child's day-to-day life. The modifications should be specific to the child's circumstances, and may involve changes to seating arrangements, lighting and noise, reducing distractions, optimising education by having shorter periods of focus with movement breaks, and the appropriate use of teaching assistants at school. These changes should form part of the discussion at the time of diagnosis of ADHD and be trialled and reviewed for effectiveness before drug treatment is started.
• In children aged under 5 years, an ADHD-focused parent-training programme that teaches parents or carers behaviour therapy techniques is recommended as first-line treatment. Specialist advice should be sought if symptoms are still causing significant impairment after completion of the programme and implementation of environmental modifications.
• In children aged 5 years and over, advice about ADHD and ADHD-focused support should be given to all parents or carers. In children with ADHD and symptoms of oppositional defiant disorder or conduct disorder, a training programme specific for the coexisting condition, involving either the parent or carer with or without the child is also recommended. Drug treatment should be reserved for children whose symptoms are causing persistent and significant impairment of at least one area of function (such as interpersonal relationships, education attainment, and risk awareness) despite environmental modifications.
• In adolescents, a course of cognitive behavioural therapy (CBT) in combination with drug treatment should be considered for those who have had some benefit from drug treatment, but still have symptoms causing significant impairment in at least one area of function (such as social skills with peers, problem-solving, self-control, active listening skills, or dealing with and expressing feelings).

Drug treatment

Child aged under 5 years

Drug treatment should only be considered in children under 5 years of age on advice from a specialist ADHD service.

Child aged 5 years and over

Drug treatment should be initiated by a specialist trained in the diagnosis and management of ADHD. Following dose stabilisation, continuation and monitoring of drug treatment can be undertaken by the child's general practitioner under a shared care arrangement. Children with ADHD and anxiety disorder, tic disorder, or autism spectrum disorder should be offered the same treatment options as other children with ADHD. Treatment options for ADHD are not licensed for use in children under 6 years of age.

• Methylphenidate hydrochloride is recommended as first-line treatment. If a 6-week trial of methylphenidate hydrochloride at the maximum tolerated dose does not reduce symptoms and associated impairment, consider switching to lisdexamfetamine mesilate. Dexamfetamine sulfate can be given to children who are having a beneficial response to lisdexamfetamine mesilate but cannot tolerate its longer duration of effect.
• Modified-release preparations of stimulants are preferred because of their pharmacokinetic profile, convenience, improved adherence, reduced risk of drug diversion (drugs being forwarded to others for non-prescription use or misuse), and the lack of need to be taken to school. Immediate-release preparations can be given when more flexible dosing regimens are required, or during initial dose titration. A combination of a modified-release and immediate-release preparation taken at different times of the day can be used to extend the duration of effect. The magnitude, duration of effect, and side-effects of stimulants vary between patients.
• Atomoxetine or guanfacine can be given to children who are intolerant of both methylphenidate hydrochloride and lisdexamfetamine mesilate, or if symptoms have not responded to separate 6-week trials of both drugs following adequate dose titration and consideration of alternative preparations. If sustained orthostatic hypotension or fainting episodes occur with guanfacine treatment, the dose should be reduced or an alternative treatment offered.
• Advice from, or referral to a tertiary specialist ADHD service should be considered if the child is unresponsive to one or more stimulant drugs (e.g. methylphenidate hydrochloride and lisdexamfetamine mesilate) and one non-stimulant drug (e.g. atomoxetine and guanfacine). A specialist service should also be consulted for advice before starting clonidine hydrochloride [unlicensed] in children with ADHD and sleep disturbances, rages or tics, and before starting atypical antipsychotics in addition to stimulants in children with ADHD and co-existing pervasive aggression, rages or irritability.
• Other treatment options such as bupropion hydrochloride, modafinil, and tricyclic antidepressants [all unlicensed] have been used in the management of ADHD, but due to limited evidence their use is not recommended without specialist advice.
• Children should be monitored for effectiveness of treatment and side-effects, in addition to changes in sleep pattern, and the potential for stimulant diversion or misuse. If the child develops new, or has worsening of existing seizures, review drug treatment and stop any drug that might be contributing to the seizures; treatment can be cautiously reintroduced if it is unlikely to be the cause. Monitor children for the development of tics associated with stimulant use. If tics are stimulant related, consider a dose reduction, stopping treatment, or changing to a non-stimulant drug. If there is worsening of behaviour, consider adjusting drug treatment and reviewing the diagnosis.

Treatment should be reviewed by a specialist at least once a year and trials of treatment-free periods, or dose reductions considered where appropriate.

Useful resources

Attention deficit hyperactivity disorder: diagnosis and management. National Institute for Health and Care Excellence. Clinical guideline 87. March 2018.
http://www.nice.org.uk/guidance/ng87