Attention-deficit hyperactivity disorder (ADHD) in adults is increasingly recognised across primary and secondary care. In the UK, NICE provides the gateway for diagnosis and treatment access, while the Royal College of Psychiatrists (RCPsych) offers practical, clinician-facing guidance with richer detail on functional impairment, titration, and monitoring. This article compares both perspectives for 2025, so teams can align access pathways with day-to-day clinical practice.
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Audience: GPs, psychiatrists, nurse prescribers, pharmacists, and allied professionals involved in adult ADHD assessment, prescribing, and follow-up.
Scope and orientation
NICE (NG87) sets structured diagnostic criteria, requires specialist assessment for diagnosis and initiation of treatment, and outlines shared-care arrangements. It provides clear access rules and prescribing governance for the NHS.
RCPsych expands on diagnostic nuance, focusing on functional impairment, developmental history, and differential diagnosis. It provides practical advice on titration, monitoring, and ongoing management, assuming specialist involvement and shared-care with primary care.
Practical takeaway: NICE defines who can diagnose and initiate; RCPsych gives clinicians detailed how-to for diagnosis, titration, and monitoring.
Diagnosis and assessment
NICE
- Requires specialist assessment (usually psychiatry/neurodevelopmental services) for diagnosis and treatment initiation.
- Structured diagnostic criteria with symptom thresholds across childhood and adulthood.
- Stresses multi-source information where possible (history, informant reports, school/occupational history).
- Encourages screening for comorbidities (anxiety, depression, substance use) and safeguarding considerations.
RCPsych
- Builds on NICE criteria but emphasises functional impairment in multiple domains (work, relationships, organisation, driving risk).
- Offers nuanced guidance on differentiating ADHD from mood/anxiety disorders, personality traits, and sleep problems.
- Highlights the role of clinician judgement when histories are incomplete, especially for adults without childhood documentation.
Key difference: NICE specifies who diagnoses and the criteria; RCPsych deepens the clinical nuance of assessing impairment and differentials.
Treatment principles
NICE
- Medication initiated by specialists; shared care with primary care once stable.
- Stimulants (methylphenidate or lisdexamfetamine) as first-line; consider non-stimulants (atomoxetine/guanfacine) when stimulants are unsuitable.
- Requires baseline cardiovascular assessment (BP, HR), weight/BMI, and risk assessment before starting medication.
RCPsych
- Aligns on stimulants first-line; provides greater depth on choosing between methylphenidate vs lisdexamfetamine and how to trial/switch.
- Detailed titration advice: dose increments, intervals, managing common side effects (appetite suppression, insomnia, BP/HR changes).
- Monitoring cadence: frequent checks early (BP/HR/weight/sleep), then spacing once stable; guidance on ECG considerations in at-risk patients.
- Non-stimulant use: more narrative on when to pivot to atomoxetine/guanfacine/clonidine, and how to switch safely.
Practical takeaway: Both recommend stimulants first-line; RCPsych provides the day-to-day playbook for titration and monitoring.
Psychosocial and functional support
Both guidelines endorse psychoeducation, workplace/academic adjustments, and coaching/CBT approaches for organisational skills and emotional regulation. RCPsych underscores functional strategies and signposting for driving advice, risk around substance use, and managing co-occurring anxiety/depression.
Monitoring and safety
NICE mandates cardiovascular baseline checks and ongoing monitoring, with clear parameters for when to pause or adjust treatment. It expects structured follow-up in shared care.
RCPsych adds practical details: when to consider ECG, managing insomnia, appetite/weight changes, and handling misuse/diversion risk. It suggests closer follow-up during titration and pragmatic advice on timing doses to minimise sleep disruption.
Key difference: NICE sets the governance; RCPsych fills in the operational monitoring detail.
Comorbidities and complexity
Both stress assessment and management of comorbid conditions (anxiety, depression, substance use). RCPsych provides more examples of adapting titration when anxiety is prominent, or when substance use increases misuse risk. It also notes the importance of sleep hygiene and addressing circadian rhythm issues to avoid misattributing symptoms.
Practical flow you can apply
- Specialist assessment: Confirm diagnosis with structured criteria; gather multi-source history; assess functional impairment.
- Baseline checks: BP, HR, weight/BMI; consider ECG if risk factors; review co-morbidities and medications.
- Start stimulant: Choose methylphenidate or lisdexamfetamine; explain benefits/risks; set expectations on onset and side effects.
- Titrate with monitoring: Increment doses every 1–2 weeks; monitor BP/HR/weight/sleep; address side effects promptly.
- Consider alternatives: If stimulants not tolerated/effective, switch within class or to atomoxetine/guanfacine; document rationale.
- Support function: Psychoeducation, workplace/academic adjustments, CBT/skills coaching; address sleep and anxiety.
- Shared care: Once stable, handover with clear monitoring plan to primary care; maintain periodic specialist review.
FAQs: quick answers
Who can diagnose and initiate meds? NICE: specialist only. RCPsych: agrees, but provides nuance on assessment and impairment.
What is first-line medication? Stimulants (methylphenidate or lisdexamfetamine) unless contraindicated; both guidelines align.
How often to monitor early? Frequently during titration (e.g., BP/HR/weight/sleep every 1–2 weeks), then space out when stable; adjust per side effects and risk.
When to switch to non-stimulants? If stimulants are ineffective, poorly tolerated, or contraindicated; atomoxetine/guanfacine are typical next steps.
What about functional support? Both endorse psychoeducation and practical adjustments; RCPsych offers more detail on functional strategies and risk mitigation.
Source links (official)
Why this matters
Adult ADHD care requires a balance of governance (who can diagnose and prescribe) and practical detail (how to titrate, monitor, and support function). NICE defines access and safety parameters for the NHS. RCPsych fills in day-to-day practice: functional impairment, titration steps, and nuanced monitoring. Using both helps clinicians deliver safe, effective, and context-aware care.