NICE vs RCPCH: Management of ADHD in Children (2025)

This guide provides a comparative analysis of two key UK clinical guidelines for the management of Attention Deficit Hyperactivity Disorder (ADHD) in children and young people under 18. The National Institute for Health and Care Excellence (NICE) guideline NG87 (2018, updated 2023 pathway) and the Royal College of Paediatrics and Child Health (RCPCH) guideline for paediatricians (2024/2025) are the primary references for clinical practice. While both aim to ensure high-quality care, they differ in scope, detail, and practical application. This comparison is intended to help clinicians navigate these differences and implement best practices.

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Diagnosis and Assessment

NICE NG87

NICE advocates for a comprehensive, multi-professional assessment. Diagnosis should be made by a specialist paediatrician, child psychiatrist, or other appropriately qualified healthcare professional with training and expertise in ADHD. The assessment must be based on:

• A full clinical and psychosocial assessment, including discussion about symptoms and impairment in different settings.
• A full developmental and psychiatric history.
• Observer reports and assessment of the child’s mental state.
• Direct observation of the child, if appropriate.
• Use of standardised assessment tools, such as the Conners' rating scales or the Strength and Difficulties Questionnaire (SDQ).

Key Takeaway: NICE emphasises a broad diagnostic process, considering the whole child and their context.

RCPCH for Paediatricians

The RCPCH guideline is more prescriptive and tailored to the practical realities of paediatric services, particularly community paediatric teams who conduct the majority of ADHD assessments. It provides a highly structured, step-by-step diagnostic framework:

• Staged Process: Clear delineation of roles between primary care (screening, referral) and specialist care (diagnosis).
• Mandatory Use of DSM-5/ICD-11 Criteria: Stricter adherence to diagnostic criteria, requiring explicit evidence of symptom presence before age 12, pervasiveness across settings, and significant functional impairment.
• Standardised Tools: Strongly recommends specific tools like the Conners 3 or ACE (ADHD Child Evaluation) to standardise symptom reporting from parents and teachers.
• Co-morbidity Screening: Mandates active screening for common co-morbidities like autism spectrum disorder, specific learning difficulties, anxiety, and oppositional defiant disorder during the assessment.

Key Takeaway: RCPCH offers a more procedural, criteria-led approach designed to ensure diagnostic consistency and efficiency within busy paediatric services.

Key Difference

While both require a thorough assessment, NICE outlines the principles of a good assessment, whereas the RCPCH provides a detailed operational protocol for paediatricians to follow, with a stronger emphasis on standardised tools and co-morbidity screening at the point of diagnosis.

Treatment Recommendations

NICE NG87

NICE promotes a stepped-care model, placing a strong emphasis on non-pharmacological interventions as first-line, particularly for preschool children and those with moderate impairment.

• First-line for 5-12 year-olds: Group-based parent training programmes are recommended as first-line treatment.
• Medication: Medication (methylphenidate first-line) is recommended if non-pharmacological interventions are insufficient or for severe impairment.
• Adolescents (12+): A combination of medication and psychological therapy (e.g., CBT) is advised.
• Dietary Advice: Does not recommend elimination diets but advises reviewing diet for adequate micronutrient intake.

RCPCH for Paediatricians

The RCPCH guideline, while acknowledging the stepped-care model, is more direct in its support for medication as a highly effective treatment for core ADHD symptoms.

• Realistic Hierarchy: Acknowledges that access to high-quality, evidence-based parent programmes is often limited. It positions medication as a primary and often necessary intervention for significant functional impairment.
• Practical Medication Guidance: Provides very detailed titration and monitoring schedules, including specific advice on dose optimisation, switching medications, and managing side effects.
• Focus on Function: Treatment goals are explicitly linked to improving specific functional outcomes (e.g., school attendance, academic engagement, family relationships) rather than just symptom reduction.
• Dietary Advice: More cautious, advising against omega-3/6 supplementation as a treatment for ADHD due to limited evidence, aligning with NICE.

Key Difference

The main difference lies in pragmatic emphasis. NICE ideally positions psychological interventions first. The RCPCH guideline, written for the front-line, recognises the limitations of service provision and provides robust, practical guidance on pharmacological management, which is often the mainstay of treatment in clinical practice.

Special Situations and Co-morbidities

NICE NG87

NICE covers co-morbidities within the broader assessment and treatment sections. It advises treating the most impairing condition first, which may not always be ADHD. It includes specific considerations for autism spectrum disorder and tic disorders, noting that ADHD medication can be used but requires careful monitoring.

RCPCH for Paediatricians

The RCPCH guideline dedicates significant attention to co-morbidities, providing explicit pathways.

• Autism and ADHD: Strongly affirms that the co-occurrence is common and both conditions should be diagnosed and treated. Medication for ADHD is effective in the context of autism.
• Tics and ADHD: States that methylphenidate is the first-line choice; if tics exacerbate, switching to guanfacine (a non-stimulant that can help tics) is recommended.
• Specific Learning Difficulties: Mandates assessment for these and clarifies that while medication may improve attention, it does not treat the underlying learning difficulty.
• Risk and Safeguarding: Includes stronger guidance on the association between ADHD and vulnerability, risk-taking behaviours, and the need for robust safeguarding protocols.

Key Difference

RCPCH provides more granular, condition-specific management algorithms for co-morbidities, which is highly practical for clinicians dealing with complex cases. It also integrates safeguarding more explicitly.

Practical Clinical Flow: From Referral to Shared Care

This is an area where the RCPCH guideline offers significantly more detail, reflecting its aim to standardise paediatric service delivery.

• RCPCH Structured Pathway:
  • Referral: Requires specific information from referrers (e.g., school reports, SDQ).
  • Triage: Clear criteria for accepting/declining referrals.
  • Assessment: Mandates use of specific standardised forms for parents and teachers.
  • Diagnostic Formulation: Recommends a standardised report template including co-morbidity findings.
  • Shared Care Agreement: Provides explicit criteria for when a patient is stable and ready for transfer to GP-led shared care, including a minimum period of stability (e.g., 6 months) and clear responsibilities for both specialist and GP.
• NICE Pathway: NICE describes the principles of care but does not provide this level of operational detail for service configuration.

Practical Takeaway: The RCPCH guideline can be used by services to design local protocols and proformas, ensuring consistency and clarity, especially for shared care arrangements.

Frequently Asked Questions (FAQs) for Clinicians

1. Which guideline should I follow?

Answer: Both. NICE sets the national standard for evidence-based practice. The RCPCH guideline translates this into a practical, operational framework for paediatricians. They are complementary. Your local service protocol should be based on NICE standards but can be operationalised using the RCPCH structure.

2. A child has clear ADHD but also has autism. Should I avoid stimulants?

Answer (per RCPCH/NICE): No. ADHD medication is effective and recommended for children with co-occurring autism. Start at a low dose and titrate slowly, with careful monitoring for side effects, which may be more pronounced. The RCPCH is particularly clear on this point.

3. A GP is reluctant to enter a shared care agreement. What are the requirements?

Answer: The RCPCH guideline provides the clearest support here. The specialist team must demonstrate that the patient is on a stable, optimised dose for a defined period (e.g., 6 months) with no significant adverse effects, and provide a clear shared care protocol outlining responsibilities. The GP's role is primarily prescribing and monitoring physical health parameters as per the protocol.

4. What is the first-line medication for an adolescent with new-onset ADHD?

Answer: Both guidelines agree on methylphenidate as first-line pharmacological treatment for all age groups over 5 years. Lisdexamfetamine is typically second-line if methylphenidate is ineffective or not tolerated.

5. How do I handle a case where teacher and parent reports are vastly different?

Answer: This is a core strength of the RCPCH approach. It mandates the use of standardised tools from both settings. Significant discrepancies require further investigation: a school observation, direct contact with the teacher, or exploration of factors in each environment that might explain the difference (e.g., highly structured vs. unstructured settings). A diagnosis of ADHD requires clear evidence of pervasiveness.

Source Links

• NICE Guideline NG87 (2018, updated 2023): NICE NG87
• RCPCH ADHD Guideline Landing Page (2024/2025): RCPCH ADHD guidance (resource) (Access may require RCPCH login).