Attention Deficit Hyperactivity Disorder (ADHD) Guideline for the treatment and care of children and young people with ADHD Table of Contents

Identification, pre-diagnostic intervention in the community and referral to secondary services .......................................................................... 2 Identification and referral...................................................................... 2 Diagnosis ............................................................................................. 3 Post-diagnostic advice ......................................................................... 4 General advice .................................................................................................... 4 Dietary advice ...................................................................................................... 4

Treatment ............................................................................................ 5 Pre-school children .............................................................................................. 5 School-age children with moderate impairment ................................................... 5 School-age children with severe ADHD (hyperkinetic disorder) and severe impairment........................................................................................................... 6 Pre-drug treatment assessment .......................................................................... 6 Choice of drug for children and young people with ADHD................................... 7 Costings………………………………………………………………………………… 8 General principles ............................................................................................... 9 Methylphenidate .................................................................................................. 9 Modified Release Preparations ........................................................................... 9 Dexamphetamine. ............................................................................................. 10 Lisdexamfetamine……………………………………………………………………..10 Contra-Indications ............................................................................................. 10 Monitoring (for methylphenidate, dexamphetamine, lisdexamfetamine) ............ 11 Side Effects ....................................................................................................... 12 Atomoxetine ...................................................................................................... 13 Monitoring.......................................................................................................... 13 Side Effects ....................................................................................................... 13 Poor response to treatment ............................................................................... 14 Improving adherence to drug treatment............................................................. 14 Duration, discontinuation and continuity of treatment in children and young people................................................................................................................ 15 Transition to adult services ............................................................................ 15

REFERENCES: ................................................................................. 16

Identification, pre-diagnostic intervention in the community and referral to secondary services Children and young people with behavioural problems suggestive of ADHD can be referred by their school or primary care practitioner for parent training/education programmes without a formal diagnosis of ADHD. The diagnosis of ADHD in children and young people should take place in secondary care.

Identification and referral Universal screening for ADHD should not be undertaken in any school setting. When a child with suspected ADHD is referred to a school’s special educational needs coordinator (SENCO), the SENCO, in addition to helping the child with their behaviour, should inform the parents about local parent-training / education programmes. When a child presents in primary care with symptoms suggestive of ADHD, primary care practitioners should determine the severity of the problems, in terms of how much they pervade different domains and settings. If the child’s symptoms are having an adverse impact on their development or family life, healthcare professionals should consider: 

a period of watchful waiting of up to 10 weeks



offering parents or carers a referral to a parent training/education programme (this should not wait for a formal diagnosis of ADHD).

If the behavioural and/or attention problems persist with at least moderate impairment, the child should be referred to secondary care for assessment. If the child’s symptoms are associated with severe impairment, referral should be made immediately to secondary care for assessment. Referral from the community to secondary care will usually be via the GP or school nurse. If problems are seen mainly in school then referral will be to paediatrics. If problems are primarily at home then referral will be to CAMHS. Primary care practitioners should not make the initial diagnosis or start drug treatment in children with suspected ADHD. A child who is currently treated in primary care with 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, or paediatrician as a matter of clinical priority.

2 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Diagnosis A diagnosis of ADHD should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD, on the basis of:   

a full clinical and psychosocial assessment of the child; this should include discussion about behaviour and symptoms in the different domains and settings of the person’s everyday life a full developmental history observer reports and assessment of the child in clinic.

A diagnosis of ADHD should not be made solely on the basis of rating scales or observational data. However rating scales such as the Conners’ rating scales are valuable adjuncts. Information will be gathered from the child’s school and this may include teacher rating scales and observation. For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:   

meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder), and be associated with at least moderate psychological, social and/or educational impairment based on interview and/or direct observation in multiple settings, and be pervasive, occurring in two or more important settings including social, familial, and/or educational settings.

Diagnosis will include an assessment of the child’s needs, coexisting conditions, social, familial and educational circumstances and physical health. Enquiries should be made into parental mental health and referral made to the family GP if there are ongoing concerns in this area. ADHD should be considered in all age groups, with symptom criteria adjusted for age-appropriate changes in behaviour. In determining the clinical significance of impairment resulting from the symptoms of ADHD in children and young people, their views should be taken into account wherever possible. If during an assessment with CAMHS there are medical or developmental issues such as dyspraxia then a referral may be made to community paediatrics for further assessment. If during a paediatric assessment there are concerns about a child’s mental health then a referral may be made to CAMHS for further assessment.

3 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Post-diagnostic advice After diagnosis people with ADHD and their parents or carers may benefit from advice about diet, behaviour and general care. General advice Following a diagnosis of ADHD, healthcare professionals should consider providing all parents/carers self-instruction manuals, and other materials such as DVDs, based on positive parenting and behavioural techniques. All patients should be offered psycho-educational workshops run by CAMHS. Dietary advice Healthcare professionals should stress the value of a balanced diet, good nutrition and regular exercise. The elimination of artificial colouring and additives from the diet is not recommended as a generally applicable treatment. Clinical assessment of ADHD should include asking about foods or drinks that appear to influence their hyperactive behaviour. If there is a clear link, healthcare professionals should advise elimination of certain food/drinks from the diet. Dietary fatty acid supplementation is not recommended for the treatment of ADHD in children and young people.

4 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Treatment Pre-school children A formal diagnosis of ADHD will not usually be made in preschool children. However it is recognised that some preschool children with significant hyperactivity/inattention will go on to a diagnosis on starting full time school. Parent-training/education programmes are the first-line intervention for parents or carers of preschool children. These programmes are the same as those recommended for the parents or carers of other preschool children with behaviour problems. Drug treatment is not recommended for preschool children. Information may be shared with the child’s nursery with parental consent. Individual-based parent-training/education programmes7 are recommended in the management of children with ADHD when:   

a group programme is not possible because of low participant numbers there are particular difficulties for families in attending group sessions a family’s needs are too complex to be met by group-based parenttraining/education programmes.

Any parent-training/education programmes that have been provided should be fed back to the child’s GP. School-age children with moderate impairment Group-based parent-training/education programmes are the first-line treatment in this group. For older age groups, individual psychological treatment may be more acceptable if group behavioural or psychological approaches have not been effective, or have been refused. For children (including older age groups) with ADHD and a learning disability, a parent-training/education programme should be offered on either a group or individual basis, whichever is preferred following discussion with the parents or carers. Following a diagnosis of ADHD in a school-age child healthcare professionals should, with the parents’ or carers’ consent, contact the child’s teacher to discuss:   

the diagnosis and severity of symptoms and impairment the care plan any special educational needs.

Teachers should then provide behavioural intervention with SENCO support if needed. 5 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Following successful treatment with a parent-training/education programme and before considering discharge from secondary care, the child should be reviewed, with their parents/carers, for any residual problems. Treatment plans should be developed for any co-morbid conditions. Following treatment with a parent-training/education programme, children with persisting significant impairment should be offered drug treatment. Any parent-training/education programmes that have been provided should be fed back to the child’s GP. School-age children with severe ADHD (hyperkinetic disorder) and severe impairment Following a diagnosis of ADHD in a school-age child healthcare professionals should, with the parents’ or carers’ consent, contact the child’s teacher for discussions as with moderate impairment (see above). The first-line treatment for school-age children with severe ADHD and severe impairment is drug treatment. If the child or family decline medication a psychological intervention may be tried but drug treatment is likely to have the greatest impact. At the same time as medication parents will be offered a group-based parenttraining/education programme. Drug treatment should only be initiated by an appropriately qualified secondary care healthcare professional with expertise in ADHD and should be based on a comprehensive assessment and diagnosis. Continued prescribing may be performed by general practitioners, under shared care arrangements. Pre-drug treatment assessment This will be carried out in secondary care prior to starting medication Before starting drug treatment, children should have a full pre-treatment assessment, which should include:   



full medical, mental health and social history physical examination, including: – heart rate and blood pressure (plus centile) – height and weight (plotted on a growth chart) an electrocardiogram (ECG) if there is past medical or family history of serious cardiac disease, a history of sudden death in young family members or abnormal findings on cardiac examination. In this situation a referral would usually be made for paediatric cardiology assessment before starting treatment risk assessment for substance misuse and drug diversion

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. 6 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Choice of drug for children and young people with ADHD2 Methylphenidate, atomoxetine and dexamfetamine should all be considered as first line treatments. Lisdexamfetamine is licensed for use second line in patients who have partially responded to methylphenidate at maximum dose. The decision regarding which product to use should be based on the following:     

the presence of comorbid conditions (for example, tic disorders, Tourette’s syndrome, epilepsy) the different adverse effects of the drugs specific issues regarding compliance identified for the individual child or adolescent (for example problems created by the need to administer a midday treatment dose at school) the potential for drug diversion and/or misuse the preferences of the child/adolescent and/or his or her parent or guardian.

When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider:     

methylphenidate for ADHD without significant comorbidity methylphenidate for ADHD with comorbid conduct disorder methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person develops significant side effects with methylphenidate. Dexamfetamine/lisdexamfetamine if partial response to methylphenidate

When using methylphenidate immediate release (IR) tablets are first choice treatment. Long-acting preparations including Concerta XL®, Equasym XL® and Medikinet XL® can be used in the following situations:  

Children where problems of safety and compliance are important. Other children who are difficult to maintain on immediate release tablets.

The decision to prescribe the long-acting preparation should be taken by a senior doctor and communicated to the GP via the clinic letter. If there is a choice of more than one appropriate drug, the product with the lowest cost should be prescribed. Costings: Methylphenidate hydrochloride containing 5mg, 10mg and 20mg tablets available in packs of 30 tablets. Cost £3.03 to 10.92 Concerta XL® tablets containing 18mg, 27mg or 36mg of methylphenidate hydrochloride available in boxes of 30 tablets. Cost £31.19 to £42.45 Equasym XL® capsules containing 10mg, 20mg or 30mg of methylphenidate hydrochloride available in boxes of 30 capsules. Cost £25.00 to £35.00 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

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Principal author: Dr J. Fellick Review date: June 2017

Medikinet XL ® capsules containing 5mg, 10mg, 20mg or 40mg of methylphenidate hydrochloride available in boxes of 30 capsules. Cost £24.04 to £57.72 Dexamfetamine sulphate containing 5mg tablets available in packs of 28 tablets. Cost £16.13 Lisdexamfetamine mesilate 30 mg (white/pink), 28-cap pack = £58.24; 50 mg (white/blue), 28-cap pack = £68.60; 70 mg (blue/pink), 28-cap pack = £83.16. Atomoxetine (as hydrochloride) containing 10mg, 18mg, 25mg, 40mg, 60mg, 80mg and 100mg capsules available in packs of 7 or 28capsules. Cost £15.62 to £83.28 (All eBNF, June2013) Antipsychotics are not recommended for the treatment of ADHD in children and young people.

8 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

General principles      

During the titration phase, doses should be gradually increased until there is no further clinical improvement in ADHD symptoms and side effects are tolerable. Children will usually be reviewed 6 - 8 weeks after starting treatment. Following titration and dose stabilisation, prescribing and monitoring should be carried out under locally agreed shared care arrangements with primary care. (see appendix 1 and 2). Side-effects resulting from drug treatment for ADHD should be routinely monitored and documented in the person’s notes. If side effects become troublesome, a reduction in dose should be considered. Dose titration should be slower if tics or seizures are present in people with ADHD.

Methylphenidate      

Starting dose 5mg bd. Titrate dose up by 5-10mg/day at weekly intervals according to clinical response. Maximum single dose 20mg. Maximum daily dose 60mg in 2-3 divided doses If there is no improvement in symptoms after treatment with an adequate dose for six weeks discontinue treatment. Medication can be used on school days only if appropriate.

Modified Release Preparations There are 3 modified release methylphenidate preparations available currently: Concerta XL® has a 12 hour duration of effect (approximating to tds dosing of immediate release Methylphenidate). Equasym XL® and Medikinet XL® both have an 8 hour duration (approximating to bd immediate release) although Medikinet® releases relatively more in the morning.

Modified release preparation

Approximate equivalent dose of methylphenidate IR

Concerta XL® 18mg. Concerta XL® 36mg. Concerta XL® 54mg. Equasym/Medikinet XL® 10mg. Equasym/Medikinet XL® 20mg. Equasym/Medikinet XL® 30mg.

5mg tds 10mg tds 15mg tds 5mg bd 10mg bd 15mg bd 9

Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Dexamfetamine 2nd line medication for children who partially respond to methylphenidate    

Starting dose 2.5mg bd or tds Titrate according to clinical response at one to two weekly intervals Maximum single dose 10mg. Maximum daily dose 30mg in three divided doses.

Lisdexamfetamine Long acting stimulant licensed as a second line medication in patients who have partially responded to methylphenidate and require a once daily formulation    

Starting dose 30mg given each morning Increase to 50mg after one week if no response Increase to 70mg after a further week Maximum dose 70mg

Contra-Indications (methylphenidate, dexamfetamine and lisdexamfetamine) For a full list of cautions and contra-indications please consult an up to date copy of the eBNFC           

severe depression suicidal ideation anorexia nervosa psychosis uncontrolled bipolar disorder hyperthyroidism cardiovascular disease (including heart failure, cardiomyopathy, severe hypertension, and arrhythmias) structural cardiac abnormalities phaeochromocytoma vasculitis cerebrovascular disorders

Monitoring (methylphenidate, dexamfetamine and lisdexamfetamine) Routine monitoring will be carried out in secondary care and shared with the GP via clinic letters 1. Weight and height should be checked at baseline and six monthly and plotted on a growth chart. Strategies to reduce poor weight gain or weight loss include:  

taking medication either with or after food, rather than before meals taking additional meals or snacks early in the morning or late in the evening when the stimulant effects of the drug have worn off 10

Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

 

obtaining dietary advice consuming high-calorie foods of good nutritional value. If growth is significantly affected by drug treatment the option of a planned break in treatment over school holidays should be considered to allow ‘catchup’ growth to occur.

2. Blood pressure should be checked at baseline, after 6 weeks and six monthly thereafter and plotted on a centile chart. If sustained resting tachycardia, arrhythmia or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions then reduce dose and refer to a general paediatrician. 3. Full and differential blood counts are not routinely indicated. Enquiry about excess infections, mouth ulcers or bruising should be made at follow-up and blood checks carried out if clinical concern arises. 4. Pyschiatric monitoring every 6 months for aggression, psychosis, tics etc If psychotic symptoms (for example, delusions and hallucinations) emerge the drug should be withdrawn and a full psychiatric assessment carried out. Atomoxetine should be considered as an alternative. If tics emerge then consider whether:  

the tics are stimulant-related (tics naturally wax and wane) tic-related impairment outweighs the benefits of ADHD treatment. If tics are stimulant-related, reduce the dose of methylphenidate or dexamfetamine, consider changing to atomoxetine, or stop drug treatment.

5. Drug holidays should be considered during routine monitoring in secondary care and are clinically useful in deciding re: on-going effect of medication. Consideration needs to be given to their timing during the school year.

11 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Side Effects (Methylpnenidate, dexamfetamine and lisdexamfetamine) For a full list of side effects please consult an up to date copy of the eBNFC

The following are relatively common (can occur in up to 10% of children) and are often transient:        

Sleep disturbance, night terrors Transient emotional instability (commoner in younger children). Appetite suppression and growth retardation Restlessness, irritability, excitability Headaches, tremor, dizziness, convulsions Increased blood pressure Abdominal pain, stomach ache Tics

Cardiac arrhythmias, leucopenia, thrombocytopenia, liver damage and psychosis are rare side effects. Anxiety symptoms, including panic, may be precipitated by stimulants. Where this is an issue, lower doses of the stimulant and/or combined treatment with an antidepressant used to treat anxiety can be used; switching to atomoxetine may be effective. Parents or carers should also be warned about the potential for liver damage in rare cases.

12 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Atomoxetine Atomoxetine should be used if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate.  

May be used first line if tics, tourettes or anxiety. For patients 70kg body weight initiate with 40mg for minimum 7 days. Maintenance dose 80mg with maximum recommended dose 100mg/day  Trial of treatment – minimum of 12 weeks. Total daily dose may be given as a single dose in the morning. Cautions Cardiovascular disease including hypertension, tachycardia, structural cardiac abnormalities and QT-interval prolongation Cerebrovascular disease Psychosis or mania Susceptibility to angle-closure glaucoma Contraindication Phaeochromocytoma

Monitoring Will be carried out in secondary care and communicated to the GP via clinic letters At baseline and then 6 monthly:  Weight  Height  BP  Pulse Monitor for appearance or worsening of anxiety, depression or tics; history of seizures; aggressive behaviour, hostility, or emotional lability; Side Effects Side effects of atomoxetine may be reduced by giving as two divided doses. Abdominal pain, reduced appetite, vomiting, nausea, irritability, fatigue, somnolence, dry mouth, sexual dysfunction, insomnia, dizziness, sweating, constipation. Parents and/or carers should be warned about the potential for suicidal thinking and self-harming behaviour with atomoxetine and asked to report these to their healthcare professionals. Parents or carers should also be warned about the potential for liver damage in rare cases. 13 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Poor response to treatment If there has been a poor response to parent-training/education programmes, psychological treatment and drug treatment with methylphenidate and atomoxetine, a comprehensive review is required including:         

the diagnosis any co-existing conditions response to drug treatment, occurrence of side effects and treatment adherence uptake and use of psychological interventions for the child or young person and their parents or carers effects of stigma on treatment acceptability concerns related to school and/or family motivation of the child or young person and the parents or carers the child or young person’s diet.

The following are further options for treatment:   

higher doses of methylphenidate or atomoxetine; switching to dexamfetamine or lisdexamfetamine further or alternative psychological treatments.

Improving adherence to drug treatment For children with ADHD, the strategies outlined below should be considered to improve treatment adherence. Communication between the prescriber and the child or young person should be improved by educating parents or carers and ensuring there are regular three-way conversations between prescriber, parent or carer and the child or young person. Clear instructions about how to take the drug should be offered in picture or written format, which may include information on dose, duration, side effects, dosage schedule, the need for supervision and how this should be done. Peer-support groups for the child and their carers can be invaluable if adherence to drug treatment is difficult or uncertain. Simple drug regimens (for example, once-daily modified-release doses) are recommended for people with ADHD. Encourage patients to be responsible for their own health, including taking their medication as required, and support parents and carers in this endeavour. Advise parents or carers to provide the child or young person with visual reminders to take medication regularly (for example, alarms, clocks, pill boxes, or notes on calendars or fridges). Advise children and their parents / carers that taking medication should be incorporated into daily routines (for example, before meals or after brushing teeth). 14 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Where necessary help parents or carers develop a positive attitude and approach in the management of medication, which might include praise and positive reinforcement for the child with ADHD. Duration, discontinuation and continuity of treatment in children and young people It is advisable to review each year whether children need to continue drug treatment and to ensure that the long-term pattern of use is tailored to the person’s needs, preferences and circumstances. Following an adequate treatment response, drug treatment for ADHD should be continued for as long as it remains clinically effective. This should be reviewed at least annually. The review should include a comprehensive assessment of clinical need, benefits and side effects, taking into account the views of the child or young person, as well as those of parents, carers and teachers, and how these views may differ. The effect of missed doses, planned dose reductions and brief periods of no treatment should be taken into account and the preferred pattern of use should alsobe reviewed. Co-existing conditions should be reviewed, and the child or young person treated or referred if necessary. The need for psychological and social support for the child or young person and for the parents or other carers should be assessed. Drug holidays are not routinely recommended; however, consideration should be given to the parent or carer and child or young person with ADHD working with their healthcare professional to find the best pattern of use, which may include periods without drug treatment. Transition to adult services Young people with ADHD receiving treatment and care from CAMHS or paediatric services should normally be transferred to adult services if they continue to have significant symptoms of ADHD or other coexisting conditions that require treatment. Transition should be planned in advance by both referring and receiving services. If needs are severe and/or complex, use of the care programme approach should be considered. A young person with ADHD receiving treatment and care from CAMHS or paediatric services should be reassessed at school leaving age to establish the need for continuing treatment into adulthood. If treatment is necessary, arrangements should be made for a smooth transition to adult services with details of the anticipated treatment and services that the young person will require. Precise timing of arrangements may vary locally but should usually be completed by the time the young person is 18 years. During the transition to adult services, a formal meeting involving CAMHS and/or paediatrics and adult psychiatric services should be considered, and full information provided to the young person about adult services. For young people aged 16 years and older, the care programme approach (CPA) should be used as an aid to transfer between services. The young person, and when appropriate the parent or carer, should be involved in the planning. 15 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

After transition to adult services, adult healthcare professionals should carry out a comprehensive assessment of the person with ADHD that includes personal, educational, occupational and social functioning, and assessment of any coexisting conditions, especially drug misuse, personality disorders, emotional problems and learning difficulties.

REFERENCES: 1

Parent-training/education programmes in the management of children with conduct disorders’ (NICE technology appraisal guidance 102).

2

Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents’ (NICE technology appraisal 98).

Related documents Shared care guidelines Atomoxetine for ADHD in Children and Adolescents Shared Care guideline Atomoxetine for ADHD in children & adolescents Methylphenidate for ADHD in Children and Adolescents Shared Care guideline Methylphenidate for ADHD children & adolescents Patient Information leaflets http://www.medicinesforchildren.org.uk/search-for-a-leaflet/atomoxetine-for-adhd/ http://www.medicinesforchildren.org.uk/search-for-a-leaflet/methylphenidate-foradhd/

Auditable standards 1.

2. 3.

4.

Diagnosis of ADHD should be based on 1) the developmental history 2)assessment of the child in clinic and 3)information from school Before starting medication children will have growth and blood pressure measured and recorded in notes Children on medication for ADHD will be seen in clinic at least every 6 months and have growth and blood pressure measured each time Children on medication for ADHD will have growth parameters plotted on a growth chart at each review

16 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Version Date of issue: Date of review: Review interval: Author: Approved by:

1 June 2014 June 2017 3 yearly Dr J. Fellick

Location of copies:

17 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Appendix 1

Suggested algorithm for medication in ADHD Decision to treat ADHD/ADD with medication

Trial period immediate release(IR)methylphenidate (MPH)

Good response

Partial response to MPH at maximum dose

No response or significant side effects from MPH

Continue with IR MPH

Dexamfetamine or lisdexamfetamine if once daily dosing required

Atomoxetine

Consider longacting preparations if concern about compliance especially on transition to secondary school

Good response

continue

Poor response or side effects

Poor response or side effects

Good response

continue

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Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017

Appendix 2 – BP percentiles for boys & girls

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Principal author: Dr J. Fellick Review date: June 2017

20 Attention Deficit Hyperactivity Disorder (ADHD) Clinical Guideline Version 1

Approved by: Medicines Clinical Guidelines Team June 2014

Principal author: Dr J. Fellick Review date: June 2017