ADHD guidelines in children and adults
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition affecting children, young people, and adults. In the UK, diagnosis and management are guided by NICE recommendations, with specialist assessment required and defined thresholds for referral and treatment.
Applies to children, young people, and adults in UK clinical practice.
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition characterised by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, with diagnosis in the UK requiring that symptoms be present before age 12, be evident in two or more settings (e.g., home and school/work), and significantly impair social, academic, or occupational functioning; for children and young people, diagnosis should be made by a specialist paediatrician, child psychiatrist, or appropriately qualified healthcare professional with training and expertise in ADHD, based on a comprehensive assessment that includes a full clinical and psychosocial assessment, discussion of symptoms and their impact, and a developmental history, while also considering the potential for co-existing conditions such as oppositional defiant disorder, conduct disorder, anxiety, and depression, and for adults, diagnosis should be conducted by a specialist ADHD service, psychiatrist, or paediatrician with training and expertise in adult ADHD, recognising that many adults present with a history of symptoms dating back to childhood that may have been previously unrecognised, and assessment should include a retrospective account of childhood symptoms, often supported by school reports or informant accounts where possible, alongside evaluation of current functioning and co-existing conditions which are common, including substance misuse, personality disorders, and mood disorders. Following a confirmed diagnosis, a collaborative management plan should be developed with the individual and, for children, their family or carers, which for all ages should encompass a range of interventions, with psychoeducation being a core first step to explain the condition, its management, and realistic expectations of treatment; for children and young people, non-pharmacological interventions are considered first-line, particularly for those with mild symptoms or preschool-aged children (under 5 years), and include group-based parent training programmes for parents of children under 12, which focus on behavioural strategies, and individual psychological interventions such as cognitive behavioural therapy (CBT) or social skills training for the child or young person if appropriate, while pharmacological treatment is recommended for school-aged children and young people with moderate-to-severe ADHD where non-pharmacological interventions have been ineffective or are insufficient, with methylphenidate (a stimulant) being the first-choice medication for children and young people, followed by lisdexamfetamine or atomoxetine (a non-stimulant) if methylphenidate is not tolerated or is ineffective, and dexamfetamine may be considered by tertiary specialists; for adults, pharmacological treatment is also a first-line intervention for core symptoms, with methylphenidate recommended as the first-choice medication, and alternatives including lisdexamfetamine, dexamfetamine, or atomoxetine if there is no response or intolerance, and all pharmacological treatment must be initiated and monitored by an appropriate specialist, with dose titration to achieve optimal effect with minimal side effects, and regular monitoring of height, weight, pulse, and blood pressure in children and cardiovascular status in adults is essential, alongside non-pharmacological interventions for adults, which should be considered in combination with medication, particularly CBT that is adapted for ADHD to address problems with organisation, time management, and emotional dysregulation. The management of ADHD is a long-term process requiring regular follow-up reviews to assess the effectiveness of treatment, monitor for side effects, and adjust the management plan as needed, with particular attention to key transition points, such as moving from child to adult services, which requires careful planning and coordination to avoid gaps in care, and for all individuals, clinicians should be alert to the potential for misuse and diversion of stimulant medication, especially in adolescents and adults, and ensure appropriate safeguards are in place. It is also crucial to consider the impact of ADHD on education and employment, providing advice and support regarding reasonable adjustments in school, university, or the workplace, such as extra time in exams, a quiet work environment, or flexible working hours, and for co-existing conditions, these should be treated according to relevant guidelines, recognising that effective management of ADHD can sometimes improve other conditions, but specific treatment for the co-existing condition may also be necessary.
Diagnostic criteria and assessment
ADHD diagnosis in the UK requires a comprehensive assessment process, typically initiated following a referral from a GP or other healthcare professional to a specialist ADHD service (often within Child and Adolescent Mental Health Services (CAMHS) for children or adult mental health services), and the core diagnostic criteria are based on the definitions outlined in the International Classification of Diseases, 11th Revision (ICD-11) or the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which share substantial overlap and require the presence of a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, with several inattentive or hyperactive-impulsive symptoms present prior to age 12, manifesting in two or more settings (e.g., at home, school, or work), and clear evidence that the symptoms significantly interfere with social, academic, or occupational functioning, while also not being better explained by another mental disorder. The assessment itself is multifaceted and should be conducted by a healthcare professional or team with appropriate training and expertise in ADHD, involving a detailed clinical interview with the individual (and for children, also with parents or carers) to explore the presenting concerns, the developmental history from childhood, and the pervasiveness and impact of symptoms across different environments. It is crucial to gather collateral history, which for children includes obtaining structured feedback from school (e.g., through standardised questionnaires like the Conners' rating scales or the Strengths and Difficulties Questionnaire (SDQ)) and for adults may involve seeking information from a partner, family member, or close friend, and where possible, reviewing old school reports to establish the early onset of symptoms. A key part of the assessment is the differential diagnosis to rule out other conditions that can mimic ADHD symptoms, such as anxiety disorders, mood disorders, autism spectrum disorder, learning disabilities, attachment disorders, or the effects of substance misuse, and to identify any co-existing conditions, which are common, particularly with oppositional defiant disorder, conduct disorder, anxiety, depression, and tic disorders. A physical examination may be considered to exclude medical causes, and while not routinely required for diagnosis, investigations such as hearing or vision tests might be necessary if there are clinical concerns. The assessment should also evaluate the individual's strengths and difficulties, their cognitive, educational, and occupational functioning, and the broader family and social context, ensuring a holistic understanding of the person beyond their symptoms. For adults presenting for the first time, a retrospective diagnosis requires establishing that the core symptomatic criteria were met in childhood, even if they were not recognised at the time, which can be challenging but is essential for a valid diagnosis. The entire process should be collaborative, involving the individual and their family in discussions about the findings, and the conclusion should lead to a clear, shared formulation that informs the subsequent management plan, which may include behavioural interventions, environmental adjustments, and consideration of medication, always tailored to the individual's specific needs and circumstances.
Medication and non-pharmacological treatment
The management of attention deficit hyperactivity disorder (ADHD) in the UK requires a comprehensive, multi-modal approach that integrates medication with non-pharmacological interventions, tailored to the individual's age, symptom severity, co-existing conditions, and personal and family preferences, with treatment decisions ideally made within a specialist ADHD service following a thorough assessment. Medication, particularly for school-aged children, adolescents, and adults with moderate-to-severe ADHD, is often a first-line treatment due to strong evidence for its efficacy in reducing core symptoms of inattention, hyperactivity, and impulsivity; the main classes of medication include stimulants (methylphenidate and lisdexamfetamine) and non-stimulants (such as atomoxetine and guanfacine), with choice influenced by factors like desired duration of effect, side-effect profile, potential for misuse, and presence of co-morbidities such as tics or anxiety. Treatment with medication should always be initiated at a low dose and titrated upwards slowly against symptoms and tolerability, with ongoing monitoring of height, weight, blood pressure, and pulse in children and young people, and cardiovascular monitoring in adults, alongside regular reviews of effectiveness, side-effects, and adherence, recognising that a proportion of patients may not respond optimally to the first medication tried, necessitating a switch to an alternative. Non-pharmacological interventions are fundamental and should be offered to all individuals with ADHD and their families, not as a replacement for medication where indicated, but as an essential component of holistic care; for children and young people, evidence-based parent training and education programmes are recommended to help parents develop strategies for managing challenging behaviour, improving communication, and establishing consistent routines, while social skills training can address difficulties with peer relationships, and for adults, psychological interventions such as cognitive behavioural therapy (CBT) adapted for ADHD can help develop coping strategies for organisation, time management, and emotional dysregulation. Crucially, environmental adjustments and support within educational and occupational settings are a key non-pharmacological strategy, involving the implementation of reasonable adjustments, such as preferential seating, clear instructions, break times, and use of assistive technology, which can significantly reduce functional impairment; for adults, occupational health assessments can identify necessary workplace modifications. The management of co-existing conditions is integral, as ADHD frequently co-occurs with other neurodevelopmental disorders (like autism spectrum disorder), learning difficulties, mental health problems (such as anxiety, depression, and conduct disorder), and physical health issues, requiring a coordinated care plan that may involve input from other specialists. The transition from child and adolescent mental health services (CAMHS) to adult services is a particularly vulnerable period that requires careful planning and coordination to avoid disengagement from care, with a focus on preparing the young person for increased self-management of their condition. Ultimately, effective treatment is a collaborative process involving the individual, their family, educators or employers, and a multidisciplinary clinical team, aiming not merely for symptom reduction but for improved overall functioning, quality of life, and attainment of personal goals.
Ongoing review and support
Ongoing review and support for individuals with ADHD is a critical, long-term component of effective management, requiring a structured and collaborative approach between primary and secondary care, with the frequency and nature of reviews tailored to the individual's age, symptom stability, comorbidities, and response to treatment. In children and young people, regular monitoring should assess not only core ADHD symptoms but also educational attainment, social functioning, family relationships, and overall development, with reviews typically occurring at least every six months, or more frequently during medication titration or periods of instability, and involving parents, teachers, and the young person themselves where appropriate; for adults, reviews should focus on symptom control, functional impairment in key domains such as employment and relationships, medication efficacy and side effects, and the presence of common co-existing conditions like anxiety, depression, or substance misuse, with annual reviews often being the minimum standard once stability is achieved, though more frequent contact may be necessary. The process of monitoring should be proactive and include standardised rating scales, such as the Conners' scales for children or the Adult ADHD Self-Report Scale (ASRS) for adults, to provide objective measures of change, alongside clinical interviews and direct observation of functioning. A key aspect of ongoing support is ensuring the continuity of care during transitions, particularly from child and adolescent mental health services (CAMHS) to adult services, which requires careful planning, joint working, and clear communication to prevent disengagement and loss of support. For all patients, non-pharmacological interventions, including psychoeducation for the individual and their family, coaching in organisational skills, and behavioural strategies, should be revisited and reinforced during reviews, as these are fundamental to long-term adaptation and coping. Medication management is a central pillar of ongoing care, necessitating regular checks on adherence, optimal dosing, and monitoring for potential side effects, including cardiovascular parameters (e.g., pulse and blood pressure) and height/weight in growing children, with a clear plan for medication holidays if appropriate and discussions about long-term treatment goals. Clinicians should also be vigilant for the emergence of new comorbidities or worsening of existing ones, as these can significantly impact the overall treatment plan and may require referral to other specialists. The role of primary care is crucial in the shared care model, often involving the renewal of stable prescriptions and monitoring physical health parameters, but GPs should have clear guidelines for when to re-refer to secondary care for specialist review, such as in cases of treatment resistance, significant side effects, or major life changes that destabilise the condition. Ultimately, the aim of ongoing review is to support the individual in achieving their personal goals, adapting the management plan as their needs evolve over their lifespan, and ensuring that care is person-centred, coordinated, and effective in mitigating the significant functional impairments associated with ADHD.